GERI Exam#3

How do we communicate?

7% non-verbal 38% voice 55% verbal

One of the most common chronic conditions noted in the United States is: a.heart disease. b.malnutrition. c.pneumonia. d.kidney failure.

A

Drug Therapy: Biologic Response Modifiers (BRMs)

Also called biologics or immunotherapy -Slow progression -Classified based on mechanism of action -Used to treat moderate to severe disease not responsive to DMARDs -Used alone or in combination with DMARDs Tumor necrosis factor (TNF) inhibitors Bind with TNF -inhibits inflammation

RN's Role in Caring for Persons with Chronic Illness -Box 21.4, P. 278

Assessing the older person & his/her family strengths & challenges Teaching related to healthy lifestyle modifications, preservation of energy and self care strategies Encouraging the reduction of modifiable risk factors Counseling the individual in the development of reasonable expectations of self Providing access to resources when possible Referring appropriately and when needed Organizing & leading interdisciplinary case conferences and team meetings Facilitating advance care planning and palliative care when appropriate

A 77-year-old woman with a recent diagnosis of osteoporosis has had calcitonin added to her medication regimen. The nurse should anticipate administering the drug by:

D. Nasal spray Rationale: Calcitonin can be administered by subcutaneous or intramuscular injection, but it is most commonly administered by nasal spray.

Etiology of RA

Etiology is unknown, but now believed to be the result of interaction among environmental exposures, genetic factors, and age-related increased autoimmunity

Diagnosis for alzhiemers

Health History Medications MRI/CT-to rule out other potential issues Lab- CBC, Glucose, Urinalysis, Cerebral fluid analysis Memory tests Official Diagnosis - Only at death

Confusion

Inability to think clearly like you normally would Difficult paying attention, remembering of making decisions NOT a normal age-related change! Often treated differently depending on whether pt. is old or young (think ageism)

Use facial expressions

Largely involves expression of emotion • Emotional contagion - we catch others' emotions when we can see them (smile and others will smile with you) • Mimicry - we mimic others' emotions of yawning, crying, smiling • Facial feedback - we can begin to feel emotions simply by expressing them

Mini mental state exam scoring chart

Mini-Mental State Exam Scoring Chart Score Level of Dementia 24 and higher Normal cognition; no dementia 19 - 23 Mild dementia 10 - 18 Moderate dementia 9 and lower Severe dementia The MMSE is a 30 point test used to measure thinking. If you have reason to suspect that you may be developing Alzheimer's or another dementia, the MMSE is a step forward making a diagnosis. The test is also used by researchers who study Alzheimer's in order to know a persons level or stage of dementia. it is the most widely used test for assessing. The test measures: orientation to time and place, short term memory, attention and ability to solve problems, language, comprehension and motor skills

Ambulatory care RA Joint protection

Modify tasks for less stress on joints Energy conservation §Work simplification techniques §Pacing and organizing §Use of carts §Joint protective devices §Delegation Occupational therapy -Assistive devices §Built-up utensils §Buttonhooks §Modified drawer handles §Lightweight plastic dishes §Raised toilet seats

limit distractions

Noise • Light • Movement • Temperature • Discomfort • Hunger/thirst • Need to use the bathroom

Are there any special nursing considerations when caring for with BPH?

Nursing considerations when caring for patients with BPH would be checking for skin breakdown due to incontinence as well as assisting the patient to the bathroom more often because of urgency and increased urinary frequency. Also because of increased urinary frequency you would want to make sure the patient doesn't become at risk for deficit fluid volume. UTI's may result therefore you would want to prevent them and manage them. Teach the client about the medication prescribed and provide information about procedures. Recommend a sitz bath to promote muscle relaxation, decrease edema and enhance voiding. Saw Palmetto is a fruit bearing palm tree that can be ground into capsule or tablets which is known for relieving symptoms of BPH. Consult with the provider first to weight out risk, benefit and drug interactions.

Osteoarthritis

Onset: insidious Classic symptoms: stiffness of joint resolved in less than 20 min after rest Classic signs: affects distal interphalangeal joints, knees, hips and vertebrae Key mgt: initital txt may be nonpharmacological such as heat and exercise, later acetaminophen and NSAID

Nursing assessment: Planning RA

Overall Goals §Satisfactory pain management §Minimal loss of functional ability §Participate in therapeutic regimen §Maintain positive self-image §Perform self-care

Trajectory model

Pre-trajectory: Before the illness course occurs, the preventive phase, no signs or symptoms present Trajectory onset: Signs and symptoms are present to some extent, includes diagnostic period Stable: Controlled illness course/symptoms Unstable: Illness course/symptoms not controlled by regimen but not requiring or desiring hospitalization Acute: Active illness or complications that require hospitalization for management Crisis: Life-threatening situation; acute threat to self-identity Comeback: While this is much less likely to occur along the trajectory of those who are frail, this is a period of temporary remission from the crisis Downward: Progressive decline in physical/mental status characterized by increasing disability/symptoms Dying: Immediate weeks, days, hours preceding deat

Are we at risk for getting BPH?

Risk factors including smoking, HTN and Heart disease, diabetes mellitus, heavy alcohol consumptions, dietary factors such as high-fat high-protein high-carbohydrate and low fiber, increased age, sedentary lifestyle, and obesity.

Late stage communication

Speaks in short (1-2 word) phrases • Vocabulary limited to common phrases • Non-word vocalizations • Relies on non-verbal communication to convey message • Relies on other senses to supplement receptive messages

Use tone and gestures

Supplementing words spoken • Signals when person is done talking • Replaces or facilitates speech (head nod, "more" gesture) • Emphasizes speech via cadence and rhythm • Emphasize/demonstrate an abstract concept with gestures (i.e. weighing pros and cons)

A model for chronic illness

The trajectory model aids health care providers to understand the realities of chronic illness and its effect on individuals

Overview of communication

Verbal - Word choice - Sentence structure - Slang • Voice - Tone - Loudness • Non-verbal - Body language

S/s of RA

tender warm swollen joints symmetrical pattern of affected joints joint inflammation often affecting the wrist and finer joints closest to the hand joint inflammation sometimes affecting other joints, including the neck shoulders elbows knees ankles and feet fatigue, occasional fevers loss of energy symptoms that last for many years variability of symptoms among people with the disease

Nutritional therapy for RA

§No special diet is needed §Balanced nutrition important §Fatigue, pain and depression §Cause loss of appetite or inability to shop for and prepare food → weight loss §OT for home modifications for easier food preparation

Drug therapy Corticosteroid therapy

§Use to treat flare-ups §Intraarticular injections §Low-dose oral for limited time to decrease disease activity §Inadequate as a sole therapy §Complication: Osteoporosis §Corticosteroid therapy → weight gain due to increased hunger §May cause patient to become distressed due to physical changes of Cushing syndrome §Moon face §Redistribution of fatty tissue to the trunk §Do not change dose or stop therapy abruptly §Weigh will return to normal several months after treatment ends

good sources of calcium

•Foods that are high in calcium content include whole and skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardines, and spinach (Table 63-14).

