Care of the Older Adult- C475

Social Security

(FDR) 1935, guaranteed retirement payments for enrolled workers beginning at age 65; set up federal-state system of unemployment insurance and care for dependent mothers and children, the handicapped, and public health. Less money if retire early.

o Medicare Part A:

- Blood - home health services - hospice - inpatient hospital care - SNF care (for transitional care)

o Medicare Part B:

- Doctor and other healthcare provider services - outpatient care - durable medical equipment - mental health services - some home care services - some screening and preventive services - laboratory services

o Medicare Part D (Medicare Prescription Drug Improvement and Modernization Act of 2003)

- Multiple plans are offered from which a beneficiary can choose. - Plans vary in prescriptions covered, deductible, premium, and copayment

-At any age hypnotic drug use can give rise to 3 major problems:

- unwanted effects on daytime mood and behavior associated with drug consumption - rebound effects associated with drug withdrawal - dependency associated with long term drug use

Describe how changes in kidney function can contribute to ADRs (adverse drug reactions).

-Adverse drug reactions in the older population occur as a result of changes in the kidneys, more specifically changes in GFR and renal clearance. -Renal blood flow in the cortical section of the kidneys declines at a much quicker rate compared to the average renal blood flow rate. This indicates that cortical nephrons are severely affected by age. -A decline in GFR becomes significant as people age because elimination of waste and toxins declines, causing an accumulation of harmful substances such as uric acid and medications in the body.

· This index was designed to measure functional levels of self-care and mobility, and it rates the ability to feed and groom oneself, bathe, go to the toilet, walk (or propel a wheelchair), climb stairs, and control bowel and bladder.

-Barthel Index:

How to facilitate autonomy?

-Encourage completion of advance directives -Provide patient-centered care -Provide appropriate education and training to patients and their family -Ensure consents and refusals are truly informed -Support and educate patients about their rights -Stay informed of regulatory guidelines and laws related to the elderly -Provide feedback to legislators developing laws that affect the elderly -Know how to assist patients to access resources and navigate insurance and the healthcare system

What are controllable risk factors for stroke?

-HTN -high cholesterol -heart disease -smoking -obesity -stress -DM -Depression -Afib

Explain "start low and go slow."

-The key phrase in geriatric pharmacy remains "start low and go slow" because of renal changes that affect pharmacokinetics and pharmacodynamics with age, body is not eliminating waste properly, can cause medications to build up in body. -The rule of thumb, "start low and go slow," for medication dosing in older adults particularly applies to AEDs (antiepileptic drugs). The elderly tends to have more side effects, adverse drug interactions, and problems with toxicity levels than younger people.

How does the heart of an older adult respond to exercise?

-When older adults began to exercise, their heart rate did not respond as well, a greater end-systolic volume existed, and heart contractility declined. -However, as these older adults continued to exercise, the end-diastolic volume increased, producing greater stroke volume and ending with an unchanged cardiac output. -Exercise also increases vascular resistance and elevates both systolic and diastolic pressure.

List ways you might manage anxiety in your patient.

-decrease environmental stimuli -do not ask the patient to make major decisions -support current coping mechanisms (crying, talking, etc.) -do not confront or argue with the patient -speak slowly in a soft, calm voice (enunciate clearly) -avoid reciprocal anxiety (emotions can be contagious, and sensing anxiety in the nurse can worsen the patient's anxiety)

Which lifestyle modifications would you teach a patient with heart failure?

-limit or eliminate alcohol use (no more than 1 oz. ethanol per day = one mixed drink, one 12-oz. beer, or one 5-oz. glass of wine) -maintain a healthy weight (extra pounds put added stress and workload on the heart) -weigh daily and report weight gains of 5 pounds or more to healthcare provider -stop smoking (no tobacco use in any form) -limit sodium intake to 2-3 g per day—read the labels: avoid canned and processed Foods -take care with how foods are cooked or prepared at home (e.g., limit oils and butters) -take medications as ordered—do not skip doses. Report any side effects to the physician. -exercise to tolerance level—this will differ for each person, remain active without overdoing it, alternate rest and activity, learn energy conservation techniques

Describe the Mini-Cog tool and how it is utilized.

-screening tool that can be administered in 5 minutes or less and requires minimal training -consists of a three-item recall and a clock-drawing test (CDT) -this reliable tool can assist nurses with early assessment of cognitive problems -through the clock test component, is used to assess language comprehension, visual—motor skills and executive function while the three-item component assess recall -it is a short test, it is seen as less stressful for older adults compared with other tools

How would you perform a functional assessment?

