Chapter 1: GERONTOLOGIC NURSING AND AN AGING SOCIETY Tend to write things off w/ older ppl o BUT pain is body

y saying something is wrong Not always JUST aging Need to be able to differentiate between normal aging and something wrong U.S. Population - 38.6 million people over age 65 o By 2050, 1 in 5 Americans will be over 65 Life Expectancy in U.S. o 1930 59.7 yearsJust over 6 million ppl over 65 o 1965 70.2 yearsOver 20 million ppl over 65 o Currently 78.7 years38.6 million ppl over 65 Study of Aging o In past, healthy older men and women were an anomaly Led to picture of older adult as frail and dependent o Religious and Secular Movements Puritans aging a sacred pilgrimage to God Victorian Age youth the symbol of growth and expansion Later elders seem cumbersome and a hindrance to progress o Reverse Ageism Largely attributable to gerontology professionals of baby boom confronting their own aging Gerontology o The scientific study of the effects of time on human development, specifically the study of older persons o Biomedicalization of Aging Geriatrics coined by Ignatz Nacher (American physician) around 1900 Realized older ppl needed special care, much like pediatrics Aging seen as biomedical problem that must be reversed, eradicated, or held at bay as long as possible o Aging and disease are separate entities o Individual ages chronologically, biologically, psychologically, sociologically, and spiritually o Old category is arbitrary and varies w/ time, place, and perception Young-old = 65-74 Middle-old = 75-84 Old-old = 85-100 Elite-old = 100+ o Parents of baby boomers called notch generation Exposed to most every disease b/c of lack of immunizations Adolescent and young adult lifestyles contributed to their current problems Ex: Cigarette abuse (didnt know effects), Lack of exercise (physical exertion only associated with hard labor jobs) o Nonagenarian Older than 90 years

Survived dangers and diseases of childhood Experienced more hardship and lifestyle disruptions than any generation o Centenarians 100+ - the elite-old 1 in 26 Americans expected to live to 100 by 2025 Almost 50% life in nursing homes 30% without dementia 85% are females HOWEVER, men less likely to have significant mental/physical disabilities at this age Racial crossover effect Persons of color over age 85 are hardier than their white counterpart Asked for their wisdomkey to longevity Myths abound o Ex: daily alcoholic drink, church, continuation of sexual activity Significant lifestyle factors include: o Diets, maintaining proper weight, exercise, no smoking, social connections, stress management o Future Old = Baby boomers Born between 1946 and 1964 High-tech orientation Most have children, but low birth rate means fewer biologic children to assist them in old age Their income tends to be higher than other groups Their leisure time is scarcer than other adults; they are more likely to feel stressed They exercise more frequently than other adults Healthier old age attainable for baby-boomers Informed and educated They are the best-educated generation ever Toughest challenge for healthcare b/c look everything up on the internet and come in knowing their condition Have to help them sort out what is right for them Predictions for baby-boomers They will have a highly active role in their health care Their ability to access information will keep them informed They will not be satisfied with the conditions of todays nursing homes o Current nursing homes will not work for this generation Their blended families may need special assistance with caregiving demands o Coordinating care with family members will pose problem as family is typically spread throughout country Common Myths About Aging o Families forget their older relatives

In some cultures, taking care of old is respected tradition o Most people become senile in old age Senile just means they are growing old Senile DEMENTIA is confusion and loss of memory o Social Security provides every elderly person with a decent retirement income o The majority of the elderly reside in nursing homes Less than 5% of older ppl in assisted living o Medicare covers all health care-related costs for older people Gerontological Nursing o A specific area or nursing practice since the 1950s o Gerontology Nurse Pioneers and Leaders Origins of gerontological nursing rooted in England Began with Florence Nightingale, continued by Agnes Jones In U.S. almshouses were destination for poor older ppl Deplorable conditions and neglect 1935 Social Security Act said SS funds could not be used to pay for care in almshouses o Led to commercial nursing homes o Current Initiative Hartford Institute for Geriatric Nursing Nurse-led organization seeking to increase quality of care of nations health care for older Americans Nurse Competence in Aging (NCA) Provides grants and technical assistance to geriatric nursing organizations o Nursing works on getting ppl back to level of wellness or to help them deal with decreased level of function o Gerontological Nursing Education Schools of nursing now include gerontological nursing content in curricula Continued need to increase numbers of faculty with preparation in gerontological nursing Less than 30% BSN programs have a faculty certified in Gero nursing GNEC (Geriatric Nursing Education Consortium): purpose is to increase geriatric content in nursing programs Every older person should expect care provided by nurses with competence in gerontological nursing CORE KNOWLEDGE for nursing profession o Gerontological Nursing Roles Functions in variety of settingshospital, home, subacute and long-term care facilities, community Advanced practice gerontological nurses Critical need for nurses w/ masters and doctoral degrees in gero Have improved health outcomes and cost-effectiveness

Mission is to preserve function, enhance health, and enhance quality of life and dying Issues in Aging Today o Demographics of Aging o Aging in the United States Gender issues More women than men HOWEVER, more heart issues w/ women now that they are working more (e.g. stress) Diversity Rise in older adults in other ethnicities (non-white) Make up about 19% of older Americans Health care problems prevalent in these communities o Hypertension, diabetes Nursing focus on providing care for this growing population o Need to meet needs of community o Need to provide clinic hours to meet needs (e.g. Many are poor and need to continue to work so must have weekend hours, nightly hours) o Operationalize care so can reach all ppl o Ex: Newark had prevalence of poor outcome after strokes UMDNJ put banner on sides of buses going through Newark Banner had signs of stroke w/ tagline: Time is Brain HAVE 3 HRS TO ADMINISTER CLOT BUSTING DRUG Marital Status Majority over 80 live independently in community Older men more likely to be married than older women 42% of older women are widowed Living Arrangements Florida has highest proportion of ppl 65+ (17.6%) Education Education of older ppl increasing Baby-boomers more educated than current old-old o Future generations will continue this trend Income and Employment Median income of 65+ is $44,188 9.7% living below poverty level o Gender, racial, and cultural disparities exist o At risk for poverty include: Women, African Americans, Hispanics, o Factors influencing poverty and women include:

Pay inequity, occupational segregation, caregiving responsibilities, longer life expectancy, rising health care costs, and womens work patterns All factors reduce pension earning, public assistance benefits, and personal savings