The result

"Denial" • Anger/Frustration • Depression/Anxiety • Use of "cover phrases" • Attempting to distract/redirect your attention • Speaking less • Withdrawal from activities of interest May swear more often • May become disinhibited or socially inappropriate • Easily distracted • Agitation/aggression • Reminisces about past

RA

A systemic inflammatory autoimmune disorder affecting primarily the joints, where it causes pain, swelling, stiffness, and loss of function Inflammation of the synovium causes destruction of the surrounding cartilage and bone Serological testing for RA Rapid diagnosis is necessary, so treatment can begin as early as possible, providing greatest chance the joints can be preserved

Delirium

Acute confusion Abrupt onset Reversible when cause found Potential causes: Urinary tract infection Medication s/e Dehydration Substance withdrawl Sepsis Dementia! Causes? Table 29.3

Result of late stage

Agitation/aggression • Only able to follow one-step instructions, if at all • Hand-over-hand care more helpful than verbal instructions

Behavior and Psychological Symptoms of Dementia (BPSDs)

Anxiety Depression Hallucinations Delusions Aggression Screaming Sleep disturbances Restlessness Agitation Resistance to care Outcome of multiple, interacting factors (some are modifiable) Heighted vulnerability Form of meaningful communication Doing their best to communicate unmet needs

What to avoid

Arguing with the person • Ordering the person around • Telling the person what they cannot do • Being condescending • Asking, "do you remember?" • Talking about them in front of others

what is BPH and what causes it?

BPH is when the enlargement of the prostate gland begins to cause urinary dysfunction. It can significantly impair the outflow of urine from the bladder, making the client susceptible to infection and retention. Excessive amounts of urine retained can cause reflux of urine into the kidney, dilating the ureter and causing kidney infections. The cause of BPH is uncertain (Honan, 1044).

Which is a sign of frailty? a.Unintentional weight gain b.Hyperactivity c.Weak grip strength d.All of the above

C

The result of middle stage

Cannot form full, complex sentences • Sentence structure may be disorganized • May revert to a primary language • Relies more on non-verbal communication • Conversations become "empty" or self-centered

Osteoporosis

Characterized by a reduction in bone density and a change in bone structure: Normal homeostatic bone turnover is altered; the rate of bone resorption is greater than the rate of bone formation, resulting in reduced total bone mass. Results from age, genetic factors, hormonal factors, nutritional factors, and lifestyle factors. Assessment reveals skeletal changes and decreased bone density.

Nursing assessment: Implementation

Health promotion §Prevention not possible at this time §Early treatment to prevent further joint damage §Community education programs -Symptom recognition to promote early diagnosis and treatment Acute care: Primary goals in RA management §Decrease inflammation §Manage pain §Maintain joint function §Prevent or correct joint deformity Newly diagnosed: §Usually treated on an outpatient basis §Start with assessment -Physical -Psychosocial needs §Identify problems §Plan a program for rehabilitation and education §Interprofessional care team

Use space

Intimate distance - contact to 18 inches • Personal distance - 18 inches to 4 feet • Social distance - 4 feet to 12 feet • Public distance - 12 feet to 25 feet When someone doesn't follow these implicit rules, we choose either fight (defend our territory) or flight (avoid the uncomfortable situation)

Other Drug Therapy

Not commonly used §Antibiotics (minocycline) §Immunosuppressants §Azathioprine [Imuran] §Penicillamine (Cuprimine) §Gold preparations (auranofin [Ridaura])

Wandering

One of the most difficult Complex, not well understood Definition: Wandering is defined as "a syndrome of dementia-related locomotion behavior having a frequent, repetitive, temporally disordered and/or spatially disoriented nature that is manifested in lapping, random and or pacing patterns, some of which is associated with eloping, eloping attempts or getting lost unless accompanied" Worsens as cognitive function declines Safety issues: falls, elopement, injury, death. Assessment: physical causes (illness, fatigue, medication, constipation, unmet needs, pain,

why more common in women?

Osteoporosis is more common in women than in men for several reasons: (1)Women tend to have lower calcium intake than men throughout their lives (men between 15 and 50 years of age consume twice as much calcium as women). (2)Women have less bone mass because of their generally smaller frame. (3)Bone resorption begins at an earlier age in women and becomes more rapid at menopause. (4)Pregnancy and breastfeeding deplete a woman's skeletal reserve unless calcium intake is adequate. (5)Longevity increases the likelihood of osteoporosis.

Medical and Nursing Management: The Patient With Osteoporosis

Osteoporosis necessitates sufficient calcium, vitamin D, sunshine, and weight-bearing exercise Pharmacologic interventions: Selective estrogen receptor modulators (SERMs) Bisphosphonates Calcitonin Nursing priorities include improving bowel function, preventing injury, and managing fractures

Ambulatory care RA psychologic support

Patient teaching important §RA §Nature and course of disease §Goals of therapy Patient is constantly challenged by problems of §Limited function and fatigue §Loss of self-esteem §Altered body image §Fear of disability or deformity

Nursing implementation cont

Plan care around morning stiffness To relieve joint stiffness and ↑ ability to perform ADLs §Sit or stand in warm shower §Sit in tub with warm towels around shoulders §Soak hands in warm water Nondrug relief of pain §Therapeutic heat and cold §Rest §Relaxation techniques §Joint protection §Biofeedback §Transcutaneous electrical nerve stimulation §Hypnosis Lightweight splints §Rest an inflamed joint or prevent deformity §Removed at regular intervals §Perform ROM exercises §Reapply as prescribed Occupational therapist → additional self-help devices

Use eye contact

Signals emotions • Making eye contact invites participation and establishes a positive relationship • Lack of eye contact says "stay away" • Too much eye contact can signal negative or threat emotions

What are the signs and symptoms of BPH?

Signs and symptoms include urinary frequency, urgency, hesitancy, or incontinence. Incomplete emptying of the bladder, dribbling post-voiding, nocturia, diminished force of urinary stream, straining with urination and hematuria.

Strategies for Communicating with Individuals Experiencing Cognitive Impairment (Box 29-14)

Simplification: One step directions Speak slowly (not necessarily loudly!) Allow time for response (patience!) Give cues and clues for what you want individual to do Useful for ADLs Facilitation: Use broad openings Speak to them as you would to an equal (no elderspeak) Find commonalities Share things about yourself Useful to encourage expression of thoughts and feelings Support: Introduce yourself, explain why you are with them Sit closely and face the person at eye level Limit corrections Know the person's past history Recognize feelings and respond Go to where the person is in time and space Useful in encouraging continued communication and supporting personhood

Nursing assessment RA Subjective data

Subjective Data §Recent infections, presence of precipitating factors, pattern of remissions and exacerbations §Use of aspirin, NSAIDs, corticosteroids, DMARDs §Any joint surgery §Family history §Malaise §Ability to participate in therapeutic regimen §Impact on functional ability §Anorexia, weight loss §Dry mucous membranes of mouth and pharynx

Stage 2 Alzheimers

Symptoms which vary from person to person may include, being forgetful of events or personal history, feeling moody or withdrawn especially in socially or mentally challenging situations, being unable to recall info about themselves like their address or telephone number, and the high school or college they attended, experiencing confusion about where they are or what day it is, requiring help choosing proper clothing for the season or the occasion, experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night, showing an increased tendency to wander and become lost, demonstrating personality and behavioral changes, including suspiciousness and delusions or compulsive, reparative behavior like hand-wringing or tissue shredding.

what is communication

The exchange of information, ideas, emotions • How we relate to one another - An important part of our personal relationships • It is more than talking and listening - It involves attitude, tone of voice, facial expressions, body language

Early stage communication

Tip of the tongue • Use of nouns seems to be lost first • Use made up words • Use wrong word • May not understand and/or respond appropriately • May require more processing time • May repeat self or ask repetitive questions

Drug Therapy: Biologic Response Modifiers (BRMs) cont

Tumor necrosis factor (TNF) inhibitors §Etanercept (Enbrel)- subcutaneous §Infliximab (Remicade)- IV infusion §Given with methotrexate §Adalimumab (Humira)- subcutaneous §Certolizumab (Cimzia)-given with methotrexate §Golimumab (Simponi) )-given with methotrexate Tumor necrosis factor (TNF) inhibitors §TB test and chest x-ray before start of therapy §Monitor for infection §Avoid live vaccinations §Report bruising, bleeding, or persistent fever and other signs of infection

dementia

Umbrella term Loss of memory and other thinking functions that interfere with daily life Long term confusion Not reversible Examples Alzheimer's Parkinson's (Lewy Body) Dementia Vascular Dementia Frontotemporal Dementia Huntington's Disease

Sundown Syndrome or "Late-day confusion"??

