3403: EXAM TWO

Chronic Illness

"Chronic health problems are not fixable with shiny new technology, and do not promise the suspense, exhilarating hope, and dramatic ending that acute medical crises often do. They simply continue day after day, [they are] often invisible or misunderstood". Chronic illnesses are those that occur slowly and progress slowly. They have an irreversible presence and may be hidden to outsiders. The presence of a chronic illness may be as little as an inconvenience or as great as an impairment of one's ability to perform even the most basic self-care activities. In 2013, 30% of community-resident Medicare beneficiaries ages 65 and older reported difficulty in performing one or more activities of daily living (ADLs), and an additional 12% reported difficulty with one or more instrumental activities of daily living. By contrast, 95% of Medicare beneficiaries living in nursing facilities had difficulties with one or more ADLs, and 81% of them had difficulty with three or more ADLs. According to the U.S. Census Bureau's American Community Survey, some type of disability was reported by 36% of people age 65 and older in 2014. -Continues day after day -Occur and progress slowly -Level of impairment varies greatly - 2 of every 3 older Americans have multiple chronic conditions -Consequences? physical suffering, loss, worry, grief, depression, impairment in function, increased dependence

Considerations of Common Changes in Late Life During the Physical Assessment: Chest

-Any kyphosis will alter the location of the lobes, making careful assessment more important. -Risk for aspiration pneumonia is increased, increasing the importance of the lateral exam and the need for measurement of oxygen saturation. -Evidence of pneumonia may not be evident if the person is dehydrated. -Third heart sound indicative of pathology.

Considerations of Common Changes in Late Life During the Physical Assessment: Skin

-Check for indications of solar damage, especially among persons who worked outdoors or live in sunny climates. -Because of thinning of skin, "tenting" cannot be used as a measure of hydration status.

Assessment for Delirium

-Commonly thought of as a hospital-related event, delirium can occur in the ALC, as well. Risk factors include infection, dehydration, fracture, and use of psychotropic medication. The Confusion Assessment Method (CAM) identifies the presence or absence of delirium but not does indicate severity.17 The CAM consists of 4 factors: 1) acute onset or fluctuating course of mental changes or behavior; 2) inattention; 3) disorganized thinking; and 4) altered level of consciousness. Factors 1 and 2 and either 3 or 4 must be present for the diagnosis of delirium.

Assessments for Dementia

-Mini-COG: consists of a 3-item recall and the Clock Drawing Test; used to Geriatric Nursing, Volume 31, Number 5 371 identify dementia; takes approximately 3-5 minutes to administer. Aspects of cognition tested: recall, registration, and executive function. Unlike the Mini-Mental Status Examination, education level, culture, or language have no effect on the Mini-COG score.15 Older adults who were administered the Mini-COG did not appear stressed or otherwise discomfited by the examination. -Brief Evaluation of Executive Dysfunction: recommended for 4 conditions: 1) when an older adult after hospitalization "seems not quite like his former self"; 2) the Mini-COG fails to reveal the presence of cognitive impairment (i.e., dementia); 3) delirium has been ruled out; and 4) the older adult still has memory/recall and language ability.16 Language and education level can yield false-positive results because a portion of the examination includes word association.16

Considerations of Common Changes in Late Life During the Physical Assessment: Vision

-Person exhibits increased glare sensitivity, decreased contrast sensitivity, and need for more light to see and read. -Ensure that waiting rooms, hallways, and exam rooms are adequately lit. Decreased color discrimination may affect ability to self-administer medications safely.

Considerations of Common Changes in Late Life During the Physical Assessment: Blood pressure

-Positional blood pressure readings should be obtained because of the high occurrence of orthostatic hypotension. -Both arms should be checked (at heart level) and the arm with the highest measurement should be recorded. Isolated systolic hypertension is common.

Delirium

-acute confusional state/decline in cognitive function and attention -potentially reversible cognitive impairment -occurs suddenly and worsens at night. -develops over a short time (hrs to days) -often has a physiological cause. -Fluctuates over the course of the day -Symptoms include reduced ability to focus accompanied by delusional (paranoid) thoughts and hallucinations A new onset of delirium should trigger the nurse to assess for signs and symptoms of infections such as pneumonia and UTI. The presence of delirium is a medical emergency and requires prompt assessment and intervention.

The three common conditions affecting cognition are

3 ds: delirium, dementia , and depression. Distinguishing among these three conditions is challenging. A careful and thorough assessment of older adults with cognitive changes to distinguish among them should be completed. Select appropriate nursing interventions that are specific to the cause of the cognitive impairment. -All frequently affect older adults -Not normal consequences of aging

Functional Assessment

A determination of functional status is part of the usual gerontological assessment. If the person is healthy and active, a simple statement may be all that is needed, such as "Patient is active and independent; denies functional difficulties." However, if any potential problems exist, such as for a person who has Parkinson's disease or for a person who recently fell, a more detailed assessment is conducted. A thorough functional assessment includes the following: • Identifying the specific areas in which help is needed • Identifying changes in abilities from one period of time to another • Assisting in the determination of the need for specific service(s) • Providing information that may be useful in determining the safety of the current living situation

Activities of Daily Living

Activities of daily living (ADLs) were first classified by Sidney Katz and colleagues in 1963. The Katz Index has served as a basic framework for most of the subsequent measures. 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). Over the years this instrument has been refined to afford more sensitivity to the nuances of, and changes in, functional status. Despite these limitations, the tool is useful because it creates a common language about patient function for all caregivers involved in planning overall care. ex: Bathing, dressing, eating, and getting around the house

Considerations of Common Changes in Late Life During the Physical Assessment: Neurological

Although there is a gradual decrease in muscle strength, it still should remain equal bilaterally. Greatly diminished or absent ankle jerk (Achilles) tendon reflex is common and normal. Decreased or absent vibratory sense of the lower extremities is common, making testing unnecessary.

