MF Exam 1

What is the difference between dementia and delirium?

Dementia: Insidious, slow, over years and often unrecognized until deficits obvious. Is a stable condition Delirium: Sudden, abrupt, and fluctuating, often worse at night

What are some questions we should ask to indicate driving risk?

Directions If you answer "yes" to one or more of the following questions, you may want to limit your driving or take steps to improve a problem. If you answer "yes" to most of the questions, it may be time to consider letting someone else do your driving. • Does driving make you feel nervous or physically exhausted? • Do you have difficulty seeing pedestrians, signs, and vehicles? • Do cars frequently seem to appear from nowhere? • At night, does the glare from oncoming headlights temporarily "blind" you? • Do you find intersections confusing? • Are you finding it harder to judge the distance between cars? • Do you have difficulty coordinating your hand and foot movements? • Do you have difficulty staying in a lane? • Are you slower than you used to be in reacting to dangerous situations? • Do you sometimes get lost in familiar neighborhoods? • Do other drivers often honk at you? • Have you had any tickets? • Have you been pulled over by the police? • Have you had an increased number of traffic violations, accidents, or near-accidents in the past year? • Do you have any vision problems? • Do you have any hearing problems? • Do you take any of the following medications: antihistamines, antipsychotics, tricyclic antidepressants, benzodiazepines, barbiturates, sleeping medications, muscle relaxants? • Do you have any memory impairment? • Do you have any muscle stiffness or weakness?

What is the goal of secondary prevention?

Early detection of a disease or health problem that has already developed.

How do we promote oral health?

Encourage annual dental exams, including individuals with dentures. Brush and floss twice daily; use a fluoride dentrifice and mouthwash. Ensure dentures fit well and are cleaned regularly. Maintain adequate daily fluid intake (1500 mL). Avoid tobacco. Limit alcohol. Eat a well-balanced diet. Use an ultrasonic toothbrush (more effective in removing plaque). Use a commercial floss handle for easier flossing. Adapt toothbrush if manual dexterity impaired. Use a child's toothbrush or enlarge the handle of an adult-sized toothbrush by adding a foam grip or wrapping it with gauze or rubber bands to increase handle size. If medications cause a dry mouth, ask your health care provider if there are other drugs that can be substituted. If dry mouth cannot be avoided, drink plenty of water, chew sugarless gum, avoid alcohol and tobacco.

How do we promote ongoing management of oral intake?

1. Calculate a daily fluid goal. • All older adults should have an individualized fluid goal determined by a documented standard for daily fluid intake. At least 1500 mL of fluid/day should be provided. 2. Compare current intake to fluid goal to evaluate hydration status. 3. Provide fluids consistently throughout the day. • Provide 75% to 80% of fluids at mealtimes and the remainder during non-mealtimes such as medication times. • Offer a variety of fluids and fluids that the person prefers. • Standardize the amount of fluid that is offered with medication administration (e.g., at least 6 oz). 4. Plan for at-risk individuals. • Have fluid rounds midmorning and midafternoon. • Provide two 8-oz glasses of fluid in the morning and evening. • Offer a "happy hour" or "tea time," when residents can gather for additional fluids and socialization. • Provide modified fluid containers based on resident's abilities—for example, lighter cups and glasses, weighted cups and glasses, plastic water bottles with straws (attach to wheelchairs, deliver with meals). • Make fluids accessible at all times and be sure residents can access them—for example, filled water pitchers, fluid stations, or beverage carts in congregate areas. • Allow adequate time and staff for eating or feeding. Meals can provide two-thirds of daily fluids. • Encourage family members to participate in feeding and offering fluids. 5. Perform fluid regulation and documentation. • Teach individuals, if possible, to use a urine color chart to monitor hydration status. • Document complete intake including hydration habits. • Know volumes of fluid containers to accurately calculate fluid consumption. • Frequency of documentation of fluid intake will vary among settings and is dependent on the individual's condition. In most settings, at least one accurate intake and output recording should be documented, including amount of fluid consumed, difficulties with consumption, and urine specific gravity and color. • For individuals who are not continent, teach caregivers to observe incontinent pads or briefs for amount and frequency of urine, color changes, and odor, and report variations from individual's normal pattern.

How do we screen for dehydration?

Acronym: DEHYDRATIONS Drugs (e.g., diuretics) End of life High fever Yellow urine turns dark Dizziness (orthostasis) Reduced oral intake Axilla dry Tachycardia Incontinence (fear of) Oral problems/sippers Neurological impairment (confusion) Sunken eyes

What are the medications from the Beers' criteria that are potentially inappropriate for older adults?

First-generation antihistamines Nitrofurantoin (Macrobid) Alpha1-blockers Antiarrhythmics, especially amiodarone Digoxin (no dose >0.25 mg) Nifedipine, immediate release Tricyclic antidepressants Many of the antipsychotics Barbiturates Benzodiazepines Sliding scale insulin Sulfonylureas, long duration Glyburide Demerol Non-COX-selective NSAIDs*

What are the main medications that could be affecting sleep?

Selective serotonin reuptake inhibitors (SSRIs) Antihypertensives (clonidine, beta-blockers, reserpine, methyldopa) Anticholinergics Sympathomimetic amines Diuretics Opiates Cough and cold medications Thyroid preparations Phenytoin Cortisone Levodopa

How do we intervene to help stop UI?

Use therapeutic communication skills and a positive and supportive attitude to help individuals overcome any embarrassment about UI. • Teach about the range of interventions available for management of UI. • Share helpful resources for continence management. • Share techniques found useful by others. • Collaborate with the individual to help him or her choose the most appropriate and acceptable intervention based on needs. • Assist individual to develop a detailed, realistic action plan and set goals. • Determine an evaluation plan to assess the effectiveness of interventions. • Review progress, identify any barriers to implementation, set alternative goals, or select alternate treatments if indicated. • Consider using various teaching formats: face-to-face counseling, small-group sessions, computer-based continence promotion systems, informative written materials. • Make teaching collaborative and interactive. • Reinforce effort and persistence.

What is the general background of a gerontologic nurse?

A gerontological nurse may be a generalist or a specialist. The generalist functions in a variety of settings (primary care, acute care, home care, subacute and long-term care, and the community), providing nursing care to individuals and their families. National certification as a gerontological nurse is a way to demonstrate one's special knowledge in care for older adults and should be encouraged

How can we reduce fall risk without restraints?

Assessment • Work with the interdisciplinary team; nurses cannot manage these complicated challenges alone. • Perform fall risk screening; gait, balance, and mobility assessment; and multifactorial assessment as indicated. • Individualize the patient's plan of care based on risk factors and condition. • Assess ambulation ability; refer to physical therapy for walking and/or strengthening programs. • Check for postural hypotension (orthostasis). • Use a behavior log to track when the person is trying to get up and/or when he or she seems agitated. • Assess mental status (delirium/dementia). • Assess vision and hearing. If the person wears glasses, hearing aid, or dentures, ensure that the assistive devices are worn. • Assess continence status. • Assess for pain and ensure that pain is well managed. • Involve family and all staff in fall risk-reduction education and activities. • Inform all staff of fall risk, and put fall risk and fall risk-reduction interventions on care plan. • Use identification bracelet or door sign to indicate patients at risk for falling. Use red socks with treads to identify patient at risk. Patient room • Lower the bed to the lowest level, or use a bed that is especially designed to be low to the floor. • Use a concave mattress. • Use bed boundary markers to mark the edges of the bed, such as mattress bumpers, rolled blanket, or "swimming noodles" under sheets. • If the person is (or has been married), line the spouse's side of the bed with pillows or bolsters. • Place a soft floor mat or a mattress by the bed to cushion any falls. • Use a water mattress to reduce movement to the edge of the bed. • Have the person at risk sleep on a mattress on the floor. • Remove wheels from the bed. • Clear the floor of debris or excessive furniture; make sure it is not wet or slippery. • Place nonskid strips on the floor next to the bed; ensure that floors are nonskid. • Use night lights in the bedroom and bathroom. • Place a call bell within reach, and make sure the patient can use it—attach the call bell to the patient's garment or obtain an adapted call device. • Provide visual reminders to encourage the patient to use the call bell. • Have a purse (empty or without harmful items or important papers or money) in the bed with the person, if a woman. • Ensure all personal items are within reach. • Have ambulation devices within reach, and make sure the patient knows how to use them properly. • Use bed, chair, or wrist alarms (the best alarm tells you only that there is an emergency; still need frequent checks, supervised areas). Apply a patient-worn sensor (lightweight alarm worn above the knee that is position-sensitive). • Provide a trapeze or patient assist handles (transfer bars) to enhance mobility in bed. • If the person is able, he or she should walk at every opportunity possible. If the patient walked in or could walk before hospitalization, make every effort to keep the patient walking during hospitalization. • Do frequent bed checks, especially during the evening and at night. • Be especially alert for falls at change-of-shift times. • Understand that very few people spend all day in bed; activity is necessary. • Provide diversional activities (catalogues, puzzles, therapeutic activity kit) (http://consultgerirn.org/uploads/File/trythis/try_this_d4.pdf). • Know sleeping patterns—if the person is usually up during the night, get him or her up in a chair and keep at nursing station or involve in activities. Bathroom • Establish toileting plan, and take the person to the bathroom frequently. • Have the person use a bedside commode. • Make sure the person knows the location of the bathroom—leave the door open so that he or she can see the toilet, or put a picture of a toilet on the door; clear the path to the bathroom. • Provide grab bars in the bathroom and shower; provide a shower chair with suction bottom. • Provide an elevated toilet seat. • Have the person wear clothing that is easy to pull down for toileting. On the unit • Assess for environmental hazards. • Keep the person in a supervised area or room within view of the nursing station. • Have the person sit in a reclining chair, chair with a deep seat, bean bag chair, rocker—keep close to nurses' station in the chair. • Consider occupational therapy evaluation for seating devices. • Provide a supervised area and meaningful activities. • If the person is wandering or trying to exit, create a grid with masking tape on the floor in front of the doorway, use a black half-rug, and camouflage exit doors with wallpaper or window treatments. These adaptations may cause the person to stop before going out the door. • Provide hip protectors, helmets, and arm pads for high-risk individuals.

What are the main hearing changes related to aging

-Cochlear hair cell degeneration - inability to hear high frequency sounds -Degeneration of basilar (Cochlear) conductive membrane of cochlea - inability to hear at all frequencies; more pronounced at higher frequencies. -Decreased vascularity of the cochlea - Equal loss of hearing at all frequencies; inability to localize sounds -How to take care of hearing aids

What are the tips for practice of cane and walker use?