What is it? Increased problems, confusion, agitation, pacing, etc... at dusk Interventions: Quiet time early evening Leave nightlight on when dark Close curtains to prevent shadows Identify soothing activities Routines Walk

Functions of the brain

frontal lobe: judgement, reasoning Brain stem: involuntary functions for survival and movement, balance Parietal lobe: language, temp touch pain occipital lobe: vision temporal lobe: memory language

RA onset, classic symp, classic signs and key mgt

onset: more acute in OA than in younger adults classic symptoms: stiffening lasting more than 20-30 min after rest classic signs: affects proximal joints, may be systemic key mgt: use of DMARDs as soon as diagnosis is made

Gout:

onset: sudden/acute classic symptoms: acute pain classic signs: inflammation, esp at the base of the great tie Key mgt: NSAIDs

Diagnostic studies of RA

§Diagnosis often based on H&P findings §Laboratory studies §Rheumatoid factor (RF) §ESR and C-reactive protein (CRP) §Increase in antinuclear antibody (ANA) §Antibodies to citrullinated peptide (anti-CCP) §Synovial fluid analysis §X-rays of involved joints §Bone scan - more useful than X-ray

Ambulatory care RA psychologic support cont

§Discuss alterations in sexuality §Patient vulnerable to unproven or even dangerous remedies §Help patient recognize fears and concerns §Evaluate family support system §Financial planning §Consider community resources §Self-help groups are helpful for some patients §Strategies to decrease depression

Etiology and patho of RA

§Exact cause is unknown §Most widely accepted theory is - Autoimmune etiology §Combination of genetics, environmental exposures and age-related auto-immunity §Susceptible person has an immune response to an antigen §Antigen triggers formation of abnormal immunoglobulin G (IgG) §Autoantibodies develop against the abnormal IgG §Rheumatoid factor (RF)

Nursing assessment: Nursing diagnosis RA

§Impaired physical mobility §Chronic pain §Disturbed body image

surgical therapy for RA

§Relieve severe pain §Improve function §Synovectomy - removal of joint lining §Total joint replacement (arthroplasty)

s/s of PD

•4 cardinal signs: •Bradykinesia (slowness of movement) •Rigidity •Tremor at rest (but not during sleep) •Gait changes (imbalance or Incoordination, shuffling gait) •Other: tendency to fall backward, vocal changes, swallowing problems, bowel and bladder dysfunction, and sleep pattern disturbances. Tends to start with asymmetrical movement disorder at onset. (Intention tremor may be benign familiar tremor...know how to differentiate.) Difficulty initiating ambulation - but once a patient with PD begins walking, propelled forward, increased risk of falls. (Honan book: TRAP - tremor, rigidity, akinesia/bradykinesia, postural disturbance/instability)

Parkinson Disease

•A slowly progressing neurologic movement disorder that eventually leads to disability. •Associated with decreased levels of dopamine resulting from destruction of pigmented neuronal cells in the basal ganglia region. •Typically manifests with tremor, rigidity, akinesia/bradykinesia (without or decreased body movement), and postural disturbances. •Complications are typically related to disorders of movement.

Remodeling

•Bone is continually being deposited by osteoblasts and resorbed by osteoclasts, a process called remodeling. •Rates of bone deposition and resorption are normally equal so total bone mass remains constant. •In osteoporosis, bone resorption exceeds bone deposition.

Clinical manifestations of parkinson

•Clinical Manifestations (Tremor, Rigidity, Akinesia, Postural Disturbances •Other manifestations: vCognitive changes vPsychiatric Changes vSleep Disturbances vHypokinesia vShuffling gait vMicrographia vDysphonia

Patho of PD

•Degenerative disorder of the central nervous system •Loss of neurons in the substantia nigra in the brainstem causes a reduction in dopamine •Dopamine is a neurotransmitter responsible for fine motor movement and also important for feelings and emotions •One distinct physiological change that is used to diagnose Parkinson's is the presence of a Lewy Body (which under a microscope looks like a dying neuron)

Diagnostic studies for osteoporosis

-History and physical exam -X-ray and lab studies not diagnostic •Osteoporosis often goes unnoticed because it cannot be detected by conventional x-ray until 25% to 40% of calcium in the bone is lost. Serum calcium, phosphorus, and alkaline phosphatase levels usually are normal, although alkaline phosphatase may be elevated after a fracture. •Bone mineral density (BMD) is determined by peak bone mass and amount of bone loss. •BMD may be measured by quantitative ultrasound (QUS) and dual-energy x-ray absorptiometry (DXA). •QUS uses sound waves to measure bone density with in the heel, kneecap, or shin. •DXA (considered the gold standard of BMD studies by the World Health Organization), measures bone density in the spine, hips, and forearm. These represent the most common sites of fragility fractures from osteoporosis. •DXA studies are also useful to evaluate changes in bone density over time and assess the effectiveness of osteoporosis treatment.

Assessing Causes of BPSDs (con't)

3. what does the behavior mean? Framework for Asking Questions about the Meaning of Behavior (Box 29-18) What? What is being sought? What is happening? Does the behavior have a physical or emotional component or both? What are the person's responses? What would be done if the person was 20 years old instead of 80? What is the behavior saying? What is the emotion being expressed? Where? Where is the behavior occurring? What are environmental triggers? When? When does the behavior most frequently occur: after activities of daily living (ADLs), family visits, mealtimes? Who? Who is involved? Other residents, caregivers, family? Why? What happened before? Poor communication? Tasks too complicated? Physical or medical problem? Person being rushed or forced to do something? Has this happened before and why? What now? Approaches and interventions (physical, psychosocial) Changes needed and by whom? Who else might know something about the person or the behavior or approaches? Communicate to all and include in plan of care. 4. Behavior and Environmental Modification Strategies for Managing BPSDs - Examples in Box 29-23 Examples: Aggression and repetitive questioning Hearing voices: Evaluate hearing or adjust amplification of hearing aids. Assess quality and severity of symptoms. Determine whether they present an actual threat to safety or function. Assess noise around patient's room (e.g., staff talking in hallway). Aggression: Determine and modify underlying causes of aggression (e.g., pain, caregiver interaction, being forced to do something). Teach caregiver not to confront individual, use distraction, observe facial expression and body posture, leave individual alone if safe, return later for the task (e.g., bathing). Create a calmer, more soothing environment. Repetitive questioning: Respond with a calm, reassuring voice. Use calm touch for reassurance. Place warm water bottle covered with soft fleece cover on the lap or abdomen. Inform individual of events only as they occur. Structure daily routines. Involve person in meaningful activities.