Global aging Western Europe and Japan have more older people than young people Will be joined by rest of Asia in 2040 and U.S. shortly thereafter Japan, Hong Kong, Iceland, and Switzerland have longest life expectancy Influence by infant mortality rate (they have lowest rate globally) o Caring for an Aging Society Eldercare workforce understaffed and unprepared Eldercare Workforce Alliance A group of 28 national organizations representing older adults and the eldercare workforce Includes: family caregivers, health care professionals, and direct care workers Immediate goals are: o Strengthen direct care workforce o Address clinician and faculty shortages o Ensure a competent workforce o Redesign healthcare delivery Diversity of the Aged Population o Percentage of total population 65+ *Including this info b/c it was one of the PP slides* o Non-hispanic white 2003: 83% 2030: 72% 2050: 61% o Black: 2003: 8 % 2030: 10% 2050: 12% o Asian: 2003: 3% 2030: 5% 2050: 8% o Hispanic 2003: 6% 2030: 11% 2050: 18% Baby Boom Generation o Born between 1946 and 1964 o High-tech orientation

Most have children, but low birth rate means fewer biologic children to assist them in old age o They are the best-educated generation ever o Their income tends to be higher than other groups o Their leisure time is scarcer than other adults; they are more likely to feel stressed o They exercise more frequently than other adults Nursing Research o Dementia Reality orientation telling pt the truth Has catastrophic event dealing with the truth Instead we lie to avoid this event o Reducing falls Older adults think a fall means the end: Fall = hip fx = death Bring beds lower Research of falls in community and reasons why ppl fall o Use of restraints No restraintsthey cause injury o Pain management o Delirium NOT DEMENTIA Treatable and typically caused by medications o Humane end-of-life care Politics of Aging o White House Conferences on Aging Make recommendations to President and Congress to help guide national aging policies o Older Americans Act Delivers community-based services through state Area Agencies on Aging (AAAs) The Elderly in New Jersey o Population age 65 or older 1,113,136 ranked 9th in the US o Percent of population age 65 or older 13.2% - ranked 18th in the US Healthcare Resource Utilization o Higher rates of hospitalization, surgery, and physician visits exist Care is more likely to be paid by federal dollars than private insurers or the elderly themselves o Less than 5% of the older population is institutionalized at any given time o Utilizing health care on their own: BP cuffs at pharmacy rather than going to hospital/doc each time BP and glucose home test that can be uploaded to hospital/doc Fit Bit bracelet that monitors your health

Chapter 2: HEALTH AND WELLNESS Health o Healthy = absence of disease o Health Continuum Medical interpretation of health continuum: if individual is in good health or is well, disease or impairment is absent o Older ppl dont fit into this category o Healthy aging Individual engaged in health Individual engaged in social life o Healthy People 2020 Looks at where we want to be w/ healthcare in next 5 years Older Adults & Healthy People 2020 o Use of Welcome to Medicare benefit o Older adults up to date on clinical preventive services Ex: PSA test for males o Older adults confidence in managing their chronic conditions Fully educate older ppl on disease process o Receipt of Diabetes Self-Management Benefits by older adults Encourage ppl to take advantage of benefits o Functional limitations in older adults Decrease number of functional limitations Encourage ppl to know signs of a stroke and come in if they think they have had one only have 3 hour window!! o Pressure ulcer-related hospitalizations among older adults Reduce pressure ulcers Prevention is key o Need for long-term services and support o Caregiver support services Elderly spouse needs support as caregiver o Health care workforce with geriatric certification o Emergency department visits due to falls among older adults o Information on elder abuse, neglect, and exploitation Wellness o Involves ones whole being: physical, emotional, mental, social, spiritual, and environmental o Wellness approach sees possibility of everyone (regardless of level on wellness continuum p. 22) achieving well-being by being at an optimal level of functioning for their level o When one uses wellness or holistic approach, which has been suggested as a more appropriate model for older people, one regards health and wellness continuum from more positive direction and role of individual is more active Strategies for Improving Health of Older People o Healthy lifestyle behaviors

Injury prevention Delivery of culturally appropriate clinical preventive services Immunization and preventive screenings Self-management techniques for chronic illnesses CHF Educate pt on what to look for (e.g. getting fatigued faster) Pt needs to take initiative and let doc know when having problems Healthy Aging o Healthy aging is process of slowing down, physically and cognitively, while resiliently adapting and compensating in order to optimally function and participate in all areas of ones life (textbook definition) o Older adults describe healthy aging as having functional independence, self-care management of illness, positive outlook on life, and personal growth and social contribution o Healthy aging must start from birth and continue throughout life Health Status of Older People o Self-reported health In 2008, 39% of older persons rated their health as excellent or very good o Disability and Chronic Illness Current generation of older adults is healthier than previous generations Rates of disability and chronic illness higher among racially diverse older adults Incidence of chronic illness increases with age More than 80% of 70+ have at least one chronic condition o Causes of Death Heart disease, stroke, and cancer are leading causes Preventable risk factors: Smoking High BP Elevated blood glucose Obesity Disease Prevention and Health Promotion for Older Adults o Older adults taking responsibility for their health Implies control and places ones wellness in ones own hands Strong effect on ones health behavior People are learning how to be in touch with their body signals and to take and seek action accordingly o Steps for Health Behavior Change Precontmeplation Extended time period Negative aspects of undesirable behavior stay in periphery of mind Contemplation Has ideas of change Examines behavior problem Considers balance between cost and benefit

o o o o

May take long time Preparation Intention to change unite w/ plan of action Concrete steps to be taken within 1 month Action Actual steps taken to modify behavior Person feels empowered and in control of life Frequently relies on support from others Takes 1 day at a time Maintenance Begins 6 months after action Prevention of relapse Lasts a lifetime Medicare Coverage for Preventive Services One-time Welcome to Medicare physical examination Cardiovascular screening (cholesterol, lipid, triglyceride levels) Breast cancer screening mammograms (once every 12 months) Cervical and vaginal cancer screening (Pap test and pelvic examination once every 24 months unless high risk) Colorectal cancer screening (fecal occult blood every 12 months, flexible sigmoidoscopy every 48 months, screening colonoscopy once every 24 months if high risk), barium enema (instead of colonoscopy or sigmoidoscopy) every 24 months for high risk or every 48 months if not high risk) Prostate cancer screening (digital rectal examination every 12 months, PSA test once every 12 months) Influenza, pneumococcal, hepatitis B immunizations Bone mass measurements (once every 24 months for people at risk for osteoporosis or more often if medically indicated) Diabetes screening, supplies, and self-management training (fasting plasma glucose test, glucose monitors, test strips, lancets, diabetes self-management training) Glaucoma tests (once every 12 months for people at high risk for glaucoma) Adopting healthier lifestyles and habits Nutritional Awareness Nation obese and undernourished because of imbalanced diet Weight problems among older adults o Increase risk of disabilities related to cardiovascular disease, diabetes, arthritis o Associated with increased functional limitations and decreased physical performance Physical Fitness Inactivity poses serious health hazards to young and old alike