The Assessment Process

At a minimum, health assessment includes the collection of physical data and the integration of spiritual and psychosocial factors within an individual's cultural context. When working with older adults, additional assessment areas further include functional and cognitive status, caregiver stress or burden, patterns of health and health care, advance care planning, and the presence or absence of any of the geriatric syndromes (e.g., delirium, falls, dizziness, syncope, and urinary incontinence [see Chapter 17]). Areas or problems frequently not addressed by the care provider or mentioned by the elder that should be addressed are sexual function, depression, alcoholism, hearing loss, oral health, and environmental safety. Although not usually conducted by a nurse, a driving assessment may be recommended any time there is a question of ability. Questions regarding genetic background in this age group, especially for those in the younger range, have most relevance as they relate to Alzheimer's disease, stroke, diabetes, and several types of cancer. Conducting an assessment begins with establishing rapport. It is never appropriate to address the patient by the first name unless invited to do so. The assumption of familiarity of any kind including the use of the first name in addressing an elder can easily be perceived as condescending, especially when the nurse is younger than the patient or of a different ethnic background

Sensory Impairments in Older Adults

Because of common sensory impairments experienced by older adults, you need to promote existing sensory function and be sure that patients live in safe environments. Whenever you provide care activities, make sure that patients wear assistive devices such as a hearing aid or glasses so that they can fully participate in care. Chapter 49 describes in detail the nursing interventions used to maintain and improve sensory function.

Considerations of Common Changes in Late Life During the Physical Assessment: Abdomen

Because of deposition of fat in the abdomen, auscultation of bowel sounds may be difficult.

Considerations of Common Changes in Late Life During the Physical Assessment: Neck

Because of loss of subcutaneous fat it may appear that carotid arteries are enlarged when they are not.

A—Aeration

Because of the close relationship between pulmonary function (aeration) and cardiovascular function, they are assessed simultaneously. Is the person's oxygen exchange adequate for full respiratory functioning? Measurement of the oxygen saturation rate is a part of this exam and easily done in any setting with a small, inexpensive fingertip device, familiar to most nurses. Persons with any amount of peripheral cyanosis will have artificially low readings. Is supplemental oxygen required and, if so, is the person able to obtain it? What is the respiratory rate and depth at rest and during activity, talking, walking, and exercising and while performing activities of daily living? What sounds are auscultated, what is learned from palpation and percussion, and what do they suggest? For the older person, it is particularly important to carefully assess lateral and apical lung fields.

Acute Illness

Before chronic disorders can be discussed, their relationship to acute illness must be addressed. They cannot really be separated in the health of older adults because so many conditions are intricately intertwined. A previously stable chronic condition condition can and often does worsen when an acute illness occurs. An episode of pneumonia may trigger acute congestive heart failure even though before the episode the failure had been present but controlled through diet and medications.

Considerations of Common Changes in Late Life During the Physical Assessment: Ears

Cerumen impactions are common. These must be removed before hearing can be adequately assessed or tympanic membrane visualized.

Cognitive Changes in Older Adults

Cognitive Changes A common misconception about aging is that cognitive impairments are widespread among older adults. Because of this misconception, older adults often fear that they are, or soon will be, cognitively impaired. Younger adults often assume that older adults will become confused and no longer able to handle their affairs. Forgetfulness as an expected consequence of aging is a myth and not a fact or expectation. Some structural and physiological changes within the brain are associated with cognitive impairment. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes. There are standard assessment forms for determining a patient's mental status, including the Mini-Mental State Exam-2 (MMSE-2), the Mini-Cog, and the Clock Drawing Test

Assessment for Depression

Contrary to myth, depression is not a normal part of aging, can delay recovery from a medical illness, and is treatable. The short-form (15-item) Geriatric Depression Scale (GDS) is a valid and reliable assessment instrument that can differentiate between depressed and nondepressed older adults. It takes approximately 5-7 minutes to administer and score but is not a substitute for a clinical interview, nor does it identify suicide risk. -Use an assessment tool -Ask about thoughts of self harm -Sleep/nutrition -Physical exam -Psychosocial assessment -Cognitive assessment -Functional assessment -Lab work/medications -Involve family

Dementia

Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer's disease (most common type), Lewy body disease, frontal-temporal dementia, and vascular dementia. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs and IADLs. Unlike delirium, dementia is characterized by a gradual, progressive, and irreversible decline in cerebral function. Because of the similarity between delirium and dementia, you need to assess carefully to rule out the presence of delirium whenever you suspect dementia.

Depression

Depression Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. It sometimes exists and is exacerbated in patients with other health problems such as stroke, diabetes, dementia, Parkinson's disease, heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or admission to a nursing center sometimes causes depression. The Geriatric Depression Scale is an easy-to-use screening tool that can be used in conjunction with an interview with the older adult. Clinical depression is treatable. Treatment includes medication, psychotherapy, or a combination of both. Electroconvulsant therapy (ECT) is sometimes used for treatment of resistant depression when medications and psychotherapy do not help. Of special note, suicide attempts in older adults are often successful. Suicide rates in all age-groups are on the rise over the past several years; the age-group of 85 years of age and older has the second highest suicide rate of all age-groups. Therefore, suicide prevention considerations for older adults are similar to those for the general population.