Notes on patho of PD

A Lewy Body is an abnormal collection of Proteins inside nerve cells. Again, Lewy Body would be found on autopsy. More likely to diagnose based on clinical symptoms and response to medications. 70-90% of dopamine-producing cells may be lost before clinical symptoms occur. Honan Med-Surg book - p. 1339 Pathophysiology: Loss of dopamine-producing cells causes imbalance between acetylcholine (excitatory) and dopamine (inhibitory) neurotransmitters. Affects semiautomatic functions an coordinated movements --> tremors Patients with PD MAY develop dementia in late stages.PD will ALWAYS begin with movement disorder.

Nursing assessment: Implementation cont

Acute intervention: Comprehensive program §Drug therapy §Balance of rest and activity §Joint protection §Heat and cold applications §Exercise §Patient and caregiver teaching Acute intervention: Suppression of inflammation §NSAIDs §DMARDs §BRMs - biologic response modifiers Patient teaching about medications §Timing of administration - to decrease s/s §Action and side effects §Adherence

Frailty, Aging, and Chronic Disease

Associations between age and chronic disease and the development of frailty remains unclear Frailty is "a multidimensional syndrome characterized by decreased reserves and diminished resistance to stressors" The frailer, the faster one proceeds along the Chronic Illness Trajectory, the less likely one can move backward toward stability, and the greater the risk for death at any time the person becomes unstable.

Approaches to listening

Be supportive and patient • Show your interest and engagement through non-verbal signs • Offer comfort and reassurance through tone of voice, touch, facial expressions • Validate feelings and emotions • Be accepting of any communication efforts made by the individual • Watch for non-verbal signs of emotions, identity, and/or needs

Clinical manifestations of PD

Beginning stages •Mild tremor, slight limp, ↓ arm swing Later stages •Shuffling, propulsive gait with arms flexed, loss of postural reflexes •90% experience hypokinetic dysarthria (speech abnormalities) Decreased arm swing is very notable...but assess your patient and don't make assumptions. (Patients with CVA history may also have decreased arm swing unilaterally.)

Signs and symptoms related to the diagnosis of PD includes all of the following except: a.dramatic improvement with administration of levodopa. b.resting tremor. c.symmetry of motor symptoms. d.muscular rigidity.

C

Osteoporosis PP2

Chronic, progressive metabolic bone disease marked by ◦Low bone mass ◦Deterioration of bone tissue Leads to increased bone fragility Over 54 million people in the United States One in 2 women and 1 in 4 men over 50 will sustain an osteoporosis-related fracture Known as the "silent thief" because it slowly robs the skeleton of its banked resources. Bones eventually become so fragile that they cannot withstand normal mechanical stress.

Making a positive physical approach

Come from the front • Go slow • Get to the side • Get low • Offer your hand (palm up) • Get attention by using the person's preferred name • Wait for a response

Summary

Communication challenges with dementia • Non-verbal communication strategies • Positive physical approach • Ten guidelines for improving verbal communication

complications of RA

Complications Are largely a consequence of orthopedic deformities and pain Most common deformity is boutonniere deformity or hyperextension of the distal interphalangeal (DIP) joint with flexion of the proximal interphalangeal (PIP) joint Persons with RA are most likely to die of CV disease and at a higher rate than the general population

BOX 29.25 "Tips for Best Practices" Interventions for Wandering or Exiting Behaviors - Remember all the other tips in communicating with adult with A.D., goal - redirect, get them to safety - PATIENCE

Face the person, and make direct eye contact (unless this is interpreted as threatening). • Gently touch the person's arm, shoulders, back, or waist if he or she does not move away from a door or other exit. • Call the person by his or her formal name (e.g., Mr. Jones). • Listen to what the person is communicating verbally and nonverbally; listen to the feelings being expressed. • Identify the agenda, plan of action, and the emotional needs of the behavior being expressed. • Respond to the feelings expressed, staying calm. • Repeat specific words or phrases, or state the need or emotion (e.g., "You need to go home; you're worried about your husband"). • If such repetition fails to distract the person, accompany him or her and continue talking calmly, repeating phrases and the emotion you identify. • Provide orienting information only if it calms the person. If it increases distress, stop talking about the present situations. Do not "correct" the person or belittle his or her agenda. • At intervals, redirect the person toward the facility or the home by suggesting, "Let's walk this way now" or "I'm so tired, let's turn around." • If orientation and redirection fail, continue to walk, allowing the person control but ensuring safety. • Make sure you have a backup person, but he or she should stay out of eyesight of the person. • Have someone call for help if you are unable to redirect. Usually the behavior is time limited because of the person's attention span and the security and trust between you and the person.

Tips for managing frailty (Box 21-4)?

Frailty is loosely defined as evidence of three of the following: unexplained weight loss, self-reported exhaustion, weak grip strength, slow walking speed, and low activity. It is better to ask the patient specifically about each one of these symptoms. Many people consider the signs as "just a normal part of aging."

Assessing causes of BPSD's

Goal of Assessment: Understanding what triggers behavior in order to develop interventions that address the individual's unmet needs 1. Rule out medical causes Pneumonia Dehydration Urinary tract infection Pain Fractures Infection/Sepsis Depression 2. Conditions precipitating behavioral symptoms in individual with dementia Communication deficits Sleep disturbances Need for social contact Loss of control Changes - environment or people Noise Forced to do something, rushed care Fear, loneliness, (Box 29-17)?? You are asleep in the chair at home when suddenly you are awakened by a person you have never seen before trying to undress you. Then he or she puts you naked into a hard, cold chair and wheels you down a hallway. Suddenly cold water hits you in the face and the person is touching your private areas. You don't understand why the person is trying to do this to you. You are embarrassed, frightened, cold, and angry. You hit and scream at this person and try to get away.

Interprofesional care of RA

Goal: Minimize disability by preventing further damage and adequate pain relief §Patient teaching §Drug therapy - cornerstone of treatment §Disease process §Home management strategies §Physical therapy §Occupational therapy

stage 1 Early stage Alzheimer's (mild)

In the early stage of Alzheimer's a person may function independently. He or she may still drive work and be part of social activities. Despite this, the person may feel as if he or she is having memory lapses such as forgetting familiar words or the location of everyday objects. Symptoms may not be widely apparent at this stage, but family and close friends may take notice and a doctor would be able to identify symptoms using certain diagnostic tools. Common difficulties include: coming up with the right word or name, remembering names when introduced to new people, having difficulty performing tasks in social or work settings, forgetting material that was just read, losing or misplacing a valuable object, experiencing increased trouble with planning or organizing.

Stage 3 Alzheimer's (severe)

In the final stage of the disease, dementia symptoms are severe. Individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases but communicating pain becomes difficult. As memory and cognitive skills to worsen, significant personality changes may take place and individuals need extensive care. At this stage, individuals may: require around the clock assistance with daily personal care, lose awareness of recent experiences as well as of their surroundings, experience changes in physical abilities, including walking, sitting and eventually swallowing, having difficulty communication, become vulnerable to infections, especially pneumonia.