Many older people believe that they are too old to begin or participate in active fitness program, but even with chronic conditions, a fitness program is possible Reduce proportion of adults who engage in no leisure time physical activity Increase proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day Increase proportion of adults who engage in vigorous physical activity that promotes development and maintenance of cardiorespiratory fitness 3+ days per week for 20+ minutes per occasion Increase proportion of adults who perform physical activities that enhance and maintain muscular strength and endurance Increase proportion of adults who perform physical activities that enhance and maintain flexibility Tai Chi Training Purpose o Explores extent and time course over which tai chi (TC) impacts measures of physical performance and cardiovascular function in older adults who are becoming frail Sample/Setting o 311 participants ages 70 to 97 (M 80.9) living in 20 independent congregate living facilities Method o 8-week randomized trial provided to 291 women and 20 men who were transitionally frail (+70 years and had fallen at least once in past year) o Participants randomized to either TC exercise or wellness education (control) interventions o Physical performance (gait speed, reach, chair-rises, 360-degree turn, picking up an object from floor, and single-limb support) and hemodynamic outcomes (heart rate and blood pressure) were obtained at baseline and after 4, 8, and 12 months Results o Positive impact on body mass index, systolic blood pressure, and heart rate, as well as on chair rises o Fall occurrences reduced. Positive outcomes apparent after 4 or 8 months of training and persisted through completion Implications o Positive benefits for frail older adults, including improved cardiovascular performance, decreased falls, and increased functional ability Stress Management Meditation Form of relaxation and coping with stress

Involves working toward psychological state termed transcendental awareness that restricts focus of attention to object of meditation, physiological process, or internal sensation Biofeedback Feedback from bodys internal processes By observing monitoring devices, person can learn to influence heart rate, circulation, and muscle tension Learned skill in stress control Explores body-mind connection Autogenic Training Total body biofeedback or self-regulation without machinery Combination of yoga and autosuggestion Effective in treatment of gastrointestinal, circulatory, and endocrine disorders as well as anxiety, irritability, and fatigue Progressive Relaxation Achieved through tension-relaxation techniques of specific muscles or muscle groups or, without tension, through countdown method, imagery, or recall of pleasant events or experiences Arranging Ones Environment to Reduce Stress Design quiet environment Proximity of familiar belongings and environment Developing Selfishness Clearly understand older persons goals Ensure that goals are expressive of self and not someone elses goals

Racially diverse populations less likely to have recommended preventive services Higher incidence of poverty which tends to mean lower health care and selfcare behaviors Goals include: Reducing premature mortality and morbidity Maintaining functional independence Extending life expectancy Primary and Secondary Disease Prevention Primary prevention: prevention of disease before it occurs Healthy lifestyle behaviors such as regular exercise, smoking cessation, moderate alcohol use, low-fat diets, stress management, active social engagement, and cognitive stimulation Secondary prevention: detection of disease at an early stage

HEALTH PROMOTION pneumonic:

Cognitive Health Not enough evidence to ID factors which may increase or decrease risk of developing Alzheimers or other cognitive declines Nurses need to educate effective strategies to enhance cognition Suggested strategies include: Prevention and management of chronic conditions Maintaining a healthy weight Avoiding excess caloric intake Limiting sodium and fat intake Increasing antioxidant defense by consuming fruits/veggies Physical activity Participation in mentally stimulating activity Social engagement Environmental Sensitivity Physical components Air; Water; Land mass Social components Government; Economics; Culture Avenues through which individuals health and wellness can be enhanced or limited Encourage independence and let pts do for themselves what they can Dont just do it for them because its easier and faster

Hypertension screen Environmental screen for safety issues Apnea during sleep screen Loss of weight Tetanus vaccination Hear in a noisy environment Pain screen and treatment Resistance and other exercises Osteoporosis screen Mood screen (depression) Occult blood in stool Testosterone deficiency (andropause) Influenza and pneumococcal vaccinations Oral screen for caries and abscesses Nicotine education Sugar screen (diabetes mellitus)

GERONTOLOGY THEORIES OF AGING

CHAPTER 3

THEORIES: explain phenomena, give sense of order, and provide a framework from which we can view a world

AGING most often described in terms of chronology, or by the measurement of time since birth.

Various definitions based on different cultures: e.g., functional no longer able to perform usual activities; social determined by a role, e.g., becoming a grandparent; physiological aging phenotype (gray hair, wrinkled skin, etc.)

Biological Theories of Aging

Biological aging SENESCENCE a complex, genetically regulated, interactive process of change. Aging phenotype reflects declining functional capacity of the most basic structures in the cells.

Cellular Functioning The cells accumulate changes in damage resulting in errors seen in replication. These changes are made visible in the traits we associate with aging. At this point we dont question the association of cellular errors and the aging phenotype, but the cause and patterns, e.g., are the changes predictable or random and chaotic.

Programmed Aging Theories Aging is the result of predictable cellular death. All cells and organisms have genetically determined life span (biological clock or the Hayflick limit). Researchers: Hayflick & Moorehead

Neuroendocrine Control or Pacemaker Theory

Aging programmed decline in the functioning of the nervous, endocrine, and immune systems. Cells dont die; their ability to reproduce is lost (replicative senescence).

Secretion of hormones such as DHEA and melatonin is decreased with aging.

Immunity Theory

Aging programmed accumulation of damage and decline in function of immune system (immunosenescence).

Error Theories

Aging phenotype the result of an accumulation of random errors in the synthesis of cellular DNA and RNA. With each replication, more errors occur until the cells are no longer able to fully function.

Wear-and-Tear Theory

Cell errors are the result of wearing out over time because of continued use. Internal and external stressors including pollutants and injurious metabolic by-products (free radicals) have harmful effects on cells. They may cause decline in cellular function or death.

Cross-linkage Theory

Aging the result of accumulated damage from error associated with cross-linked proteins. Cross-linking between the protein and glucose causing them to become stiff and thick. The newly cross-linked proteins are called AGEs (advanced glycation end-products). Cross-linking of collagen (the most abundant protein) can be seen in stiffening of joints and skin. Cross-linking may also cause cholesterol to attach to cell walls, leading to atherosclerosis. Other cross-linking agents include unsaturated fats and metal ions such as aluminum, zinc and magnesium.

Oxidative Stress Theory (Free Radical Theory)

Errors are the result of random damage from free radicals (molecules containing unpaired ions extra electrical charge). The accumulation of free radicals is called oxidative stress or oxidative damage. Over time, production of free radicals increases and the bodys ability to remove them decreases. The most effected appears to be mitochondrial DNA.