Prevalence of Depression in Older Adults

Depression remains underdiagnosed and undertreated in the older population and is considered a significant public health issue. Depression is the fourth leading cause of disease burden globally and is projected to increase to the second leading cause by 2030. Approximately 1% to 2% of adults 65 years and older are diagnosed with major depressive disorder. An additional 25% have significant depressive symptoms that do not meet the criteria for major depressive disorder. -Is common in later life -Becoming depressed doubles the probability of becoming sick -Is underdiagnosed and undertreated in older adults

Considerations of Common Changes in Late Life During the Physical Assessment: Extremities

Dorsalis pedis and posterior tibial pulses are very difficult or impossible to palpate. Must look for other indications of vascular integrity.

Considerations of Common Changes in Late Life During the Physical Assessment: Temperature

Even a low-grade fever could be an indication of a serious illness. Temperatures as low as 100° F may indicate pending sepsis.

Considerations of Common Changes in Late Life During the Physical Assessment: Mouth

Excessive dryness is common and exacerbated by many medications. Cannot use mouth moisture to estimate hydration status. Periodontal disease is common. Decreased sense of taste occurs. Tooth surface may be abraded.

Preventing Iatrogenesis

Expect iatrogenesis among your residents. Identify residents at high risk for iatrogenesisd that is, older adults who are aged 80 years or older, are frail, have multiple physical and cognitive comorbidities, and have new-onset geriatric syndromes. Educate the resident and family, to the extent possible, about where they are at risk, what is being done to minimize that risk, and the things they need to do to remain hale and hearty. Dispel the myths of aging among residents, family, and staff. Develop a proactive approach to prevention and recognition of iatrogenesis, recognizing that the early warning signs may be fragmented. Monitor and communicate unexplained signs, symptoms, and complaints.5 Develop, foster, and maintain a blame-free culture of safety so that when an iatrogenic event does occur, its origin and resolution can be better understood and managed.

Falls

Falls are a leading cause of serious injury in older people. There are many risk factors for falling, including safety hazards in the home, medication side effects, walking and vision problems, dizziness, arthritis, weakness, and malnutrition. Like other geriatric syndromes, falls usually have more than one cause. -Tell your healthcare provider immediately if you have fallen. They will look into what caused your fall and suggest steps to prevent future falls. There are many treatments, such as exercise and physical therapy, that can help improve your gait and walking and prevent falls. (Common And Often Related Medical Conditions In Older Adults)

Mini-Mental State Examination

For many years the 30-item Mini-Mental State Examination (MMSE) has been the mainstay for the gross screening of cognitive status. It is used to screen and monitor orientation, short-term memory and attention, calculation ability, language, and ability to correctly copy a figure. There is now a revised 16-item instrument, the MMSE-2, and a slightly longer Expanded Version. Both are reported to be equivalent to the original instrument and are available in multiple languages. To ensure reliability, the nurse must be able to administer them correctly each time they are used. The instruments, permission for use, and instructions for use can be purchased from Psychological Assessments Resources (PAR, http://www.parinc.com).

Assessing Frailty

Frailty is loosely defined as evidence of three of the following: unexplained weight loss, self-reported exhaustion, weak grip strength, slow walking speed, and low activity. It is better to ask specifically about each one of these symptoms. Many people consider the signs as "just a normal part of aging." To provide a method of quantifying frailty to the extent possible, a number of scales have been developed and some of them tested. Most are available free of charge for educational and professional practice use.

Considerations of Common Changes in Late Life During the Physical Assessment: Hearing

High-frequency hearing loss (presbycusis) is common. The person often complains that he or she can hear but not understand because some, but not all, sounds are lost. The person with severe but unrecognized hearing loss may be incorrectly thought to have dementia.

Resident Assessment Instrument (RAI)/Minimum Data Set (MDS 3.0)

In 1986 the Institute of Medicine (IOM; now called the Health and Medicine Division of the National Academy of Medicine) completed a study indicating that although considerable variation existed, residents in skilled nursing facilities in the United States were receiving an unacceptably low quality of care (IOM, 1986). As a result, nursing home reform was legislated as part of the Omnibus Budget Reconciliation Act (OBRA) of 1987. The creators of OBRA recognized the challenging work of caring for increasingly ill persons discharged from acute care settings to nursing homes and, along with this, the need for comprehensive assessments, complex decision-making, and documentation regarding the care that was needed, planned, implemented, and evaluated. In 1990 a Resident Assessment Instrument (RAI) was created and mandated for use in all skilled nursing facilities that receive compensation from either Medicare or Medicaid. In March 2014, Quality Measures were updated to provide a standardized measure of the quality of care provided. This includes consideration of 992 different measures, ranging from postoperative infection to fall prevention strategies.

The Mini-Cog

In some settings the use of the Mini-Cog has replaced the MMSE as a screening tool for cognitive impairment. It has been found to be as accurate and reliable as the MMSE but less biased, easier to administer, and possibly more sensitive to dementia. The Mini-Cog combines the test of short-term memory in the original MMSE with the Clock Drawing Test. It has been found to be equally reliable with English-speaking and non-English-speaking individuals. It serves as an indicator of the need for more detailed assessments leading to diagnosis. It requires the same basic skills as the Clock Drawing Test. 1. Name three objects and ask person to repeat them (3 tries max) 2. Do clock drawing test (next slide) 3. Have them repeat the objects again Score ◦0 recall- indication of dementia ◦0-2 recall- indication of dementia ◦3-5 recall- no indication

Observation

In the observational approach the nurse collects and records objective and subjective data using parameters considered to be objective for performance-based functional assessments (e.g., the distance the person can walk). The usual physical examination includes measurement of objective data such as blood pressure, pulse rate, and respirations, as well as subjective data such as the patient's appearance and level of awareness. Observation and the use of previously developed tools are probably the most accurate assessment methods but they are limited because they only represent a snapshot in time. It is especially dangerous to base conclusions

Self-report

In the self-report format, either questions are asked directly or the person is expected to respond to written questions about his or her health status. Patients tend to overestimate their own abilities, and older adults in particular have been found to under-report symptoms, often because of the erroneous belief that their symptoms are normal parts of aging.

