Gero test 3

-unpleasant and unwarranted feelings of apprehension, which may be accompanied by physical symptoms -anxiety is a normal human reaction and part of fear response; it is rational, within reason but anxiety disorders are not part of the normal again process -becomes problematic when prolonged and exaggerated and begins to interfere with functioning -usually underdiagnosed

Anxiety disorders

Safety and belonging: -for clients in nursing homes with alterations in mental health, they may tell you extreme stories about other patients or staff, in some cases very paranoid -make certain they know that they can use the call bell if they become frightened -don't validate the story but listen and give them an option for dealing with their issue -this gives the person assurances that they will Be protected, but it neither confirms their suspicions nor makes a promise that cannot be kept -may need to turn over to supervisor to launch an investigation just to be certain that the story is part of the disease process

Application of Maslows hierarchy

Cognitive decline is not a normal change in aging, what should you do?

Assess for cognitive factors

Instruments used for assessment include: -mini-mental state exam (MMSE-2 on admission to detect delirium) -confusion assessment method (CAM) -Neelon and Champagne (NEECHAM) confusion scale -determine the patients usual mental status

Assessment of delirium

-brief pain inventory -Visual analog scales -pain assessment tool: numeric rating scale, faces pain scale, faces pain scale revised( good for males or stoic patients)

Assessment of pain

Veterans Health Administration (VA) system has long held leadership position in gero research, medical care, and extended care -TRICARE for life and veteran aid and dependence

Care for veterans

Describes disturbances in cognitive function: -memory -orientation -concentration Other disturbances of cognition affect: -intelligence -judgment -learning abilities -perception -problem solving -psychomotor abilities -reaction time -social intactness

Cognitive impairment

-pain assessment in advanced dementia scale (PAINAD) -pain assessment checklist for seniors with limited ability to communicate (PACSLAC, let's you compare to previous assessments)

Cognitive impairment tools for pain in older adults

Communication Behavior concerns ADLs care Wandering

Common care concerns

-Complete assessment -lab work up -need to rule out possible causes for cognitive impairments (brain tumor) -neuropsychological exam -interview with family and client -observation -functional assessment -

Comprehensive evaluation for cognitive impairment

Which test is great for nonverbal client?

Confusion assessment method (CAM)

-medications that older adults take for chronic illness can have adverse effects when combined with alcohol -urinary incontinence, gait disturbances, peripheral neuropathy, depression, sleep disturbances and insomnia, an dementia or delirium can occur with alcohol abuse in older adults -major factor in trauma, including falls, fires, drownings, crashes, and homicide

Consequences of alcohol use

-significant distress for the patient, their family/significant others and nurses -high morbidity and mortality -functional decline -increased postoperative complications -increased hospital stay -increased services after discharge -long term cognitive decline -a substantial minority will never recover or recover only partially

Consequences of delirium

-stressful experience for older adults -can be perceived as intrusive, intimidating, fatiguing, and offensive -poor performance on tests of memory cause anxiety -assessments need to be performed with hearing aids and glasses if needed -environment should be free of distractions when assessment is performed -assessment is best completed immediately upon wakening (or when client is at their best) -an older person with a change in cognitive function needs a thorough assessment to identify the presence of specific pathological conditions -it is important for nurses to have the skills to recognize cognitive impairment and monitor cognitive function

Considerations in cognitive assessment

What does a yellow, amber colored lens do?

Decreases glare

*orientation is the assessment parameter the nurse should use to differentiate between delirium and depression In delirium: orientation is usually impaired (worse at night) In depression: orientation is usually normal (worse in the morning) -Psychomotor activity should not be used to differentiate these

Delirium verses depression

-ADLs: bathing and care for ADLs can be perceived with fright as a personal attack and client may respond by screaming or striking out -maintenance of health and function -safety -communication -caregiver needs: limit the number of staff working with them and consistent staff assignments -talk before bathing, explain each step, keep covered -schedule activities when he/she is at their best

Dementia

-Alzheimer's type is the most common: confirming the development of neurofibrillary tangles is the only accurate method for diagnosing AD -affects more than 5 million individuals older than 65 in the US -societal costs are high related to the disease

Dementia

-keep active during the day to promote sleep -address safety -individuals can live fully with dementia -if a choice is given and patient says no, respect it

Dementia

Delirium: rapid onset Dementia: slow progression *as disease progresses, he/she will make something up to cover their confusion

Dementia

What is a chronic, progressive, subtle, and permanent state of cognitive impairment?

Dementia

What are the 3 D's of cognitive impairment?

Dementia Delirium Depression *not a normal consequence of aging but these impairments increase with age

Associated with: -medical disorders -medications -alcohol abuse, loss of spouse or partner, decrease in income, caregiver stress, gender, and others

Depression

Dry or wet AMD? -The light-sensitive cells in the macula slowly break down, blurring central vision in the affected eye -One of the most common early signs is Drusen, yellow deposits under the retina -SLOW

Dry AMD

Who is expected to use "substituted judgment" in making decisions? -what they would want done for them

Durable POA

-health and fitness -a sense of control over events -awareness of self and others -patience and tolerance -resilience -hardiness -resourcefulness -social support -a strong sense of self -availability of disposition (are they living where they want to live)

Factors influencing ability to manage stress

If a heavy drinker says "I'm going to decrease my alcohol intake" what should you do?