*Cane use* • Place your cane firmly on the ground before you take a step, and do not place it too far ahead of you. Put all of your weight on your unaffected leg, and then move the cane and your affected leg at a comfortable distance forward. With your weight supported on both the cane and your affected leg, step through with your unaffected leg. • Always wear low-heeled, nonskid shoes. It is best to have the person wear the kind of shoes he or she is accustomed to wearing, and consideration should be given to properly fit orthotic shoes as appropriate. • When using a cane on stairs, step up with the unaffected leg and down with the affected leg. Use the cane as support when lifting the affected leg. Bring the cane up to the step just reached before climbing another step. When descending, place the cane on the next step down, move the affected leg down, and then move the unaffected leg down. • Every assistive device must be adjusted to individual height; the top of the cane should align with the crease of the wrist. • Choose a size and shape of cane handle that fits comfortably in the palm; like a tight shoe, it will be a constant irritant if it is not properly fitted. • Cane tips are most secure when they are flat at the bottom and have a series of rings. Replace tips frequently because they wear out, and a worn tip is insecure. *Walker use:* • When using a walker, stand upright and lift or roll the walker with both hands a step's length ahead of you. Lean slightly forward, and hold the arms of the walker for support. Step toward it with the affected leg and then bring the unaffected leg forward. • Do not climb stairs with a walker.

What is the CAM assessment? What are the points?

*It is a standardized way to assess mental status.* Feature 1: Acute onset or fluctuating course Feature 2: Inattention. Feature 3: Disorganized thinking. Feature 4: Altered level of consciousness.

What is the prompted voiding protocol?

1. Contact resident every 2 hours from 8 am to 9 pm (or the resident's usual bedtime). 2. Focus attention on voiding by asking if the resident is wet or dry. 3. Ask a second time if the resident does not respond. 4. Check clothes and bedding to determine if wet or dry. Give feedback on whether response was correct or incorrect. 5. Whether wet or dry, ask if the resident would like to use toilet or urinal. If the resident says YES: Offer assistance. Record results on bladder record. Praise for appropriate toileting. If the resident says NO: Repeat the question once or twice. If wet and declines to use the toilet, change him or her. Inform the resident you will be back in 2 hours and request that the resident try to delay voiding until then. If there has been no attempt to void in the past 2 to 3 hours, repeat the request to use the toilet at least twice more before leaving. 1. Offer fluids. 2. For nighttime management, use either modified prompted voiding schedule, toilet when awake, or use padding, depending on individual's sleep pattern and preferences. 3. If the individual who has been responding well has an increase in incontinence frequency despite adequate staff implementation of the protocol, further evaluation for reversible factors is indicated.

What are the provisions of oral care?

1. Explain all actions to the individual; use gestures and demonstration as needed; cue and prompt to encourage as much self-care performance as possible. 2. If the individual is in bed, elevate his or her head by raising the bed or propping it with pillows, and have the individual turn his or her head to face you. Place a clean towel across the chest and under the chin, and place a basin under the chin. 3. If the individual is sitting in a stationary chair or wheelchair, stand behind the individual and stabilize his or her head by placing one hand under the chin and resting the head against your body. Place a towel across the chest and over the shoulders. 4. The basin can be kept handy in the individual's lap or on a table placed in front of or at the side of the patient. A wheelchair may be positioned in front of the sink. 5. If the individual's lips are dry or cracked, apply a light coating of petroleum jelly or use lip balm. 6. Inspect the oral cavity to identify teeth in ill repair, pain, lesions, or inflammation. 7. Brush and floss the individual's teeth (use an electric toothbrush if possible, with sulcular brushing). It may be helpful to retract the lips and cheek with a tongue blade or fingers in order to see the area that is being cleaned. Use a mouth prop as needed if the individual cannot hold his or her mouth open. If manual flossing is too difficult, use a floss holder or interproximal brush to clean the proximal surfaces between the teeth. Use a dentifrice containing fluoride. 8. Provide the conscious individual with fluoride rinses or other rinses as indicated by the dentist or hygienist

What are the 10 leading causes of noncommunicable causes of death in order from most to least prevalent?

1. Ischemic heart disease 2. Stroke 3. COPD 4. Lower respiratory infections 5. Trachea, bronchus, lung cancers 6. HIV/AIDS 7. Diarrheal disease 8. DM 9. Road injury 10. HTNsive heart disease

What should we teach about sleep medications?

1. Normal changes in sleep patterns with age 2. Importance of appropriate assessment of sleep problems before any medications are used 3. Nonpharmacological treatment of sleeping problems as first-line treatment (sleep hygiene, stimulus control, sleep restriction, relaxation techniques) 4. Avoiding OTC medications that contain diphenhydramine, which can have side effects of confusion, blurred vision, constipation, falls 5. Adverse effects of sleep medications, even OTC medications; include problems with daily function, changes in mental status, possibility of motor vehicle accidents, increase in daytime drowsiness, and increased risk of falls with only minimal improvement in sleep 6. Avoiding benzodiazepines (flurazepam, triazolam, temazepam) for sleep due to long-acting sedation effects 7. If sleeping medications are prescribed, the benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon) or ramelteon is preferred; given at the lowest possible dose for short-term use only (2-3 weeks, never longer than 90 days). Medications for sleep should be taken immediately before bedtime 8. Avoiding the use of alcohol, narcotic pain relieving medications, and antianxiety medications if taking sleeping medications 9. Reviewing all medications, including OTC, with health care provider for interactions with sleeping medications 10. Using caution the day after taking sleeping medications, particularly with driving and activities that require full alertness; accidents are common

What is the bowel training program?

1. Obtain a bowel history and establish a schedule for the bowel training program that is normal and comfortable for the patient and conforms to his or her lifestyle. 2. Ensure adequate fiber and fluid intake (normalize stool consistency). a. Fiber i. Add high-fiber foods to diet (dried fruit, dried beans, vegetables, and wheat products). ii. Suggest adding one to three tablespoons of bran or Metamucil to the diet once or twice each day. (Titrate dosage on the basis of response.) b. Fluid i. Consume 2 to 3 liters daily (unless contraindicated). ii. Four ounces of prune, fig, or pear juice (or a warm fluid) may be given daily as a stimulus (e.g., 30 to 60 min before the established time for defecation). 3. Encourage an exercise program. a. Pelvic tilt, modified sit-ups for abdominal strength b. Walking for general muscle tone and cardiovascular system c. More vigorous program if appropriate 4. Establish a regular time for the bowel movement. a. Established time depends on patient's schedule. b. Best times are 20 to 40 minutes after regularly scheduled meals, when the gastrocolic reflex is active. c. Attempts at evacuation should be made daily within 15 minutes of the established time and whenever the patient senses rectal distention. d. Instruct patient about normal posture for defecation. (The patient normally sits on the toilet or bedside commode; for the patient who is unable to get out of bed, the left side-lying position is best.) e. Instruct the patient to contract the abdominal muscles and "bear down." f. Have the patient lean forward to increase the intraabdominal pressure by use of compression against the thighs. g. Stimulate the anorectal reflex and rectal emptying if necessary. 5. Insert a rectal suppository or mini-enema into the rectum 15 to 30 minutes before the scheduled bowel movement, placing the suppository against the bowel wall, or insert a gloved, lubricated finger into the anal canal and gently dilate the anal sphincter.

How do you care for dentures?

1. Remove dentures or ask individual to remove dentures. Observe ability to remove dentures. 2. Inspect oral cavity. 3. Rinse denture or dentures after each meal to remove soft debris. Do not use toothpaste on dentures because it abrades denture surfaces. 4. Once each day, preferably before retiring, remove denture and brush thoroughly. a. Although an ordinary soft toothbrush is adequate, a specially designed denture brush may clean more effectively. (Caution: Acrylic denture material is softer than natural teeth and may be damaged by being brushed with very firm bristles.) b. Brush denture over a sink lined with a facecloth and half-filled with water. This will prevent breakage if the denture is dropped. c. Hold the denture securely in one hand, but do not squeeze. Hold the brush in the other hand. It is not essential to use a denture paste, particularly if dentures are soaked before being brushed to soften debris. Never use a commercial tooth powder because it is abrasive and may damage the denture materials. Plain water, mild soap, or sodium bicarbonate may be used. d. When cleaning a removable partial denture, great care must be taken to remove plaque from the curved metal clasps that hook around the teeth. This can be done with a regular toothbrush or with a specially designed clasp brush. 5. After brushing, rinse denture thoroughly; then place it in a denture-cleaning solution and allow it to soak overnight or for at least a few hours. (NOTE: Acrylic denture material must be kept wet at all times to prevent cracking or warping.) In the morning, remove denture from the cleaning solution and rinse it thoroughly before inserting it into the mouth. Use denture paste if necessary to secure dentures. 6. Dentures should be worn constantly except at night (to allow relief of compression on the gums) and replaced in the mouth in the morning.

What is the learn model?

A negotiated plan of care and includes the identification of the availability of culturally appropriate and sensitive community resources L Listen carefully to what the person is saying. Attend not just to the words but to the nonverbal communication and the meaning behind them. Listen to the perception of the person's situation, desired goals, and ideas for treatment. E Explain your perception of the situation and the problems. A Acknowledge and discuss both the similarities and the differences between your perceptions and goals and those of the elder and their significant other/decision-makers as appropriate. R Recommend a plan of action that takes both perspectives into account. N Negotiate a plan that is mutually acceptable and possible.

*How do we prevent a CAUTI using the ABCDE approach?*

Adherence to general infection control principles (hand hygiene, surveillance, aseptic catheter insertion, proper maintenance of a sterile, closed, unobstructed drainage system, and education) Bladder ultrasound may aid indwelling catheterization Condom catheters or other alternatives to an indwelling catheter such as intermittent catheterization should be considered in appropriate patients Do not use the indwelling catheter unless you must. Do not use antimicrobial catheters. Do not irrigate catheters unless obstruction is anticipated (e.g., as might occur with bleeding after prostatic or bladder surgery). Do not clean the periurethral area with antiseptics (cleansing of the meatal surface during daily bathing or showering is appropriate) Early removal of the catheter using a reminder or nurse-initiated removal protocol

What do we ask to assess sleep disturbances?

