Gero Test 2

• A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. • Physical Restraints- restrict, restrain or prevent movement of a person. • Chemical Restraint- the use of medication as a restriction to manage a patient's behavior that is not a standard treatment or dosage for the patient's condition • Historically used for "protection" of the patient. o Protected mentally ill patients from harming themselves • Over the last 20 yrs research has shown restraints are "ineffective and hazardous". • Physical Restraints- wrist, vests, side rails o Do not protect patients from falling, wandering or pulling on tubes o Can cause serious injury and death o Are a source of physical and psychological distress • Restraint Alternatives o If disrupting catheter consider: If catheter is necessary Proper securing to leg o If disrupting IV line/site consider: Long sleeved robe Hep-Lock and cover with gauze Place IV bag out of visual field o If disrupting any device consider: Reassess frequently to determine if device is necessary If mild-moderate cognitive impairment consider explaining device to patient Providing a supervised area for meaningful activity A restraint management cart with restraint alternative products Eliciting family/caregiver participation Always start with least restrictive measures first • Research has shown that the practice of physical restraint is ineffective and hazardous. • Physical restraints, intended to prevent injury, do not protect patients from falling, wandering, or removing tubes and other medical devices. • Physical restraints may exacerbate many problems • Physical restraints are associated with higher mortality rates, injurious falls, nosocomial infections, incontinence, contractures, pressure ulcers, agitation, and depression. • Although prevention of falls is most frequently cited as the primary reason for using restraints, restraints do not prevent serious injury and may even increase the risk of injury and death. • The use of restraints is a great source of physical and psychological distress to older adults and may intensify agitation and contribute to depression. Side rails may be seen as a barrier rather than a reminder of the need to request assistance with transfers. • Side rails may cause fear and agitation and a feeling of being jailed or caged. • Side rails are no longer viewed as simply attachments to a patient's bed but are considered restraints with all the accompanying concerns just discussed. • Side rails are now defined as restraints or restrictive devices when used to impede a person's ability to voluntarily get out of bed and the person cannot lower them by themselves. • There are many negative effects of side rail use. • Restraint-free care is now the standard of practice and an indicator of quality care in health care settings, although transition to that standard is still in progress, particularly is acute care settings. • Suggestions for fall risk reduction and restraint alternatives involve: o Assessment o Patient Rooms o Bathrooms o The unit o Tubes, lines, and medical devices

Discuss the controversy about using restraints for fall protection. Describe examples of restraint alternatives that may be used for confused patients.

Abstinence

no alcohol in previous year

SMAST-G alcohol screen

o 10 yes-no items o Administered by questionnaire o Covers alcohol only o Validated for ages 55 to 81 o Sens: 89% Spec: 72%

Two-Item Conjoint Alcohol Screen

o 2 yes/no questions (1 yes = positive) o Administered by interview o Covers alcohol and drugs o Screens for abuse and dependence o Add quantity and frequency questions to screen for at-risk use o Sens: 81% Spec: 81%

• PAINAD (Pain assessment in Advanced Dementia Scale)

o A simple, short, focused tool that can be used on a more frequent basis; it has been found to demonstrate sensitivity to change with intervention. o Four behaviors are rated by an observer on a scale of 0 to 2: Breathing independent of vocalization Negative vocalizations Facial expression Body language Consolability

NIAAA Clinician's Guide Recommendations for alcohol screening

o Do you sometimes drink beer, wine, or other alcoholic beverages? o How many times in the post year have you had.... 5 or more drinks in a day? (men) 4 or more drinks in a day? (women)

Chamomile

- Main Use: Anti-inflammatory, antispasmodic, GI upset, sleep d/o, anxiety - Common Side Effects: GI upset, contact dermatitis, hypersensitivity reactions - Nursing Implications: If take with warfin, can increase risk of bleeding

Hawthorn

- Main Use: Chronic Heart Failure - Common Side Effects: Vertigo and dizziness - Nursing Implications: May interact with CV drugs and can alter blood sugar levels

Glucosamine Sulfate

- Main Use: OA, ↓pain, ↑function - Common Side Effects: GI upset, insomnia, HA, skin rxn's - Nursing Implications: Warn of interaction effects with multiple drug/supplement use

Ginkgo Biloba

- Main Use: Positive cognitive effects - Common Side Effects: Bleeding, GI upset, HA, dizziness, constipation - Nursing Implications: Before surgery, d/c herb at least 1 week before surgery

Echinacea

- Main Use: Prevent and treat URI's - Common Side Effects: Fever, sore throat, allergic rxn's, N/V/D - Nursing Implications: If taken with Tylenol, can cause liver inflammation

Garlic

- Main Use: Protect against CVA and CAD - Common Side Effects: Allergic rxn's, ↑ flatulence, bleeding, upper GI irritation - Nursing Implications: Some drug metabolism altered by garlic, topical preps can irritate skin

Saw Palmeto

- Main Use: Tx BPH - Common Side Effects: Dizziness, fatigue, rhinitis, ↓libido - Nursing Implications: May prolong bleeding

St. John's Wort

- Main Use: Tx mild to mod depression - Common Side Effects: Photosensitivity, GI upset, HA, dry mouth - Nursing Implications: D/C antidepressant 2 wks prior to SJW. Avoid sun exposure

Ginseng

- Main Use: ↑well-being and ↓stess - Common Side Effects: ↑HR, HTN, Hypotension, edema, diarrhea, mania - Nursing Implications: If on blood thinners, can increase risk of bleeding

Red Yeast Rice

- Main Use: ↓LDL-C - Common Side Effects: Muscle pain, renal damage, heartburn, GI upset, dizziness - Nursing Implications: FDA warns to purchase from respected sources

Dementia

- Onset: Insidious, slow, over years and often unrecognized until deficit obvious - Course over 24 hours: Fairly stable, may see changes with stress - Consciousness: Clear - Alertness: Generally normal - Psychomotor activities: Normal, may have apraxia or agnosia - Duration: Years - Attention: Generally normal but may have trouble focusing - Orientation: Often impaired; may make up answers or answer close to the right thing or may confabulate but tries to answer - Speech: Difficulty finding word, perseveration - Affect: Slowed response, may be liable

Depression

- Onset: Recent, may relate to life changes - Course over 24 hours: Fairly stable, may be worse in the morning - Consciousness: Clear - Alertness: Normal - Psychomotor activities: Variable, agitation or retardation - Duration: Variable and may be chronic - Attention: Little impairment - Orientation: Usually normal; may answer "I don't know" to questions or may not try to answer - Speech: May be slow - Affect: Flat

Delirium

- Onset: Sudden, abrupt - Course over 24 hours: Fluctuating, often worse at night - Consciousness: Reduced - Alertness: Increased, decreased, or variable - Psychomotor activities: Increased, decreased, or mixed Sometimes increased, other times decreased - Duration: Hours to weeks - Attention: Distorted, fluctuates - Orientation: Usually impaired, fluctuates - Speech: Often incoherent, slow, or rapid; may call out repeatedly or repeat the same phrase - Affect: Variable but may look disturbed, frightened

"Aging in Place"

Allowing older adults to remain in their own homes and communities for as long as possible, thus minimizing traumatic uprooting moves to other residential and care settings.

• Aging in Place: Allowing older adults to remain in their own homes and communities for as long as possible, thus minimizing traumatic uprooting moves to other residential and care settings. • Services/Resources Which May Foster "Aging in Place" o Personal Care assistance with ADL's (caregiver) home health care o Nutrition meal preparation nutrition sites home delivered meals or groceries o Home Maintenance home repair &/or modifications housekeeping yardwork o Transportation shopping, medical appointments, etc. o Emergency call/response systems • Services that Support Independent Elders: o Local Social Service Agencies o Religious Organizations What services o Area Agencies on Aging (AAA) are provided o Social Security Administration by these agencies? Local VA offices o Senior Centers & Nutrition sites o AARP - Amer. Assoc. of Retired Persons o Better Business Bureau o Dept. of Housing & Community Development o Health Departments o Local Legal Aid Bureaus o Senior Citizen Discounts

Define "aging in place" and state factors which might facilitate it.

• Fallophobia- fear of falling • Falls lead to loss of confidence which reduces physical activity which increases dependency and leads to social withdrawal. • The nursing staff may contribute to the fear of falling in their patients by telling them not to get up by themselves or by using restrictive devices to keep them from independently moving about. More appropriate nursing responses include assessing fall risk and designing individual interventions and safety plans that will enhance mobility and independence, as well as reduce fall risk.

Define "fallophobia," how nurses may contribute to it, and its consequences.