Clock Drawing Test

In use since 1992, the Clock Drawing Test is reported to be second in frequency of use to the MMSE across the world. It is not appropriate for use with those who are blind or who have limiting conditions such as tremors, or a stroke that affects their dominant hand. Although reading fluency is not necessary, completion of the Clock Drawing Test requires number fluency, adequate vision and hearing, manual dexterity sufficient to hold a pencil, and experience with analog clocks. This tool cannot be used as the sole measure for dementia but it does test for constructional apraxia, an early indicator. The Clock Drawing Test is an evidence-based instrument that has been found to be useful across cultures and languages and is a sensitive instrument to differentiate among those with and without some level of dementia.

C—Communication

Is the person able to communicate his or her needs adequately? Do the persons who provide care understand the patient's form of communication? What is the person's ability to hear in various environments? Are there any situations in which understanding of the spoken word is inadequate? If the person depends on lip-reading, is his or her vision adequate? Is the person able to clearly articulate words that are understandable to others? Does the person have either expressive or receptive aphasia, and if so has a speech therapist been made available to the person and significant others? What is the person's reading and comprehension levels? The impoverished childhoods of some individuals and the racist educational practices for others, even in developed countries, have resulted in very low or no literacy levels in these groups. It is best to assume that an elder's literacy is no greater than at a fifth-grade level in most settings. Inadequate assessment of communication by the nurse will lead to erroneous conclusions and significantly reduce the quality of care.

P—Pain

Is the person experiencing physical, psychological, or spiritual pain? Rarely does one type of pain occur in isolation. Is the person able to express pain and relief of pain? Are there cultural barriers between the nurse and the patient that make the assessment or expression of pain difficult? Do cognitive limitations provide further barriers? How does the person customarily attain pain relief? As a result of the increasing amount of pain common with each decade of life (e.g., progression of arthritis or number of losses), this deserves particular attention by gerontological nurses.

Sleep Disorders

It is important to know (and perhaps to reassure the resident) that although the amount of sleep in 24 hours is unchanged, there are changes in sleep pattern and quality. Impaired sleep can be related to diseases (e.g., restless leg syndrome), medications, or an environment that does not promote good sleep (e.g., room temperature, mattress, noise, roommate habits, etc.). Sleep assessment includes getting a thorough sleep history from the resident and past use of any medications or routines (e.g., exercise) to induce sleep and restfulness. The Pittsburgh Sleep Quality Index (PSQI) is a self-rated instrument that measures sleep quality.10 The Epworth Sleepiness Scale (ESS) is another self-rated instrument that measures excessive daytime sleepiness.11 Both the PSQI and ESS can be used to measure the effectiveness of interventions. Daytime sleepiness is more than a simple need for a daytime nap; it could be iatrogenesis.

Bladder Control Problems

Lack of bladder control, or "urinary incontinence," is an embarrassing topic. Please know that you are not alone! Urinary incontinence can lead to problems such as falls, depression, and isolation. In most cases, incontinence can be cured or greatly improved with treatment. So don't hesitate to tell your healthcare provider if you have bladder control problems. (Common And Often Related Medical Conditions In Older Adults)

Considerations of Common Changes in Late Life During the Physical Assessment: Eyes

Lids sag and position of lids may change. Reduced pupillary responsiveness (miosis) occurs (normal if equal bilaterally). Gray ring around the iris (arcus senilis) may develop.

Considerations of Common Changes in Late Life During the Physical Assessment: Heart

Listen carefully for third and fourth heart sounds. Faint fourth heart sounds may be heard. Determine if this was present in the past or is new. Up to 50% of persons have a heart murmur.

Considerations of Common Changes in Late Life During the Physical Assessment: Genitourinary male

Men have pendulous scrotum with less rugae. Have thin and graying pubic hair.

Considerations of Common Changes in Late Life During the Physical Assessment: Height and weight

Monitor for changes in weight. Weight gain: Especially important if the person has any heart disease; be alert for early signs of heart failure. Weight loss: Be alert for indications of malnutrition from dental problems, depression, or cancer. Check for mouth lesions from ill-fitting dentures.

Problems with Eating or Feeding

Most nutritional issues are associated with a disease or illness, but other causes include dietary restrictions, oral cavity and denture issues, medications, reduced sense of smell and taste, and inability to carry food and fluid to the mouth.12 Many eating or feeding problems in older adults can be severe. Nutritional assessment includes diet(ary) history (e.g., previous interventions that were successful as well as unsuccessful) and oral cavity examination. Individuals who are overweight (i.e., body mass index [BMI] . 25) are as at risk for malnutrition as those who are underweight (i.e., BMI \ 19).12 Both can have loss of muscle mass and a compromised immune system. The Mini Nutritional Assessment can identify older adults at risk for malnutrition.12 Information about the older adult's culture, food preferences, and social customs with regard to eating, as well as lab work and a 72-hour food diary, should be part of the assessment.

Frailty

Most older adults who live to an advanced age will become frail. Not really a disease, frailty is a combination of age-related changes and assorted medical problems. Eluding precise definition, the "Fried framework" suggests that an individual having 3 or more of the following conditions should be considered frail: exhaustion, unintentional weight loss of more than 10 pounds in 1 year, muscle weakness, walking slowly, and low physical activity level. Research indicates that frailty is a reliable indicator of imminent decline in health status and includes falls, reduced mobility, low functional reserve, easy tiring, and high susceptibility to disease. Certain diseases and medical conditions are associated with frailty, including anorexia, sarcopenia, atherosclerosis, impaired balance, mood disturbance (depression), and cognitive impairment.