Basic Sleep History Questions • Where do you sleep at night (bed, couch, recliner chair)? • Do you have any difficulty falling asleep? • What do you do at night before you go to bed? • Are you having any difficulty sleeping until morning? • Are you having difficulty sleeping throughout the night? • How often do you awaken and how long are you awake? What prevents you from falling back to sleep? • Have you or someone else ever noticed that you snore loudly or stop breathing in your sleep? • Do you find yourself falling asleep during the day when you do not want to? Follow-Up Questions • What time do you usually go to bed? Fall asleep? • What prevents you from falling asleep? • Do your legs kick or jump around while you sleep? • Are you outside in natural light most days? • Do you have any pain, discomfort, or shortness of breath during the night? • What type of exercise do you get during the day? • Individual's bed partner, family member, or caregiver can also be asked to provide information Review intake of alcohol, nicotine, caffeine, and medications Review risk factors (obesity, arthritis, poorly controlled illnesses) Review of depressive symptoms; weight loss; sadness, or recent losses Review involvement in social activities Review functional status/ADL/IADL performance Objective Measures • Sleep diary (keep for 24 hours daily for 2 to 4 weeks) • Self-rating of sleep scales—Pittsburgh Sleep Quality Index; Epworth Sleepiness Scale; Insomnia Severity Scale • On a scale of 1 to 10 (10 the highest), how would you rate your sleep?

What are the guidelines to working with interpreters?

Before an interview or session with a client, meet with the interpreter to: • Explain the purpose of the session. • Instruct the interpreter to use the person's own words and avoid paraphrasing. • Instruct the interpreter to avoid inserting his or her own ideas or omitting any information. • Look and speak directly to the client, not the interpreter. • Be patient. Interpreted interviews take more time because of the need for three-way communication. • Use short units of speech. Long, involved sentences or complex discussions create confusion. • Use simple language. Avoid technical terms, professional jargon, slang, abbreviations, abstractions, metaphors, and idiomatic expressions. • Listen to the client and watch nonverbal communication (facial expression, voice intonation, body movement) to learn about emotions regarding a specific topic. • Clarify the client's understanding and the accuracy of the interpretation by asking the client to tell you in his or her own words what he or she understands, facilitated by the interpreter.

What is the protocol for cerumen removal?

Before cerumen removal • Ask the patient if he or she has ever had a problem with his or her eardrum and is currently having ear pain or drainage. If so, refer the person to an otolaryngologist for care. • Using an otoscope, gently insert it into the ear canal while pulling up on the auricle; while doing so, examine the canal for trauma and the presence of excess cerumen or a cerumen impaction (when the TM is not visible or only partial visible). Cerumen removal procedure* 1. If the cerumen is somewhat dry and close to the canal opening, it may be easily removed with the use of a curette† specially designed for this purpose. Gently scoop the cerumen and bring it forward, being careful to avoid scratching the canal. 2. Once the cerumen is slightly extended from the canal, it can be removed easily with the use of forceps† or clamps. 3. Reexamine the canal for remaining cerumen. 4. If the cerumen is hard and cannot be removed easily, it may be necessary to soften it before further removal. Softening agents may be instilled into the ear before the removal attempt using mineral or olive oil, commercial products, or a liquid stool softener twice daily for 1 to 2 days. 5. Alternatively, hydrogen peroxide may be instilled and allowed to soften the wax several minutes before the removal is attempted. The patient will tell you when the "bubbling has stopped." 6. If it is still not possible to remove the wax safely using the curette, a water flush may be effective. a. Protect clothing and linens with a water-proof material. b. Follow the directions on a commercial ear irrigating product. This usually involves pumping a small amount of water into the canal through a small short cannula, at which time the water returns into a collection cup with dissolved cerumen (hopefully). c. Before the flush, test the water temperature by pumping a few drops on the external ear. The acceptable temperature for the irrigation is highly individual. d. Check the canal frequently for effectiveness and check with the patient for tolerability. e. During the irrigation, the cerumen will either be returned with the water or brought closer to the surface so that it can be removed with the curette (see procedure 1). f. Any time the patient expresses nausea or dizziness, stop immediately and refer to an otolaryngologist for further treatment.

What should we teach about fiber?

Benefits of fiber • Facilitates absorption of water; helps control weight by delaying gastric emptying and providing feeling of fullness; improves glucose tolerance; prevents or reduces constipation, hemorrhoids, diverticulosis; reduces risk of heart disease; protects against cancer Diet tips to add fiber • Best to get fiber from food rather than supplements because they do not contain essential nutrients found in high-fiber foods and anticancer benefits are questionable; the more refined or processed the food becomes, the lower the fiber content (e.g., apple with peel higher fiber than applesauce or juice) • Increase consumption of fresh fruits and vegetables; eat dry beans, peas, and lentils; leave skin on fruits and vegetables; eat whole fruit rather than drink juice; eat whole-grain breads and cereals; add finely chopped veggies to pasta sauce, soups, and casseroles; add a cup of spinach or other leafy greens to a smoothie (you will not taste the spinach at all but your drink will be green); sprinkle unsweetened bran on cereals or put in soups, meat loaf, or casseroles • Some foods naturally high in fiber: large pear with skin (7 g); 1 cup fresh raspberries (8 g); 1⁄2 medium avocado (5 g); 1 oz almonds (3.5 g); 1⁄4 cup cooked black beans (7.5 g); 3 cups air-popped popcorn (3.6 g); 1 cup cooked pearled barley (6 g) How much bran? • Generally 1-2 tablespoons daily; begin with 1 teaspoon and increase gradually to avoid bloating, gas, diarrhea, other colon discomforts How much fluid? • 64 oz daily unless fluid restriction

How do we teach a patient to use a cane and walker?

Cane use • Place your cane firmly on the ground before you take a step, and do not place it too far ahead of you. Put all of your weight on your unaffected leg, and then move the cane and your affected leg at a comfortable distance forward. With your weight supported on both the cane and your affected leg, step through with your unaffected leg. • Always wear low-heeled, nonskid shoes. It is best to have the person wear the kind of shoes he or she is accustomed to wearing, and consideration should be given to properly fit orthotic shoes as appropriate. • When using a cane on stairs, step up with the unaffected leg and down with the affected leg. Use the cane as support when lifting the affected leg. Bring the cane up to the step just reached before climbing another step. When descending, place the cane on the next step down, move the affected leg down, and then move the unaffected leg down. • Every assistive device must be adjusted to individual height; the top of the cane should align with the crease of the wrist. • Choose a size and shape of cane handle that fits comfortably in the palm; like a tight shoe, it will be a constant irritant if it is not properly fitted. • Cane tips are most secure when they are flat at the bottom and have a series of rings. Replace tips frequently because they wear out, and a worn tip is insecure. Walker use • When using a walker, stand upright and lift or roll the walker with both hands a step's length ahead of you. Lean slightly forward, and hold the arms of the walker for support. Step toward it with the affected leg and then bring the unaffected leg forward. • Do not climb stairs with a walker.

What is proper pressure ulcer treatment/maintenance?

Debride Identify and treat infection Pack dead space lightly Absorb excess exudate Maintain moist wound surface Open or excise closed wound edges Protect healing wound from infection/trauma Insulate to maintain normal temperature

How do we teach patients to care for their feet?

Comprehensive annual foot examination for all persons with diabetes mellitus (DM) including identification of risk factors for ulcers and amputations, test for loss of protective sensation, assessment of pedal pulses • Care of toenails: Trimmed after bath or shower when softened or soak 20 to 30 minutes before cutting • Clip straight across and even with top of toe, edges filed slightly to remove sharpness but not to the point of rounding (Figure 19-3) • Diabetic foot care done only by podiatrist or RN with expertise; persons with DM or PVD should not have pedicures from commercial establishments • Ingrown toenails are a fragment of nail that pierces the skin at the edge of the nail; may be due to hypertrophy of the nail with onychomycosis, improper cutting, pressure on toes from tight hosiery or shoes. Should be treated by podiatrist due to risk of infection. Temporary relief can be provided by inserting a small piece of cotton under affected nail corner • Counsel individual about proper footwear. Shoes should cover, protect, and stabilize the foot and provide maximal toe space. Feet increase in size with age and one foot is usually larger than the other. Shoes should be fitted to the largest foot and purchased in the afternoon when feet may be larger. Velcro closures are helpful for those with limited finger dexterity. Closed back shoes of low heel height and high surface contact may reduce risk of falls. Rubber-soled shoe such as sneakers may increase risk of stumbling while walking and may promote too much "sway" and affect balance if person not accustomed to shoes of this kind • Orthotic and orthopedic shoes may be indicated for certain foot problems. Medicare Part B covers one pair of therapeutic shoes and inserts as durable medical equipment (DME) for individuals with DM

What are the fall risk factors for elder adults?

Conditions (intrinsic) Sedative and alcohol use, psychoactive medications, opioids, diuretics, anticholinergics, antidepressants, antihypertensives, anticoagulants, bowel preparations Four or more medications Unrelieved pain Previous falls and fractures Female, 80 years of age or older Acute and recent illness; recent hospitalization Cognitive impairment (delirium, dementia) Chronic pain Dehydration Weakness of lower extremities Abnormalities of gait and balance Unsteadiness, dizziness, syncope Foot problems Depression, anxiety Decreased vision or hearing Wearing multifocal glasses while walking Fear of falling Orthostatic hypotension Postprandial drop in blood pressure Sleep disorders Anemia Vitamin D deficiency Osteoporosis Chronic conditions including arthritis, diabetes, stroke, Parkinson's disease Functional limitations in self-care activities Inability to rise from a chair without using the arms Slow walking speed Wheelchair-bound Situations (extrinsic) Urinary incontinence, urgency, nocturia Environmental hazards Recent relocation, unfamiliarity with new environment Inadequate response to transfer and toileting needs Improper use of assistive devices Inadequate or missing safety rails, particularly in bathroom Poorly designed or unstable furniture High chairs and beds Slippery or uneven surfaces Glossy, highly waxed floors Wet, greasy, icy surfaces Inadequate visual support (glare, low wattage bulbs, lack of nightlights) General clutter Inappropriate footwear/clothing Pets that inadvertently trip an individual Electrical cords Loose or uneven stair treads Throw rugs Reaching for a high shelf Inability to reach personal items, lack of access to call bell or inability to use it Side rails, restraints Lack of staff training in fall risk-reduction techniques

What should we assess a patient for after a fall?