HEALTHY AGING PROMOTION:

Help people identify pollutants in their environments (e.g., industrial emission, ultra- violet light, second hand smoking, etc.)

Encourage the healthiest diet, careful use of herbs and supplements Promote immunizations and avoidance of exposure to others with infections

Psychosocial and Developmental Theories of Aging

These theories attempt to explain and predict the changes in roles and relationships in middle and late life, with emphasis on adjustment.

Role Theory The ability of an individual to adapt to changing roles over the life course is a predictor of adjustment to personal aging (developed in 1942 by Cottrell). Resistance to role changes indicates poor adjustment to ones own aging.

Age Norms socially and culturally constructed expectations of what is deemed as acceptable behavior. The aging of baby boomers proposes challenges to the role theory and age norms. Behavior and roles that were in the past questionable and unimaginable are becoming more acceptable.

Activity Theory Continued activity indicator of successful aging (Havinghurst, Albrecht 1953) Activity is necessary to maintain life satisfaction and positive self-concept.

Disengagement Theory In the natural course of aging, individuals should withdraw from their former roles and activities to enable the transfer of power to younger generations necessary for maintenance of social equilibrium.

Continuity Theory Individuals tend to develop and maintain a consistent pattern of behavior, substituting one role for a similar one as the person matures. Personality influences the chosen roles and activities and the level of satisfaction drawn from life.

Age-stratification Theory

Social aging can be best understood by considering the individual as a member of an age group, with similarities to others in the group (cohort effects).

Modernization Theory

Social changes resulted in a diminished value of the contribution of older people. The status and value of elders are lost when their labors are no longer considered useful, their information is not pertinent to the society, and culture they live in no longer reveres them.

Developmental Theories of Aging

Aging is an ongoing and incremental step-wise progression between birth and death.

Jungs Theory of Personality A personality is either extroverted (oriented toward the external world) or introverted (oriented toward the subjective inner world of the individual). Aging results in a movement from extraversion to introversion. The development of the inner person is accompanied by a search for personal meaning and the spiritual self.

Erikson Successful mastery of one task is necessary for successful movement to the next stage of maturity (famous Ericksons Eight stage (Task Model)).

Ericksons task of middle age: generativity (establishment and contribution in meaningful ways for the future generation) vs. stagnation Final task: ego integrity (sense of completeness and cohesion of the self) vs. despair In later modifications of the either/or stance, Erickson recognized the balance of each of the tasks; the goal is to achieve balance rather than an absolute resolution of despair and replacement with integrity.

Peck Robet Peck (1968) took Eriksons last stage to a deeper level. An achievement of the following three tasks would result in ego integrity or even Maslows self-actualization: Ego differentiation vs. work role preoccupation: The person no longer defines herself of himself by life work role but by individual personhood.

Body transcendence vs. body preoccupation: The body and changes are accepted as part of life rather than as a source of identity and focus.

Ego transcendence vs. ego preoccupation: The person sees oneself as part of a greater

whole rather than as an individual requiring special attention.

Maslow Maslow hierarchy of needs combines the bio/psycho/social needs of the individual from the most basic need for food and shelter to the most complex such as self-actualization, or gerotranscendence. Moving toward healthy aging is an evolving and developing process.

Biological and Physiological Integrity Safety and Security Belonging Self-Esteem SelfActualization (Introversion)

For more detailed description, please refer to a pyramid on page 41 of the book.

Tornstam Tornstam (Swedish psychologist) proposed the theory of gerotranscendence. Aging is viewed as the movement from birth to death and maturation toward wisdom. Gerotranscendence implies achieving wisdom through personal transformation. Drawing inward does not have to be disengagement with the world and can be instead, a time of introspection leading to wisdom. HEALTHY AGING PROMOTION:

Maslows hierarchy of needs is an example of how the theories can benefit patients and nurses. Application of the theory will lead to better understanding of individuals and their concerns at any particular time and in any particular situation. This theory can serve as a guide to set priorities in nursing interventions to promote healthy aging. A person whose basic needs are met, who feel safe and secure, and who has a sense of belonging will also have self-esteem and self-efficacy. Self-actualization is seen as people reaching out beyond themselves and finding meaning in their lives and sense of fulfillment.

Nurses especially in assisted living facilities or nursing homes can work with older people to form new alliances and associations and create environments in which meaningful relationships and activities can remain a part of the elders life.

Chapter 4: Physiological Changes THE INTEGUMENT (skin, hair, nails) I. Skin -protects internal organs -regulate body temp -serves as vehicle for salt excretion, water, & organic waste -stores fat -provides protection from UV rays -makes vitamin D

Causes of skin changes Extrinsic factors: environmental (exposure to pollutants, chemicals, solar radiation); sun exposure (increases extent & speed of normal skin aging) Intrinsic factors: occurs over time. Related to oxidation & cross-link theories of aging

Epidermis (outer layer) -normally is in constant state of renewal thru regeneration, cornification, & shedding Physiological Changes: epithelial renewal in young adults is every 20 days, whereas for older adult (OA), it takes 30-50% longer because keratinocytes become smaller & regeneration slows number of melanocytes decrease 10-20% per decade, resulting in lighter skin tone and therefore decreasing the amount of protection from UV rays pigment spots (nevi & freckles) enlarge with age & become more numerous with increased exposure to natural & artificial light

lentigines (age/liver spots) common in older, lighter skinned people

Dermis -provides stretch, recoil & tensile strength -supports blood vessels; nerves; hair follicles; & sebaceous (oil), eccrine (sweat-moisture) & aprocrine (sweat-odor) glands

Physiological Changes: dermis loses 20% thickness (which makes the skin more transparent & fragile) dermal blood vessels are reduced resulting in skin pallor & cooler skin temp collagen synthesis decreases, causing skin to tear more easily less elastic & resilience causing a sagging appearance sebum production decreases, causing drier skin & risk for cracking, and xerosis reduced sweat gland activity

Hypodermis -contains connective tissues, blood vessels, nerves, but major component is subcutaneous fat (adipose tissue). Purpose of the fat is to store calories & thermoregulation -Helps give the body shape & act as a shock absorber Physiological Changes: lean muscle is replaced by fat tissue in some areas of the body subcutaneous fat reduced. Loss of fat around orbit of eye creates a sunken appearance. Landmarks become more prominent. Muscle contours easily IDd risk of hyperthermia is elevated because the eccrine glands are not as efficient (become fibrotic & surrounding connective tissue becomes avascular, resulting in the decline in bodys ability to cool itself thru perspiration) risk of hypothermia (sebaceous glands secrete less oil, moisture evaporates more readily; cold weather accelerates loss of body heat by evaporation)

II. Hair Physiological Changes:

becomes thinner becomes gray due to diminishing melanocytes diffuse hair loss (alopecia) in men & women axillary, extremity & pubic hair diminishes (sometimes disappears) in men & women amount of hair increases in the ears, nose, & eyebrows

III. Nails Physiological Changes: nails become more brittle, flat, or concave with longitudinal striations cuticle becomes less thick & wide due in part to decreased circulation, fingernails & toenails thicken, change shape & color.