Middle stage communication

Increase in frequency and severity of early stage problems • Repeats self more often • Loses or forgets words: relies on more familiar ones • Hears words, but has difficulty interpreting meaning • May be able to read words, but may not be able to understand meaning

Communication guidelines

Introduce yourself and your role • Treat her as an adult • Use familiar words and phrases • Speak slowly and clearly • Ask for what you want Keep it simple when giving directions or choices • Use concrete terms/phrases and avoid pronouns • Offer multiple cues • Use the same words when repeating • Check hearing aids and glasses

Are there any medical tests or labs that are done to help confirm the diagnosis?

Lab tests include urinalysis and culture (WBC elevated, hematuria, and bacteria present with urinary tract infection), CBC (RBC possibly decreased due to hematuria), BUN and Creatinine (elevated, indicating kidney damage), Prostate- specific antigen (to rule out prostate cancer) and Culture and sensitivity of prostatic fluid (can be performed if fluid is expressed during digital rectal examination). Diagnostic procedures digital rectal exam (will reveal an enlarged, smooth prostate), Transrectal ultrasound with needle aspiration biopsy (performed to rule out prostate cancer in the presence of an enlarged prostate) and Early prostate cancer antigen (blood test can be prescribed instead of a biopsy to rule out prostate cancer.

Notes on Rx for PD

Levodopa can have a side effect of hallucinations, psychosis. Dopamine agonists bind to dopamine receptors and mimic action of dopamine. May be used alone in early PD or in combination with carbidopa/levodopa. Patients may have "on" and "off" periods where drugs do and then don't appear to work..."off" episodes can last minutes to hours. Both carbidopa/levodopa and dopamine agonists may cause dyskinesias - sudden uncontrollable movements. Dopamine agonists may also decrease impulse control, resulting in increased urges for gambling, sexual activity, etc. See Honan book - p. 1341, table 46-2 Antiparkinsonian medications - less commonly used. Anticholinergics - trihexyphenidyl hydrochloride (Artane), benztropine mesylate (Cogentin) - control tremor, risk for increased IOP and urinary retention Amantadine hydrochloride (Symmetrel) - not as commonly used as in the past bromocriptine (Parlodel) and pergolide (Permax) - dopamine agonists - new drugs such as Requip and Mirapex more commonly used now. MAOI's - selegiline (Eldepryl)

Chronic illness cont

Many chronic diseases could be eliminated through preventative strategies, especially when started at a young age Major global lifestyle risk factors for the development of chronic disease (Box 21-1) -Tobacco use -Unhealthy diet -Physical inactivity -Alcohol abuse

Are there any medications used to treat this condition?

Medications include Dihydrotestosterone (DHT)- lowering medication such as 5-alpha reductase inhibitor (5-ARI), and alpha-blocking agents such as tamsulosin. Alpha-adrenergic blockers relax the smooth muscle of the bladder neck and prostate, improve urine flow, and relieve BPH symptoms. 5-alpha reductase inhibitor interfere with the conversion of testosterone to dihydrotestosterone (DTH) which is associated with prostate growth. Decreased DTH lead to decreased activity of glandular cells and prostate size.

Medication-Alzheimer's NO CURE

Namenda (memantine) u Purpose: Decreases abnormal activity in brain; may improve ability to think and remember or may slow loss of these abilities Side Effects: ***shortness of breath and hallucination*** Time of administration: take at the same time every day Aricept (donepezil) Purpose: Improves mental function by increasing a naturally occurring substance in brain; may improve ability to think and remember or may slow loss of these abilities Side Effects: ***tarry stools*** Time of administration: take at the same time every day

Chronic illness

Persists regardless of treatment, is of long duration, and usually progresses slowly Chronic diseases are not always obvious and may not interfere with the person's day-to-day life until late in the disease, but are nonetheless present and require ongoing treatment The most common chronic diseases are heart disease, stroke, cancer, diabetes, obesity, and osteoarthritis In older adults, a chronic disease may not be diagnosed until some amount of "end organ damage" has already occurred.

Other influences

Poor attention • Impaired judgement • Poor sequencing/organization abilities

Are there any psychosocial considerations that I need to know about to care for him?

Psychosocial considerations that you would need to know about to care for your patient include signs of depression, anxiety, suicidal thoughts and stress. BPH could also affect their social functions and further affect their quality of life. Patient with BPH can have a negative affect on their economic activity. Other consideration include ability to manage self-care of their condition. Medication such as Finasteride can cause decrease in ability in achieving an erection and decrease in sexual desires. Consult with a provider to discuss these changes in sexual dysfunction and ways to manage them. You could recommend stress relieving activities such as yoga, meditation, music therapy and guided imagery to manage stress and anxiety.

Ambulatory care RA

Rest §Alternate rest periods with activity §Helps relieve pain and fatigue §Amount of rest varies §Avoid total bed rest §8-10 hours of sleep + daytime rest §Modify activities to avoid overexertion -IE: sitting while preparing meals Body alignment §Firm mattress or bed board §Encourage positions of extension §Avoid flexion positions §No pillows under knees §Small, flat pillow under head and shoulders

Cliff notes- the three R's

Right - The person with memory loss is always right • Reassure - Respond to the emotion, not to the words • Redirect - Change the subject to something else

risk factors of osteoporosis

Risk factors for osteoporosis include the following: •Advancing age (>65 yr) •Female gender •Low body weight •White or Asian ethnicity •Current cigarette smoking •Prior fractures •Sedentary lifestyle •Estrogen deficiency in women (surgical or age-related menopause) •Family history of osteoporosis •Diet low in calcium or vitamin D deficiency •Excessive use of alcohol (>2 drinks/day) •Low testosterone level in men •Specific diseases associated with osteoporosis include inflammatory bowel disease, intestinal malabsorption, kidney disease, rheumatoid arthritis, hyperthyroidism, alcoholism, cirrhosis of the liver, hypogonadism, and diabetes mellitus. •Many drugs can interfere with bone metabolism, including corticosteroids, antiseizure drugs (e.g., divalproex sodium [Depakote], phenytoin [Dilantin]), aluminum-containing antacids, heparin, some chemotherapy drugs, and excessive thyroid hormones. When one of these drugs is prescribed, inform the patient of this possible side effect. Long-term corticosteroid use is a major contributor to osteoporosis.

Use touch

Signals degree of interest, involvement, and attraction • Appropriate versus inappropriate touch leads to perception of personality • Can signal threat, so ask first

signs and symptoms of RA

Signs and symptoms Three variations of RA: •Monocyclic—one episode lasting 3-5 years •Polycyclic—intensity of symptoms varies over time •Progressive—increase in severity and present all the time Affects the joints and the system as a whole; pain, fatigue, malaise, weakness, and fever may be present Characterized by symmetrical polyarticular limitations affecting five or more joints RA usually affects the small joints of the wrist, ankle, and hand, although it can also affect the large joints such as the knee

Vitamin D

Vitamin D necessary for calcium absorption/function; bone formation Sunlight for 20 minutes adequate Supplemental (800-1000 IU/day) ◦Postmenopausal ◦Older adults ◦Homebound/long-term care ◦Minimal sun exposure •Vitamin D is important in calcium absorption and function and may also have a role in bone formation. •Most people get enough vitamin D from their diet or naturally through synthesis in the skin from exposure to sunlight. •Being in the sun for 20 minutes a day is generally enough. •However, supplemental vitamin D (800 to 1000 IU) is recommended for postmenopausal women, older adults, persons who are homebound or in long-term care settings, and in those northern climates due to decreased sun exposure.