Physical Assessment

Nurses learn to conduct a complete "head-to-toe" when conducting a physical assessment. Although this is usually done when assessing younger persons, it is rarely possible when working with an older adult, especially one who is medically complex or fragile. To do so would be excessively time-consuming and burdensome to all involved. Instead the assessment is first directed to that which is most likely associated with the presenting problem or major diagnoses and progresses from there. When performing a physical assessment the gerontological nurse must be able to quickly prioritize what is the most necessary to know (based on the chief complaint) and proceed to what would be "nice to know."

Medication Use in Older Adults

One of the greatest challenges for older adults is safe medication use. Medication categories such as analgesics, anticoagulants, antidepressants, antihistamines, antihypertensives, sedative-hypnotics, and muscle relaxants create a high likelihood of adverse effects in older adults. They are at risk for adverse medication effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs, collectively referred to as the process of pharmacokinetics. Medications sometimes interact with one another, adding to or negating the effect of another drug. Examples of adverse effects include confusion, impaired balance, dizziness, nausea, and vomiting. Because of these effects, some older adults are unwilling to take medications; others do not adhere to the prescribed dosing schedule, or they try to medicate themselves with herbal and over-the-counter medications.

Considerations of Common Changes in Late Life During the Physical Assessment: Musculoskeletal

Osteoarthritis is very common and pain is often undertreated. Ask about pain and function in joints. Conduct very gentle passive range of motion if active range of motion not possible. Do not push past comfort level. Observe for gait disorders. Observe the person get in and out of chair in order to assess independent function and fall risk.

Osteoporosis

Osteoporosis, or "thinning bones," is a condition that makes the bones of older adults more fragile and easy to break. Women 65 and older, and men over age 70, should get a bone mass density (BMD) test. Increased calcium and vitamin D intake, strength training exercises, and weight-bearing exercises such as walking are important to keeping your bones healthy. Your healthcare provider may also recommend medications or other treatments. (Common And Often Related Medical Conditions In Older Adults)

Pain in Older Adults

Pain is a symptom and a sensation of distress, alerting a person that something is wrong. It is prevalent in the older-adult population and may be acute or chronic. The consequences of persistent pain include depression, loss of appetite, sleep difficulties, changes in gait and mobility, and decreased socialization. Many factors influence the management of pain, including cultural influences on the meaning and expression of pain for older adults, fears related to the use of analgesic medications, and the problem of pain assessment with older adults who are cognitively impaired. Nurses caring for older adults have to advocate for appropriate and effective pain management. Again, the goal of nursing management of pain in older adults is to maximize and maintain function and improve quality of life.

Sleep Problems

Sleep problems can affect your quality of life and can contribute to falls, injuries, and other health problems. If you have trouble sleeping at night or feel sleepy during the day, tell your healthcare provider so they can identify the type of sleep problem you have. (Common And Often Related Medical Conditions In Older Adults)

S—Socialization and Social Skills

Socialization and social skills include the individual's ability to negotiate in society, to give and receive love and friendship, and to feel self-worth. The selection of persons included in one's social network is highly culturally influenced. Assessment focuses on the individual's ability to deal with loss and to interact with other people in give-and-take situations.

Racial, Ethnic, and Cultural Considerations of Depression

Studies have consistently found that older racial and ethnic minorities are less likely to be diagnosed with depression than their white counterparts but are also less likely to get treated. Hispanic adults aged 50 and older are reported to experience more depression than white, non-Hispanic adults; black, non-Hispanic adults; or other, non-Hispanic adults. Gender differences are also present in depression prevalence, and older women suffer depression at twice the rate of older men . Differences in the prevalence of major depressive disorder and other mental disorders may be due to differences in the presentation of self-reported symptoms or other aspects of cultural context. The new criteria in the DSM-5 addressing culturally based explanatory models will assist in better understanding differences in presentation, help-seeking behavior, and provision of more culturally appropriate treatment for all individuals. Racial, ethnic, and gender differences in mental illness, as well as differences within racial groups, have not received adequate attention in the United States.

Barthel Index

The Barthel Index (BI) is a quick and reliable instrument for the assessment of both mobility and the ability to perform ADLs. The items are rated in various ways, depending on the item. The BI has been found to be sensitive enough to identify when a person first needs help and to measure progress or decline, especially following a stroke.

Fulmer SPICES

The Fulmer SPICES is a simple and overall assessment tool of older adults focusing on geriatric syndromes. It has proved reliable and valid when used with older persons either in health or with illness, regardless of the setting. The acronym SPICES refers to the sometimes vague but nonetheless very important problems that require nursing interventions: Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, and Skin breakdown. Nurses are encouraged to use this acronym as a reference when caring for older adults (see http://www.hartfordign.org). It is a system that alerts the nurse to the most common problems that occur

Functional Independence Measure

The Functional Independence Measure (FIM) was designed to assess a person's need for assistance with ADLs during inpatient stays and for discharge planning, especially following a stroke. In some studies the BI and FIM were found to be comparable. In other studies, the FIM was deemed preferable. The FIM is a highly sensitive functional assessment tool and includes measures of ADLs, mobility, cognition, and social functioning. The tasks are rated using a seven-point scale that ranges from totally independent to totally dependent. Although the FIM is commonly used in acute rehabilitation and Veteran's Administration hospitals in the United States and several other countries, it cannot yet be applied across all countries.