Give follow up or get them help

-Depression -sleep disturbances -loss or worsening of physical function and fitness -loneliness attributable to loss of social support, withdrawal from social activities -loss of ability to perform usual role activities and prior leisure activities -potential for drug, alcohol abuse or misuse

Impact of persistent pain in the older adult

-inadequate education about delirium -lack of formal assessment methods or failure to use them -view that delirium is not essential to the patients well being -failure to recognize -failure to initiate timely interventions -attributing delirium in those with dementia to cognitive decline and old age

Lack of recognition of delirium

-glaucoma -cataracts -diabetic retinopathy -macular degeneration -dry eye

Leading causes of visual impairment in US

What plan of Medicare? -offers optional prescription coverage -should re-evaluate their coverage each year as their required medications and plan coverage change

Medicare D

What should you look at with an older adult who has psych issues?

Medications

Analgesics Antibiotics Antidepressants Antipsychotics Benzodiazepines H2 receptor antagonists NSAIDs Herbal medications Tylenol taken on regular basis with alcohol= liver damage Alcohol diminishes the effects of oral hypoglycemic, anticoagulants, and anticonvulsants

Medications interacting with alcohol

Anticholinergics Digitalis Theophylline Antihypertensives Beta blockers Beta adrenergic stimulators Corticosteroids OTC meds (cough and cold meds) Caffeine Nicotine Withdrawal from alcohol, sedatives, hypnotics

Medications that may cause anxiety symptoms

-mental health is the same later in life as it is earlier in life except that the challenges may be greater -factors that interfere with mental health because of the effect on adaptation: developmental transitions, life events, physical illness, cognitive impairments, situations calling for psychic energy -mental energy or psychic energy is a concept in some psychological theories or models of a postulated unconscious mental functioning on a level between biology and consciousness

Mental health considerations

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

Most common conditions (geriatric syndromes)

Anxiety Severe cognitive impairment Mood disorders Alcohol abuse and dependence (emerging)

Most prevalent mental health problems in late life

What model provides the framework for studying and understanding behavioral symptoms of dementia and interventions are performed to minimize behaviors or actions?

Need-Driven, Dementia-compromised Behavior Model

Acetaminophen -used for the most common causes of physical pain such as osteoarthritis and back pain -SAFEST FOR OLDER ADULT -should be considered a first line approach unless contraindicated -if used appropriately, does not usually cause G.I. bleeding, renal, or cardiac effects NSAIDs -used when pain is from inflammation or during a short arthritic flare -accompanied by higher risk for adverse drug affects

Non-opioid analgesics

-cutaneous nerve stimulation -transcutaneous electrical nerve stimulation -acupuncture and acupressure -Touch -biofeedback -distraction -relaxation, meditation, and imagery -pain clinics

Non-pharmacological treatment for pain in the older adult

Therapeutic activities: -meaningful and enjoyable activities provide cognitive stimulation and opportunities for interaction with others -enhance feelings of self worth, promote a sense of belonging and accomplishment, and encourage expression of feelings and thoughts Exercise: -maintain or improve function, prevent excess disability, improve mood

Nonpharmacological approaches for dementia

-those with dementia are particularly at risk for weight loss and inadequate nutrition -predisposing factors include lack of awareness of the need to eat, depression, loss of independence, agnosia, apraxia, vision impairments, wandering, pacing, and behavior disturbances -collaborate with a dietitian to develop strategies to minimize or improve nutritional status -establish a routine so that the person does not have to remember time and places for eating -serve food and fluids that the person likes and has always eaten in a nice calm environment -they don't remember they are hungry

Nutrition concerns with dementia

If there is any injury to dominant arm who should you consult?

Occupational therapist

Those that are not successful have: -lack of social supports -accumulated stressors -unresolved grief -preexisting psychiatric illness -cognitive impairment -inadequate coping resources Those more at risk have life transitions and a loss of social support

Older adults not successful at stress management

-misuse of prescription and OTC medications -use of a drug for reasons other than that for which it was prescribed -older adults may not be informed if the side effects of medications -older adults are not going to report drug dealers

Other substance abuse concerns

-pain is consistently untreated and undertreated in older adults with cognitive impairments -nurses must be attuned to nonverbal responses to pain -even if they can speak, their verbal response may not reflect their true pain level due to cognitive impairment -should assume that any condition that is painful to a cognitively intact person is painful to a person who cannot express him or herself -consistent staff assignments can be crucial

Pain in older adults with cognitive impairments

-promote comfort -balance the risks and benefits of the various treatment options -maintain the highest level of functioning and self-care possible -Uses a holistic approach because of the complex nature of pain in later life

Pain management goals

Which part of Medicare covers acute hospital care, short term acute rehabilitative care and costs associated with hospice and home health care under certain circumstances?