History • Description of the fall from the individual or witness • Individual's opinion of the cause of the fall • Circumstances of the fall (trip or slip) • Person's activity at the time of the fall • Presence of comorbid conditions, such as a previous stroke, Parkinson's disease, osteoporosis, seizure disorder, sensory deficit, joint abnormalities, depression, cardiac disease • Medication review • Associated symptoms, such as chest pain, palpitations, light-headedness, vertigo, loss of balance, fainting, weakness, confusion, incontinence, or dyspnea • Time of day and location of the fall • Presence of acute illness Physical examination • Vital signs: postural blood pressure changes, fever, or hypothermia • Head and neck: visual impairment, hearing impairment, nystagmus, bruit • Heart: arrhythmia or valvular dysfunction • Neurological signs: altered mental status, focal deficits, peripheral neuropathy, muscle weakness, rigidity or tremor, impaired balance • Musculoskeletal signs: arthritic changes, range of motion (ROM), podiatric deformities or problems, swelling, redness or bruises, abrasions, pain on movement, shortening and external rotation of lower extremities Functional assessment • Functional gait and balance: observe resident rising from chair, walking, turning, and sitting down • Balance test, mobility, use of assistive devices or personal assistance, extent of ambulation, restraint use, prosthetic equipment • Activities of daily living: bathing, dressing, transferring, toileting Environmental assessment • Staffing patterns, unsafe practice in transferring, delay in response to call light • Faulty equipment • Use of bed, chair alarm • Call light within reach • Wheelchair, bed locked • Adequate supervision • Clutter, walking paths not clear • Dim lighting • Glare • Uneven flooring • Wet, slippery floors • Poorly fitted seating devices • Inappropriate footwear • Inappropriate eyewear

What are the ways to prevent pressure ulcers?

I. Risk assessment 1. Consider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers. 2. Use a valid, reliable, and age-appropriate method of risk assessment that ensures systematic evaluation of individual risk factors. 3. Assess on admission to the patient care setting, at regular intervals thereafter, and with any change in condition. 4. Inspect skin regularly for color changes such as redness in lightly pigmented persons and discoloration in darkly pigmented persons. 5. Assess surgical patients for increased risk of pressure ulcers including the following factors: length of operation, number of hypotensive episodes, and/or low-core temperatures intraoperatively, reduced mobility on first postoperative day. 6. Look at the skin under any medical devices. 7. Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device-related pressure, friction, shear, immobility, inactivity, nutritional deficits, tissue tolerance) to guide specific preventive treatments. Modify care according to individual factors. 8. Document risk assessment subscale scores and total scores and implement a risk-based prevention plan. II. Skin care 1. Perform a head-to-toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium, trochanters, heels, elbows, and back of the head. 2. Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water and excessive rubbing. Use lotion after bathing. 3. Establish a bowel and bladder program for the patient with incontinence. When incontinence cannot be controlled, cleanse skin at time of soiling, and use a topical barrier to protect the skin. Select underpads or briefs that are absorbent and provide quick-drying action. 4. Use moisturizers for dry skin. Minimize factors leading to dry skin such as low humidity and cold air. 5. Avoid massage over bony prominences. 6. Protect high-risk areas such as elbows, heels, sacrum, and back of head from friction injury. III. Nutrition 1. Identify and correct factors compromising protein/calorie intake consistent with overall goals of care. 2. Consider nutritional supplementation/support for nutritionally compromised persons consistent with overall goals of care. 3. If appropriate, offer a glass of water when turning to keep patient hydrated. 4. Administer multivitamin with minerals per provider order. IV. Mechanical loading and support surfaces 1. Reposition bed-bound persons at least every 2 hours and chair-bound persons every 4 hours consistent with overall goals of care. Follow repositioning guidelines when person is on pressure-redistributing mattress. 2. Consider postural alignment; distribution of weight, balance, and stability; and pressure redistribution when positioning persons in chairs and wheelchairs. Evaluate fit of the wheelchair. 3. Teach chair-bound persons, who are able, to shift weight every 15 minutes. 4. Use a written repositioning schedule. 5. Place at-risk person on pressure-redistributing mattress and chair cushion surfaces. 6. Avoid using donut-type devices and sheepskin for pressure redistribution. 7. Use pressure-redistributing devices in the operating room for individuals assessed to be at high risk for pressure ulcer development. 8. Use lifting devices (e.g., trapeze or bed linens) to move persons rather than drag them during transfers and position changes. 9. Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other. Pad skin subjected to device-related pressure and inspect regularly. 10. Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under calf to raise heel off the bed. Place heel suspension boots for long-term use. 11. Avoid positioning directly on the trochanter when using side-lying position; use the 30-degree lateral inclined position. 12. Maintain the head of the bed at or less than 30 degrees or at the lowest degree of elevation consistent with the person's medical condition. 13. Intitute a rehabilitation program to maintain or improve mobility/activity status. V. Education 1. Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers. 2. Include information on: a. Etiology of and risk factors for pressure ulcers b. Risk assessment tools and their application c. Skin assessment d. Nutritional support e. Program for bowel and bladder management f. Development and implementation of individualized programs of skin care g. Demonstration of positioning to decrease risk of tissue breakdown h. Accurate documentation of pertinent data 3. Include mechanisms to evaluate program effectiveness in preventing pressure ulcers.

What are some ways to bring about driving cessation?

IMPOSED TYPE Report person to division of motor vehicles for possible license suspension Use of deception or threats such as false keys, disabling the car, saying car was stolen Attempts to order or control, such as provider writing a prescription, commands from children to stop driving INVOLVED TYPE All family members and individual meet, discuss the situation, and come to a mutual agreement of the problem Dialogue is ongoing from the earliest signs of cognitive impairment about the eventuality of the need to stop driving Arrangements are made for alternative transportation plans that are available when needed and acceptable to the individual

What are some of the examples asked on the Modified Caregiver Strain Index?

If the caregiver... -Has disturbed sleep -Feels caregiving is inconvenient -is a physical strain -is confining -There have been family adjustments -Changes in personal plans -There have been other demands on (their) time -There have been emotional adjustments -Some behavior is upsetting -It is upsetting to find the person I care for has changed so much from his/her former self -there have been work adjustments -Financial strain -I feel completely overwhelmed

How do we improve nutritional intake in long term care?

Improving Nutritional Intake in Long-Term Care • Assess nutritional and oral health status. • Assess ability to eat and amount of assistance needed. • Serve meals with the person in a chair rather than in bed when possible. • Provide analgesics and antiemetics on a schedule that provides comfort at mealtime. • Determine food preferences; provide for choices in food; include foods appropriate to cultural and religious customs. • Consider buffet-style dining, use of steam tables rather than meal delivery service from trays, café or bistro type dining. • Make food available 24 hours/day—provide snacks between meals and at night. • Do not interrupt meals to administer medication if possible. • Limit staff breaks to before and after mealtimes to ensure adequate staff are available to assist with meals. • Walk around the dining area or the rooms at mealtime to determine if food is being eaten or if assistance is needed. • Encourage family members to share the mealtimes for a heightened social situation. • If caloric supplements are used, offer them between meals or with the medication pass. • Recommend an exercise program that may increase appetite. • Ensure proper fit of dentures and denture use. • Provide oral hygiene, and allow the person to wash his or her hands before meals. • Have the person wear his or her glasses during meals. • Sit while feeding the person who needs assistance, use touch, and carry on a social conversation. • Provide soft music during the meal. • Use small, round tables seating six to eight people. Consider using tablecloths and centerpieces. • Seat people with like interests and abilities together, and encourage socialization. • Involve in restorative dining programs. • Make diets as liberal as possible depending on health status, especially for frail elders who are not consuming adequate amounts of food. • Consider a referral to occupational therapist for individuals experiencing difficulties with eating.

What are some helpful strategies we should use when teaching a patient about safe driving?

Include the person in all discussions about driving safety. • Encourage the individual to conduct a self-assessment of driving abilities. • Assess vision and hearing and ensure appropriate use of corrective lenses and hearing devices. • Evaluate medical conditions that may interfere with driving ability (arthritis, Parkinson's disease, dementia, stroke) and ensure appropriate treatment, as well as adaptations that may be necessary to enhance driving safety. • Discuss the impact of medical conditions and sensory impairments on driving safety. • Suggest vehicle adaptations and elder driving assessment programs if indicated. • Encourage the individual to modify driving habits, such as not driving on unfamiliar roads, during rush hour, at dusk or at night, in inclement weather, or in heavy traffic. • Discuss strategies to decrease the need to drive including arranging for home-delivered groceries, prescriptions, and meals; having personal services provided in the home; asking a caregiver to obtain needed supplies or act as a copilot; and exploring community resources for transportation. • If the individual has driving safety risk factors and should not be driving, ask the individual's health care provider to "prescribe" driving cessation. This may be better received than reporting the individual to the DMV. • Ask the family to have the family lawyer discuss with the individual the financial and legal implications of a crash or injury.

What are the Top 10 foods to avoid when taking warfarin?

Kale Spinach Collards Swiss chard Mustard greens Turnip greens Parsley Broccoli Brussels sprouts

What are some common myths about aging and the brain?

MYTH: People lose brain cells every day and eventually just run out. FACT: Most areas of the brain do not lose brain cells. Although you may lose some nerve connections, it can be part of the reshaping of the brain that comes with experience. MYTH: You cannot change your brain. FACT: The brain is constantly changing in response to experiences and learning, and it retains this "plasticity" well into aging. Changing our way of thinking causes corresponding changes in the brain systems involved; that is, your brain believes what you tell it. MYTH: The brain does not make new brain cells. FACT: Certain areas of the brain, including the hippocampus (where new memories are created) and the olfactory bulb (scent-processing center), regularly generate new brain cells. MYTH: Memory decline is inevitable as we age. FACT: Many people reach old age and have no memory problems. Participation in physical exercise, stimulating mental activity, socialization, healthy diet, and stress management helps maintain brain health. The incidence of dementia does increase with age, but when there are changes in memory, older people need to be evaluated for possible causes and receive treatment. MYTH: There is no point in trying to teach older adults anything because "you can't teach an old dog new tricks." FACT: Basic intelligence remains unchanged with age, and older adults should be provided with opportunities for continued learning. Minimizing barriers to learning such as hearing and vision loss and applying principles of geragogy enhance learning ability.

What are the common myths and facts about peg tubes in advanced dementia and end-of-life care?

Myths • PEGs prevent death from inadequate intake. • PEGs reduce aspiration pneumonia. • PEGs improve albumin levels and nutritional status. • PEGs assist in healing pressure ulcers. • PEGs provide enhanced comfort for people at the end of life. • Not feeding people is a form of euthanasia, and we cannot let people starve to death. Facts • PEGs do not improve quality of life. • PEGs do not reduce risk of aspiration and increase the rate of pneumonia development. In one study, the use of feeding tubes was associated with an increased risk of pressure ulcers among nursing home residents with advanced cognitive impairment (Teno et al., 2012). • PEGs do not prolong survival in dementia. • Nearly 50% of patients die within 6 months following PEG tube insertion. • PEGs cause increased discomfort from both the tube presence and the use of restraints. • PEGs are associated with infections, gastrointestinal symptoms, and abscesses. • PEG tube feeding deprives people of the taste of food and contact with caregivers during feeding. • PEGs are popular because they are convenient and labor beneficial.

What are the exercise guidelines for older adults?