The Global Deterioration Scale

The Global Deterioration Scale is a classic measure of the levels of cognitive changes as one passes through the process of dementia. It uses an ordinal scale from stage 1 (no cognitive decline; i.e., no dementia) to 7 (late-stage dementia; i.e., very severe cognitive decline) and is sensitive enough to show therapeutic changes (e.g., those related to medication adjustments). It is commonly used in the United States, Canada, and many other countries. It is useful to both the nurse and the family to develop appropriate interventions to help the person optimize his or her health and anticipate future needs and changes.

The Shifting Perspectives Model of Chronic Illness

The Shifting Perspectives Model is derived from a synthesis of qualitative research findings of living with chronic illness as an ongoing, continually shifting process in which the person moves between the perspectives of wellness in the foreground or illness in the foreground. This model is more reflective of an "insider" perspective on chronic illness as opposed to the more traditional "outsider" view. At any point in time, one may take precedence over the other, but the goal is to move toward the highest level of well-being even in the presence of illness through appropriate interventions. The focus is on health within illness rather than illness first. People's perspective of the chronic illness is neither right nor wrong but is a reflection of their needs and situation. How people perceive the chronic illness at any given time influences how they interpret and respond to the disease, themselves, caregivers, and situations affected by the illness. -Ongoing and focusing on the emotional, spiritual, and social aspects

A—Activity

The ability to continue to participate in enjoyable activities is an important part of healthy aging. However, activity assessment is exceedingly complex because of the range of abilities among those referred to as "older adults." As more baby boomers join this group, the complexity of assessment increases. It ranges from the risk for falling and the need for, and correct use of, assistive devices to the degree to which one can participate in aerobic exercises. Assessment of activity abilities may be accomplished by the combined efforts of nurses, physical therapists, and personal trainers.

Atypical Presentation of Illness

The atypical presentation of illness in older adults means that the presentation itself is vague, altered, or not presented at all. In some cases, the signs of 1 disease might be hidden by the signs of another. Conditions in which atypical presentation is common are infections, falls, urinary incontinence, myocardial infarct, and congestive heart failure. Signs and symptoms of atypical presentation include acute confusion (delirium), inability to eat or drink (anorexia), absence of temperature elevation or fever even with an elevated white blood count (leukocytosis), no complaint of pain with a disease/condition known to cause pain (e.g., gastric ulcer), reduced mobility and overall functional decline, generalized weakness and fatigue, falls, and urinary incontinence.

The OARS Multidimensional Functional Assessment Questionnaire (OMFAQ)

The classic instrument, the Older Americans Resources and Services (OARS), was developed at the Center for the Study of Aging and Human Development at Duke University. It was later updated as the OMFAQ. The areas evaluated in the OMFAQ include social and economic resources, mental and physical health, and ADLs. The person's functional capacity in each area is rated on a scale of 1 (excellent functioning) to 6 (totally impaired functioning). At the conclusion of the assessment, a cumulative impairment score (CIS) is calculated ranging from the most capable (6) to total disability (30). An analysis of the data results in (1) an evaluation of the ability, disability, and capacity level at which the person is able to function, and (2) the determination of the extent and intensity of utilization of resources.

The health history

The initiation of the health history marks the beginning of the assessment process. It begins with a review of what the person reports as a problem, known as the "chief complaint." This is considered subjective data that are documented in the patient's own words. In older populations, the "complaint" is often very vague because the interaction of the numbers of chronic diseases, medications used, and other factors obscures what may be a specific or even multifactorial problem. For example, it is not unusual for the person to say, "I just don't feel well."

Geriatric Depression Scale

The most commonly used mood measure in both middle-aged and older adults is the Geriatric Depression Scale (GDS), developed by Yesavage and colleagues. The GDS has been extremely successful in determining depression because it deemphasizes physical complaints, sex drive, and appetite—those things most affected by medications. It has been tested extensively with translations in multiple languages. A shortened 15-item version is now used, with the free resources provided by Drs. Yesavage and Brink. The instrument can be completed on an iPhone or ANDROID with an automatic calculation of the results, which can be downloaded to a computer. It cannot be used in persons with dementia or cognitive impairment. Dr. Yesavage may be contacted directly at Stanford University for more information and a description of the products he has available.

Instrumental Activities of Daily Living

The original tool for the assessment of IADLs was developed by Lawton and Brody . Both the original tool and the subsequent variations use the self-report, report-by-proxy, and observed formats with three levels of functioning (independent, assisted, and unable to perform). EX: • Ability to use the telephone • Ability to travel • Ability to shop for necessities • Ability to prepare meals • Ability to do housework • Ability to self-administer medication • Ability to manage money

Outcome and Assessment Information Set (OASIS-C1)

The skilled care provided in the home is based on, and documented in, the Outcome and Assessment Information Set (OASIS) (CMS, 2012). Now in its third revision (OASIS-C), further modifications were effective October 1, 2014 (OASIS-C1). The assessment is very comprehensive and focuses on the development of interventions to prevent rehospitalization and ensure safety in the home setting. Among the items on the instrument are those that identify the person's risk for hospitalization. The majority of the documentation takes place in the patient's home and is entered into a laptop or tablet for transmission to the agency database, and ultimately to the Centers for Medicare and Medicaid Services. Completion is required for all care that is compensated by Medicare or Medicaid, and forms the basis for the level of reimbursement. As with other instruments, the assessment is completed at the time the care is begun and at intervals thereafter. Nurses supplement the OASIS data with information necessary to personalize the care provided. It is exceedingly complex and training is required. For more information, see http://www.cms.gov or search OASIS-C.