Part A

-sensory enhancement (glasses, hearing aids, etc) -mobility enhancement (ambulating at least 2x a day) -bedside presence of a family member whenever possible -pain management -cognitive stimulation -simple communication standards -sleep enhancement -medication review -adequate oxygenation -prevention of constipation -normalize the environment

Prevention of delirium

What is the first model to plan and care for those with dementia and categorizes symptoms of dementia into 4 groups? -care decreases the stressor and provides a safe, predictable environment

Progressively lowered stress threshold (PLST)

-Belief that pain is a normal part of aging that should be lived with and not complained about (not true!) -The nurse and healthcare provider fear that providing adequate pain relief may lead to respiratory depression or addiction -The older adult is afraid of becoming addicted to opioids analgesics or that complains of pain may lead to additional testing -cost

Reasons for under treatment of pain in older adults

Often not recognized by physicians or nurses Factors contributing to lack of recognition: -inadequate education about delirium -lack of formal assessment methods -ageist attitudes -failure to initiate timely interventions

Recognition of Delirium

What are the 3 things older adults manage transitions and stressors through?

Resilience Hardiness Resourcefulness

-getting lost -bumping into objects -straining to read, not reading, restricting reading to a well lit room -stumbling or falling, decreased sense of balance -spilling food on clothing -social withdrawal -less eye contact -placid facial expression -TV viewing at close range -mismatched clothes -multiple bruises

Signs and behaviors that may indicate visual problems

-set up as an "age entitlement" program, a pay as you go system -must meet criteria to receive funds -designed as a pay as you go system -age of eligibility has increased over time (67 years old)

Social security

Pain Fatigue Grieving Fostering self care Preventing complications Assistive technology Working with families, caregivers

Special considerations in chronic illness

Healthy people 2020 goals and objectives Preventive measures: -lifestyle choices, changes -risk factor identification -early detection and management of risk factors Wellness approach to chronic illness: -increase physical activity -improve nutrition -decrease tobacco use -decrease excessive alcohol consumption -decrease stress

Strategies that improve the health of older adults

Agitation Irritability Pacing Crying Repetitive verbalizations -often the presenting symptom of depression -can't always trust hearing from family members/friends

Symptoms of anxiety

The shifting perspectives model of chronic illness: -views living with chronic illness as an ongoing, continually shifting process focusing on the emotional, spiritual, and social aspects of life -The person moves between having a perspective of wellness or illness in the foreground

Theoretical frameworks for chronic disease

Dementia Electrolytes Lungs, liver, heart, kidney, brain Infection Rx(polypharmacy, psychotropics) Injury, pain, stress Unfamiliar environment Metabolic

Things that can cause delirium

True or false, the majority of health problems in late life are chronic

True

What do patients with delirium need related to sleep?

Uninterrupted periods of sleep

-Visual impairment has a negative impact on the quality of life -more than 2/3 of those with visual impairment are older than 65 years of age -many age related diseases have no symptoms in the early stages but can be detected through a comprehensive dilated eye exam -usually no early symptoms, yearly dilated eye exam for at risk individuals

Vision

Forms of wandering: Lapping, pacing, random -can lead to falls, elopement, disturbances in care routines such as eating, and interference with the privacy of others

Wandering

-high level wellness is in integrated method of functioning that maximizes the individual's unique potential -even in chronic illness and dying, a level of wellness and well-being is attainable for each individual ("today is a good day")

Wellness in chronic illness

Physiology: -older adults develop higher blood alcohol levels because of age related changes that alter absorption and distribution of alcohol -reduced liver and kidney function slow alcohol metabolism and elimination -risks if GI ulceration and bleeding may be higher in older people

Alcohol

What is when a person if able to understand a problem, the risk and benefits of a decision, the alternative options, and the consequences of the decision? -is presumed when the legal age of "adult" is reached unless the person has been adjudicated (decided by the court) to lack such capacity -when seeking healthcare, must be individually assessed for factors that could impact capacity (head injury, dementia, delirium)

Capacity

What is the most common type of pain late in life? -persistent, non-cancerous, musculoskeletal in nature from arthritis and other degenerative spinal conditions, neuralgias from long standing diabetes, peripheral vascular disease, herpes Zoster, stroke, chemotherapy, can bring about long-term changes in lifestyle -loneliness and emotional pain from loss decrease the ability to cope with physical pain

Chronic (persistent) pain

What is the majority of health care costs spent on?

Chronic Illness

What is managed rather than cured and is always present but not always visible (back pain)?

Chronic illness

-characterized by a rapid onset and fluctuating course (acute or subacute) -symptoms develop over a short time (hours to days) -symptoms fluctuate over the course of the day and are worse in the evening *most likely show fear with this

Delirium

What is an acute and sudden impairment of cognition that is considered temporary and usually has an identifiable biophysical cause?