• Polypharmacy: o Use of multiple medications for the same problem (or more than 4 medications overall) o Very common in older adults o Can occur intentionally or unintentionally o Commonly occurs with multiple specialists and lack of communication o Two major concerns: Increased risk for drug interactions Increased risk for AE's o Appropriate All drugs in the regimen address recognized indications o Inappropriate More drugs prescribed than necessary, drugs with unacceptable adverse effects or toxicity prescribed (alone or combined with other drugs), or redundant drugs prescribed • Beers Criteria o Historically developed to bring attention and action to inappropriate prescribing in older adults o Modified to include disease-drug interactions in 1997 o Recently updated with 3 goals Reevaluate the 1997 criteria Assign a relative rating of severity Identify new conditions or considerations o Drugs that are: have some indications, but that are often misused are rarely appropriate should always be avoided o Some of these drugs include: Propanolol Methyldopa Resperine • Evidence based measures for reducing adverse drug events: by paying attention to the following principles for prescribing and monitoring medications for older adults, one might also reduce risk for adverse drug events: o Give the lowest dose possible o Discontinue unnecessary therapy o Attempt nondrug approaches first o Give the safest drug possible o Assess renal function o Always consider the risk to benefit ratio when adding drugs o Assess for new interactions with any new prescription o Avoid the prescribing cascade (i.e. new meds without consideration of those to be discontinued o Avoid inappropriate medications

Define polypharmacy and evidence-based measures to reduce adverse drug events including Beer's criteria (Know what BEERS is and what types of meds are on that list).

• Nociceptive Pain: o Associated with injury to the skin, muscosa, muscle, or bone and is usually the result of stimulation of pain receptors. This type of pain arises from tissue inflammation, trauma, burns, infection, ischemia, arthropathies (rheumatoid arthritis, osteoarthiritis, gout), nonarticular inflammatory disorders, skin and mucosal ulcerations, and internal organ and visceral pain from distension, obstruction, inflammation, compression, or ischemia of organs. Pancreatitis, appendicitis, and tumor infiltration are common causes of visceral pain. Nociceptive mechanisms usually respond well to common analgesic medications and non-pharmacological interventions. • Neuropathic Pain: o Involves a pathophysiological process of the peripheral or central nervous system and presents altered sensation and discomfort. Conditions causing this type of pain include postherpetic or trigeminal neuralgia, poststroke or postamputation pain (phantom pain), diabetic neuropathy, or radiculopathies (e.g. spinal stenosis). This type of pain may be described as stabbing, tingling, burning, or shooting. Neuropathic pain is very difficult to treat and may occur at the same time as nociceptive and idiopathic pain. • Mixed or Unspecified Pain: o Usually has mixed or unknown causes. Examples include recurrent headaches and vasculitis. A compression fracture causing nerve root irritation, common in older people with osteoporosis, is an example of a mix of nociceptive and neuropathic pain. • The most common pain in late life is chronic

Define the different types of pain and give examples of each.

• Extrinsic risk factors are external to the patient and related to the physical environment. • Extrinsic Factors: o Lack of support equipment by bathtubs and toilets o Height of beds o Condition of floors o Poor lighting o Inappropriate footwear o Improper use of assistive devices o Inadequate assistive devices • Extrinsic Factors in Institutional Settings: o Limited staffing, lack of toileting programs, restraints and side rails

Describe "extrinsic" risk factors that contribute to falls in older adults.

• Intrinsic factors are unique to each patient and are associated with factors such as: o Reduced vision o Unsteady gait o Cognitive impairment o Foot deformities o Hypotension o Acute and Chronic Illness o Effect of Medications • Some of the fall risk factors that increase proportionally as one ages include the following: o Disturbances in visual acuity o Cognitive impairment o Chronic pain o Orthostatic (postural) hypotension o Cardiac arrhythmias o Uncontrolled diabetes o Depressive symptoms o Lower extremity weakness o Gait disturbances o Use of four or more prescription medications

Describe "intrinsic" risk factors that contribute to fall in older adults.

• Post Fall Assessments (PFAs) are essential to prevention of future falls and implementation of risk-reduction programs, particularly in institutional settings. • The purpose of the PFA is to identify the underlying cause(s) of the fall and assist in implementing appropriate individualized risk-reduction interventions. • Postfall Assessment: o Assess for any obvious injuries and provide appropriate care o Physical Exam including vital signs o Notify MD o Description and circumstances of the fall from the patient or witness o Associated Symptoms that occurred with fall o Medication Review o Environmental Assessment • Selected Components of Fall Risk-Reduction Interventions: o Adaptation or modification of home environment o Withdrawal or minimization of psychoactive medications o Withdrawal or minimization of other medications o Management of postural hypotension o Continence programs such as prompted voiding o Management of foot problems and footwear o Exercise, particularly balance, strength, and gait training o Staff and patient education

Describe appropriate nursing interventions "after" a fall.

• NIAAA and CSAT recommend that adults age 65 and older follow these drinking guidelines: o No more than 1 drink per day o Never more than 2 drinks on any drinking day (binge drinking) • Consistent with patterns shown to have potential health benefits • Limits for older women should be somewhat lower than those for older men • Standard Drink Chart o In the U.S., a standard drink is the equivalent of the following: 12 ounce bottle of beer=4 ounce glass of wine=1½ ounces (a shot) of liquor (e.g., vodka, gin, whiskey)=4 ounces of liquor.

Describe drinking guidelines/recommendations for adults age 65 and older.

• Increasing evidence strongly points to the potential risk roles of vascular risk factors (VRFs) and disorders (e.g., midlife obesity, dyslipidemia, hypertension, cigarette smoking, obstructive sleep apnea, diabetes, and cerebrovascular lesions. • Potential protective psychological factors (e.g., higher education, regular exercise, healthy diet, intellectually challenging leisure activity, and active socially integrated lifestyle). • Mediterranean diet, increased education, increased mental activity, increased physical activity are all shown to decrease risk of dementia.

Describe factors that are said to decrease the risk of dementia

• Randomized controlled trials support the effectiveness of multicomponent fall prevention strategies in reducing fall risks. • Interventions should include an education component complementing and addressing issues specific to the intervention being provided and tailored to individual cognitive function and language. • The relationship between exercise and fall risk reduction is strong, particularly when combined with balance training, for elders in the community. • Selected Components of Fall Risk-Reduction Interventions: o Adaptation or modification of home environment o Withdrawal or minimization of psychoactive medications o Withdrawal or minimization of other medications o Management of postural hypotension o Continence programs such as prompted voiding o Management of foot problems and footwear o Exercise, particularly balance, strength, and gait training o Staff and patient education • Nursing Programs to Decrease Falls: o Ruby Slipper Fall Intervention Program o Red, Yellow, Green Socks o Hourly rounding on 3 Ps- potty, pain, positioning o Patient and Family education • Interventions center on: o Exercise Positive relationship between falls and exercise, particularly when combined with balance training o Medication Review Risk of Fall increases with the use of 4 or more medications Common offenders: benzodiazepines, anticonvulsants, antipsychotics, hypontics, TCAs, SSRI, opioids, alcohol, blood pressure medications. BEERS Criteria o Environmental Modifications Reduce the risk of falls when part of a multifactorial program. In the hospital ensure: Environment is free of clutter Easy access for toileting Unnecessary pumps, tubing, wiring is removed o Behavior and Education Programs o Assistive Devices

Describe interventions aimed to decrease the risk of falls in older adults.

• Instruments: o Hendrich II Fall Risk Model (p.212) - recommended by the Hartford Institute for Geriatric Nursing. o Morse Fall Scale - widely used in hospitals and inpatient facilities o Minimum Data Set - used in skilled nursing facilities and includes information about history of falls and hip fractures as well as an assessment of balance during transitions and walking. • Assessment tools must be used in combo with individual assessment.

Discuss a couple of fall risk assessment tools appropriate for assessing older adults.