-to identify an older adult's ability to perform self-care, self-maintenance, and physical activities, then plan appropriate nursing interventions based on the results -Tools to assess functional ability tend to address self-care (basic activities of daily living, or ADLs), higher-level activities necessary to live independently in the community (instrumental activities of daily living, or IADLs), or highest-level activities (advanced activities of daily living, or AADLs) -There are two approaches: *one approach is to ask questions about ability *other approach is to observe ability through evaluating task completion -measured by asking questions about the performance of activities of daily living (ADLs) (such as eating and dressing) and instrumental activities of daily living (IADLs) (such as meal preparation and hobbies) -In selecting or using tools to measure functional ability, the nurse must be clear on two questions: -First, is performance or capacity being assessed? *do you dress without help? (performance) *can you dress without help? (capacity) -The second question is, "Who is the source of information on functional ability? -from the family or from the older adult

Describe nutrition bull's-eye.

-was developed by Covert Bailey (1996) -its goal is for people to consume the nutritious foods that are listed in the center of the bull's-eye. -These foods are low in saturated fat, sugar, and sodium, and high in fiber · Whole-wheat products · Fresh fruits and vegetables · Skim milk · low-fat and nonfat cottage cheese · part-skim mozzarella

What are the three models of transition care?

1) BOOST 2)CMI 3)TCM

What three things are most important in transitional care?

1) Med rec is correct (can they access meds) 2) do they understand when to call Dr. 3) electronic records being sent to accepting facility without delay

What are the 3 triple aim goals?

1)Better Care 2)Better Outcomes 3) Lower Costs

What can relieve dyspnea of a dying patient?

A fan

What exercise recommendations for an older adult?

Aerobic exercise 150 min a week.

What does BOOST stand for?

Better Outcomes for Older Adults through Safe Transitions

What does CTI stand for?

Care Transitions Intervention

wear and tear theory

Cells wear out and cannot function with aging.

CTI

Developed by Eric Coleman. Four week intervention program designed to improve quality of care and contain costs for pts with complex care needs as they transition across care settings.

Autonomy

Each person has a right to make independent choices and decisions.

How to slow fraility?

Exercise

What is the leading cause of unintentional injury death in older adults in the U.S.?

FALLS

Hospice Care

Family is involved. 6 months or less.

Quality of life

Independence and autonomy

· Stress Incontinence

Involuntary loss of urine during activities that increase intraabdominal pressure (e.g., lifting, coughing, sneezing, and laughing).

This assessment tool attempted to identify a resident's strengths, preferences, and functional abilities in a systematic way in order to better address his or her needs

Minimum Data Set (MDS):

_____ is cultural and public display of grief through one's behavior.

Mourning

Functional Decline

New loss of independence typically associated with decrease mobility and performance of ADLs.

____ is what the pt says it is.

Pain

Who qualifies for Medicaid?

Persons with insufficient income

Older women experience bone loss, more susceptible to hip fracture. What can you do?

Raise toilet seat

What are the 3 R's in detecting & reporting elder abuse?

Recognize, respond, report.

ADL distinguished between independence and dependence in activities and created an ordered relationship among ADLs. · It addressed the need for assistance in bathing, eating, dressing, transfer, toileting, and continence.

The Katz Index

Which factors would you include in your assessment of sleep?

The SPICES: · Sleep disorders · Problems with eating or feeding · Incontinence · Confusion · Evidence of falls · Skin breakdown

TCM

The nurse acts as the main care manager, who consults with the patient in hospital, at home within 24 hours of discharge, accompanies the patient to post discharge follow-up visits, and provides weekly home visits and ongoing telephone support for an average of 2 months.

What does TCM stand for?

Transitional Care Management

Functional Incontinence

Unable to get to the restroom because of physical or mental conditions.

What happens with atrophy of sweat glands?

Very susceptible to heat and cold. Decrease wound healing process.

What physical activity promotes optimal aging?

Walking

Who qualifies for Medicare?

adults > 65 years; ESRD; disability

What is the emphasis of TCM?

care coordination and continuity of care

Respite Care

care for caregiver to allow them time off from caring for their family member.

what do restraints put you at risk for?

death, increase falls, injure self, mortality rate increase

Permanent decrease in mental capacity

dementia

Nonmaleficence

do no harm

Outline the 7 components of the Affordable Care Act.

elimination of lifetime limits for health insurance coverage for essential services --- -Elimination of the ability of insurance companies to rescind coverage -Free preventive care -Development of a prevention and public health fund -Increased access to affordable care, including a provision for preexisting conditions -Quality improvement and cost reduction programs -Increased access to health care in the community or at home, which provides more options for care outside of institutional settings

Palliative Care

for life debilitating diseases and have quality of life but active treatment.

health disparities seen among African American population in US:

gonorrhea congenital syphilis diabetic HTN CKD Breast CA Most likely to lose vision (cateracts, glaucoma)

what teaching preferences are desired by most older adults?

hands on experience nontechnology driven keep them up with what is going on in the world improve quality of life able to use what they have learned right away

o somatic pain

localized pain

Effective communication techniques for pts who have cognitive impairment:

minimize demand on memory use pictures, objects, or music from pts past allow adequate time to respond do not argue or reason with delusion or hallucination encourage discussion of life events, traditions use large print calendars and clocks pictures of family

· Functional Incontinence

o Results from problems external to the lower urinary tract, such as: § cognitive impairment § physical disability § environmental barriers.