Delirium

-assessment includes screening for alcohol abuse and physical signs of use -alcohol related problems may be overlooked -alcoholism is a disease of denial and not easy to diagnose -older adults may not view alcohol use as harmful -depression -interventions are a stepped care approach -can have 1 glass of wine

Implications of alcohol use

What is a health insurance program jointly funded by federal and state governments using tax dollars collected into general funds of each? -provides health coverage to millions of Americans, including eligible low income adults, children, pregnant women, elderly adults, and people with disabilities

Medicaid

-states establish and administer their own Medicaid programs and determine the type, amount, duration, and scope of services within broad federal guidelines -states are required to cover certain "mandatory benefits" and can choose to provide other "optional benefits" through the Medicaid program

Medicaid benefits

-treat both acute and persistent physical pain -requires caution in their use with older adults: May produce a greater analgesic effect, a higher peak, and a longer duration of effect -Side effects include gate disturbance, dizziness, sedation, falls, nausea, pruritus, constipation -sedation increases risk for the geriatric syndromes -a bowel regimen should be instituted at the same time as opioid treatment (stole softeners and laxatives) Morphine: reliable and safe for older adult -DO NOT give Mepiridine (Demerol) or Pentazine (Talwun)

Opioid analgesics

What is a simple tool to use with advanced dementia, end up with a 0 to 10 pain scale?

PAINAD

-legal document/device in which one person designates another person to act on his/her behalf -least restrictive form of protection and assistance, providing decision-making for persons with impaired capacity -chosen by the elder, not the courts General POA: makes financial decisions but not necessarily to make decisions related to health care Durable POA: has additional rights and responsibilities to make health related decisions for persons when they are unable to do so themselves

Power of attorney

What should we do if a patient is afraid to move because of pain?

Pre medicate before getting them up

What is used for a patient who needs a nursing home stay but spouse is able to stay in the community? -burial funds and only half of the combined value of the household goods, including the automobile, are counted as belonging to the patient, are used to determine eligibility for Medicaid, and are not expected to be used to pay for care -after the death of both spouses, it is expected that the amount Medicaid has spent on the care be reimbursed with any remaining funds in the couples estate

Spousal impoverishment

-the experience of stress is an internal state accompanying threats to self -healthy stress levels-motivate one towards growth -stress overload: diminishes ones ability to cope effectively -stress tolerance: variable and based on current and ongoing stressors as well as coping ability; application of what one has learned from previous situations can help dissipate the intensity of stress -crises and stressors can impair physical health: loss of family, taking on caregiver role, moving to a new location, retirement

Stress and stressors

If an older adult comes in with flu, what should you assess?

Stressors

Hyperactive Hypoactive Mixed

Subtypes of delirium

-rates are higher in older adults than in any other population group -those 85 years of age and older make up the largest group -common precipitants include physical or mental illness, death of spouse or partner, and substance abuse (crisis can contribute) -older adults rarely threaten to commit suicide, they just do it -use of firearms in older men is the lethal method -all providers need to inquire about recent life events, implement screening, recognize warning signs and risk factors, and intervene as needed

Suicide

Geriatric depression scale (GDS) Clock drawing test (CDT) Mini-cognition (mini-cog) Confusion assessment method (CAM) Mini-mental state exam (MMSE)

Screening for cognitive impairment

What are older adults 85 years of age and older more at risk for?

Suicide

What occurs suddenly and often without warning; stroke, myocardial infarction, hip fracture, infection?

Acute illness

What is a cute, non-cancerous pain experienced late in life is usually episodic in nature? -is it temporary type of pain -examples include post operative, procedural, or traumatic pain -often superimposed on a pre-existing chronic pain -use of analgesic agents can decrease the risk for falls and delirium

Acute pain

-typically used with an analgesic but may be used alone -most effective for neuropathic pain syndromes, such as postherpetic neuralgia and diabetic neuropathy -topical agents may have mild to moderate Local effects (lidocaine patch, capsaicin)

Adjuvant medicstions

-maintains or promotes a cause -defends, pleads, or acts on behalf of cause for another -fights for someone who cannot fight -often gets involved in getting someone to do something he/she would not otherwise do

Advocacy

What is deterioration of the central portion of the retina, the inside back layer of the eye that records images we see and sends them via the optic nerve from the eye to the brain. The retinas central portion known as the macula, is responsible for focusing central vision in the eye? -causes the progressive loss of central vision leaving only peripheral vision intact -no cure just treatments

Age related macular degeneration

-substance abuse often arises in old age as a coping mechanism to deal with loss, anxiety, depression, boredom, or pain associated with chronic illness -often goes unrecognized although the residual effects of alcohol abuse complicate the presentation and treatment of many chronic disorders -heavy drinking is the most common form of alcohol abuse in older adults, experts in the field recommend only one regular size drink a day