• Treatment and intervention strategies should include cognitive-behavioral approaches, individual and group counseling, medical and psychiatric approaches, referral to AA, family therapy, case management and community and home care services, and formalized substance abuse treatment. • There is a spectrum of prevention-intervention-treatment strategies for older adults that include: 1) prevention/education; 2) brief advice; 3) brief interventions; 4) pre-treatment interventions; and 5) formal specialized treatment. Each of these strategies has its place in working with older adults with problems related to alcohol/medication misuse/abuse/ dependence. More than one strategy may be applied to any one individual. For example, an individual who is currently abstinent (but has had problems related to alcohol at mid-life) may benefit from prevention/education to encourage continued abstinence. If this patient starts consuming alcohol again at some point in the future, brief interventions and even formal treatment may be needed. The process can repeat over time. It is important for providers to stay flexible in their approach. Knowledge and skills can allow a clinical response based on the needs of the patient at any point in time. A nonconfrontational, flexible approach provides the widest array of options when working with this vulnerable patient group. • The Spectrum of Interventions for Older Adults o Prevention/Education is used for no drinking and light-moderate drinking. o Brief advice is used for light-moderate drinking to heavy drinking. o Brief Interventions are used for light-moderate drinking, heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence. o Pre-treatment intervention is used for heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence. o Formal specialized treatments are used for heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence. • Screen Results and Actions: o Abstinence or Prevention low-risk drinker message o At-risk drinker or Brief drug user with other- intervention wise negative screen o Positive screen for abuse Brief or dependence assessment • Unless the person is in immediate danger, a stepped-care intervention approach beginning with brief interventions followed by more intensive therapies, if necessary, should be used. • Brief Intervention o A time limited, patient centered strategy focused on changing behavior and assessing patient readiness to change. o Definition: Time-limited (5 minutes to 5 brief sessions) and targets a specific health behavior o Goals: reduce alcohol consumption facilitate treatment entry o Relies on use of screening techniques o Empirical support of effectiveness for younger and older drinkers o The SAMHSA/CSAT Treatment Improvement Protocol # 34, Brief Interventions and Brief Treatments for Substance Abuse (Barry, CSAT, 1999) defined brief interventions as time limited (5 minute to 5 brief sessions) targeting a specific health behavior (e.g., at-risk drinking). The goals of a brief alcohol intervention are to: a) reduce alcohol consumption; or b) facilitate discontinuing use and/or entering specialized treatment. Interventions rely on the use of screening instruments to help to specify the level of use and consequences to determine intervention strategy. o Key Components of Alcohol Brief Interventions: Screening Feedback Motivation to change Strategies for change Negotiated behavioral contract Follow-up • Age-Specific Treatment Elements: o Attention paid to age-related issues (e.g. illness, depression, loss) o Consistent linkage with medical services o Staff with geriatric training o Avoid condescension and respect patient's views on spirituality, swearing, etc. o Longer treatment duration, slower pace o Less confrontation and probing for "private" information o Accommodate sensory and cognitive declines in educational components o Groups are especially helpful in reducing shame and improving social network o Preparation for AA is important due to high level of confrontation o Less use of self-help jargon o Less clinical distance/warmer relationships using appropriate self-disclosure o Attention to calming fears regarding confidentiality o Assistance from social services/family in medication monitoring o More family involvement o Home visitation o All treatment approaches for older patients need a strong social support component. Group socialization experiences can help the patient overcome some of the isolation often accompanying alcohol problems in this age group. Social intervention appears to benefit both early and late onset disorders. In some communities, Alcoholics Anonymous has special meetings appropriate to older adults. Older patients tend to be more faithful than younger patients in attending support group meetings and in completing specialized treatment programs. They, however, tend to be uncomfortable with the high noise level, rough language, and cigarette smoke in larger groups. Hearing and visual impairment affect the types of specialized and self-help groups that provide the most comfort. o There are a number of elements listed in slides 29-31 that improve the potential for specialized substance abuse treatment programs to show positive results with older adults. • Proposed Medicaid - Substance Abuse o Benefits Assessment Detoxification Residential treatment Outpatient treatment Medication assisted therapy

Discuss appropriate interventions for older adults with substance abuse disorders.

o Non-Opioid Analgesics o Acetaminophen (Tylenol) and NSAIDs are the non-opioids most often used for pain relief in older adults. o Acetaminophen has been found to be effective for the most common causes of pain, osteoarthritis, and back pain and should always be considered a first line approach. o The max dose for Tylenol is 4000 mg in 24 hours and is reduced for people with renal or hepatic dysfunction or who drink alcohol. o When persistent pain is of an inflammatory nature, during a short arthritic flair or in persistent rheumatoid arthritis, one of the NSAIDs may be needed. o NSAIDs bind with proteins and may induce toxic responses in elders if serum albumin levels are low. COX-2 inhibitors have been introduced to reduce GI side effects. o NSAIDs should be used carefully • Opioid Analgesics o If long-term management of moderate to severe pain is needed, opioids may be preferred because of their lower or predictable rate of adverse reactions, especially in light of the safety concerns noted with NSAIDs and acetaminophen. o Opioids have been found to be effective for all types of pain but not for all persons. o Due to a number of age-related changes, opioids may produce a greater analgesic effect, higher peak, and a longer duration of effect; a short trial with clear goals is recommended along with careful clinical observation of effect. o Sedation and impaired cognition often occur when opioid analgesics are started or doses increased. o Opioid treatment should begin with "as-needed" doses of short-acting medications and should be titrated based on the amount needed, response obtained, and side effects over a 24-hour period. o Side effects of opioids are significant to older adults; they include gait disturbance, dizziness, sedation, falls, nausea, pruritus, and constipation. • Adjuvant Drugs o There are a number of drugs developed for other purposes that have been found to be useful in pain management, sometimes alone, but more often in combination with an analgesic; these have come to be referred to as adjuvant drugs. o These include antidepressants, anticonvulsants, and other agents that alter neural membranes, or neural processing. o Thought to be most effective in treating neuropathic pain.

Discuss non-opioid, opioid, and adjuvant drugs.

• Energy/Touch Therapies • TENS • Acupuncture/Acupressure • Relaxation, Meditation, Guided Imagery • Music • Hypnosis • Activity • Cognitive-Behavioral Therapy

Discuss non-pharmacological methods of pain management.

• Persons with cognitive impairment are consistently untreated or undertreated for pain. Studies have shown that older adults who are cognitively impaired receive less pain medication, even though they experience the same painful conditions as elders who are cognitively intact. • Many caregivers believe that people who are cognitively impaired do not experience pain as severely as those who are cognitively intact. However, there is no evidence for this. • Must assume any procedure painful to cognitively intact elders will also be painful to cognitively impaired elders • Mild to moderate cognitively impaired can self-report pain that is valid • Severely cognitive impaired need to be treated • Non-verbal expressions of pain: o Agitation o Aggression o Increased confusion o Passivity o Changes in behavior o Activities of daily living o Vocalizations o Physical changes • Pain Assessment o Pain is real o Ask about pain regularly o Isolation o Notice nonverbal pain signs o Evaluate pain characteristics o Does pain impair function? o Onset o Location o Duration o Characteristics o Aggravating factors o Relieving factors o Treatment previously tried

Discuss pain assessment and management in elders with cognitive impairment

• Drugs developed to treat anxiety are referred to as anxiolytics or antianxiety agents. • These agents include benzodiazepines and buspirone. • Benzodiazepines: o Highly effective anxiolytic and hypnotic agents. o They are popular because of their quick sedating effects for the person who is experiencing acute anxiety, such as a new resident in a long-term care facility. o Side effects include: Drowsiness Dizziness Ataxia Mild cognitive deficits Memory impairment o Signs of toxicity include: Excessive sedation Unsteady gait Confusion Disorientation Cognitive impairment Memory Impairment Agitation Wandering o Because these symptoms resemble dementia, persons can easily be misdiagnosed once the benzodiazepines have been taken. o Almost all have long half-lives an when combined with the normal changes in aging, profound sedation and toxicity are significant risks. • Buspirone (BuSpar) o Nondiazepine alternative o Although a side effect is dizziness, this is often dose related and resolves with time. o It is not addictive, and may have an additive effect when combined with some of the SSRIs, so lower doses can be used.

Discuss the anxiolytic medications.

• Healthcare Professional Barriers: o Lack of education regarding pain assessment and management. o Concern regarding regulatory scrutiny. o Fears of opioid-related side effects/addiction. o Belief that pain is a normal part of aging. o Belief that cognitively impaired elders have less pain, lack of ability to assess pain in cognitively impaired. o Personal beliefs and experiences with pain. o Inability to accept self-report without "objective" signs. • Patient and Family Barriers: o Fear of medication side effects. o Concerns related to addiction. o Belief that pain is a normal part of the aging process. o Belief that nothing much can be done for pain in older people. o Fear of being a "bad patient" if complaining/fear of what pain may signal/ • Health Care System Barriers: o Cost o Time o Cultural bias regarding opioid use

Discuss the barriers to pain management

• Falls and other accidents • Functional Impairment • Slowed rehabilitation • Mood changes • Increased health care cost • Caregiver strain • Sleep disturbance • Changes in nutritional status • Impaired cognition • Increased dependency and helplessness • Depression, anxiety, fear • Decline in social and recreational activities • Increased health care utilization and costs

Discuss the consequences of untreated pain

• MYTH: Pain is expected with aging. • FACT: Pain is not normal with aging. The presence of pain in the elderly necessitates aggressive assessment, diagnosis, and management similar to that of persons at any age. • MYTH: Pain sensitivity and perception decrease with aging. • FACT: While an older adult may have developed excellent coping skills making it more difficult for others to observe cues for pain, there is no evidence that there is a reduction in actual pain. • MYTH: If a patient does not complain of pain, there must not be much pain. • FACT: This is erroneous in all ages but particularly in the elderly. Older patients may not report pain for a variety of reasons. They may fear the meaning of pain, diagnostic workups, or pain treatments. Depending on one's belief systems they may not want to be a bother, may believe suffering is necessary to atone for past sins, may fear addiction, or may think pain is a normal part of aging. Cognitive and communication difficulties also may make older people unable to report pain. • MYTH: A person who has no functional impairment, appears occupied, or is otherwise distracted from pain must not have significant pain. • FACT: Patients have a variety of reactions to pain. Many patients are stoic and refuse to "give in" to their pain. Over extended periods, the elderly may mask any outward signs of pain. This varies highly by culture. • MYTH: Narcotic medications are inappropriate for patients with persistent nonmalignant pain. • FACT: Opioid analgesics are often indicated in persistent nonmalignant pain. • MYTH: Potential side effects of narcotic medication make them too dangerous to use in the elderly. • FACT: Narcotics may be used safely in the elderly. Although elderly patients may be more sensitive to narcotics, this does not justify withholding narcotics and failing to relieve pain. • MYTH: People with dementia do not feel pain. • FACT: Older adults with cognitive impairment are just as likely to experience painful illnesses. They feel pain, but changes in the brain may change the way pain is processed. They may not understand or even remember their pain or may not be able to report what they feel. Changes in behavior (e.g., agitation, aggression, calling for help, sleep pattern changes, appetite changes) are common pain behaviors in cognitively impaired elders.