Drug therapy NSAID and salicylates

§Anti-inflammatory, analgesic, and antipyretic §May take 2 to 3 weeks for full effectiveness §NSAIDs: Celebrex (effective in RA as well as OA)

Rheumatoid arthritis

§Chronic, systemic autoimmune disease - immune system attacks healthy cells in your body by mistake, causing inflammation in the affected parts of the body §Inflammation of connective tissue in synovial joints §Periods of remission and exacerbation

Rheumatoid arthritis cont

§Extra articular manifestations §Skin, eye, heart, lung, renal, nervous and gastrointestinal systems §Affects all ethnic groups §Can occur any time in life, with incidence ↑ with age, peaks in the sixth decade §Estimated 1.5 million Americans §Three times as many women as men

Drug Therapy: Biologic/Targeted Therapies

§IL-1 receptor antagonist (IL-1Ra) -Anakinra (Kineret) - given SQ -Reduces pain and swelling §Tocilizumab (Actemra) §Abatacept (Orencia) - given IV -Blocks T-cell activation §Rituximab (Rituxan)- given IV -Targets B cells

Ambulatory care RA exercise

§Individualized exercise plan to -Improve flexibility and strength -Increase overall endurance §Encourage program participation and reinforce correct performance §Need both recreational (swimming) and therapeutic exercise (maintain joint motion) §Gentle ROM exercises done daily to keep joints functional §Aquatic exercises in warm water beneficial -Provides 2-way resistance that makes muscles work harder §During acute inflammation -Limit to one or two reps

Clinical manifestations Joints of RA cont

§Joint stiffness after inactivity §Morning stiffness 60 minutes to several hours or longer §Fingers spindle shaped §Joints tender, painful, warm to touch §Pain ↑ with motion, intensity varies §Joint pain, swelling, warmth, erythema and lack of function §Tenosynovitis - inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon §Deformity and disability §Subluxation - muscle atrophy and tendon destruction causes 1 joint to slip past the other §Walking disability §Deformities in the hands

Complications of RA

§Largely related to orthopedic deformities, pain and side effects of medications §Most common deformity - Boutonnière's or hyperextension of distal interphalangeal joint

Drug therapy: DMARDs

§Leflunomide (Arava) -Teratogenic -blocks immune cell overproduction §Tofacitinib (Xeljanz) -moderate to severe active RA §Sulfasalazine (Azulfidine) -mild to moderate disease §Hydroxychloroquine (Plaquenil) -mild to moderate disease -Doesn't slow progression -Baseline and then yearly eye exam due to the risk of vision loss

Objective data RA

§Lymphadenopathy, fever §Keratoconjunctivitis §Rheumatoid nodules §Skin ulcers §Shiny, taut skin over joints §Peripheral edema §Raynaud's phenomenon - cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis §Distant heart sounds, murmurs §Dysrhythmias §Chronic bronchitis, tuberculosis §Fibrosing alveolitis §Splenomegaly (Felty syndrome)

Without adeq txt of RA

§More than 60% may develop marked functional impairment within 20 years §Need of mobility aids §Loss of self-care ability §Need for joint reconstruction §By end-stage, patients experience loss of independence, require daily care Genetic link of RA §Genetic predisposition to developing RA §Smoking increases risk in patients genetically predisposed

Clinical manifestations Joints of RA

§Onset typically insidious §Fatigue, anorexia, weight loss, generalized stiffness, fever §Stiffness may become more localized §May report history of precipitating event §Infection, stress, exertion, childbirth, surgery, emotional upset §Specific joint involvement §Pain, stiffness, limited motion, and signs of inflammation §Symptoms occur symmetrically §Often affects small joints of the hands, wrists, and feet § As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints

Ambulatory care Heat and Cold therapy RA

§Relieve pain, stiffness, and muscle spasm §Ice -Especially beneficial during periods of disease exacerbation -Application should not exceed 10-15 minutes at one time Moist heat §Heating pads, moist hot packs, paraffin baths, warm baths, or showers §Relieve stiffness §Should not exceed 20 minutes at a time §Be alert for burn potential

Etiology and patho of RA cont

§Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates inflammatory response §Neutrophils attracted to site → release proteolytic enzymes → damage cartilage and thicken synovial lining

Clinical Manifestations Extraarticular Manifestations of RA

§Rheumatoid nodules §Fingers, elbows §Treatment usually not needed for these §Nodular myositis §Muscle fiber degeneration §Heart nodules §Sjögren's syndrome: dry mouth and eyes §Felty syndrome: enlarged spleen, low WBC §Flexion contractures §Cataracts §Depression

Stage 3 and 4 of RA

§Stage III §Formation of synovial pannus - formation of vascular granulation tissue §X-ray: extensive cartilage loss, erosion at joint margins, possible deformity §Stage IV §Inflammatory process subsides §Loss of joint function §Formation of subcutaneous nodules

Nursing assessment RA subjective data cont

§Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue §Paresthesia - abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) of hands and feet §Loss of sensation §Symmetric joint pain and aching that ↑ with motion or stress on joint

objective data RA cont

§Symmetric joint involvement §Swelling, erythema §Heat, tenderness §Deformities §Joint enlargement §Limitation of movement §Muscle contractures; atrophy §+ Rheumatoid factor §↑ ESR §↑ WBCs in synovial fluid §X-ray findings §Joint space narrowing §Bony erosion §Deformity §Osteoporosis

Stage 1 and 2 RA

§Synovitis - inflammation of synovial membrane §X-ray: No destructive changes seen §Soft tissue swelling, possible osteoporosis, no joint destruction §Stage II §Increased joint inflammation §Gradual destruction in joint cartilage §Narrowing joint space from loss of cartilage

Methotrexate

§Usually taken once per week for RA §Methotrexate is usually not taken every day §Can also be used to treat certain types of cancer or to control severe psoriasis §Do not receive a "live" vaccine while using methotrexate

Effects of dementia on communication?

• Dysfunction in at least one area identified with memory: registration, storage, and retrieval • An individual may require several sensory inputs (visual, auditory, and tactile) to help them remember/comprehend

•Which of the following interventions is most likely to preserve and promote the mobility of a patient with Parkinson disease? A.Implementation of a progressive exercise program B.Health education around energy conservation C.Appropriate use of splints and limb-support devices D.Administration of analgesics on a scheduled basis

•A. Implementation of a progressive exercise program •Rationale: A progressive program of daily exercise will increase muscle strength, improve coordination and dexterity, reduce muscular rigidity, and prevent contractures that occur when muscles are not used. Energy conservation may be relevant, but this will not necessarily enhance mobility. Pain is not normally a central problem, and limb support is not normally required.

Drug therapy Bisphosphonates: •Alendronate (Fosamax), •Zoledronic acid (Reclast)

•Alendronate (Fosamax) is available as a daily or weekly oral tablet. •Ibandronate (Boniva) is available as a once-per-month oral tablet or can be given every three months by IV infusion. The immediate-release form of risedronate (Actonel) is given daily, weekly, or monthly based on the dose. •Zoledronic acid (Reclast) is approved as a once-yearly IV infusion to treat osteoporosis, or is given every two years to prevent the disease. Renal function tests and serum calcium must be assessed before administration of the drug.