Alcohol

Gender issues: -Men are four times more likely to abuse alcohol than women -Women are more susceptible to the effects of alcohol because they have less body water, less lean muscle mass, and lower enzymes than men to breakdown alcohol -often, alcohol abuse in women is undetected until the consequences are severe

Alcohol

-intervene early Hospital Elder Life Program (HELP): well researched program of delirium in the acute care setting that looks at: -cognitive impairment -sleep deprivation -immobility -visual impairments -hearing impairments -Dehydration Anti psychotic drugs should not be routinely used

Delirium interventions

-patients at high risk should be hospitalized -patients at moderate risk maybe treated as outpatients provided they have adequate social support and no access to lethal means -patients at low risk should have a full psychiatric evvaluation and be followed up carefully

Suicide interventions

-many criteria must be met for this program, but ultimately requires a very low income and few resources -provides stipends to low income people who are aged 65 years or older, blind, or disabled

Supplemental security income (SSI)

Assessment: -use direct and straightforward questions -have you ever thought about killing yourself, how often have you had these thoughts, how would you kill yourself if you decided to do it? Assessing lethality potential: -internal resources (personality factors, coping strategies) -external resources (money, family, friends, services) -Communication skills (ability to ask for help and express feelings)

Suicide assessment

Assess for anxiety -focus on physical, social and environmental factors as well as past life history, long standing personality, coping skills, and recent events -look for coexisting medical conditions that mimic symptoms of anxiety -older adults deny psychological symptoms -thorough medication review Treatment -choices depend on the symptoms, specific anxiety diagnosis, comorbid medical conditions, and current medication regimen Non pharmacological interventions -preferred and are often used in conjunction with medication Avoid anti anxiety medications -without an assessment for factors associated with anxiety (no meds if just 1 person says older adult is anxious, ASSESS first)

Care for anxiety

Goals: -maintain function and prevent excess disability -structure the environment and relationships to maintain stability -compensate for the losses associated with the disease -create a therapeutic environment

Care if patients with neurocognitive disorders

-case managers responsibilities overlap with the responsibilities of the care manager -must be experts regarding community resources and understand how these can best be used to meet the client's needs -a resource person who the client can seek for advice/counsel and for brokering (negotiating, arranging) the flow of services -getting patient ready for discharge

Case and care management

-exposure to UV light -Poor dietary habits -diabetes, hypertension -kidney disease -Eye trauma -history of alcohol intake and tobacco use -after glaucoma, other eye surgery

Cataract risk factors

-cloudy or blurred vision -everything becomes dinner like glasses need cleaning -appearance of halos around objects as light is diffused -Poor night vision -sensitivity to glare -perception that colors are faded or that objects are yellowish -need for brighter light when reading -Red reflex may be absent or may appear as a black area

Cataract symptoms

What disease affecting vision puts a fog over vision?

Cataracts

What is a clouding of the eyes normally clear crystalline lens, causing the lens to lose transparency or scatter light? -most common causes are heredity in advancing age -an increase of yellow in dark leafy vegetables in the diet in vitamin E from foods and supplements may lower the risk in women

Cataracts

-The most common diseases occurring among older person in the US include hypertension, heart disease, arthritis, and diabetes -chronic illnesses can be an inconvenience or impairment involving activities of daily living -chronic illness is unending, and coping can be influenced by the perception of uncertainty -deal with them on good days and bad days -has a psychological impact -older adult has slower diagnosis of chronic illness -over 50% have hypertension over 50 years old

Chronic illness and aging

What typically has a gradual onset and a slow, steady pattern of decline without alterations in consciousness and an irreversible state that progresses over years? Clinical features: Aphasia- absence or impairment of the ability to communicate through speech, writing, or signs because of brain dysfunction Apraxia- inability to perform purposive movements although there is no sensory or motor impairment, inability to use objects properly Agnosia- inability to recognize or comprehend sights, sounds, words, or other sensory information Disturbances- in executive functioning

Dementia

Prevention is a priority: -identify high risk patients -assess every older adult who comes in -prompt and appropriate assessment -continued surveillance Goal: identify reversible conditions

Delirium implications

-is common in later life and is usually treatable; however, it can be life threatening if left unrecognized and untreated -becoming depressed increases the probability of becoming sick -is underdiagnosed and undertreated in older adults -failure to treat increases morbidity and mortality

Depression

-not a disease but a frequent complaint among older adults -tear production normally diminishes with age (dry, scratchy feeling to marked discomfort in mucus production) -causes can include medications such as anti-histamines, anti-cholinergics, diuretics, beta blockers, and some Hypnotics -common treatment is artificial tears, saline gel, vitamin A ointments, using a home humidifier and avoiding wind and hairdryers

Dry eye (Keratoconjunctivitis Sicca)