Discuss the fact and fiction of pain the elderly

• The initial step in ensuring that drug use is safe and effective is to conduct a comprehensive drug assessment. • To determine possible misunderstanding or misuse, it is best to ask the person how he or she actually takes the medicine rather than to depend on how the label is written. • The nurse's analysis of the assessment data is centered on identifying unnecessary or inappropriate medications, establishing safe usage, determining the patient's self-medication management ability, monitoring the effect of current medications and other products, and evaluating effectiveness of any education provided. • Patient education is the most common intervention used to promote medication adherence. • Because of the complex needs of the older patient, education can be particularly challenging. • The following tips may be helpful when the goal of the nurse is to promote healthy aging related to medication use: o Key persons: Find out who, if anyone, manages the person's medications, helps the person, or assists with decision making; and with the elder's permission, make sure that the helper is present when any teaching is done. o Environment: Minimize distraction, and avoid competing with television or others demanding the patient's time; make sure the person is comfortable and is not hungry, thirsty, tired, too warm or too cold, in pain, or in need of the toilet. o Timing: Provide the teaching during the best time for the day for the person, when he or she is most engaged and energetic. Keep the education sessions short and succinct. o Communication: Ensure that you will be understood. o Reinforce Teaching: Many elders continue to use the strategies they have developed over the years to remember to take their medications. • A safe, optimal, and feasible drug plan is one to which the patient can adhere.

Discuss the implications of care in terms of nursing assessment and patient education for med use.

• Changes in Behavior: o Restlessness and/or agitation or reduction in movement o Repetitive movements o Physical tension such as clenching teeth or hands o Unusually cautious movements, guarding • Activities of daily living: o Sudden resistance to help from others o Decreased appetite o Decreased sleep • Vocalizations: o Person groans, moans, or cries for unknown reasons o Person increases or decreases usual vocalizations • Physical Changes: o Pleading expression o Grimacing o Pallor or flushing o Diaphoresis (sweating) o Increased pulse, respirations, or blood pressure

Discuss the pain cues in older adults who have difficulty with communication

• Checklist of Nonverbal Pain Indicators (CNPI) • NOPAIN • PAINAD (Pain assessment in Advanced Dementia Scale) o A simple, short, focused tool that can be used on a more frequent basis; it has been found to demonstrate sensitivity to change with intervention. o Four behaviors are rated by an observer on a scale of 0 to 2: Breathing independent of vocalization Negative vocalizations Facial expression Body language Consolability • PATCIE (Pain Assessment Tool in Cognitively Impaired Elders) • PACSLAC o A comprehensive behavioral assessment tool that may be very useful as an initial pain screen as well as an interval measure. o There are four domains of observation: Facial expression Activity/body movement Social/personality/mood Physiological/sleeping/eating/vocal • The use of rating scales, such as those found in Figures 17-2 and 17-3, have become the standard of care. A patient with persistent pain is asked to rate the "worst" and "best" pain. If the cause is something for which there is little control, such as one of the pain syndromes, a "pain" or "comfort" goal can be set (Box 17-10). The scales also serve as a basis for evaluation of the effectiveness of the pain-relieving intervention, leaving the determination of the relative painfulness to the patient and avoiding variation by the nurse. Scales have been found to be useful for persons who are cognitively intact and those with mild to moderate cognitive impairment. Scales that are currently available and tested may not be reliable for persons with delirium or more severe impairments (Herr et al., 2010). • For cognitively intact older adults, the Numeric Rating Scale (NRS) (see Figure 17-3 b), a verbally administered 0-10 numerical rating scale, may be a good first choice, especially if the patient has limited vision (Hanks-Bell et al., 2004). • The Verbal Descriptor Scale (VDS) and the Pain Thermometer, an adaptation of the VDS, are also good choices and have been shown to be effective in the older adult population (Herr, 2002). The VDS includes adjectives describing pain, such as mild, moderate, severe, and worst pain imaginable. • The Pain Thermometer is a diagram of a thermometer with word descriptions that show increasing pain intensities. • The Faces Pain Scale (FPS) and the Faces Pain Scale-Revised (FPS-R) (Hicks et al., 2001) show a series of faces, with each depicting a different facial expression indicating level of pain. They were originally developed for children but may be effective for older adults as well, especially for persons with poorer verbal skills. However, it may be difficult to determine if pain or mood is being measured when using the FPS (Hanks-Bell et al., 2004). • Both the Pain Thermometer and the FPS depend on visual acuity and may need to be enlarged for the visually impaired older person • The comprehensive pain assessment is only possible when caring for an elder who is cognitively intact or minimally to moderately impaired. • The Pain Assessment in Advanced Dementia (PAINAD) and Pain assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC). These are used in addition to the MDS-3 already required due to the complexity of assessing pain in a non-verbal adult.

Discuss the pain rating scales

• Medications used to lower blood pressure: o Coenzyme Q10 o Garlic o Green Tea o Hawthorn o Melatonin o Magnesium • Medications used for Gastrointestinal Disorders: o Psyllium - used to treat IBS, assist with constipation, and as a bulk laxative o Calcium supplements - used to reduce gastric acidity o Probiotics - control harmful GI organisms • Medications used for Cancer: o Calcium, garlic, gingko, and psyllium are possibly helpful for decreasing colorectal and gastric cancer risk. • Medications used for Alzheimer's Disease: o Gingko is often used by older persons with dementia because it increases blood supply to the brain. o Sage (Salvia officinalis) significantly improved cognitive outcomes measured by the cognitive subscale of the AD assessment scale and on the clinical dementia rating scale. o Caffeine for protection against cognitive decline. • Medications used for Diabetes: o Fenugreek can induce a hypoglycemic response. o Cinnamon has also been linked with lowering blood glucose. o Chromium, Ginseng, Gymnema, and Stevia have also been linked with lowering blood glucose.

Discuss the use of herbs and supplements for select medical conditions

• Once pain is assessed, negotiate a pain relief/comfort goal with patient. • Be aware of co-morbidities that may affect assessment and management of pain. • Anticipate age-associated, but unpredictable, differences in sensitivities and toxicities. • Anticipate the possibility of increased sensitivity to opioids. • Always start at a low dose and slowly titrate to relief. • Use the least-invasive route of administration possible first. • Plan timing of medication administration to the needs of the patient. • Never use placebos. • Consider complementary, non-pharmacological, and pharmacological approaches. • Accept that "rational polypharmacy" may be necessary when no one agent can achieve the desired effect.

General principles of pharmacological management of pain in older adults.

• Adult Day Care Facilities: o Provides supervision, meals, medication administration, and social & recreational activities during day hours. Some provide health-related services and transportation. o Provide respite for caregivers. o Convenient for families who work during the day. • Reimbursed by Medicaid (Slide 41 Alternative living) • Some ADS are private pay, and others a funded through Medicaid home and community-based waiver programs, state and local funding, and the Veteran's Administration.

How is adult day care reimbursed?

• Skilled Nursing/Long Term Care Facility (N.H.): o Provide round the clock personal care (skilled care also for some facilities). o May specialize in short-term or acute nursing care, intermediate care or long-term skilled nursing care, & rehab. o May be freestanding or part of a seniors community. o Licensure required in TX (Agency - DADS) • The majority of nursing homes are for-profit organizations (67%), with 31% managed by not-for-profit organizations. • Nursing home chains own 54% of all nursing homes. • 1935 - Social Security Act passed & provided additional funds for purchase of services. • Some facilities opened, offered room & board, & personal care services. • 1946 - Govt. granted funds to help construct N.H. thru the Hill-Burton Hospital Survey & Construction Act. • Original intent was to assist in construction of hospitals. • 1965 - Older Americans Act - developed to create a national network for the comprehensive planning, coordination, & development of aging services. • Services provided under the OOA: I & R, Care management, In-home services (homemaker asst., respite, emergency response systems, friendly visitors, telephone reassurance), senior centers, nutrition programs, & legal assistance/advocacy. • 1965 - enactment of Medicare & Medicaid. o The number of nursing homes increased. • 1987 - Omnibus Budget Reconciliation Act Requirements: o Use of a standardized assessment tool (MDS); o Timely development of a written care plan. o Reduction in use of restraints & psychotopic drugs o Increase in staffing o Protection of residents' rights. o Training for nursing assistants o Deficient nursing homes could receive sanctions • Costs of Care: o The majority of the cost of care in nursing homes is borne by Medicaid (42%), followed by Medicare (25%), out of pocket (22%), and private insurance and other sources (11%). o Medicare covers 100% of the costs for the first 20 days. o Beginning on day 21 of the nursing home stay, there is a significant co-payment (patient pays 20%, Medicare pays 80% of cost). This co-payment may be covered by a Medigap policy. o After 100 days the individual is responsible for all costs. o In order for a nursing home stay to be covered by Medicare, you must enter a Medicare-approved "skilled nursing facility" or nursing home within 30 days of a hospital stay that lasted at least 3 days. o Medicare does not cover the costs of care in chronic, custodial, and long-term units. If the older person was admitted to the nursing home because of a dementia diagnosis and the need for assistance with ADLs and maintenance of safety, Medicare would not cover the cost of care unless there was some skilled need. o The purchase of long-term care insurance is an option, but it is expensive and pays for less than 5% of long term care costs.