More Antiparkinsonian Medications -Table 46-2 p. 1341

•Anticholinergic Therapy •Antiviral Therapy •Dopamine Agonists •Monoamine Oxidase Inhibitors (MAOIs) •COMT Inhibitors •Antidepressants ØTricyclic ØSerotonin reuptake inhibitors (SRIs) ØAtypical antidepressants

Drug therapy for osteoporosis Bisphosphonates,

•Bisphosphonates inhibit osteoclast-mediated bone resorption and slow the cycle of bone remodeling. Although a modest increase in BMD is typical, bone remodeling may be suppressed to the extent that normal bone formation is impaired and fracture risk increases. These drugs are widely used in the prevention and treatment of osteoporosis. •Common side effects are anorexia, weight loss, and gastritis. •Teach the patient to take the medication correctly to improve its absorption. •Take with full glass of water. •Take 30 minutes before food or other medications. •Remain upright for at least 30 minutes after taking. •These precautions have also been shown to decrease GI side effects (especially esophageal irritation). •A rare and serious side effect of bisphosphonates is osteonecrosis (bone death) of the jaw. Its etiology is unknown. However, patients with dental disease, cancer, Paget's disease, or renal disease are most at risk for this complication. Patients should be evaluated by a dentist before beginning treatment, and then annually to ensure good oral health.

Drug therapy calcitonin

•Calcitonin is secreted by the thyroid gland and inhibits osteoclastic bone resorption by directly interacting with active osteoclasts. •Salmon calcitonin (Calcimar) is available in intramuscular, subcutaneous, and intranasal forms. •Administration of the intramuscular or subcutaneous form of the drug at night has been shown to decrease associated side effects of nausea and facial flushing associated with this drug. •Nausea does not occur with the nasal spray. •If patients are using the nasal form, teach them to alternate nostrils daily. Nasal dryness and irritation are the most frequent side effects. •Calcium supplementation is needed to prevent secondary hyperparathyroidism.

Screening guidelines

•Current guidelines recommend an initial bone density test in all women over age of 65. •If the results are normal and the person is at low risk for osteoporosis, another scan is not needed for 15 years. •Testing should start earlier and be done more frequently if a person is at high risk for fractures (e.g., low body weight, smoker, prior fractures). •Currently there is not sufficient evidence to demonstrate significant benefit for osteoporosis screening in men.

Preventative factors

•Decreased risk is associated with regular weight-bearing exercise and fluoride, calcium, and vitamin D ingestion.

Txts being explored PD

•Deep Brain Stimulation (DBS) •Thalamotomy •portion of the thalamus is surgically destroyed (ablated). •Fetal tissue transplants •Stem cell transplants •Tai Chi DBS sends electrical signal to brain to interfere with motor tremor. Helps to alleviate symptoms. Does NOT alter progression of disease. (Does NOT restore cells in substantia nigra, increase dopamine production, etc.) Stem cell transplants being studied to determine if they can slow progression of disease. Tai Chi may help with movement and balance.

Drug therapy Denosumab (prolia)

•Denosumab (Prolia) may be used for postmenopausal women with osteoporosis who are at high risk for fractures. It is a monoclonal antibody that binds to a protein (RANKL) involved in the formation and function of osteoclasts. Denosumab is given by a health care professional as a subcutaneous injection every 6 months. •Medical management of patients receiving corticosteroids includes prescribing the lowest effective dose and ensuring an adequate intake of calcium and vitamin D, including supplementation when osteoporosis drugs are prescribed. If osteopenia is evident on bone densitometry in people who are taking corticosteroids, treatment with bisphosphonates may be considered.

CM PD sleeping problems are common

•Difficulty staying asleep •Restless sleep •Nightmares •Drowsiness during the day •REM behavior disorder •Violent dreams •Potentially dangerous motor activity during REM sleep

complications of PD

•Dysphagia may result in malnutrition or aspiration •General debilitation may lead to pneumonia, UTIs, and skin breakdown •Orthostatic hypotension •↑ Risk for falls and injuries In contrast to dementias, Parkinson's disease is NOT considered a terminal illness. However, in late stages, high risk for morbidity and mortality related to aspiration, pneumonia, dysphagia leading to malnutrition/cachexia, falls with injuries, esp. head injury.

Nursing interventions for PD

•Education of the patient and family is essential: •Medications •Fall prevention •Disease progression •Mobility •Bowel and Bladder issues •Sleep problems •Swallowing problems •Communication •Community resources •What to expect Again, management is very sensitive to nursing interventions/management. Fall precautions Aspiration precautions Promote socialization, mobility, range of motion; encourage physical therapy.

Interprofessional Care

•Interprofessional care of osteoporosis focuses on proper nutrition, calcium supplementation, exercise, prevention of falls and fractures, and drugs. •The National Osteoporosis Foundation (www.nof.org) recommends treatment for osteoporosis for postmenopausal women with •a T-score of less than −2.5, •a T-score between −1 and −2.5 with additional risk factors (Table 63-12), or •prior history of a hip or vertebral fracture. •A patient's risk of fracture from osteoporosis can also be calculated by the Fracture Risk Assessment (FRAX) tool (www.shef.ac.uk/FRAX). The FRAX takes into account BMD and additional clinical factors when assessing fracture risk.

Medications for PD

•Levodopa - Synthetic dopamine (amino acid that converts to dopamine when it crosses the blood brain barrier). • Improves symptoms in 75% of people with bradykinesia and rigidity. • Carbidopa/Levodopa (Sinemet): This combination is used much like Levodopa, but doesn't have the added side effect of nausea that is seen in Levodopa alone. Can have a wearing off effect (often requires a "drug holiday" to reset the clock. •Dopamine agonists: Pramipexole (Mirapex), Ropinorole (Requip) •Cholinesterase inhibitor: Rivastigmine (Exelon) for PD dementia/cognitive symptoms

Clinical manifestations of PD cont

•Loss of automatic movements occur subconsciously and result in classic characteristics of a person with PD •Stooped posture •Masked face •Drooling •Festination (shuffling gait) autonomic symptoms: •Sweating/flushing •Orthostatic hypotension •Gastric & urinary retention •Constipation •Sexual/erectile dysfunction

Medical and Nursing Management: The Patient With Parkinson Disease

•Major goals are controlling symptoms and maintaining functional independence. •Antiparkinsonian medications and deep brain stimulation have proven benefits. •Nursing priorities include enhancing mobility, enhancing self-care, improving nutrition, maintaining bowel function, enhancing swallowing, improving communication, and supporting coping ability. P. 1342

Antiparkinsonian Medications: Levodopa

•Most effective agent & mainstay of treatment •Converts to dopamine in the basal ganglia, producing symptom relief •Administered in combination with carbidopa (sinemet) - an amino acid decarboxylase inhibitor which maximizes the beneficial effects of levodopa •Benefits are mostly within first few years of treatment •Adverse effects of this med become more severe with time (confusion, hallucinations, depression and sleep alteration) •Dyskinesia develops within 5-10 years (abnormal involuntary movements) •On-Off syndrome p. 1340

Etiology of PD

•No known etiology, but many different theories exist: •Virus or environmental factors •Herbicides or pesticides •Theory that it is caused by an injury related to an event or toxin exposure •Genetic: 15 % of cases have a family history Other theories of etiology: Head injury (see: Muhammad Ali) Oxygen free-radicals Chronic use of antipsychotic medications

Diagnostic tests for PD

•No specific tests exist •Diagnosis based on history and clinical features •Requires presence of TRAP (minimum 2 of 4 symptoms) •Asymmetric onset (one side) •Confirmation is a positive response to antiparkinsonian drugs •Rule out other disorder causing symptoms Suspected PD cases should be confirmed by neurologist. MRI or DaTscan (detects dopamine fx in brain) may be used to rule out other neurologic disorders. Rule out: medication side effect (esp. antipsychotics), essential tremor, other disease with Parkinsonian syndrome.