Trajectory Model of Chronic Illness

The trajectory model, has long aided health care providers to better understand the realities of chronic illness and its effect on individuals. According to this theoretical approach, chronic illness can be viewed from a life course perspective or along a trajectory. In this way, the course of a person's illness can be viewed as an integral part of the person's life rather than as an isolated event. The nurse's response is then holistic rather than isolated. The time between the diagnosis of an illness and death is divided into eight phases for the purpose of identifying goals and developing interventions. The shape and stability of the trajectory are influenced by the combined efforts, attitudes, and beliefs held by the older person, family members, and significant others, and the involved health care providers. Although it appears linear, it is instead fluid as crises reappear and are addressed and as instability becomes stable again until this is no longer possible. -Life course perspective and as an integral part of lives, not as a single event -Eight different phases

Incontinence

Urinary incontinence (UI) can occur secondary to age-related physiological changes, iatrogenesis, frailty, or disease. Urinary incontinence is not a normal age-related change or consequence of aging. -4 types of urinary incontinence: urge, stress, overflow, and functional. Fecal incontinence, almost as common as UI, is frequently a result of fecal impaction. Not surprisingly, constipation and fecal impaction are associated with chronic use of laxatives, constipating medications (e.g., opioids, iron, calcium channel blockers), limited mobility, malnutrition, reduced fluid intake, and the 3 Ds: delirium, dementia, depression.

Weight Loss

Weight loss is a very common problem in older adults. Weight loss can be caused by the diminished sense of taste that comes with aging, or it can be a suggestion of an underlying serious medical problem. No matter the cause, weight loss can lead to other problems, such as weakness, falls, and bone disorders. -Your healthcare provider should weigh you each time you visit and check for any changes. Also, be sure to let your healthcare provider know if you have any changes in your weight or appetite. (Common And Often Related Medical Conditions In Older Adults)

F—Fluids

What is the current state of hydration? Does the person have the functional capacity to consume adequate fluids to maintain optimal health? This includes the abilities to sense thirst, mechanically obtain the needed fluids, swallow them, and excrete them. Medications are reviewed to identify those with the potential to affect intake. This is especially important when working with older adults who are not able to independently access fluids because of functional limitations, or for anyone with a reduced sense of thirst, a common change with aging.

N—Nutrition

What mechanical and psychological factors affect the person's ability to obtain and benefit from adequate nutrition (see Chapter 10)? What is the type and amount of food consumed? Does the person have the abilities to bite, chew, and swallow? What is the oral health status and what is the impact of periodontal disease if present? For edentulous persons, do their dentures fit properly and are they worn? If a special diet is recommended, has it been designed so that it is consistent with the person's eating and cultural patterns? Can the person afford the special foods needed? Is the person at risk for aspiration? Have preventive strategies been taught or provided, including meticulous oral hygiene?

Report-by-proxy

When assessment information is obtained indirectly (report-by-proxy) the nurse asks another person to report his or her observations. This approach is used extensively with persons who are cognitively impaired; the elder's abilities and health are often underestimated.

E—Elimination

While difficulties with bowel and bladder functioning are not normal parts of aging, they are more common than they are in younger adults and can be triggered by such things as immobility attributable to physical limitations (e.g., following a stroke) or medications (e.g., diuretics). Incontinence can result from cognitive changes that may cause reduction, or even absence, of the sensation indicating a need to void or defecate. There are many elimination problems for older adults living in institutional settings where they are dependent on others for assistance to maintain continence (e.g., getting to the toilet in time). Is the person having difficulty with bladder or bowel elimination? Is there a lack of control? Does the environment interfere with elimination and related personal hygiene (e.g., are toileting facilities adequate and accessible)? Are any assistive devices used, such as a high-rise toilet seat or bedside commode, and if so, are they available and functioning? If there are problems, how are they affecting the person's social functioning and self-esteem?

Considerations of Common Changes in Late Life During the Physical Assessment: Genitourinary female

Women have nonpalpable ovaries; short, dryer vagina; decreased size of labia and clitoris; sparse pubic hair. NOTE: Use utmost care with exam to avoid trauma to the tissues.

The Urinary Incontinence Assessment in Older Adults

addresses frequency of urination, leakage, and discomfort when urinating. It also contains the "Impact Questionnaire," which addresses the extent to which UI or leakage has affected the individual's ability to perform household tasks and engage in recreational and social activities, as well as his or her emotional well-being (e.g., feeling depressed).

Caring for patients with chronic illness

is a combination of addressing acute events that are superimposed on underlying conditions. It is curing what can be cured, providing comfort, and assuring that the person receives optimal, evidence-based care for that which is chronic. Individuals with chronic conditions need care that is coordinated across time and centered on their needs, values, and preferences. They need self-management skills to minimize long-term complications and that help them know when to seek help. They need health care providers (including nurses) who understand the fundamental differences between episodic illness to be cured and chronic conditions to be managed over many years and over periods of stability and instability. Interventions must take into consideration all of the information learned in the assessment to work with the individual and significant others to help the person develop personal goals and achieve these whenever possible.

Assessment of the elder with a chronic illness

is a holistic and interactive process. In no other situation is it necessary to consider all aspects of a person: physiological, psychological, social, spiritual, and functional. Each aspect is affected by the presence of the disease and in the context of the person's culture. Tools can be found throughout the text that can be used for assessment purposes, both comprehensive and specific related to the chronic condition and development of an acute process. Since a chronic disease is an evolving one, so is the need for, and type of, assessment. There is the need for nursing skills to conduct ongoing evaluation of responses and outcomes, careful observation, periodic monitoring, alert watchfulness, and (most importantly) discussion and collaboration with elders about their perceptions, the meaning of their illness, and their plans for the future. The assessment helps identify the gap between the existing patient self-care abilities and needed self-care resources.