-mental health disorders in the older adult are typically underreported and not well researched -can't always treat an older adult the same way as the younger adult -attitudes and beliefs- older people are reluctant to seek help because: pride of independence, stoic acceptance of difficulty, unawareness of resources, fear of being "put away", health providers lack of knowledge -culture and mental health -availability of mental health care- lack specially trained personnel for gero mental health treatment -setting of care: shortage of trained personnel, limited availability and access for psychiatric services, lack of staff training related to mental health illness, inadequate medicate and Medicaid reimbursement for mental health services, often difficult to find placement for older adults with a mental health problem at long-term health facilities or residential living facilities

Factors influencing mental health care

Guardian Spouse Majority of adult children Parents Majority of adult siblings Adult relative Close friend Licensed clinical social worker appointed by a bioethics committee

Florida hierarchy of appointments from first to last

What visual disease is more common in one eye, and causes are variable and often unknown? -natural fluids of the eye are blocked by ciliary muscle rigidity, pressure builds, and damage to the optic nerve occurs

Glaucoma

What visual disease is when there is no peripheral vision?

Glaucoma

-beta blockers (oral or topical eye drops, lowers eye pressure) -other agents that lower eye pressure -Trabeculoplasty (laser surgery) -filtration surgery (only if trying to prevent further damage to the optic nerve)

Glaucoma management

-Family history of glaucoma -diabetes -hypertension -history of corticosteroid use -past eye injuries -age (single most important predictor) -older women 2x more than men -race: African American (blacks) and Hispanics

Glaucoma risk factors

-approximately half of those with this do not know they have it -headaches -poor vision in dim lighting -increased sensitivity to glare -"tired eyes" frequent changes in prescriptions for corrective lenses -impaired peripheral vision KEY -a fixed and dilated pupil

Glaucoma symptoms

What cannot be rushed with an older adult?

Grief

Conservator: appointed to control the finances of the ward Guardian: appointed to be responsible for the ward

Guardians and conservators

Who are the individuals, agencies, or corporations appointed by the court to have care, custody, and control of disabled person (ward) and manage his/her personal and financial affairs when the person has been found to lack capacity?

Guardians and conservators

-reduce the suicide rate -reduce the proportion of persons who experience major depressive episodes -increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral -increase the proportion of adults with mental disorders who receive treatment -increase the proportion and persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders -increase depression screening by primary care providers -increase the proportion of homeless adults with mental health problems who receive mental health services

Healthy People 2020- mental health and mental disorders

Must be knowledgeable about the impact of: -vision changes on the functional abilities and quality of life of older adults -Visual assessment -prevention and treatment of diseases affecting vision -effective communication techniques -ways to assist the individual in adapting to in compensating for these losses -assess functional status and mood when patient experienced a change

Implications for Gero nursing and healthy aging

-nurses who are consulted by clients about legal issues should not attempt to provide legal advice but instead should provide resources for the patient to find a qualified attorney -The National Elder Law Foundation (NELF): certify lawyers who have demonstrated knowledge pertinent to the legal needs of older adults

Implications for gero nursing

-older adults deny psychological symptoms (might lose independence, fear) -anxiety-related symptoms are attributed to physical illness -older adults have co-existent medical conditions that mimic symptoms of anxiety -baseline data are often lacking from an individuals earlier years

Implications for gero nursing and healthy aging

-The nurse is usually the person most attuned to the needs of patients -The nurse is in a key position to work with the elder in the management of pain: when the client is afraid to move or get out of bed because of potential pain, administer pain medication, and wait 30 minutes before assisting them up

Implications for healthy aging

-Nonpharmacological interventions (start here first) -pharmacological interventions (begin and advance slowly) -Adjuvant medications (mix of 2 or more) -pain clinic (goal): decrease pain intensity to a tolerable limit or eliminate it, improve functionality and ADLs, increased involvement in family and social activities, decrease depression and improve mood, may want to do pain diary in meds taken and how it's helping

Interventions for pain

-face the person and make direct eye contact -gently touch the person's arm, shoulders, back, or waist if he or she does not move away -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 -repeat specific words or phrases, or state the need or emotion -accompany him or her, talk calmly -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"

Interventions for wandering or exiting behaviors

-have someone call for help if you are unable to redirect -close observation to identify the person's individual patterns -camouflaging doorways -engaging the person in social interactions -providing enclosed pathways for walking, let wandering be acceptable in this safe environment

Interventions for wandering or exiting behaviors

-use warm incandescent lighting -increase the intensity of lighting -Control glare by using shades and blinds -use yellow to Amber lenses to decrease glare -wear sunglasses to block out UV light -recommend reading materials in large dark print or with good contrast and intensity -good colors for people with low vision include red, orange, and yellow

Interventions to enhance vision

-ideally, these policies would cover expenses related to co-pays for long term care and coverage for custodial care of help with day to day needs -individuals considering such a plan are encouraged to read the policy carefully and understand all the details, limitations, and exclusions before enrolling**

Long-term care insurance

-Financial and social governmental programs -insulin delivery systems -talking clocks and watches -large print books -magnifiers -telescopes with handheld devices or attached to eyeglasses -electronic magnification