How is nursing home care/long term care reimbursed/financed?

• The question, "Have you had a drink containing alcohol within the past three months?" could be included in an assessment to identify clients in whom further screening is indicated. This could then be followed by as screening instrument such as the Michigan Alcoholism Screening Test - Geriatric Version (MAST-G) or the CAGE (Cut, annoyed by others, feel Guilty, need Eye opener) Questionnaire. • Every person age 60 and older should be screened for alcohol and prescription drug use/abuse as part of regular physical examination- 'Brown Bag Approach' o Screen or re-screen if certain physical symptoms are present or if the older person is undergoing major life changes or transitions o Ask direct questions about concerns Preface questions with link to medical conditions or health concerns Do not use stigmatizing terms (e.g. alcoholic) • Definition of Screening o Application of a test to members of a population for the purpose of estimating their probability of having a specific disorder o Examples: Cancer, Depression, Hypertension • Evidence on Screening o Screening instruments are usually tested by concurrent validity o Screen is compared to a "gold standard" criterion measure o "Gold standard" is usually a lengthy diagnostic interview • Sensitivity - Measure of instrument's accuracy in detecting individuals who do have an alcohol problem (True positive/ False negative) • Specificity - Measuring of instrument's accuracy in identifying individuals who do not have an alcohol problem (True negative/ False positive) • Choose Screens By o Number of items o Method of administration o Substances covered o Accuracy by age group, gender, pregnancy status, ethnic group • CAGE o 4 yes/no questions (1 yes = positive) o Administered by interview o Alcohol only o Screens for abuse and dependence o Add quantity and frequency questions to screen for at-risk drinking o Sens: 43% - 94% Spec: 78% - 96% • AUDIT o 12 questions - multiple choice o Administered in writing o Alcohol only o Screens for at-risk drinking, abuse, and dependence o Accurate across many cultures/nations o Sens: 51% - 97% Spec: 78% - 96% o The Alcohol Use Disorders Identification Test is possibly the most accurate screening test for at-risk and problematic drinking. Each of 10 items has four multiple choice responses, and the scoring is different for each response. o The AUDIT is known to be accurate for individuals of many different nations and cultures. The major disadvantage is that it must be administered in writing. • CRAFFT o 6 yes/no questions (weighted score) o Administered by interview o Alcohol and drugs o Validated for adolescents o Sens: 92% Spec: 82% o The CRAFFT was developed because the CAGE questions are not particularly accurate for adolescents. It can be easily memorized, incorporated into routine interviews, and scored in one's head. It assesses well for alcohol and drug problems but not for at-risk use. • SMAST-G o 10 yes-no items o Administered by questionnaire o Covers alcohol only o Validated for ages 55 to 81 o Sens: 89% Spec: 72% • Two-Item Conjoint Screen o 2 yes/no questions (1 yes = positive) o Administered by interview o Covers alcohol and drugs o Screens for abuse and dependence o Add quantity and frequency questions to screen for at-risk use o Sens: 81% Spec: 81% • NIAAA Clinician's Guide Recommendations o Do you sometimes drink beer, wine, or other alcoholic beverages? o How many times in the post year have you had.... 5 or more drinks in a day? (men) 4 or more drinks in a day? (women) • Screening Instruments and Assessment Tools o Alcohol Consumption Quantity, Frequency, Binge Drinking o Alcohol Consequences AUDIT, MAST, SMAST, CAGE Elder-Specific: MAST-Geriatric Version, SMAST-G o Health Screening Survey includes other health behaviors: nutrition, exercise, smoking, depression • The most common alcohol screening questions include: 1) alcohol consumption (quantity, frequency, binge drinking); and 2) alcohol consequences. Some of the instruments that have been used with older adults are in a 'stand alone' format focusing exclusively on alcohol use (ex: Alcohol Use Disorders Identification Test (AUDIT); Michigan Alcoholism Screening Test-Geriatric version (MAST-G) (Blow et al., 1992b); CAGE (acronym for a 4-item screener: Have you felt you should 'Cut down? Have you felt Guilty about your drinking? Have you been Annoyed by others concerns about your drinking? Have you needed a drink when you first get up the morning [Eye-opener]?). The MAST-G is a validated elder-specific screening instrument that targets consequences. The Health Screening Survey (HSS) includes quantity/frequency, binge, CAGE, and perceptions of a past or present problem with alcohol (Fleming & Barry, 1991). This scale imbeds alcohol questions in a health context with three other health behaviors -- exercise, nutrition, and smoking. • Screening for alcohol use and problems is not always standardized and not all standardized instruments have good reliability and validity with older adults. This module contains examples of questionnaires that have validity and reliability when used with older adults -- the Short Michigan Alcoholism Screening Test - Geriatric Version (SMAST-G) (Blow et al., 1998) (below), and quantity/frequency questions imbedded in a Health Screening Survey (HSS) (Fleming & Barry, 1991). Both of these instruments have been widely used and tested with older adults. The CAGE, a widely used alcohol screening test, does not have high validity with older adults (Adams et al., 1996) and, if used, should be part of a larger questionnaire (e.g., the HSS) or interview that includes quantity/frequency questions, and questions about consequences.

Identify and describe well known assessment/screening tools for alcohol use/abuse in older adults?

1. Gingko 2. Sage (Salvia officinalis) 3. Caffeine

Medications (herbal supplements) used for Alzheimer's Disease: o _________ is often used by older persons with dementia because it increases blood supply to the brain. o _________ significantly improved cognitive outcomes measured by the cognitive subscale of the AD assessment scale and on the clinical dementia rating scale. o _________ for protection against cognitive decline

1. Calcium 2. garlic 3. gingko 4. psyllium

Medications (herbal supplements) used for Cancer: o ________, ________, ________, and ________ are possibly helpful for decreasing colorectal and gastric cancer risk.

1. Fenugreek 2. Cinnamon 3. Chromium 4. Ginseng 5. Gymnema 6. Stevia

Medications (herbal supplements) used for Diabetes: o ________ can induce a hypoglycemic response. o ________ has also been linked with lowering blood glucose. o ________, ________, ________, and ________ have also been linked with lowering blood glucose.

1. Psyllium 2. Calcium supplements 3. Probiotics

Medications (herbal supplements) used for Gastrointestinal Disorders: o _________ - used to treat IBS, assist with constipation, and as a bulk laxative o _________ - used to reduce gastric acidity o _________ - control harmful GI organisms

o Coenzyme Q10 o Garlic o Green Tea o Hawthorn o Melatonin o Magnesium

Medications (herbal supplements) used to lower blood pressure: 1. 2. 3. 4. 5. 6.

• Know the person's past patterns. • Look at nonverbal signs, such as tone of voice, facial expressions, and gestures. • Speak slowly. • Be calm and patient. • Face the person and keep eye contact; get to the level of the person rather than standing over him or her. • Explain all actions. • Smile. • Use simple, familiar words. • Allow adequate time for response. • Repeat if needed. • Tell the person what you want him or her to do rather than what you don't want him or her to do. • Give one-step directions; use gestures and demonstration to augment words. • Reassure of safety. • Keep caregivers consistent. • Assume that communication and behavior are meaningful and an attempt to tell us something or express needs. • Do not assume that the person is unable to understand or is demented.

State communication strategies that are helpful in caring for people experiencing delirium.

Chronic

The most common pain in late life is ________.