Older adults need at least: • 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (e.g., brisk walking, swimming, bicycling) every week and • Muscle-strengthening activities on 2 or more days that work all major muscle groups (legs, hips, abdomen, chest, shoulders, and arms) Additionally: Stretching (flexibility) and balance exercises (particularly for older people at risk of falls) are also recommended. Yoga and tai chi exercises have been shown to be of benefit to older people in terms of improving flexibility and balance, as well as reducing pain and enhancing psychological well-being (Miller and Taylor-Piliae, 2014). Tai chi can be adapted for level of function and mobility status. Home-based balance-training exercise programs are also available.

Why may older people be reluctant to disclose information?

Older people may be reluctant to disclose information for fear of the consequences. For example, if they are having problems remembering things or are experiencing frequent falls, sharing this information may mean that they might have to relinquish desired activities or even leave their home and move to a more protective setting.

How is the Katz index used?

On the Katz index the ADLs are considered only in dichotomous terms: the ability to complete the task independently (1 point) or the complete inability to do so (0 points).

Who are "those in-between"?

People between those referred to as the baby boomers and the centenarians; they are the 69- to 99-year-olds

How do you prevent and treat skin tears?

Prevention • Identify high-risk individuals: impaired activity, mobility, sensation, cognition. Patients who are dependent are at greatest risk. Top causes of skin tears are equipment injury, patient transfers, activities of daily living, and treatment and dressing removal. • Have individual wear long sleeves or pants to protect extremities. • Provide a safe environment (adequate lighting, uncluttered rooms). • Ensure adequate hydration and nutrition; provide a nutritional consultation. • Lubricate skin with hypoallergenic moisturizer twice daily; apply to damp skin after bathing. • Perform careful transfers; use a lift sheet to move and turn patients. • Pad bed rails, wheelchair arms, leg supports, and furniture edges. • Support dangling arms and legs with pillows/blankets. • Avoid use of adhesive products. Use nonadherent dressings and paper tape only as needed. • Use gauze wrap, stockinettes, flexible netting, or other wraps to secure dressings. • Use no-rinse, soapless bathing products and warm/tepid water for bathing. • Caregivers need to keep nails short and not wear jewelry that can catch and contribute to skin tears. • Educate patients, staff, and health care providers regarding prevention and management. Treatment • If skin tear occurs, assess and classify according to Payne-Martin classification system and assess size as well. • Gently cleanse skin with normal saline. • Air dry or pat dry carefully. • Approximate skin tear flap if present; consider Steri-Strips; do not suture. • Use nonadherent dressings. • Use skin sealants to protect surrounding skin. • Consider drawing an arrow to indicate direction of skin tear to minimize further injury during dressing removal; consider doing a wound tracing. • Document assessment and treatment findings.

What are the pressure ulcer risk factors?

Prolonged pressure/immobilization Lying in bed or sitting in a chair or wheelchair without changing position or relieving pressure over an extended period Lying for hours on hard x-ray and operating tables Neurological disorders (coma, spinal cord injuries, cognitive impairment, or cerebrovascular disease) Fractures or contractures Debilitation: elderly persons in hospitals and nursing homes Pain Sedation Shearing forces (moving by dragging on coarse bed sheets) Disease/tissue factors Impaired perfusion; ischemia Fecal or urinary incontinence; prolonged exposure to moisture Malnutrition, dehydration Chronic diseases accompanied by anemia, edema, renal failure, malnutrition, peripheral vascular disease, or sepsis Previous history of pressure ulcers Additional risk factors for the critically ill Norepinephrine infusion Acute Physiology and Chronic Health Evaluation (APACHE II) score Anemia Age older than 40 years Multiple organ system disease or comorbid complications Length of hospital stay

How do we increase physical activity/exercise particiipation?

Provide appropriate screening before beginning an exercise program. • Assess for functional abilities and discuss how exercise can enhance function. • Provide information about the benefits of exercise, emphasizing short-term benefits such as sleeping better, improved walking ability, decreasing fall risk. • Clarify the misconceptions associated with exercise (fatigue, injury). • Assess barriers to exercise and provide tips on how to overcome. • Provide an "exercise prescription" that specifies what exercises and how often the person should exercise. Include daily and long-term goals. • Collaborate with the person to set short- and long-term goals that are specific, achievable, and match perceived needs, health, cognitive abilities, culture, gender, and interests. • Encourage individual to keep a journal or diary to reflect experience and progress. • Provide choices about types of exercises, and design the program so that the person can do it at home or elsewhere. • Refer to community resources for physical fitness (e.g., YMCA, mall walking). • Provide self-monitoring methods to assist in visualizing progress. • Group-based programs and exercising with a buddy may be more successful. • Try to make the program fun and entertaining (walking with favorite music, socializing with friends). • Discuss potential exercise side effects and any symptoms that should be reported. • Provide safety tips and situations that may require medical attention (Box 18-7). • Share stories about the benefits of your own personal exercise program and those of older people (See Resources for Best Practice, Box 18-2). • Provide ongoing support and follow-up on progress; support from experts and family and peers is a significant factor in encouraging continued participation. • Begin with low-intensity physical activity for sedentary individuals. • Initiate low-intensity activities in short sessions (less than 10 minutes), and include warm-up and cool-down components with active stretching. • Progression from low to moderate intensity is important to obtain maximal benefits, but activity level changes should be instituted gradually. • Teach the importance of warming up and cooling down. • Encourage use of proper, well-fitted footwear. • Lifestyle activities (e.g., raking, gardening) can build endurance when performed for at least 10 minutes.

How do we teach pelvic floor muscle training exercises?

Purpose Prevent the involuntary loss of urine by strengthening the muscles under the uterus, bladder, and bowel. Who should perform these exercises? Men and women who have problems with urine leakage or bowel control Identifying pelvic floor muscles When urinating, start to go and then stop. Feel the muscles in your vagina, bladder, or anus get tight and move up. These are the pelvic floor muscles. If you feel them tighten, you have done the exercise right. If you are still not sure you are tightening the right muscle, keep in mind that all the muscles of the pelvic floor relax and contract at the same time. Because these muscles control the bladder, rectum, and vagina, the following tips may help: Women: Inset a finger into your vagina. Tighten the muscles as if you are holding your urine; then let go. You should feel the muscles tighten and move up or down. These are the same muscles you would tighten if you were trying to prevent yourself from passing gas. Men: Insert a finger into your rectum. Tighten the muscles as if you were holding your urine; then let go. You should feel the muscles tighten and move up and down. These are the same muscles you would tighten if you were trying to prevent yourself from passing gas. NOTE: Nurses can teach correct muscle identification when performing a rectal or vaginal exam. PFME routine 1. Begin by emptying your bladder. 2. You can lie down, stand up, or sit in a chair. 3. Tighten the pelvic floor muscles and hold for a count of 10. 4. Relax the muscles completely for a count of 10. 5. Do 10 repetitions, 3 to 5 times a day. 6. Breathe deeply and relax your body when doing the exercises. 7. It is very important to keep the abdomen, buttocks, and thigh muscles relaxed when doing PFME. 8. After 4 to 6 weeks, most people see some improvement but it may take as long as 3 months. The regimen should be continued for 12 weeks. 9. After a few weeks, you can also try doing a single PFME contraction at times when you are likely to leak.

What is the Lawton scale used for?

Rated the IADLs from zero (lowest functioning) to eight (highest functioning). The level of functioning is determined by a summary score. It may be useful as a screening tool to establish an overall baseline of general functioning, but like the Katz index, it is not sensitive to changes in any one area.

What are the key components of screening older drivers for safety?

S Safety record A Attention skills F Family report E Ethanol use D Drugs R Reaction time I Intellectual impairment V Vision and visuospatial function E Executive functions

What is the acronym SPICES used for?

SPICES refers to six common and very serious geriatric syndromes that require nursing interventions: Sleep disorders, Problems with eating, Incontinence, Confusion, Evidence of falls, and Skin breakdown.

What are some interventions for insomnia?

Sleep hygiene Develop a regular physical exercise regimen for those who are able; regular exercise can deepen sleep, increase daytime arousal, and decrease depression. Avoid exercise before bedtime. Limit computer use before bedtime. Limit tobacco, caffeine, and alcohol use before bedtime. Avoid heavy meals before bedtime. If waking due to hunger, eat light carbohydrate snack. If you have reflux, eat the evening meal 3-4 hours before bedtime. Reduce or eliminate fluids in the evening (reduce nocturia). Ensure bed and bed coverings are comfortable, not too restrictive. Keep bedroom temperature comfortable, not too warm and well ventilated. Minimize light exposure in bedroom. Remove hearing aids/use earplugs to reduce noise. Limit sleeping partner's disruptive nighttime activities and pets from bedroom. Review all medications with health care provider; evaluate administration times, review side effects/interactions/effect on sleep. Relaxation techniques Diaphragmatic breathing Progressive relaxation White noise or music Guided imagery Stretching Yoga or tai chi Sleep restriction measures Limit or avoid daytime napping; napping should not exceed 2 hours. Limit opportunities for unplanned napping or dozing, particularly in the evening. Limit time in bed to more closely match the number of hours of actual sleep. Stimulus control Create bedtime sleep rituals, such as taking a warm bath and eating a small snack. Go to bed only when sleepy. Avoid falling asleep in places other than own bed (e.g., couch, recliner). If unable to fall asleep in a reasonable time (15-20 min), get out of bed and pursue relaxing activities (e.g., reading) and return to bed only when sleepy. Use the bedroom for sleep and sex only; do not watch television from bed or work in bed. Circadian interventions Reestablish connection with various environmental signals to cue the circadian rhythm (light exposure, meals, physical activity, social interactions). Establish a regular bedtime and waking time. Maintain stable daytime routines in regard to meals, activity, medications. Increase duration and intensity (2500-5000 lux) of bright light or sunlight exposure during the day. In patients with dementia, evening bright light may help with advanced sleep phase disorder. Melatonin 1-2 hours before bedtime may be helpful.

What does FANCAPES stand for?

Stands for Fluids, Aeration, Nutrition, Communication, Activity, Pain, Elimination, and Socialization.

What is primary prevention?

Strategies that can and are used to prevent an illness before it occurs.

What is a Mini-Cog? How do you conduct one?

The Mini-Cog combines the test of short-term memory in the original MMSE with the Clock Test 1. State three unrelated words, such as "chair," "coin," "tree"; state each word clearly and slowly, about 1 second for each. 2. Ask the person to repeat these words; if the person is unable to do so, you may repeat the words up to 3 times to give the person three attempts to say them back to you correctly. 3. The person is asked to draw a clock as in the Clock Drawing Test. a. Provide the person with a piece of plain white paper with a circle drawn on it. b. Ask the person to draw numbers in the circle so that it looks like a clock, and then to put the hands in the circle to read "10 after 4." 4. The person is asked to recall the three words from step 1.