CM of PD nonmotor symptoms

•Nonmotor symptoms •Depression and anxiety •Apathy •Fatigue •Pain •Memory changes PD dementia affects approx. 9% of patients diagnosed before age 70 but nearly 40% of patients dx with PD after age 70.

PD

•One of the most common neurological diseases affecting 6.3 million people worldwide (2014) • •The likelihood of Parkinson's increases with age. The average age of onset is 59 years old •Men>Women •Chronic and progressive disease with no cure

Clinical manifestations of osteoporosis

•Osteoporosis occurs most commonly in bones of the spine, hips, and wrists. •Typically early manifestations are back pain or spontaneous fractures. The loss of bone mass causes the bone to become mechanically weaker and prone to spontaneous fractures or fractures from minimal trauma. A person who has one vertebral fracture due to osteoporosis has an increased risk of having a second vertebral fracture within 1 year. •Over time, vertebral fractures and wedging cause gradual loss of height and a humped thoracic spine (kyphosis or "dowager's hump").

Etiology and patho of osteoporosis

•Peak bone mass (maximum bone tissue) is typically achieved before age 20. •It is largely determined by a combination of four major factors: hereditary, nutrition, exercise, and hormone function. •Heredity may be responsible for up to 70% of a person's peak bone mass. •Bone loss from midlife (age 35 to 40 years) onward is inevitable, but the rate of loss varies. •At menopause, women experience rapid bone loss when the decline in estrogen production is the greatest. This rate of loss then slows and eventually matches the rate of bone lost by men ages 65 to 70 years old. •Genetic factors influence not only bone mineral density but also bone size, bone quality, and turnover.

Clinical manifestations cont PD

•Pill rolling hand tremor •Diaphragm, tongue, lips, jaw may be involved •Essential tremor is not associated with PD •Occurs during voluntary movement, has more rapid frequency, is familial •Rigidity • ↑ Resistance to passive motion when limbs are moved through their ROM •Cogwheel rigidity •Jerky quality •Like intermittent catches in passive movement of a joint •Sustained muscle contraction •Elicits the following •Complaint of soreness •Feeling tired and achy •Pain in the head, upper body, spine, or legs •Slowness of movement

Drug therapy cont Raloxifene and Teriparatide

•Raloxifene (Evista) is a selective estrogen receptor modulator (SERM). This drug mimics the effect of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. Raloxifene in postmenopausal women significantly increases BMD. Side effects include leg cramps, hot flashes, and blood clots. Raloxifene may decrease breast cancer risk. Similar to tamoxifen, it blocks the estrogen receptor sites of cancer cells. •Teriparatide (Forteo) is a recombinant form of human parathyroid hormone (PTH) that increases the action of osteoblasts. This drug is used to treat osteoporosis in men and postmenopausal women at high risk for fractures, including risk related to long-term corticosteroid use. Side effects can include leg cramps and dizziness. Teriparatide is the first drug approved for the treatment of osteoporosis that stimulates new bone formation in osteoporosis; most drugs only prevent further bone loss. It is administered daily by subcutaneous injection from a preloaded pen.

T scores and Z scores

•The BMD test results are compared to the ideal or peak bone mineral density of a healthy 30-year-old adult, and reported as T-scores. A T-score of 0 means the BMD is equal to the norm for a healthy young adult. Differences between the BMD and that of the healthy young adult norm are measured in units called standard deviations (SDs). The more standard deviations below 0 (indicated as negative numbers), the lower the BMD and the higher the risk of fracture. •A T-score between +1 and −1 is considered normal. •A T-score between −1 and −2.5 indicates osteopenia (bone loss that is more than normal, but not yet at the level for a diagnosis of osteoporosis). •A T-score of −2.5 or lower indicates osteoporosis. The greater the negative number, the more severe the osteoporosis •With a Z-score, a person is compared with someone his or her own age, gender, and/or ethnic group instead of a healthy 30-year-old. Among older adults, Z-scores can be misleading because decreased bone density is common. If the Z-score is -2 or lower, it may suggest that something other than aging is causing abnormal bone loss.

Drug therapy DMARDs

↓ Permanent effects of RA §Methotrexate - preferred drug §Monitor for bone marrow suppression and hepatotoxicity (with cirrhosis) §Lowers your ability to fight infections §Therapeutic effects within 4 to 6 weeks. §Side Effect nNausea, vomiting, stomach pain nDrowsiness nDizziness nTemporary hair loss§↓ Permanent effects of RA §Methotrexate - preferred drug §Monitor for bone marrow suppression and hepatotoxicity (with cirrhosis) §Lowers your ability to fight infections §Therapeutic effects within 4 to 6 weeks. §Side Effect Nausea, vomiting, stomach pain Drowsiness Dizziness Temporary hair loss

Adequate calcium intake

◦1000 mg/day for ◦women ages 19-50 years ◦Men ages 19-70 years ◦1200 mg/day for ◦Women 51 years or older ◦Men 71 years or older •Prevention and treatment of osteoporosis focuses on adequate calcium intake of 1000 mg/day in women ages 19-50 years and men ages 19-70 years; 1200 mg/day in women 51 years or older and men 71 years or older.

weight bearing exercises

◦Build up and maintain bone mass ◦Increase strength, coordination, balance ◦Walking, hiking, weight training, stair climbing, tennis, dancing Quit smoking Decrease alcohol intake •Regular physical activity is important to build up and maintain bone mass. •Exercise also increases muscle strength, coordination, and balance. •The best exercises are weight-bearing exercises that force an individual to work against gravity. •These exercises include walking, hiking, weight training, stair climbing, tennis, and dancing. •Walking is preferred to high-impact aerobics or running, both of which may put too much stress on the bones and may cause stress fractures. •Encourage patients to walk 30 minutes, 3 times a week, is recommended. •Instruct patients to quit smoking and decrease alcohol intake to minimize the negative effects on bone mass.

Supplemental calcium

◦Take in divided doses ◦Calcium carbonate ◦40% elemental calcium ◦Take with meals ◦Calcium citrate ◦20% elemental calcium ◦Less dependent on stomach acid •Calcium is difficult to absorb in single doses greater than 500 mg. Teach the patient the importance of taking calcium supplements as divided doses to increase absorption. The amount of elemental calcium varies in different calcium preparations. •Calcium carbonate has 40% elemental calcium. It should be taken with meals because stomach acid is needed to dissolve and absorb this supplement. •Calcium citrate offers about 20% elemental calcium but is less dependent on stomach acid for absorption. It is also better absorbed by patients taking a proton-pump inhibitor (e.g., esomeprazole [Nexium]) or histamine receptor blocker (e.g., cimetidine [Tagamet]) for acid reflux. •Calcium lactate and calcium gluconate are not recommended because they have small amounts of elemental calcium.