NOT a normal process of aging, but are common in OA: onychogryphosis (thickening & distortion of nail plate) and fungal infection onycholysis

MUSCULOSKELETAL SYSTEM I. Structure & Posture Physiological Changes: shortening of the trunk due to the thinning of vertebral disks as a result of gravity & dehydration. Combined with slight curving of cervical vertebra, height is lost. stooped, slightly forward-bent posture is common these changes occur because of age-related bone calcium loss and atrophic cartilage & muscle shoulder width decreases because of shrinkage of the deltoid muscles & acromion processes. Chest width & pelvic width increase, and abdominal length decreases while its girth increases.

II. Bones

-ongoing & cyclic resorption (into the bloodstream) and renewal (into the bones) of minerals, esp. calcium. Physiological Changes: resorption is more rapid than renewal, resulting in reduced bone mineral density (BMD) increased risk of fall-rated fractures (this is the most important issue related to osteoporosis)

*Reduced BMD is 4x more common in older women than in men. Its due to hormonal changes following menopause. In men, reduced BMD is primarily due to prolonged steroid use.]

III. Joints, Tendons, Ligaments -joints responsible for movement -tendons & ligaments are connective tissue that bind bones to each other & allow joints to articulate -cartilage lines the joints & supports specific body parts (eg. ears & nose)

Physiological Changes: changes in articular cartilage. As cartilage in joints dries up, it becomes thinner, resulting in less fluid movement or pain as bone rubs on bone. tendons may shorten & move from usual positions

IV. Muscles -three types of muscles: 1. Skeletal: for movement, posture, & heat production. Voluntary control 2. Smooth: throughout body, primarily in lining or organs & red blood vessels 3. Cardiac: heart muscle

Physiological Changes: sarcopenia: decrease of muscle mass (atrophy). Seen mostly in skeletal muscle. Loss is caused by physical inactivity, change in central & peripheral nervous systems, & reduced skeletal protein synthesis

CARDIOVASCULAR SYSTEM Responsible for the transport of oxygen & nutrient rich blood to organs & transport of metabolic waste products to the excretory organs

Most relevant age-related changes: -myocardial & blood vessel stiffening -decreased beta-adrenoceptor responsiveness -impaired autonomic reflex control of the heart rate -left ventricular hypertrophy -fibrosis

I. Heart -catecholamines & certain enzymes that influence force & speed of heart contractions diminish in concentration, resulting in longer interval betw contractions, weakened cardiac force, & more energy demand on heart muscle -presbycardia/reduced cardiac reserve: decreased maximal heart rate, stroke volume, cardiac output, ejection fraction, & oxygen uptake. Healthy older heart is still able to function well despite these limitations. Presbycardia becomes significant only when the person in physically or mentally challenged

Valves -four valves control blood flow in, out, & within heart

-when a valve is compromised, some blood may leak backward (regurgitate) during the hearts contraction or relaxation. The sound of backflow is a murmur -normal aging: valves may be thicker & stiffer from lipid deposits & collagen cross-linking, making mild systolic murmurs an expected finding.

Conductivity

-heart contracts & relaxes on its own. Stimulation starts in pacemaker cells in SA node, AV node & bundle of His. The bundle splits into right & left bundle branches. Beating movement produces the S1 & S2 sounds.

The aging heart is able to adapt to changes: -number is SA node cells decrease significantly in the 6th decade of life -AV node & bundle of His lose a number of conductive cells in 4th decade of life -left bundle loses cells betw 5th & 7th decades -resting heart rate unchanged with age, but max heart rate is achieved thru decreased activity -sinus rates <60 beats/min are common in elderly & dont necessarily mean disease in SA node

II. Blood Vessels -most significant age-related change is reduced elasticity & lumen; increased peripheral resistance -systolic BP increases with age

RESPIRATORY SYSTEM

Risk for respiratory infection is higher in OA due to structural changes in the respiratory system (along with lower immune system). (Cilia, which are normally responsible for pushing foreign bodies and mucus out of the body, are fewer in number & less effective. Compounded by diminished cough reflex)

Specific age-related changes: -loss of elastic recoil -stiffening of chest wall -inefficiency in gas exchange -increased resistance to airflow

[IMPORTANT: instead of typing the entire table, please see Table 4-1 on pg 51 for more age-related changes. It includes some of the points from the PowerPoint]

I. Airways

Physiological Changes: Nose: nose droops downward (esp. in men), restricting airflow Trachea & Larynx: stiffening on larynx & tracheal cartilage, resulting from calcification & cross-linking.

NOT a normal part of aging: breathlessness in speech resulting from air escaping thru incompetent glottis

II. Chest Wall & Lung Physiological Changes: ossification or rigidity of costal cartilage & downward slant of the ribs create a less compliant, more rigid rib cage limiting chest expansion

RENAL & UROLOGICAL SYSTEMS Responsible for excreting toxins, regulating water & salt, maintain acid-base balance in blood.

I. Kidneys Physiological Changes: size & function begin to decrease in 4th decade, and even more so by the 6th decade. Kidneys are 20-30% smaller by 8th decade

II. GFR Physiological Changes: decline of GFR begins around 40 yrs old; may be reduced by 50% by 75 yrs old ability to concentrate urine decreases: OA cant tolerate dehydration or fluid overflow. As a result, hyperkalemia is common. sudden changes in pH or fluid overload can lead to hypervolemia or hypovolemia change in GFR also changes the way drugs are metabolized & excreted

III. Ureters, Bladder, Urethra

Physiological Changes: some tone & elasticity are lost. total bladder capacity decreases from 600mL to 300 mL (powerpoint slide states from 500-600mL to 250mL) weakened contractions during emptying can lead to postvoid residual & increased risk for baldder infection

IV. Renal Vessels Physiological Changes: renal blood flow decreases by 50% by age 80 or 10% per decade of adult life

ENDOCRINE SYSTEM Produce & secrete hormones. Hormones control reproduction, growth & development, maintain homeostasis, response to stress, nutrient balance, cell metabolism, energy balance. Primary glands in endocrine syst: thyroid, parathyroid, adrenal, pituitary, pineal, & thymus.