What do we use to determine appropriate interventions of pressure ulcers for the older adult?

These 5 P's: Prevention: Address excessive pressure, friction, shear, moisture, suboptimal nutrition, immobilization, tissue tolerance, comorbid conditions. Prescription: Interventions for a treatable lesion. Even in the stress of dying, some lesions are healable after appropriate treatment. Interventions need to be aimed at treating the cause and at patient-centered concerns (pain, quality of life) before addressing the components of wound care consistent with the patient/family goals and wishes. Preservation: If opportunity for wound healing is limited, maintenance of the wound in the present clinical state may be the outcome. Palliation: Refers to situations in which the goal of treatment is comfort and care, not healing. In some situations, palliative wounds may benefit from interventions such as surgical debridement or support surfaces even if the goal is not to heal the wound. Preference: Take into account the preferences of the patient and the patient's circle of care.

Who are the baby boomers?

Those that were born somewhere between approximately 1946 and 1964 depending on how they have been defined by any one country.

Who are centenarians?

Those who are between 100 and 109 years of age

Who are the super-centenarians?

Those who live until at least 110 years of age

What are the goals of tertiary prevention?

To promote wellness to the extent possible in the presence of an active health challenge.

What are some things we should teach patients to do to reduce their fire risk?

When you smell smoke, see flames, or hear the sound of fire, evacuate everyone in the house before doing anything else. • Use normal exits unless blocked by smoke or flames. Never use elevators unless instructed by the fire department. • Make sure smoke alarms are installed on each level of your home and outside all sleeping areas; test smoke alarms monthly and replace batteries at least once a year. • Know at least two exits from every room. • Make any necessary accommodations, such as providing exit ramps and widening doorways, to facilitate an emergency exit. • Contact your local fire department's non-emergency line and explain your special needs; they may suggest escape plan ideas and may perform a home fire safety inspection and offer suggestions about smoke alarm placement and maintenance. • In a high-rise apartment, remain in the room with doors and hall vents closed unless smoke is in your apartment. Open or break a window to obtain fresh air. • Rehearse what to do if clothing catches fire: do not run; lie down and then roll over and over ("stop, drop and roll"). If another person's clothing is burning, smother the flames with the handiest item such as a rug, coat, blanket, or drapes. • If you live in a multistory home, arrange to sleep on the ground floor and near an exit.

What is ageism?

is the systematic stereotyping of and discrimination against people because they are old, in the way that racism and sexism discriminate against color and gender

What is cognition?

is the process of acquiring, storing, sharing, and using information. Components of cognitive function include language, thought, memory, executive function, judgment, attention, and perception

How do we assess how we should handle a patient safely according to their physical ability?

• Ability of the patient to provide assistance • Ability of the patient to bear weight • Upper extremity strength of the patient • Ability of the patient to cooperate and follow instructions • Patient height and weight • Special circumstances likely to affect transfer or repositioning tasks, such as abdominal wounds, contractures, pressure ulcers, presence of tubes • Specific physician orders or physical therapy recommendations that relate to transferring or repositioning patients (e.g., knee or hip replacement precautions)

How can we reduce a patient's fall-risk?

• Adaptation or modification of the home environment • Withdrawal or minimization of psychoactive medications • Withdrawal or minimization of other medications • Management of orthostatic hypotension • Continence programs such as prompted voiding • Management of foot problems and footwear • Exercise, particularly balance, strength, and gait training • Staff and patient education

What are the risk factors for sleep disturbances in older adults?

• Age-related changes in sleep architecture • Comorbidities (cardiovascular disease, diabetes, pulmonary disease, musculoskeletal disorders), CNS disorders (Parkinson's disease, seizure disorder, dementia), GI disorders (hiatal hernia, GERD, PUD), urinary disorders (incontinence, BPH) • Pain • Depression, anxiety, delirium, psychosis • Polypharmacy • Life stressors/response to stress • Sleep-related beliefs • Sleep habits (daily sleep/activity cycle, napping) • Limited exposure to sunlight • Environmental noises, institutional routines • Poor sleep hygiene • Lack of exercise • Excessive napping • Caregiving for a dependent elder • Sleep apnea • Restless legs syndrome • Periodic leg movement • Rapid eye movement behavior disorder • Alcohol • Smoking

What are some ways we can suggest to promote sleep when hospitalized or in a nursing home?

• Allow individual to stay out of bed and out of the room for as long as possible before bed. • Provide 30 minutes or more of sunlight exposure in a comfortable outdoor location. • Provide low-level physical activity three times a day. • Keep noise level at a minimum, speak in hushed tones, do no use overhead paging, reduce light in hallways and resident rooms. • Institute a sleep improvement protocol—"do not disturb" times, soft music, relaxation, massage, aromatherapy, sleep masks, headphones, allowing patients to shut doors. Consider having a kit that can be taken to bedside with music, aromatherapy. • Perform necessary care (e.g., turning, changing) when the individual is awake rather than awakening the individual between the hours of 10:00 pm and 6:00 am. • Limit intake of caffeine and other fluids in excess before bedtime. • Provide a light snack or warm beverage before bedtime. • Discontinue invasive treatments when possible (Foley catheters, percutaneous gastrostomy tubes, intravenous lines). • Encourage and assist to the bathroom before bed and as needed. • Give pain medication before bedtime for patients with pain. • Institute the same time for resident to arise and get out of bed every morning. • Maintain comfortable temperature in room; provide blankets as needed. • Provide meaningful activities (individualized and group) during the daytime.

What are the symptoms of dysphagia or possible aspiration?

• Difficult, labored swallowing • Drooling • Copious oral secretions • Coughing, choking at meals • Holding or pocketing of food/medications in the mouth • Difficulty moving food or liquid from mouth to throat • Difficulty chewing • Nasal voice or hoarseness • Wet or gurgling voice • Excessive throat clearing • Food or liquid leaking from the nose • Prolonged eating time • Pain with swallowing • Unusual head or neck posturing while swallowing • Sensation of something stuck in the throat during swallowing; sensation of a lump in the throat • Heartburn • Chest pain • Hiccups • Weight loss • Frequent respiratory tract infections, pneumonia

How do we tell patients to exercise safely?

• Always wear comfortable, loose-fitting clothing and appropriate shoes for your activity. • Warm-up: Perform a low- to moderate-intensity warm-up for 5-10 minutes. • Drink water before, during, and after your exercise session. • When exercising outdoors, evaluate your surroundings for safety: traffic, pavement condition, weather, and strangers. • Wear clothes made of fabrics that absorb sweat and remove it from your skin. • Never wear rubber or plastic suits. These could hold the sweat on your skin and make your body overheat. • Wear sunscreen when you exercise outdoors. Stop exercising right away if you: • Have pain or pressure in your chest, neck, shoulder, or arm. • Feel dizzy or sick. • Break out in a cold sweat. • Have muscle cramps. • Feel acute (not just achy) pain in your joints, feet, ankles, or legs. • Have trouble breathing. Slow down; you should be able to talk while exercising without gasping for breath. Times exercise should not be done • Avoid hard exercise for 2 hours after a big meal. (A leisurely walk around the block would be fine.) • Do not exercise when you have a fever and/or viral infection accompanied by muscle aches. • Do not exercise if your systolic blood pressure is greater than 200 mm Hg and your diastolic blood pressure is greater than 100 mm Hg. • Do not exercise if your resting heart rate is greater than 120 beats/min. • Do not exercise if you have a joint that you are using to exercise (such as a knee or an ankle) that is red and warm and painful. • If you have osteoporosis, always avoid stretches that flex your spine or cause you to bend at the waist, and avoid making jerky, rapid movements. • Stop exercising if you experience severe pain or swelling in a joint. Discomfort that persists should always be evaluated. • Do not exercise if you have a new symptom that has not been evaluated by your health care provider, such as pain in your chest, abdomen, or a joint; swelling in an arm, leg, or joint; difficulty catching your breath at rest; or a fluttering feeling in your chest.

How do we give function-focused care in acute care?

• Ask or encourage the individual to move in bed and give the person time to move rather than moving the person yourself. • Give step-by-step cues on how to move in bed (e.g., "put your right hand on the rail and pull yourself over on your left side"). • Ask or encourage the individual to transfer and wait for the individual to move rather than transferring the individual yourself or automatically using lift equipment (use of assistive equipment depends on mobility and cognitive status). • Give step-by-step cues and use gestures/demonstration on how to transfer safely (e.g., "plant feet firmly on the floor and slide to the edge of the chair"). • Ask or encourage the individual to walk or independently propel wheelchair and give the person time to perform the activity rather than doing it yourself. • Give step-by-step cues and use gestures/demonstration (e.g., "move your left foot forward; now move your right foot"). • Assist, ask, and/or encourage use of assistive devices; provide instruction on use and ensure that device is available and appropriate.

How do we give functional focused care in the acute care setting?

• Ask or encourage the individual to move in bed and give the person time to move rather than moving the person yourself. • Give step-by-step cues on how to move in bed (e.g., "put your right hand on the rail and pull yourself over on your left side"). • Ask or encourage the individual to transfer and wait for the individual to move rather than transferring the individual yourself or automatically using lift equipment (use of assistive equipment depends on mobility and cognitive status). • Give step-by-step cues and use gestures/demonstration on how to transfer safely (e.g., "plant feet firmly on the floor and slide to the edge of the chair"). • Ask or encourage the individual to walk or independently propel wheelchair and give the person time to perform the activity rather than doing it yourself. • Give step-by-step cues and use gestures/demonstration (e.g., "move your left foot forward; now move your right foot"). • Assist, ask, and/or encourage use of assistive devices; provide instruction on use and ensure that device is available and appropriate.

How do we communicate with elders who have visual impairements?

• Assess for vision loss. • Make sure you have the person's attention before speaking. • Clearly identify yourself and others with you. State when you are leaving to make sure the person is aware of your departure. • Position yourself at the person's level when speaking. • When others are present, address the visually impaired person by prefacing remarks with his or her name or a light touch on the arm. • Ensure adequate lighting and eliminate glare. • Select colors for paint, furniture, pictures with rich intensity (e.g., red, orange). • Use large, dark, evenly spaced printing. • Use contrast in printed material (e.g., black marker on white paper). • Use a night light in bathroom and hallways and use illuminated switches. • Do not change room arrangement or the arrangement of personal items without explanations. • If in a hospital or nursing home, use some means to identify patients who are visually impaired and include visual impairment in the plan of care. • Use the analogy of a clock face to help locate objects (e.g., describe positions of food on a plate in relation to clock positions, such as meat at 3 o'clock, dessert at 6 o'clock). • Label eyeglasses and have a spare pair if possible; make sure glasses are worn and are clean. • Be aware of low-vision assistive devices such as talking watches, talking books, and magnifiers, and facilitate access to these resources. • If the person is blind, ask the person how you can help. If walking, do not try to push or pull. Let the person take your arm just above the elbow, and give directions with details (e.g., the bench is on your immediate right); when seating the person, place his or her hand on the back of the chair. • Recommend screening for vision loss and annual dilated eye exams for older people.