Geriatric Syndromes

refers to a sign or symptom, or a group of specific signs and symptoms, that occur more often in older adults than in younger adults. -multiple etiological and pathological pathways of some of the geriatric syndromes. -contributing factors include multiple chronic diseases, normal age-related changes, polypharmacy, multiple providers, and the adverse effect of therapeutic or diagnostic interventions. -SPICES is an effective way to assess -can be an outcome of iatrogenesis & frailty. -impact on morbidity and mortality. -multiple causes and risk factors -involves multiple organ systems -occurs primarily in older persons ex: •Falls and gait abnormalities •Frailty •Delirium •Urinary Incontinence •Sleep Disorders •Pressure Ulcers

There are three approaches used for collecting assessment data:

self-report, report-by-proxy, and observation.

FANCAPES

setting. It is a model for a comprehensive yet prioritized, primarily physical assessment that is especially useful for the frail elder (Resnick & Mitty, 2009). It emphasizes the determination of very basic needs and the individual's functional ability to meet these needs independently. It can be used in all settings, may be used in part or whole depending on the need, and is easily adaptable to functional pattern grouping if nursing diagnoses are used. Fluids Aeration Nutrition Communication Activity Pain Elimination Socialization

Iatrogenesis

the causation of a disease, a harmful complication, or other ill effect by any medical activity, including diagnosis, intervention, error, or negligence.

Among the predisposing factors for iatrogenesis among older adults, the most likely culprits are:

the number of prescribed medications and polypharmacy (as well as OTC and use of herbal remedies), atypical presentation of illness, and more comorbid chronic illnesses. Impaired cognitive and functional capacity, reduced physiologic reserve, and altered compensatory mechanisms add to the risk.

Key Points to Consider in Observing Cultural Rules and Etiquette

• Be aware of past experiences in the health care setting. • Ask if there are persons (e.g., males in the family) that need to be present or involved in some way with the exam. • Respect the communication style used, especially in the health care setting. • Do not intrude into personal space without permission. • Be aware of general health orientation related to time (past, present, future). • Inquire as to appropriate wording reference to the person; presume using last name unless otherwise welcomed. • Inquiry as to acceptable level of touch and gender of provider.

Constitutional Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Change in the level of energy

Neurological Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in sensation, especially in extremities • Changes in memory other than very minimal • Ability to continue usual cognitive activities • Changes in sense of balance or episodes of dizziness • History of falls, trips, slips

Urinary Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in urine stream and length of time condition has been present; difficulty starting stream • Incontinence and, if present, under what circumstances and degree; personal strategies used to address urinary incontinence (e.g., pads)

Senses Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Changes in vision or hearing acuity and situations in which changes occur, or complaints of others related to these changes • Increase in dental caries, changes in taste, presence of bleeding gums, level of current dental care • Changes in smell

Cardiac Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Chest, shoulder, or jaw pain and circumstances in which pain occurs • If already taking antianginal medication such as nitroglycerin, how often is it needed • Sense of heart palpitations • If using anticoagulants, any evidence of bruising or bleeding

Gastrointestinal Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Continence, constipation, bloating, anorexia

Vascular Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Cramping of extremities, decreased sensation (see also Neurological), edema (including time of day and amount) • Change of color to the skin, especially increased pigmentation of the lower extremities, cyanosis, or any other change in color

Sexual Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Desire and ability to continue physical sexual activity • Ability to express other forms of intimacy • Changes with aging that may affect sexual functioning (e.g., vaginal dryness, erectile dysfunction)

Integument Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Dryness, frequency of injury, and speed of healing • Itching, history of skin cancer, sun exposure

Most Common Conditions Referred to as "Geriatric Syndromes"

• Falls and gait abnormalities • Frailty • Delirium • Urinary incontinence • Sleep disorders • Pressure ulcers

Characteristics of Successful Chronic Illness Management Models

• Interdisciplinary team of health care professionals, often led by a nurse • Ability to conduct initial and intermittent comprehensive assessments • Skill in the development of a comprehensive care plan that is individualized, incorporates evidence-based protocols, and is culturally appropriate • Adequate funding to implement the plan over time • Actively engages the patient and family caregivers in care • Proactive monitoring of the patient's clinical status and ability and willingness to modify the care plan as needed • Success in facilitating transitions across settings • Facilitation of the patient's access to community resources

Challenges for the Person With a Chronic Illness

• Long-term and uncertain nature of the illness • Costs associated with care including preventive and long-term personal care • Little coordination of care across the continuum • Lack of health care professionals with expertise in geriatrics and chronic care • Focus of health care system on acute and episodic care • Continued disparities in health care outcomes for vulnerable groups

Musculoskeletal Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Pain in joints, back, or muscles • Changes in gait and sense of safety in ambulation • If stiffness is present, when it is the worst and when it is relieved by activity • If limited, effect on day-to-day life

Respiratory Areas of Emphasis When Conducting a Review of Systems With an Older Adult

• Shortness of breath and, if present, circumstances in which this occurs • Frequency of respiratory problems • Need to sleep in chair or with head elevated on pillows

Major Risk Factors for the Development of Chronic Diseases

• Smoking or exposure to second-hand smoke • Lack of exercise • High sugar and fat diet • Obesity

Key Points in the Chronic Illness Trajectory Framework

• The majority of health problems in late life are chronic. • Chronic illness and its management often profoundly affect the lives and identities of both the individual and the family members or significant others. • The acute phase of illness management is designed to stabilize physiological processes and return to a state of stability. • Maintaining stable phases is central in the work of managing chronic illness. • Maintaining stable phases is central in the work of managing chronic illness. • A primary care nurse often has the role of coordinator of the multiple resources that may be needed to promote quality of life at any point along the trajectory.