• Assisted Living Facility: o Private apartments - residents receive assistance with non-medical aspects of daily activities (e.g. meals, personal care, housekeeping, laundry, transportation, & medication supervision prn). o 1 or 2 rooms & bathroom; share common areas for meals and social activities. o May be a part of CCRC, N.H., or stand alone. o Licensure required in TX (Agency: DADS) • 86.9 years old • Female (74%) • 70% moved to the assisted living facility from a private home or apartment • Needs help with at least two activities of daily living (ADLs) o Bathing: 64% o Dressing: 39% o Toileting: 26% o Transferring: 19% o Eating: 12% • Needs help with instrumental activities of daily living (IADLs) o Meal preparation: 87% o Medications: 81% • 42% have Alzheimer's disease or other dementia types of diagnosis • Length of stay: 28.3 months o 59% move to a nursing facility o 33% die while a resident

Typical Assisted Living Resident:

PLST Model

Using this model, care is structured to decrease the stressors and provide a safe and predictable environment for patients with dementia

• Among older adults, falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma. • Falls and their subsequent injuries result in physical and psychosocial consequences. • Twenty percent to 30% of people who fall suffer moderate to severe injuries (bruises, hip fractures, TBI). • Consequences include: Hip fractures, TBI, and fallophobia.

What are consequences of falls in the older adult?

• Substance abuse often arises in old age as a coping mechanism to deal with loss, anxiety, depression, boredom, or pain associated with chronic illness. • Issues Unique to Older Adults: o Loss (people, vocation, status) o Social Isolation and loneliness o Major financial problems o Changes in housing o Family concerns o Burden of time management o Complex medical problems o Multiple medications o Sensory deficits o Reduced mobility o Cognitive impairment or loss o Impaired self-care • Older women may be at greater risk for alcohol problems due to potential loneliness and depression from outliving spouse, other losses

What are issues and concerns unique to older adults that may increase risk of substance abuse?

• Barriers to Seeking Alcoholism Treatment for Older Adults: o Resistance to asking for help o Disdain of labels (alcoholic, old) o Lack of transportation o No significant others to assist in motivation to seek help o Providers less likely to refer older adults o Gaps in substance abuse, aging, and mental health services o Limited funds o Limited mobility o Limited support o Denial o Lack of treatment designed specifically for older adults o Health status • Working with staff and family members (if appropriate) to help patients deal with these barriers will improve the potential for positive outcomes from any specialized treatment programs. • Older patients are often reluctant to enter a hospital or residential treatment center because they are concerned about leaving their homes unprotected or about making arrangements for their stay. • Some older patients may be reluctant to turn to "outsiders" for help. • Inpatient treatment is preferred when the patient is suffering the effects of poor nutrition, poor overall health status, a history of DT's or seizures, or cognitive problems. Inpatient treatment is also needed when there are no obvious community support systems for the patient (i.e., family, caretakers, services for aging). In the U.S. there are a very few alcohol and drug treatment programs that have specialized services for older adults (Blow, CSAT, 1998). • Although alcohol abuse/dependence is a significant and growing health problem in the United States (Council on Scientific Affairs, AMA, 1996), there have been few systematic studies of formal alcoholism treatment outcome among older adults (Atkinson, 1995). The study of treatment outcomes for older adults who meet criteria for alcohol abuse/dependence has become a critical issue because of their unique needs for targeted treatment intervention. • Because traditional alcoholism treatment programs generally provide services to few older adults, sample size issues have been a barrier to studying treatment outcomes for older adults in formalized treatment. The development of elder-specific alcoholism treatment programs in recent years has provided sufficiently large numbers of older adults with alcohol abuse/dependence to begin to facilitate studies of this special population (Atkinson, 1995). • A remaining limitation with this population is the lack of longitudinal studies of treatment outcomes. More work needs to be done in this area to determine if elder-specific treatment is effective and if older clients in an elder-specific program show better outcomes than older clients in a mixed age program.

What are potential barriers to treatment for older adults who have substance abuse problems?

• 1st Stage - Young-Old; Snowbirds • 2nd Stage - Chronic Illness • 3rd Stage - Disability • Relocation: A major decision: o Loss of space o Change of neighborhood o Move from friends o Abrupt moves may increase stress, illness, & disorientation. o The greater the change, the longer it will take to adapt. • Least Restrictive Living Environment: A living arrangement which maximizes choice and minimizes lifestyle disruption.

What are potential reasons an elder might have to relocate from his/her home?

• Address safety • Structure daily living to maximize remaining abilities • Monitor general health and impact of dementia on management of other medical conditions • Support advance care planning and advanced directives • Educate caregivers in the areas of problem-solving resource access, long range planning, emotional support, and respite. • Several nursing models of care are helpful in recognizing and understanding the behavior of individuals with dementia and can be used to guide practice and assist families and staff in providing care from a more person-centered framework. The Progressively Lowered Stress Threshold model (PLST) and the Need-driven Dementia-compromised Behavior model (NDDB) focus on "the close interplay between person, context, and environment. These models propose that behavior is used to communicate or express, in the best way the person has available, unmet needs (physiological, psychosocial, disturbing environment, uncomfortable social surroundings) and/or difficulty managing stress as the disease progress." • PLST Model: o Using this model, care is structured to decrease the stressors and provide a safe and predictable environment. • NDB Model: o Proposes that the behavior of persons with dementia carries a message of need that can be addressed appropriately if the person's history and habits, physiological status, and physical and social environment are carefully evaluated. o Rather than behavior being viewed as disruptive, it is viewed as having meaning and expressing needs.

What are several non-pharmacologic interventions for treating dementia?

• Medications that interact with alcohol include analgesics, antibiotics, antidepressants, antipsychotics, benzodiazepines, H2 receptor antagonists, nonsteroidal anti-inflammatory drugs (NSAIDS), and herbal medications (Echinacea, valerian). Acetaminophen taken on a regular basis, when combined with alcohol, may lead to liver failure. • Alcohol diminishes the effects of oral hypoglycemic, anticoagulants, and anticonvulsants. • Psychoactive Meds with Significant Alcohol Interactions: o Anxiolytic Benzodiazepines Alprazolam Chlordiazepoxide Diazepam Lorazepam Oxazepam Clonazepam Buspirone Meprobamate o Sedative/Hypnotic Benzodiazepines Flurazepam Prazepam Quazepam Temazepam Triazolam o Other Sedatives Zolpidem Choral hydrate Hydroxyzine Diphenhydramine Doxylamine Glutethimide o Opiate/Opioid Analgesics Methylmorphine Codeine Hydrocodone Meperidine Oxycodone Propoxyphene Pentazocine Morphine o Anticonvulsants Phenytoin Phenobarbital Primidone Carbamazepine o Other Psychotropics - Phenothiazines Chlorpromazine Trifluoperazine Lithium o Other Drugs - Antidepressants, tricyclic Amitriptyline Nortriptyline Imipramine Desipramine o Barbiturates Phenobarbital

What classes of drugs have significant interaction with alcohol?

• For a drug to be effective, it must be absorbed into the bloodstream. The amount of time between the administration of the drug and its absorption depends on a number of factors, including the route of administration, bioavailability, and the amount of drug that passes through the absorbing surfaces in the body. • Most solid oral drugs are designed to dissolve in the stomach. • There does not seem to be conclusive evidence that absorption in older adults is changed appreciably. • Diminished salivary secretion and esophageal motility may interfere with swallowing some medications, which could in turn lead to erosions is adequate fluids are not taken with the medications. • Decreased gastric pH, common in the elderly, will retard the action of acid-dependent drugs. • Delayed stomach emptying may diminish or negate the effectiveness of short-lived drug that could become inactivated before reaching the small intestine. Can affect enteric coated aspirin. • Slowed intestinal motility, frequently seen with aging, can increase the contact time and increase drug effect because of prolonged absorption, significantly increasing the risk for adverse reactions or unpredictable effects. • In normal aging, both liver mass and blood flow are significantly decreased, resulting in reductions in the metabolism rate with potential but unknown implications for the older adult. • Drying of the mouth, a common side effect of many of the medications taken by older adults, may reduce or delay buccal absorption. • Transdermal routes overcome any first-pass effect problems. • Age changes that occur that can effect absorption: o Decreased salivary secretion o Diminished esophageal motility o Slowed intestinal motility o ↓ gastric acid output o ↑ gastric pH • Outcomes of these changes: o No significant change in quantity absorbed. o Time to onset or peak may be delayed.

What is absorption and how are drugs affected by it due to the effects of aging?

• Systemic circulation transports drug through the body • High blood flow organs receive highest concentration • Low blood flow organs receive lowest • Fat-soluble drugs • Water-soluble drugs • Plasma proteins • The organs of high blood flow (e.g., brain, kidneys, lungs, liver) rapidly receive the highest concentrations. • Distributions of organs more slowly and results in lower concentrations of the drug in these tissues. • Drugs that are highly lipid soluble are stored in the fatty tissue, thus extending and possibly increasing the drug affect, depending on the level of adiposity. • Decreased body water in normal aging leads to higher serum levels of water-soluble drugs, such as digoxin, ethanol, and aminoglycosides. This can result in a higher relative volume of lipophilic drugs and a decreased relative volume of hydrophilic drugs. • Distribution also depends on the availability of plasma protein in the form of lipoproteins, globulins, and especially albumin.

What is distribution and how are drugs affected by it due to the effects of aging?