How do you improve nutritional intake in the hosptial?

• Assess nutritional and oral health status, including ability to eat and amount of assistance needed. • Ensure proper fit and cleanliness of dentures and denture use. • Provide oral hygiene, and allow the person to wash his or her hands before meals. • Ensure environment is conducive to eating (remove objects such as urinals and bed pans; clear bedside tables). Ask yourself if you would want to eat the food in the environment in which it is presented. • Position patient for safe eating (head of bed elevated or sit in a chair if possible). • Stop non-essential clinical activity during meals (e.g., procedures, rounds, medication administration). • Emphasize the importance of mealtimes/eating; increase presence and interaction during mealtimes; make mealtime rounds. • Ensure that all nursing staff are aware of the patients who need assistance with eating and adequate help is provided. • Ensure that all necessary items are on the tray; prepare all food on the tray if needed; butter bread, open containers, provide straws, provide adaptive equipment as needed. • Consider volunteers or family members to assist with eating and train and supervise. • Administer medication for pain or nausea on a schedule that provides comfort at mealtime. • Determine food preferences; provide for choices in food; include foods appropriate to cultural and religious customs. • Accurately assess dietary intake using a validated method. • Make dietary changes/referrals readily. • Make food available 24 hours/day—provide snacks between meals and at night. • Limit periods of NPO status and provide food as soon as patient is able to eat. • Consider liberalizing therapeutic diet if intake is inadequate; offer diet options/alternatives as indicated, including flavor enhancement.

How do we teach to prevent fires and burns in the older adult?

• Do not smoke in bed or when sleepy. • When cooking, do not wear loose-fitting clothing (e.g., bathrobes, nightgowns, pajamas). • Set thermostats for water heater or faucets so that the water does not become too hot. • Install a portable hand fire extinguisher in the kitchen. • Keep access to outside door(s) unobstructed. • Identify emergency exits in public buildings. • If you consider entering a boarding or foster home, check to see that it has smoke detectors, a sprinkler system, and fire extinguishers. • Wear clothing that is nonflammable or treated with a permanent fire-retardant finish. • Use several electrical outlets rather than overloading one outlet.

What are some crime reduction suggestions?

• Do not wear flashy jewelry in public places. • Have your key ready when approaching your front door. • Do not dangle your purse away from your body or carry large bulky shoulder bags. • Purse and wallet snatchers are usually not interested in injuring anyone. You are less likely to get hurt when accosted if you hand over your purse or wallet readily. • Carry only a little money and a few personal items in your wallet or purse. Keep your car keys, larger amounts of money, and credit cards in an inside pocket of clothing. • Do not leave your purse on the seat beside you in the car; put it on the floor where it is more difficult for someone to grab it. • Lock bundles or bags in the trunk. • When returning to your car, check the front seat, back seat, and floor before entering. • Wear a small police whistle around your neck, or carry mace. • Identify police and security personnel who are available in high-risk areas. • Institute informal surveillance agreements with neighbors to increase security. • Receive a home security check by police, and follow through on their security suggestions. • Attend a crime-prevention program. • Keep doors locked, install deadbolt locks, and choose locks that you can easily manipulate. If your key is lost or if you move, have locks replaced. Do not attach an ID tag to your key ring. • Never open your door automatically. Use an optical viewer. Confirm authenticity of a service person's ID by calling that service agency before opening the door. Never open doors to strangers or let them know you are alone. • Lock windows. Get fire department-approved grates installed on ground floor/fire escape windows. Keep all hidden entries locked (e.g., garage, basement, roof). Draw curtains and blinds at night. • Protect valuables: Keep money and securities in a bank. • Beware of phone tricks. • Hang up on (and report) nuisance callers. • Do not give any information to strangers over the phone. • Consider a pet. A dog—even a small one—can provide excellent protection and good company if you are willing to care for one. • Organize a buddy system. Neighbors can watch out for each other, go to the basement/laundry room together, and so on. • Keep alert to stories and coverage of fraud, bogus schemes, and protective actions on the news media. • Take advantage of self-defense courses and public awareness programs. • Do not be afraid to report crime or suspicious activities.

How do we teach older adults to prevent hyperthermia?

• Drink 2 to 3 L of cool fluid daily. • Minimize exertion, especially during the warmest times of the day. • Stay in air-conditioned places, or use fans when possible. • Wear hats and loose clothing of natural fibers when outside; remove most clothing when indoors. • Take tepid baths or showers. • Apply cold wet compresses, or immerse the hands and feet in cool water. • Evaluate medications for risk of hyperthermia. • Avoid alcohol.

How do you promote a healthy bladder?

• Drink 8 to 10 glasses of water a day before 8 pm. • Eliminate or reduce the use of coffee, tea, brown cola, and alcohol, particularly before bedtime. • Empty bladder completely before and after meals and at bedtime. • Urinate whenever the urge arises; never ignore it. • Limit the use of sleeping pills, sedatives, and alcohol because they decrease sensation to urinate. • Make sure toilet is nearby with a clear path to it and good lighting, especially at night. Consider a grab bar or a raised toilet seat if there is difficulty getting on and off the toilet. • Maintain ideal body weight. • Get regular physical exercise. • Avoid smoking. • Seek professional treatment for complaints of burning, urgency, pain, blood in urine, or difficulties maintaining continence.

How should we deal with tubes, lines, and other medical devices on an older adult?

• First question: "Is the device really necessary?" Remove it as soon as possible. • Preoperative teaching about the device: Allowing the person to see the tubes may be effective in decreasing anxiety about devices. • Use guided exploration and a mirror to help the patient understand what devices are in place and why. • Provide comfort care to the site—oral and nasal care, anchoring of tubing, topical anesthetic on site. • Foley catheters should be used only if the patient needs intensive output monitoring or has an obstruction. • Weigh risks and benefits of restraint versus therapy: alternatives available—for example, replace intravenous (IV) tubing with saline lock, deliver medications intramuscularly (IM), consider intermittent IV administration or hypodermoclysis. • Use camouflage: clothing or elastic sleeves, temporary air splint (occupational therapy can be helpful), skin sleeves to prevent IV tube dislodgement. • Use mitts instead of wrist restraints; use roll belts instead of vest restraints. • Use diversional activity aprons (zipping-unzipping, threading exercises, dials and knobs), busy box, therapeutic activity kit, twiddle (activity) muff. • Hide lines by placing them in an unobtrusive place; place tubing behind the patient, out of his or her view; have patient wear long sleeves or double surgical gowns with cuffs to prevent access. • Hang IV bags behind the patient's field of vision. • Nasogastric (NG) tubes—replace with percutaneous endoscopic gastrostomy (PEG) tube if necessary but obtain comprehensive speech therapy swallowing evaluation. If NG tube is used, use as small a lumen as possible to minimize irritation; consider taping with occlusive dressings. • Cover the PEG tube or abdominal incisions and other tubes with an abdominal binder and/or sweat pants. • For men with Foley catheters—shave area just above pubis, and tape catheter to pubis. Never secure catheter to leg (causes discomfort and can cause a fistula). Run tubing around back and down leg to a leg bag. Patient should wear underpants and pajama pants. • Remove restraints while working with the patient. • Use a modified soft collar for tracheostomy protection.

How do you prevent and treat candidiasis?

• Identify high-risk individuals (e.g., obese, bedridden, incontinent, diaphoretic, immunocompromised) and limit conditions that encourage fungal growth. • Provide adequate drying of target areas after bathing and prompt management of incontinent episodes. A hair dryer on the low setting can help dry hard-to-reach, vulnerable areas. • A dry, folded washcloth or cotton sanitary pad can be placed under the breasts or between skinfolds to promote exposure to air and light. • Use loose-fitting clothing and underwear; change clothing and bedding when damp. • Avoid incontinent products that are tight or have plastic that touches the skin. • Avoid use of cornstarch because it promotes growth of Candida organisms. • Optimize nutrition and glycemic control. • The goal of treatment is to eradicate the infection and may include the use of a prescribed antifungal medication for 7 to 14 days or until the infection is completely cleared. Antifungal preparations are available as powders, creams, and lotions. Powders are recommended because they trap moisture less than the others.

How do we care for individuals with orthostatic hypotension?

• Keep head of bed elevated 30 degrees at all times. • Avoid rapid changes in position, especially in the morning. When transferring out of bed, have individual sit up gradually and dangle feet on side of bed for a few minutes. After assisting to standing position, support for a few minutes before walking. • Wear compression stockings during the daytime (thigh or knee high). Put on in the morning before getting out of bed; remove at night. • Encourage coffee or tea with breakfast if tolerated. • Have individual sit for 20 minutes following a meal. • Delay physical activity from morning to afternoon or evening when blood pressure is naturally higher. • Encourage sitting after any type of exercise. • Avoid standing up too quickly after toileting. • Encourage adequate fluid intake. • Encourage dorsiflexion of feet several times before standing. • Encourage crossing and uncrossing of legs when sitting.

What are some suggestions for encouraging reminiscence?

• Listen without correction or criticism. Older adults are presenting their version of their reality; our version belongs to another generation. • Encourage older adults to discuss various ages and stages of their lives. Use questions such as, "What was it like growing up on that farm?", "What did teenagers do for fun when you were young?", or "What was WWII like for you?" • Be patient with repetition. Sometimes people need to tell the same story often to come to terms with the experience, especially if it was meaningful to them. If they have a memory loss, it may be the only story they can remember, and it is important for them to be able to share it with others. • Be attuned to signs of depression in conversation (dwelling on sad topics) or changes in physical status or behavior, and provide appropriate assessment and intervention. • If a topic arises that the person does not want to discuss, change to another topic. • If individuals are reluctant to share because they do not feel their life was interesting, reassure them that everyone's life is valuable and interesting and tell them how important their memories are to you and others. • Keep in mind that reminiscing is not an orderly process. One memory triggers another in a way that may not seem related; it is not important to keep things in order or verify accuracy. • Keep the conversation focused on the person reminiscing, but do not hesitate to share some of your own memories that relate to the situation being discussed. Participate as equals, and enjoy each other's contributions. • Listen actively, maintain eye contact, and do not interrupt. • Respond positively and give feedback by making caring, appropriate comments that encourage the person to continue. • Use props and triggers such as photographs, memorabilia (e.g., a childhood toy or antique, short stories or poems about the past, favorite foods, YouTube videos, old songs). • Use open-ended questions to encourage reminiscing. If working with a group, you can prepare questions ahead of time, or you can ask the group members to pick a topic that interests them. One question or topic may be enough for an entire group session. • Consider using questions such as the following: How did your parents meet? What do you remember most about your mother? Father? Grandmother? Grandfather? What are some of your favorite memories from childhood? What was the first house you remember? What were your favorite foods as a child? Did you have a pet as a child? What do you remember about your first job? How did you celebrate birthdays or other holidays? If you were married, what are your memories of your wedding day? What was your greatest accomplishment or joy in your life?