senile kyphosis

occurs with advancing age. Development of this can be postural, often corrected with exercise and strengthening program.

nociceptive pain

pain from a normal process that results in noxious stimuli being perceived as painful o Responds to traditional pain interventions, such as analgesics, and nonpharmacological methods

· Neuropathic Pain

pain from damage to neurons of either the peripheral or central nervous system o Does not respond well to traditional interventions such as nonsteroidal antiinflammatory drugs (NSAIDs) or opioids o requires combination therapy with adjuvant medications such as anticonvulsants, antidepressants, and antiarrhythmic drugs § phantom limb pain § postherpetic neuralgia o Adjuvants/coanalgesics, often more effective than opioids Opioids (second line)

active eunthanasia

person directly and deliberately causes the patient's death. (given an overdose of painkillers)

passive euthanasia

person does not directly cause patient's death, they just allow them to die. (withhold meds or feedings, taken off of 02)

Example of isometric exercise

pushing against a wall

Goal of BOOST?

reduce 30 day readmission rates for older adults improve pt satisfaction identify high risk patients to prevent adverse events improve communication between provider and pts better prepare pt and family for discharge PROVIDES TOOLS TO SUPPORT NURSES IN IMPROVING CARE TRANSITIONS

Example of Isotonic exercise

resistance bands

Fraility

there are three or more ADL deficiencies, combined with weakness and chronic exhaustion

When evaluating an older patient they show signs of high depression and shows signs of low self-esteem

they are at risk for suicide

orthopenic position

upright position to prevent SOB

o Visceral pain

§ arthritis (bone and joint) § myofascial (muscle) pain § pain from gallstones § appendicitis § pancreatitis o Antiinflammatory: NSAID, steroids Acetaminophen Opioids Adjuvants rarely needed

What are common causes of depression?

· Decline in health or new onset of illness · Exposure to multiple medications and their associated side effects, as well as drug-drug interactions, can cause elders to feel physically and mentally "down" · Having outlived spouses, loved ones, and friends · Having to move from private homes to assisted living or long-term care because of decreasing ability to live independently

Which characteristics describe the "moderate" stage of Alzheimer's disease?

· Increased memory loss and confusion · Short attention span · Difficulty with language or numbers · Difficulty with reasoning · Inability to learn new things or to adapt to new situations · Restlessness, agitation, anxiety, tearfulness, wandering—especially in the late afternoon or at night ("sundowner syndrome") · Repetitive statements, questions, or movements · Hallucinations, delusions, paranoia, irritability · Impulsivity (saying or doing things he or she normally would not) · Perceptual-motor problems (interfering with ADLs)

Outline risk factors for a victim of elder abuse.

· Older age · dementia · depression · isolation · caregiver strain low social support · caregiving burden or stress · family disharmony · poor or conflicted relationship · living with elder adult · psychiatric illness or psychological problems · personality traits

List factors that can lead to poor outcomes in the transition of care.

· Poor communication · incomplete transfer of information · inadequate education of older adults and their family caregivers · limited access to essential services · absence of a single point person to ensure continuity of care all contribute.

Allow Natural Death (AND):

· Used as an advance directive in some locations instead of a DNR (do not resuscitate) order; promotes a more positive approach to consideration of a person's wishes at end of life · AND order is considered a more descriptive and more positive order than a DNR · Its focus is on allowing death as nature takes its course at the end of an illness. · provides for comfort measures so that even with the withdrawal of artificially supplied nutrition and hydration, the dying process would occur as comfortably as possible

Do No Resuscitate (DNR):

· implies taking something away, or not doing something for the patient (i.e., resuscitation) · can be viewed as a harsh and insensitive statement of medical care that promotes a feeling of abandonment by patients and families alike

The goal of palliative care?

· is to achieve the best possible quality of life for patients and their families, control of pain, other symptoms, and psychological, social, and spiritual problems is paramount

Describe a brown bag assessment and the advantages of this.

· means that patients bring in all of the medications they are currently taking, including OTCs, supplements, and herbals, to their clinic or hospitalizations for assessment. · The benefit of the brown bag assessment, other than being superior to self-report, is that the clinician can see how many tablets or capsules are present versus the last time the medications were filled (date on label) to probe for adherence.

delirium

· the onset of confusion and disordered thinking occurs abruptly, within a short period of time, such as a few hours, days, or weeks · attention is significantly impaired · characterized by fluctuation in mentation and thinking throughout the day

dementia

· typically begins with minor symptoms that gradually progress over time, such as months to years. · generally able to remain alert until latter stages of the disease · can have "good and bad periods" during the day, their memory and thinking skills tend to stay at a fairly constant level.

What is true of hispanic americans?

● often use folk remedies before traditional Western medicine. o emphasize family interdependence over independence. o self-care is not as important as receiving care in recovery from illness. o first seek the use of homeopathic remedies in conjunction with religious artifacts before engaging a healthcare professional