I. Thyroid gland (influence metabolic rate & produces body heat) Physiological Changes: diminished T4 (thyroxine) & decreased T3 (plasma triiodothyronine) are age-related decreased thyroid gland activity & secretion of hormones

II. Adrenal Glands Physiological Changes: these glands become more fibrous with age ACTH secretion decreases with age hormones influenced by adrenals are reduced

III. Endocrine Pancreas Physiological Changes:

decreased sensitivity to insulin

DIGESTIVE SYSTEM

I. Mouth & Teeth Physiological Changes: teeth lose enamel & dentin becoming more vulnerable to cavities gums more susceptible to periodontal disease taste buds & sense of smell decline, leading to decreased ability to taste less saliva leading to dry mouth (xerostomia)

II. Esophagus Physiological Changes: presbyesophagus: in aging, contractions increase in frequency but more disordered with less effective propulsion

III. Stomach Physiological Changes: decreased gastric motility & volume and reductions in bicarbonate & gastric mucus. Reductions are caused age-related gastric atrophy that results in hypochlorhydria (insufficient hydrochloric acid) decreased production of intrinsic factor (which can lead to anemia if stomach isnt able to digest B12 vitamins) more susceptible to peptic ulcer disease (because the protective alkaline mucus of stomach is lost due to increase in stomach pH) loss of smooth muscle in stomach delays emptying time, which can lead to anorexia/weight loss as a result of distention, meal induced fullness, & premature satiety

IV. Small Intestine Physiological Changes:

villi become broader, shorter, less functional; blood flow decreases nutrient absorption slows down [proteins, fats, minerals (calcium), vitamins (B12), & carbs (lactose)]

V. Large Intestine Physiological Changes: peristalisis slows down

[fyi: constipation is more the result of side effects of meds, life habits, immobility, inadequate fluid intake]

VI. Liver & Gallbladder Physiological Changes: liver decreases in weight/mass (which results in decrease in liver blood flow, which in turn, effects drug metabolism) no specific age-related changes in the gallbladder, BUT incidence of gallstones increases

VII. Exocrine Pancreas Physiological Changes: with age, the pancreas become more fibrotic, has increased fatty acid deposits, & atrophies slightly (but these changes dont affect function)

NERVOUS SYSTEM Includes the central nervous system (CNS) and peripheral nervous system (PNS). Working with the endocrine system, its responsible for maintaining homeostasis. Neurons generate electrical & chemical impulses; neurotransmitters are the chemicals that allow transmission of signals from one neuron to another. Although neurophysiological changes occur with aging, they dont occur in all older adults and dont always have the same effect.

I. CNS

Physiological Changes: reduction in the number of neurons, cerebral blood flow, & metabolism loss of neurons, along with cellular changes, is related to slowed responses to sensory stimuli slower reflexes, delayed responses, and changes in balance

II. PNS Physiological Changes: functioning of PNS slows down & prolonged recovery phases after activation, especially of the ANS kinesthetic perception (ability of a person to automatically respond to changes in environmental stimuli) becomes less reliable

[IMPORTANT: see Table 4-2 on pg 55 for more age-related changes. One of the powerpoint slides only listed the changes, but it does not explain specifically what the changes are. The table explains it.]

SENSORY

I. Smell Physiological Changes: sense of smell declines & therefore can affect taste acuity. Safety implications are also involved if an older adult is unable to smell toxic substances (smoke or gas) in the environment

II. Taste Physiological Changes: taste perception declines (thats why some OA pile on the salt on their food)

III. Touch

Physiological Changes: Somateshesia (tactile sensitivity) decreases because of skin changes. Ability to sense pressure & pain and differentiate temperature is reduced.

IV. Sight A. Extraocular changes eyelids lose elasticity & drooping (senile ptosis) may result. In extreme cases, it can interfere with vision entropion (lower lid may turn inward. When this happens, the eyelashes cause irritation and scratch the cornea) ectropion (lower lid turns out. When this happens, tears run down the cheek instead of bathing the cornea, which can lead to dry eyes)

B. Ocular changes With aging, cornea becomes flatter, less smooth, thicker, loss of sparkling transparency resulting in increased incidence of astigmatism With aging, the anterior chamber decreases slightly in size & volume capacity because of lens thickening. Resorption of intraocular fluid becomes less efficient, and if change is great it can lead to glaucoma. With age, color of iris becomes paler as result of pigment loss & increase in density of collagen fibers.

From the powerpoint slide, changes in vision: Presbyopia (decreased near vision) Narrowing of visual field Less pupil response to light Hardening of the pupil Reduced pupil size High prevalence of cataract development Yellowing of the lens

V. Hearing Physiological Changes: A. Outer ear: with aging, pinna loses flexibility & becomes longer & wider. Ear lobe sags, elongates, & develops wrinkles. Tragus becomes larger in men. Cerumen glands atrophy, making ear wax thicker & dryer & harder to remove. As a result, impaction may occur & can cause conducive hearing loss. B. Middle ear: with aging, tympanic membrane becomes dull, less flexible, a little retracted, reducing sound transmission

From slide: Progressive hearing loss can distort speech

[IMPORTANT: see Table 4-4 on pg 58 for Changes in Hearing caused by Aging]

REPRODUCTIVE SYSTEM

I. Female Physiological Changes: Perimenopause: period of time 5-10 years before cessation of menses. Follicular loss slowly accelerates. Changes may/may not be accompanied by mood swings, hot flashes, night sweats. Ovulation is variable. Menopause: occurs around 51 yrs of age. Cessation of menses.

Other age related changes occur: ovaries/uterus atrophy; vagina shortens, loses elasticity; vaginal dryness; pH of vaginal epithelium rises; menopause often accompanied by lower libido

II. Male Physiological Changes: Fertility is reduced because of higher number of sperm lack motility or due to structural abnormalities Erectile changes: more stimulation needed Enlarged prostate

IMMUNE SYSTEM Decreased immune functioning as we age is associated with interrelated factors: decrease in T-cell function & cell-mediated response to infectious agents & other foreign substances. Thymus decreases in size & volume over time. These changes are called immunosenescence.

From the powerpoint slide (immune system changes): Skin is thinner & less resistant to bacterial invasion Reduced number of cilia in lungs leads to increased risk for pneumonia Friability of urethra increases risk for urinary track infection Reduced immunity at cellular level

Average temp for OA is 95-97F; a low grade fever of 98.6F can signify a serious illness.