• Drugs and their metabolites are excreted in sweat, saliva, and other secretions but primarily through the kidneys. They are excreted either unchanged or as metabolites. A few drugs are eliminated through the lungs, as unreabsorbed metabolites in bile and feces, or in breast milk. Very small amounts of drugs and metabolites can also be found in hair, sweat, saliva, tears, and semen. • Excretion occurs through: o Sweat o Saliva o Lungs o Bile o Feces o Breast milk o Kidneys (Primarily occurs here) • Because kidney function declines in many older persons, so does the ability to excrete or eliminate drugs in a timely manner. The significantly decreased glomerular filtration rate leads to prolongation of the half-life of drugs eliminated through the renal system, resulting in more opportunities for accumulation and potential toxicity or other adverse events. • The doses of many drugs eliminated through the renal system are based on the patient's measured or estimated creatinine clearance.

What is excretion and how are drugs affected by it due to the effects of aging? For example, anticholinergic affects?

• Health insurance for persons 65+, receiving SS disability for 24+ months, permanent kidney failure, or ALS • 65 & older • Receiving Social Security disability benefits at least 24 months • Permanent kidney failure • Amyotrophic Lateral Sclerosis (ALS) • Medicare Enrollment Periods: o Initial - at age 65 o Special - if still working o General - January-March • An insurance plan for persons who are age 65, blind, or totally disabled, including those with end-stage renal disease. • Of the costs of Medicare part B, Part C, and Part D, 75% comes from general revenue of the federal government. The remainder comes primarily from the beneficiaries themselves in the form of premiums and co-pays. • Persons enrolled in medicare pay a monthly premium for components B through D, usually deducted directly from their social security income. • In the 7 months surrounding a person's 65th birthday (from 3 months before), all persons who are eligible for medicare part A must select and apply for part B or C through the social security administration.

What is medicare and who is eligible?

• Process where chemical structure of drug converted to metabolite. A drug will continue to exert a therapeutic effect as long as it remains either in its original state or as an active metabolite or metabolites. • Determines the duration of a drug • Active metabolites increase chance of adverse effects • Cytochrome P450 monooxygenase system • Metabolism occurs in two phases: o Phase I - Oxidative o Phase II - Conjugative • The oxidative metabolizing enzymes are known as the cytochrome P450 (CYP450) monooxygenase system. It consists of 50 isoforms. These isoforms metabolize the parent compound by adding or subtracting a part of the drug molecule. These can vary on the genetics of the person. • Because of the high level of variability in metabolism from individual to individual, it is difficult to ascribe decreased drug metabolizing capability to increased age. With aging, liver activity, mass, and volume and blood volume are diminished, with resultant decreases in hepatic exposure. • Drugs that do not undergo significant first-pass metabolism are not affected by the aging liver, but those that undergo extensive first-pass metabolism may exhibit decreased metabolism, increased bioavailability, and a decreased rate of biotransformation.

What is metabolism and how are drugs affected by it due to the effects of aging?

• Abstinence: no alcohol in previous year • Low-risk use: alcohol use within guidelines and not associated with problems • At-risk and problem use: alcohol use that has resulted in adverse medical, psychological or social consequences; or substantially increases the likelihood of such problems • Dependence: medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite problems, physiological symptoms such as tolerance and withdrawal

What is the difference between low risk and at risk alcohol use, and dependence?

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

What nursing interventions might be used for "wandering" residents in nursing homes?

• Risk of Fall increases with the use of 4 or more medications • Benzodiazepines • Anticonvulsants • Antipsychotics • Hypnotics • TCAs • SSRIs • Opioids • Alcohol

What types of medications are most likely to contribute to falls?

• Age-related changes make older adults more vulnerable to adverse alcohol effects o Higher BAC from a given dose o More impairment at a given BAC • Implications for older adult drinkers: o Moderate levels of consumption can be more risky o More consequences from maintaining consumption o Increased consumption may quickly result in consequences • Older women are more susceptible to the effects of alcohol since they have less body water than men, less mean muscle mass, and lower levels of the enzyme that breaks down alcohol. • Many drugs that elders use for chronic illnesses cause adverse effects when combined with alcohol. Alcohol interacts with at least 50% of prescription drugs. • Older people develop higher blood alcohol levels because of age-related changes (increased body fat, decreased lean body mass and total body water content) that alter absorption and distribution of alcohol. Reduced liver and kidney function slow alcohol metabolism and elimination • A decrease in the gastric enzyme alcohol dehydrogenase results in slower metabolism of alcohol and higher blood levels for a longer time.

Why might older adults be more vulnerable to adverse alcohol effects?

Formal specialized treatments

____________ are used for heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence.

Brief Interventions

____________ are used for light-moderate drinking, heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence.

Pre-treatment intervention

____________ intervention is used for heavy drinking, alcohol problems, mild dependence, and chronic/severe dependence.

Brief adviceBrief advice

____________ is used for light-moderate drinking to heavy drinking.

Prevention/EducationPrevention/Education

____________ is used for no drinking and light-moderate drinking.

At-risk and problem use

alcohol use that has resulted in adverse medical, psychological or social consequences; or substantially increases the likelihood of such problems

Low-risk use

alcohol use within guidelines and not associated with problems

Dependence

medical disorder characterized by loss of control, preoccupation with alcohol, continued use despite problems, physiological symptoms such as tolerance and withdrawal

AUDIT alcohol screen

o 12 questions - multiple choice o Administered in writing o Alcohol only o Screens for at-risk drinking, abuse, and dependence o Accurate across many cultures/nations o Sens: 51% - 97% Spec: 78% - 96% o The Alcohol Use Disorders Identification Test is possibly the most accurate screening test for at-risk and problematic drinking. Each of 10 items has four multiple choice responses, and the scoring is different for each response. o The AUDIT is known to be accurate for individuals of many different nations and cultures. The major disadvantage is that it must be administered in writing.

CAGE alcohol screen

o 4 yes/no questions (1 yes = positive) o Administered by interview o Alcohol only o Screens for abuse and dependence o Add quantity and frequency questions to screen for at-risk drinking o Sens: 43% - 94% Spec: 78% - 96%

CRAFFT alcohol screen

o 6 yes/no questions (weighted score) o Administered by interview o Alcohol and drugs o Validated for adolescents o Sens: 92% Spec: 82% o The CRAFFT was developed because the CAGE questions are not particularly accurate for adolescents. It can be easily memorized, incorporated into routine interviews, and scored in one's head. It assesses well for alcohol and drug problems but not for at-risk use.

PACSLAC

o A comprehensive behavioral assessment tool that may be very useful as an initial pain screen as well as an interval measure. o There are four domains of observation: Facial expression Activity/body movement Social/personality/mood Physiological/sleeping/eating/vocal

Brief Intervention for alcohol

o A time limited, patient centered strategy focused on changing behavior and assessing patient readiness to change. o Definition: Time-limited (5 minutes to 5 brief sessions) and targets a specific health behavior o Goals: reduce alcohol consumption facilitate treatment entry o Relies on use of screening techniques o Empirical support of effectiveness for younger and older drinkers o The SAMHSA/CSAT Treatment Improvement Protocol # 34, Brief Interventions and Brief Treatments for Substance Abuse (Barry, CSAT, 1999) defined brief interventions as time limited (5 minute to 5 brief sessions) targeting a specific health behavior (e.g., at-risk drinking). The goals of a brief alcohol intervention are to: a) reduce alcohol consumption; or b) facilitate discontinuing use and/or entering specialized treatment. Interventions rely on the use of screening instruments to help to specify the level of use and consequences to determine intervention strategy. o Key Components of Alcohol Brief Interventions: Screening Feedback Motivation to change Strategies for change Negotiated behavioral contract Follow-up

Non-Opioid Analgesics

o Acetaminophen (Tylenol) and NSAIDs are the non-opioids most often used for pain relief in older adults. o Acetaminophen has been found to be effective for the most common causes of pain, osteoarthritis, and back pain and should always be considered a first line approach. o The max dose for Tylenol is 4000 mg in 24 hours and is reduced for people with renal or hepatic dysfunction or who drink alcohol. o When persistent pain is of an inflammatory nature, during a short arthritic flair or in persistent rheumatoid arthritis, one of the NSAIDs may be needed. o NSAIDs bind with proteins and may induce toxic responses in elders if serum albumin levels are low. COX-2 inhibitors have been introduced to reduce GI side effects. o NSAIDs should be used carefully

Dementia

o An irreversible state that progresses over years and causes memory impairment and loss of other intellectual abilities severe enough to cause interference with daily life. o Degenerative dementias include Alzheimer's disease (AD), Parkinson's disease dementia (PDD), dementia with Lewy bodies (DLB), and frontotemporal lobe dementias (FTDs). o AD accounts for 50% to 70% of all dementia cases.