Low vision assistive devices

Early signs: -awareness of a blurry spot in the middle of vision -cannot see what is in front of them -blurred vision -difficulty reading and writing -increased need for bright light -colors that appear dim or gray As progresses, the blurred area can grow larger in blank spots can develop in central vision

Macular degeneration

Age Genetic predisposition, family history Smoking Hypertension Atherosclerosis Obesity Caucasian and Asian American -excessive sunlight -diet lack of green leafy vegetables and fruit

Macular degeneration risk factors

Social security Income from assets Private pensions Government employee pensions Earnings

Major sources of income for older adults

-behavior issues occur in all types of dementia -Include anxiety, depression, hallucinations, delusions, aggression, screaming, sleep disturbances, restlessness, agitation, and resistance to care -may be a consequence of multiple, but sometimes modifiable interacting factors -should be viewed as a form of communication that is meaningful: *talk to patient about the behavior in question *dont assume they can't understand *gives you time to assess what the behavior might be pertaining to *often be an unmet need (bathroom, hunger, pain) *investigate the possible sources of distress -meds should not be first or even second line of response

Managing behavior

What plan of Medicare? -Person automatically receives this when he/she turns 65 years old and has paid Medicare taxes for at least 30 quarters (10 years) Insurance plan covering: -acute hospital care -short term acute rehabilitative care -costs associated with hospice and home health care under certain circumstances

Medicare A

What plan of Medicare? -in the 6 months surrounding a person's 65th Birthday (from 3 months before to 3 months after) all persons eligible for Medicare part A must select and apply for Part B through a social security administration office -designed to cover some of the costs associated with outpatient or ambulatory services. Deductibles and co-pays are required in most cases -location of services different from A to B

Medicare B

What plan of Medicare? -the Medicare advantage plan (MAP) -replaces both Medicare part A and Part B Can be a: Preferred provider organization (PPO) -only specific providers can be used; allowable charges preset Managed care plan (MCPs) -maximize the use of sub-acute care; most effective for an older adult who seeks regular primary care and preventive strategies to maintain health

Medicare C

What should HCPs do for older adults with mental illness?

Screen them

-a dilated eye exam and tonometry for diagnosis ( annual for those 65 and older at high risk) -those being treated for glaucoma reassessed every 6 months

Screening and treatment for glaucoma

What is a sensation of physical, psychological, or spiritual distress? -is subjective and whatever the client says it is -can reduce socialization, impaired mobility, and can result in a reconsideration of the meaning of one's life -do you not want them to withdrawal -pain sensitivity does not change with age, usually have more pain -"no pain" May be a part of culture, look at nonverbal pain signs

Pain

Changes in behavior: -restlessness and agitation or reduction in movement -repetitive movements -unusually cautious movements, Guarding Activities of daily living: -sudden resistance to help from others -decreased appetite -decreased sleep Vocalizations: -person groans, moans, or cries for unknown reasons -person increases or decreases usual vocalizations Physical changes: -pleading expression -grimacing -pallor or flushing -physical tension such as clenching teeth or hands -diaphoresis -increased pulse, respirations, or blood pressure

Pain cues in The person with communication or cognitive limitations

-comprehensive assessment and the use of medications are treatments of choice -behavioral changes occur with distressing conditions such as constipation, urinary tract infections, unfamiliar sounds and people, and many others -behavioral symptoms include fear, discomfort, illness, fatigue, depression, and need for autonomy and control -must work with the caregiver -check medication records, don't think it's the disease process -may utilize language and actions that their loved one would never have utilized before the dementia -work with the caregiver in an attempt to figure out what the patient is trying to say with the behavior

Person centered care for dementia

-are in effect only at the specific request of the elder or in the case of the durable POA, in the event that the person is unable to act in his or her own behalf -as soon as the person regains abilities, the POA is no longer in force unless the individual requests it to continue -the elder retains all of the rights and responsibilities afforded by the usual laws

Power of attorney

-do not smoke -eat a diet rich in green leafy vegetables and fish -exercise -maintain normal blood pressure and blood glucose measurements -wear sunglasses and a brimmed hat when outside in bright sunshine -wear safety eyewear when doing jobs that put eyes at risk or playing sports -see an eye care professional routinely

Promoting healthy eyes

-know the person's lifetime bathing routines and preferences -provide care only when the person is receptive -respect refusals to participate in care and explain all care -realize that a bath is not an essential intervention -encourage self care to the extent possible -make bathrooms and shower areas warm, comfortable, and safe -be attentive to pain and discomfort -use alternative bathing methods -they are striking out at you because they are afraid and protecting themselves

Providing care for ADLs with dementia

-positive interpersonal relationships -a willingness to extend oneself to others -optimistic of positive affect -keeping things in perspective -setting goals and taking steps to achieve these goals -high self esteem and self efficacy -determination -a sense of purpose in life -creativity -humor -a sense of curiosity