Changes in the Mind

(powerpoint slide)

Psychological changes are influenced by general health status, generic factors, education, and activity Basic personality does not change Retrieval of long term memory info can be slower Basic intelligence is maintained More factors interfere with ability to learn Older adults more easily distracted

Page 45 Box 4-1 Examples of normal age changes potentially misinterpreted as indicators of pathology

Slight delay in reflex response Loss of hair in lower extremities

Decreased spoken word recognition Reduced papillary response (bilateral) Decreased color discrimination

Box 4-2 Examples of indicators of pathology potentially misinterpreted as normal age changes

Memory loss Incontinence Falling Sudden confusion Constipation

CASE STUDY from the textbook website:

An 88-year-old World War II veteran: He ambulates using a cane that he obtained from the Veterans Administration Clinic to alleviate pain and stiffness in his knees. He is hard of hearing and does not have a hearing aid. He tells you, I am old and things are falling apart. All things break eventually and cannot always be fixed. A 69-year-old widow, a retired nursery school teacher: She tells you that she is pretty healthy, but her major problem is very embarrassing, and she is reluctant to speak about it. On further probing, she reveals that she has to urinate very frequently and sometimes wets herself before she gets to the bathroom. She states, I guess I am going to have to start wearing diapers like my friend did. An 89-year-old divorced woman: She reports that she has a boyfriend who lives in the same apartment building as she does. She reports that she has shrunk over the past few ages and is concerned that she is getting a hunched back like her grandmother had.

For each of the above participants: Which of the changes they described are normal age-related changes? Suggested Answers 88-year-old veteran:

Hearing loss is a normal part of aging. Age-related changes affect the structure and function of the ear. Some hearing loss affects about one third of all adults between ages 65 and 74 and about one half of those between 75 and 79. More than 10 million older adults have hearing loss. Knee pain: Age-related changes in cartilage result from biochemical changes. As the cartilage dries, it becomes thinner, causing pain or less movement and pain when moving. Worn-down cartilage around joints causes slower and painful movement. 69-year-old widow: Frequent urination: The capacity of the bladder decreases significantly as one ages. 89-year-old divorced woman: Loss in height: Cartilage in the intervertebral disks shrinks and contributes to the loss of height.

Which are abnormal changes? Suggested Answers The 69-year-old widows complaint of involuntary loss of urine or incontinence is not normal aging. There are normal age-related changes such as a decrease in the capacity of the bladder that would lead to complaints of urinating more frequently, but incontinence is not normal.

Gero Chapter 7 Health AsSeSsment

Assessment of older adult requires special abilities of the nurse: to listen patiently, to allow for pauses, to ask question that are not often asked, to observe minute details, to obtain data from all available sources and to recognize normal changes associated with late life that might be considered abnormal in one who is younger.

In Gerontological nursing, assessment takes more time than it does with younger adults because of the increased medical and social complexities of living longer. Nurses should obtain a skill level that can handle high degree of sensitivity, knowledge of normal changes with aging, and appropriate assessment tools. Assessment provides the information to plan for care that will enhance personal health status, decrease the potential for the severity of chronic conditions, encourage self-efficacy and empowerment for self-care.

(In this chapter we provide an overview of parts of the assessment and discussion of tools that are particularly unique or helpful in caring for the older adult.)

THE HEALTH HISTORY

Health history is collected either in written format or verbally in face-to-face interview or in combination. (a knowledgeable interpreter if needed)

Any health history form should include patient profile, a past medical history, a review of symptoms and systems, a medication history, and a social history *Social History- current living arrangements, economic resources to deal with current health issues, amount of family and friend support if needed, and the types of community resources availability if needed or used.

To meet the needs of our increasingly diverse population of elders they use the question related to the explanatory model-Kleinman 1980 ~ e.g. How would you describe the problem? How long have you had this problem? What do you think is wrong with you? Why do you think this happened to you?

Comprehensive assessment includes psychological parameters such as. Cognitive and emotional well-being Caregiver stress or burden The individuals self-perception of health Patterns of health and health care, education, family structure, plans for Retirement and living environment.

PHYSICAL ASSESSMENT

its followed right after HEALTH HISTORY. Techniques of examination do not differ significantly from those used with younger people, but the knowledge of the normal changes with aging is essential. When assessing people from different ethically distinct groups, its necessary to be aware of the cultural rules of etiquette such as.. social organization and expectation Communication style use of personal space and eye contact Appropriate wording, use of names, and touch

Two tools for a basic overall assessment who are medically vulnerable are SPICES AND FANCAPES.

The acronym FANCAPES stands for..

F=Fluids A=Activity N=Nutrition C=Communication A=Activity P=Pain E=Elimination S=Social Skills

SPICES

S=Sleep disorders P=problems with eating or feeding I=Incontinence C=Confusion E=Evidence of Falls S=Skin Breakdown -----------------Fancapes Fluids: clients state of hydration Physiological, situational, and mental factors that contribute to the maintenance of adequate hydration

Aeration: adequacy of oxygen exchange. Respiratory rate and depth at rest and during activity such as talking, walking, and situations requiring added exertion; presence or absence of edema; breath sounds should be evaluated; determine oxygen saturation level

Nutrition: type and amount of food consumed. Mechanical and psychological factors. Ability to bite, chew and swallow Dentures fitting and gums and teeth condition. Functional or economic status may interfere with obtaining groceries or food for Special diets.: who prepares it for them For the visual and neurological impairment, may interfere with the persons Ability to prepare a meal or feed him Functional or economic status for obtaining food for special diets

Communication: sending or receiving verbal and nonverbal information. Sight and sound acuity; voice quality; adequate function of the tongue, teeth, and pharynx/larynx. Ability to read and write and understand the spoken language. Activity: ability to ambulate Ability to eat, toilet, dress and groom; preparing meals; to use the telephone Coordination, balance, grip strength etc.

Pain: physical, mental, and spiritual pain Presence and absence of pressure and discomfort Information about recent losses and symptoms of anxiety helps identify the pain Ways to attain relief from pain provides more information.

Elimination: Bladder and bowel elimination includes evidence of urinary dribble or incontinence, protective garments or devices usage, and medications that affect and intestinal peristalsis voiding

Social Skills: individuals ability to deal with loss and interact with other people in give- in-take situations --_--___---_----

Spices- refers to 6 common geriatric syndromes of the elderly that require nursing

interventions (used for more in-depth assessment) It is a system used for alerting the nurse to the most common problems that interfere with the health and well-being of older adults, particularly those who have more than one medication conditions.

Functional Assessment- encompasses the evaluation of a persons ability to carry out basic tasks for self-care and tasks needed to support independent living. identify specific areas in which help is needed identify changes in abilities from one period of time to another determine the need for specific services information useful for assessing safety of their living situation

major tools used for functional assessmentADLs Activities of Daily Living & IADLs instrumental activities of daily living

Most of the tools result in a score of some kind- a rating of the persons ability to do the task alone, to need assistance, or to not be able to perform the task at all.