How do we prevent cold discomfort and development of accidental hypothermia in frail elders?

• Maintain a comfortably warm ambient temperature no lower than 65° F. Many frail elders will require much higher temperatures. • Provide generous quantities of clothing and bedcovers. Layer clothing and bedcovers for best insulation. Be careful not to judge your patient's needs by how you feel working in a warm environment. • Limit time patients sit by cold windows or air conditioners to short periods in which they are adequately dressed and covered. • Provide a head covering whenever possible—in bed, out of bed, and particularly out-of-doors. • Cover patients well when in bed or bathing. The standard—a light bath blanket over a naked body—is not enough protection for frail elders. • Cover patients with heavy blankets for transfer to and from showers; dry quickly and thoroughly before leaving shower room; cover head with a dry towel or hood while wet. Shower rooms and bathrooms should have warming lights. • Dry wet hair quickly with warm air from an electric dryer. Never allow the hair of frail elders to air-dry. • Use absorbent pads for incontinent patients rather than allowing urine to wet large areas of clothing, sheets, and bedcovers. • Provide as much exercise as possible to generate heat from muscle activity. • Provide hot, high-protein meals and bedtime snacks to add heat and sustain heat production throughout the day and as far into the night as possible.

What are the best tips to guide older adult learners?

• Make sure the person is ready to learn before trying to teach. Watch for cues that would indicate that the person is preoccupied, fatigued, or too anxious to comprehend the material. • Ensure that the person is comfortable (appropriate seating, room temperature); pain and discomfort can interfere with learning. Provide pain medication if needed before teaching. • Be sensitive to cultural, language, health literacy level, and other differences among the older adults you serve. Some suggestions may not be appropriate for everyone and materials need to be individualized. • Provide adequate time for learning, and use self-pacing techniques. • Create a shame-free environment where older adults feel free to ask questions. • Provide regular positive feedback. • Avoid distractions, and present one idea at a time. • Present pertinent, specific, practical, and individualized information. Emphasize concrete rather than abstract material. • Use past experience; connect new learning to what has already been learned. • Use plain language, use large readable font (e.g., Arial, 14 to 16 points), and use both uppercase and lowercase letters. • Use high contrast on visuals and handout materials (dark colors for text and lighter for background; black print on white, dark blue on pale yellow). • Pay attention to reading ability; use tools other than printed material such as pictures, videos, discussion, demonstrations. • Use bullets or lists to highlight pertinent information. Use only two to three main concepts. • Sit facing the client so that he or she can watch your lip movements and facial expressions. • Speak slowly, keeping the pitch of your voice low; low sounds are heard better than high-frequency sounds. • Encourage the learner to develop various mediators or mnemonic devices (e.g., visual images, rhymes, acronyms, self-designed coding schemes). • Use shorter, more frequent sessions with appropriate breaks; pay attention to fatigue and physical discomfort. • If using computers, adapt as needed for physical limitations (large icons and font, voice systems, touch screens, volume adjustments). • Use "teach-back" methods to ensure understanding.

How do we measure orthostatic blood pressure?

• Orthostatic hypotension is more common in the morning, and therefore assessment should occur then. • Have the individual lie down for 5 minutes. • Measure the blood pressure and pulse rate in both arms. Use the arm with the higher blood pressure for measurements following position change. • Have the individual stand (use safety precautions as needed). If unable to stand, measure blood pressure sitting with feet hanging. • Take the blood pressure immediately after standing and ask about dizziness. • Repeat blood pressure and pulse rate measurements after standing for 3 minutes and ask about dizziness. • A drop in BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg or experiencing light-headedness, dizziness, or loss of balance is considered abnormal.

What should be our environmental safety checks for fall risk patients?

• Outdoor grounds and indoor floor surfaces free checked for spills, wet areas, and unevenness. • Hallways, doorways have clear paths free of clutter, equipment • Proper illumination and functioning of lights, including night lights • Tabletops, furniture, and beds are sturdy and in good repair • Grab rails and nonskid appliqués or mats are in place in the bathroom (toilet and shower) • Appropriate shoe wear is available and used • Adaptive aids work properly and are in good repair • Bed rails do not collapse when used for transitioning or support • Bed wheels lock • Patient gowns/clothing does not cause tripping • IV poles are sturdy if used during ambulation and tubing does not cause tripping

How do you prevent aspiration in patients with dysphagia?

• Provide a 30-minute rest period before meal consumption; a rested person will likely have less difficulty swallowing. • The person should sit at 90 degrees during all oral (PO) intake. • Maintain 90-degree positioning for at least 1 hour after PO intake. • Adjust rate of feeding and size of bites to the person's tolerance; avoid rushed or forced feeding. • Alternate solid and liquid boluses. • Have the person swallow twice before the next mouthful. • Stroke under chin downward to initiate swallowing. • Follow speech therapist's recommendation for safe swallowing techniques and modified food consistency (may need thickened liquids, pureed foods). • If facial weakness is present, place food on the nonimpaired side of the mouth. • Avoid sedatives and hypnotics that may impair cough reflex and swallowing ability. • Keep suction equipment ready at all times. • Supervise all meals. • Monitor temperature. • Observe color of phlegm. • Visually check the mouth for pocketing of food in cheeks. • Check for food under dentures • Provide mouth care every 4 hours and before and after meals, including denture cleaning.

What are the best ways to promote healthy skin?

• Seek the shade. • Do not burn. • Avoid indoor tanning booths and sunlamps. • Wear hats with a brim wide enough to shade face, ears, and neck, as well as clothing that adequately covers the arms, legs, and torso. Cover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses. • Use a broad-spectrum (UVA/UVB) suncreen with an SPF of 30 or higher every day. • Apply 1 ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outdoors. Reapply every 2 hours or immediately after swimming or excessive sweating. • Examine your skin head-to-toe every month. • See your health care provider every year for a professional skin exam.

What are the factors to consider in selecting pressure ulcer dressings?

• Shallow, dry wounds with no/minimal exudate need hydrating dressings that add or trap moisture; very shallow wounds require cover dressing only (gels/transparent adhesive dressings, thin hydrocolloid, thin polyurethane foam). • Shallow wounds with moderate to large exudate need dressings that absorb exudate, maintain moist surface, support autolysis if necrotic tissue present, protect and insulate, and protect surrounding tissue (hydrocolloids, semipermeable polyurethane foam, calcium alginates, gauze). Cover with an absorptive cover dressing. • Deep wounds with moderate to large exudate require filling of dead space, absorption of exudate, maintenance of moist environment, support of autolysis if necrotic tissue present, protection, and insulation (copolymer starch, dextranomer beads, calcium alginates, foam cavity). Cover with gauze pad, ABD, transparent thin film, or polyurethane foam.

What are the interventions for accidental bowel leakage?

• Use therapeutic communication skills and a positive and supportive attitude to help individuals overcome any embarrassment. • Use the term accidental bowel leakage rather than fecal incontinence. • Emphasize the importance of thorough evaluation. • Teach about the range of interventions available for management. • Share helpful resources for continence management. • Have individual keep a bowel diary and identify triggers. For example, if eating a meal or drinking a cup of coffee stimulates defecation, use the toilet at a given time after the trigger event. Have a regular toileting routine. • Encourage being prepared. Schedule outings, appointments, exercise routines around anticipated bowel patterns; suggest keeping a change of underwear, clothing, and toileting supplies with them when out; use an absorbent pad and have bags to dispose of pad if soiled; deodorant sprays for odor; wear darker clothing when away from home so that if soiling occurs, it will be less noticeable; scan environment when out for toilet locations. • Avoid greasy and flatus-producing foods, dairy products, fruits with edible seeds, acidic citrus fruits, nuts, spicy foods, and other foods that trigger leakage. Bake or broil foods instead of frying; eat meals at regular times; eat after public events to reduce likelihood of leakage.

What is elderspeak?

• Using a singsong voice, changing pitch and tone, and exaggerating words • Using short and simple sentences • Speaking more slowly • Using limited vocabulary • Repeating or paraphrasing what has just been said • Using pet names (diminutives) such as "honey" or "sweetie" or "grandma" • Using collective pronouns such as "we"—for instance, "Would we like to take a bath now?" • Using statements that sound like questions

How do you care for and use a hearing aid?

• When a hearing aid is first purchased: Initially it is advisable to wear for 15 to 20 minutes per day until one is adjusted to the new sounds. • Gradually increase the wearing time to 10 to 12 hours. • Be patient and realize that the process of adaptation is difficult but ultimately will be rewarding. • Make sure your fingers are dry and clean before handling hearing aids. Use a soft dry cloth to wipe your hearing aids. • Each day, remove any earwax that has accumulated on the hearing aids. Use the brush that is included with the aid to clean difficult-to-reach areas. • You will be instructed how to best insert the model you purchase. • If it is not pre-programmed, adjust the volume to a level that is comfortable for you. You may be able to adjust the volume for differing environments, depending on the model. • Use great caution to avoid getting the aid wet; do not wear when swimming or taking a shower or bath. • Also avoid use when around fine particles that can clog the microphone such as hair spray, make-up, or blowing sand and dirt. • Many aids will slowly decrease in volume and may make a "peep" when it is time to change the battery. Check the battery by turning the hearing aid on, turning up the volume, cupping your hand over the ear mold, and listening. A constant whistling sound indicates that the battery is functioning. A weak sound indicates that the battery is losing power and needs replacement. • Be sure to remove the battery and return the aid to its case when not in use. This will extend the life of the battery and protect the aid.

How do we teach patients to adapt to safer driving?

• Wider rear-view mirrors • Pedal extensions • Less complicated, larger, and legible instrument panels • Electronic detectors in front and back that signal when the car is getting too close to other cars, drifting into another lane, or likely to hit center dividers or other highway infrastructure • Technology that facilitates left turns by warning drivers when it is safe to make the turn • Better protection on doors • Booster cushions for shorter-stature drivers • "Smart" driving assistants (under development) that automatically plan a safe driving route based on the person's driving habits • GPS devices