Nociceptive Pain

o Associated with injury to the skin, muscosa, muscle, or bone and is usually the result of stimulation of pain receptors. This type of pain arises from tissue inflammation, trauma, burns, infection, ischemia, arthropathies (rheumatoid arthritis, osteoarthiritis, gout), nonarticular inflammatory disorders, skin and mucosal ulcerations, and internal organ and visceral pain from distension, obstruction, inflammation, compression, or ischemia of organs. Pancreatitis, appendicitis, and tumor infiltration are common causes of visceral pain. Nociceptive mechanisms usually respond well to common analgesic medications and non-pharmacological interventions.

Delirium

o Characterized by an acute or sub-acute onset, with symptoms developing over a short period of time (usually hours to days). o Symptoms tend to fluctuate over the course of the day, often worsening at night. o Symptoms include disturbances in consciousness and attention and changes in cognition (memory deficits, perceptual disturbances). Perceptual disturbances are often accompanied by delusional (paranoid) thoughts and behavior.

Benzodiazepines

o Highly effective anxiolytic and hypnotic agents. o They are popular because of their quick sedating effects for the person who is experiencing acute anxiety, such as a new resident in a long-term care facility. o Side effects include: Drowsiness Dizziness Ataxia Mild cognitive deficits Memory impairment o Signs of toxicity include: Excessive sedation Unsteady gait Confusion Disorientation Cognitive impairment Memory Impairment Agitation Wandering o Because these symptoms resemble dementia, persons can easily be misdiagnosed once the benzodiazepines have been taken. o Almost all have long half-lives an when combined with the normal changes in aging, profound sedation and toxicity are significant risks.

o If long-term management of moderate to severe pain is needed, opioids may be preferred because of their lower or predictable rate of adverse reactions, especially in light of the safety concerns noted with NSAIDs and acetaminophen. o Opioids have been found to be effective for all types of pain but not for all persons. o Due to a number of age-related changes, opioids may produce a greater analgesic effect, higher peak, and a longer duration of effect; a short trial with clear goals is recommended along with careful clinical observation of effect. o Sedation and impaired cognition often occur when opioid analgesics are started or doses increased. o Opioid treatment should begin with "as-needed" doses of short-acting medications and should be titrated based on the amount needed, response obtained, and side effects over a 24-hour period. o Side effects of opioids are significant to older adults; they include gait disturbance, dizziness, sedation, falls, nausea, pruritus, and constipation.

o If long-term management of moderate to severe pain is needed, opioids may be preferred because of their lower or predictable rate of adverse reactions, especially in light of the safety concerns noted with NSAIDs and acetaminophen. o Opioids have been found to be effective for all types of pain but not for all persons. o Due to a number of age-related changes, opioids may produce a greater analgesic effect, higher peak, and a longer duration of effect; a short trial with clear goals is recommended along with careful clinical observation of effect. o Sedation and impaired cognition often occur when opioid analgesics are started or doses increased. o Opioid treatment should begin with "as-needed" doses of short-acting medications and should be titrated based on the amount needed, response obtained, and side effects over a 24-hour period. o Side effects of opioids are significant to older adults; they include gait disturbance, dizziness, sedation, falls, nausea, pruritus, and constipation.

Neuropathic Pain

o Involves a pathophysiological process of the peripheral or central nervous system and presents altered sensation and discomfort. Conditions causing this type of pain include postherpetic or trigeminal neuralgia, poststroke or postamputation pain (phantom pain), diabetic neuropathy, or radiculopathies (e.g. spinal stenosis). This type of pain may be described as stabbing, tingling, burning, or shooting. Neuropathic pain is very difficult to treat and may occur at the same time as nociceptive and idiopathic pain.

Buspirone (BuSpar)

o Nondiazepine alternative o Although a side effect is dizziness, this is often dose related and resolves with time. o It is not addictive, and may have an additive effect when combined with some of the SSRIs, so lower doses can be used.

Depression

o Not a normal part of aging, and studies show that most older people are satisfied with their lives, despite physical problems. o The most common mental health problem of late life and among the most treatable, but it can be life-threatening if unrecognized and untreated. o The prevalence of major depression in older adults is somewhat lower than that in the general population, but minor depression and depressive symptoms are experienced by a large number of older people. o Depression and illnesses are likely to co-occur. o Depression is a major source of morbidity in older adults.

NDDB Model

o Proposes that the behavior of persons with dementia carries a message of need that can be addressed appropriately if the person's history and habits, physiological status, and physical and social environment are carefully evaluated. o Rather than behavior being viewed as disruptive, it is viewed as having meaning and expressing needs.

Adjuvant Drugs

o There are a number of drugs developed for other purposes that have been found to be useful in pain management, sometimes alone, but more often in combination with an analgesic; these have come to be referred to as adjuvant drugs. o These include antidepressants, anticonvulsants, and other agents that alter neural membranes, or neural processing. o Thought to be most effective in treating neuropathic pain.

Mixed or Unspecified Pain

o Usually has mixed or unknown causes. Examples include recurrent headaches and vasculitis. A compression fracture causing nerve root irritation, common in older people with osteoporosis, is an example of a mix of nociceptive and neuropathic pain.

Medicare Part B

• Designed to cover some of the costs associated with outpatient or ambulatory services. Deductibles and co-pays are required in most cases • Supplemental medical insurance • Covers 80% of doctor bills and other outpatient medical expenses after 1st $147 in approved charges. • Have to pay premium for this. • Covers the costs associated with the services provided by physicians; nurse practitioners; outpatient services (e.g, lab services); qualified physical, speech, and occupational therapists. • Referred to as "Original Medicare," based on a traditional fee-for-service arrangement wherein the charge was individually determined by the provider and payment due at the time services rendered. • Covers limited durable medical equipment. • Diabetic supplies covered. • At this time, there are two models for reimbursement - one in which the provider "accepts assignment" or accepts the fees set by Medicare or does not. • Advantages of this include choice and access. Participants can seek the services of any provider they choose and do so without referral. • With this, the patient is responsible for an annual deductible, co-pays, coinsurance charges, and a monthly premium.

Types of medications that may cause depression

• Hypertensives • Angiotensin-converting enzyme (ACE) inhibitors • Methyldopa • Reserpine • Guanethidine • Antidysrhythmics • Anticholesteremics • Antibiotics • Analgesics • Corticosteroids • Digoxin • L-dopa

Medicare Part A

• This is designed primarily to partially cover the costs of inpatient hospital care and other specialized care. • Pay as you go system like social security. Taxes collected for employers and employees are used for payment of current Medicare beneficiaries and are not placed in a fund earmarked for tax payer's future medical expenses. • Covers most inpatient hospital expenses. • Acute hospitalization coverage. There is a deductible for days 1-60. This is repeated any time a person is rehospitalized after 60 days. After 60 days, there is a daily co-pay that increases over time. There is no coverage after 150 days. Deductibles and co-pays increase every year. The deductibles and co-pays are either paid out-of-pocket or by Medicaid or medigap policies. • Nursing home care is covered by medicare only if the person had been in an acute care setting for 3 days before admission and only as long as a skilled service is needed and for a maximum of 100 days. For the patients, the first 20 days are covered at 100%, and for days 21-100 a substantial daily co-pay is required. There is no coverage if skilled care is not continuously needed. • Home health care may be covered by medicare on an intermittent and/or part time basis for skilled nursing care, physical therapy, and rehabilitative services. The person must be ill enough to be considered homebound. Custodial care is not covered. Medicare pays 80% of the approved amount for durable medical equipment and supplies. • Hospice care is provided for terminally ill persons expected to live less than six months who elect to forgo traditional medical treatment for the terminal illness. Medicare pays for all but limited co-pays for outpatient drugs and inpatient care. Hospice Medicare replaces Medicare parts A and B for all costs associated with the terminal condition. • Inpatient psychiatric care is a limited number of days in a lifetime; partial payment; other limitations apply.

PLST (progressively lowered stress threshold) model for dementia care

• Using this model, care is structured to decrease the stressors and provide a safe and predictable environment. • Principles of care derived from this model: o Maximize functional abilities by supporting all losses in a prosthetic manner. o Establish a caring relationship, and provide the person with unconditional positive regard. o Use behaviors indicating anxiety and avoidance to determine appropriate limits of activity and stimuli. o Teach caregivers to try to find out causes of behavior and to observe and evaluate verbal and nonverbal responses. o Identify triggers related to discomfort or stress reactions (factors in the environment, caregiver communication). o Modify the environment to support losses and promote safe function. o Evaluate care routines and responses on a 24-hour basis, and adjust plan of care accordingly. o Provide as much control as possible; encourage self-care, offer choices, explain all actions, do not push or force the person to do something. o Keep environment stable and predictable. o Provide ongoing education, support, care, and problem solving for caregivers. • Categorizes symptoms in four groups: o Cognitive or intellectual losses o Affective or personality changes o Conative or planning losses that cause a decline in functional abilities. o Loss of the stress threshold, causing behaviors such as agitation or catastrophic reactions. • Positive outcomes from use of this model include: o Improved sleep o Decreased sedative and traquilizer use o Increased food intake and weight o Increased socialization o Decreased episodes of aggressive, agitated, and disruptive behaviors o Increased caregiver satisfaction with care o Increased functional level