Resilience

Early onset anxiety disorder Frailty Lack of social support Poor self rated health Vision impairment Medications High stress life events: losses, traumatic events Presence of another psychiatric illness Substance abuse Cognitive decline and dementia

Risk factors for anxiety

-chronic mental illnesses, disability, functional decline -Alzheimer's disease and other dementias -bereavement -caregiving -female (2:1 risk) -socioeconomic deprivation -family history of depression -previous episode of depression -admission to long term care or other change in environment -medications -alcohol or substance abuse -living alone -widowhood

Risk factors for depression

-disturbance in attention and awareness -disturbance develops over a short period of time (usually a few hours to a few days) and represents a change from baseline attention and awareness -at lease one additional disturbance in cognition (memory deficit, disorientation, language, visuospatial, perception) -evidence that the disturbance is a direct physiological consequence of another medical condition, substance abuse, toxin exposure, or multiple conditions

Symptom requirements for delirium diagnosis

-physical symptoms -complaining or not complaining -insomnia -loss of appetite and weight loss -memory loss -chronic pain -hypochondriasis -decrease energy and motivation, hopelessness, increased dependency, poor grooming, withdrawal from people, decreased sexual interest, "giving up"

Symptoms of depression

-health care insurance program provided by the department of defense -available for active duty and retired military/uninformed service personnel and their dependents -requires enrollment in both Medicare Part A and Part B and pay premiums for Part B -as medigap policy. TFL covers expenses not covered by Medicare such as co-pays and prescription medicines

TRICARE for life (TFL)

Trajectory model: -views chronic illness from a life course perspective and an integral part of life, not as a single event Pretrajectory: no signs or symptoms present Trajectory onset: signs and symptoms are present, includes diagnostic period Crisis: life threatening situation Acute: Active illness Stable: controlled Unstable: uncontrolled Downward: progressive decline Dying

Theoretical frameworks for chronic disease

-reminiscence and life review -do not stifle the grief process; grief cannot be hurried, grief management -observation for side effects -cognitive-behavioral therapy: a short term goal oriented psychotherapy treatment that takes a hands on practical approach to problem solving. It's goal is to change patterns of thinking or behavior that are behind people's difficulties, and so change the way they feel -praise any effort at recovery, no matter how small -family and social support and education -exercise -humor -spirituality -psychodynamic therapy -Medications: -antidepressants if needed

Therapeutic interventions for depression

1- your Medicare coverage is protected 2- you get more preventive services for less (such as mammograms or colonoscopies, and free yearly wellness visit) 3- you can save money on brand name drugs (if in donut hole you'll get a 60% discount when buying Part D covered drugs) 4- your doctor gets more support 5- the health care law ensures the protection of Medicare for years to come

Top 5 things to know about the health care law if you have Medicare

Surgery: -removal of the lens and placement of a plastic intraocular lens -vision remains blurred for several days or weeks and then gradually improve as the eye heals -avoid heavy lifting, straining, and bending at the waist -eyedrops to prevent infection and aid healing -if bilateral cataracts, one eye at a time -need to protect eye after surgery: black sunglasses

Treatment for cataracts

-no cure, but want to slow the progression -Vitamin supplements as prescribed by healthcare provider -eating a diet full of antioxidants especially fresh, green, leafy vegetables and fruit -no smoking -manage cardiovascular disease -healthy weight and exercise regularly -for only certain candidates: implant a telescopic lens in one eye, looks like a tiny plastic tube, is equipped with lenses that magnify the field of vision. May increase both distance and close-up vision, but has a very narrow field of view. Very good in urban settings to identify street signs

Treatments for dry AMD

-laser photocoagulation -photodynamic therapy: Verteporfin (Visudyne)- A drug injected IV and used to help direct the laser to the affected area, done in physician office, procedure seals off leaking vessels while leaving healthy ones intact slows the process but cannot stop it -Anti-VEGF therapy: an intraocular injection if an anti VEGF drug inhibits the formation of new blood vessels behind the retina and may keep the retina free of leakage, often a "disconcerting experience" usually takes several injections until comfortable with experience -implantable telescope Many areas under research

Treatments for wet AMD

Hypoactive delirium: -quiet or pleasantly confused -reduced activity -lack of facial expression -passive demeanor -lethargy and inactivity -withdrawn and sluggish state -limited, slow, and wavering vocalizations Hyperactive delirium: -excessive alertness, easy distracted -increased psychomotor activity -hallucinations, delusions -agitation and aggressive actions -fast or loud speech -wandering, verbal behaviors -attempting to get out of bed

Types of delirium

Dry or wet AMD? -occurs when abnormal blood vessels behind the retina start to grow under the macula -New blood vessels are fragile and often lead blood and fluid which raise the macula from its normal place at the back of the eye -The severe loss of central vision can be RAPID

Wet AMD

Delirium present on: Admission During hospitalization ICU after operation -delirium is preventable in up to 40% of cases

Why worry about delirium

Who should we teach about vision safety, what age group?

Younger adults