FAST (Functional Assessment Staging) a tool for Alzheimers disease - the tool uses ordinal ranking of seven stages beginning with what is referred to adult to one with severe dementia as normal

Activities of Daily Living- developed by Sidney Kats 1963 Includes bathing, dressing, toileting, continence, ambulation, and feeding

A) Kats Index = served as a basic framework for most of the measures of ADLs Example pge 110 Its based on a scale and allows one to score clients performance level as independent, assistive, dependent, or unable to perform. Scores will range from 0-6. 4= moderate impairment

2= severe impairment

B) Barthel Index and Functional Independence MeasureBI and the FIM is used commonly for rehabilitation setting to assess a persons need for assistance

BI- easier to use to document improvement of a patients ability It ranks functional status as independent (intact or limited) or dependent (need a helper or unable to do it at all)

FIM- most comprehensive functional assessment tool -measures ADL, mobility, cognition, and social functioning -it rates 18 ADLs on a seven-point scale from independent to dependent (13 motor items and 5 cognitive items)

Instrumental Activities of Daily Living- (IADLs) are tasks needed for independent living, such as cleaning, yard work, shopping, management higher level of cognitive and physical functioning than do the ADLs people with dementia, loss of the ability to perform IADLs begins with those that require the highest cognitive functions, such as handling finances and shopping. Developed by Lawton and Brody, they used the orginal scoring tool- the three-levels of functioning (independent, assisted, and unable to perform) money

Timed Get-Up-and-Go test, used widely and associated with fall risk determination

Function and Cognition- when assessing they use what you call The Blessed Dementia Scale which is a 22-item tool that incorporates aspects of memory, recalling events, and finding ones way outdoors. ADLs, IADLs,

Other systems used for assessing functional status and cognitive abilities. the Clinical Dementia Rating the Global Deterioration Scale Deterioration Scale

SCREENING ASSESSEMENT OF COGNITION AND MOOD

Older adults are at great risk for impairments in mental capacity altered mental status is the first sign of anything from a heart attack to a UTI. It is helpful to have baseline measures of cognition and mood. You need trustworthy environment and relationship to get the most accurate data You must assessed when the person is comfortable, rested and free of pain.

Mental Status Examination

-Mini-Mental State Examination~ MMSE - the tool used for MENTAL STATUS- created by Folstein 1975 - its a 30-item instrument that is used to screen for cognitive function - used for grossed screening of dementia - tests for orientation, short-term memory and attention, calculation ability, language, and construction. - cannot be administered to a person who cant see or write or who isnt proficient English - a score of 30 means no impairment. 26 or less is potential dementia in

-Clock Drawing Test ~ example page 112 -used for screening dementia but not to be used to identify those with MCI -level of manual dexterity and visual acuity is required therefore its not for the blind or for people with arthritis, Parkinsons disease, or stroke that affects there

dominant hand

person is presented a piece of paper with a circle drawn in it. He/she must then draw the face of the clock and then have the hands that indicates 3:45 or 11:00 the scoring is based on the positions of the numbers and hands. (this test doesnt establish criteria of dementia but test for constructional apraxia, early indicator of dementia

-Mini-Cog - similar to the MMSE, less biased, easier to administer, and more sensitive to dementia it assesses short-term memory and executive function. It requires the ability to hear, hold a pencil, and write numbers, it is brief and highly sensitive/specific for dementia

~~~ Say three unrelated words ~~~~ ask the person to repeat ~~~~~ the person is asked to draw a clock ~~~~~~the person is asked to recall the 3 words

Assessment of mood

Additional screening tools for mood. Important because of the high rate of depression- because of medication or stroke related problems.

Anyone with untreated or undertreated depression are more functionally impaired. o prolonged hospitalization and nursing home stays, lowered quality of life, increased morbidity overall, and reduced longevity

Several tools has been used (the Beck Deptression Inventory) & (the Zung Depression Scale), the one that is used frequently is the .. GERIATRIC DEPRESSION SCALE.- (GDS) Example is on page 113 Table 7-1

GDS- is a 30-item tool used to screen older adults in the number settings there is a 15- and 5-item shortened versions it has been successful in identifying depression because it deemphasizes physical complaints, libido, and appetite only drawback is on the shortened versions- it doesnt include a question on suicidal thoughts

Center for Epidemiologic Studies Depression Scale- (CES-D) - used for studies of depression in community samples - provide most accurate results particularly for nonwhite older adults - its better than the GDS for both black and white individuals - there is a 20-items and 10-item versions-

Cornell Scale for Depression in Dementia- (CSD-D) used for people in major depressive disorders who have dementia person is interviewed followed by a proxy interview can be corroborated by skilled observation each item is introduced with I am going to ask you question about you/how your relative has been feeling during the past wk. I am interested in changes you noticed and the duration of these changes

COMPREHENSIVE GERATRIC ASSESSMENT

The Comprehensive Assessment and Referral Evaluation (CARE) tool was designed for the assessment of functional status and mental health

Minimum Data Set (MDS) is used in skilled nursing facilities In home care setting, the Outcomes and Assessment Information Set (OASIS), a computerized assessment tool is universally used

the Minimum Data Set

-MDS is a product of the Centers for Medicare and Medicaid - its used to describe the care in a Long-term care setting. - includes evidence-based measure for pain, cognition, delirium and depression (pg 114 Box 7-6) - there are resident interviews included in the 5 section of the document. (gives the resident opportunity to express their own voices revealed that past assessments underestimated depressed mood and pain significantly

- the data contained within the MDS are also used to determine the reimbursement that the facility will receive for any particular patient stay under the prospective payment system

Older Americans Resources and Services OARS - designed so that each component can be used individually. - designed to evaluate ability, disability, and the capacity level at which the person is able to function - 5 Dimensions are considered for assessment: social resources, economic resources, mental physical health, and ADLs. (ea. uses a quantitative scale- 1-excellent 2-good, 3-mildly impaired, 4-moderately impaired, 5-severely impaired 6-completely impaired) *CIS is established (cumulative impairment score) score 6= most fit score 30= total disability health,

Social Resources -the Social Resources dimension of the OARS evaluates the social skills and the ability to negotiate and make friends - # of friends? # of telephone conversations? Are they able to ask things from friends and family? Do they belong to a social group or network?

Economic Resources -Data about monthly income and sources (social security and pensions) - its needed to determine the adequacy of income compared with the cost of living - this information can provide insight into the elders standard of living and points out the areas of need Mental Health intellectual function, the presences or absence of psychiatric symptoms, and the of enjoyment the person gets in life amount

Physical Health the diagnosis of major and common diseases of the type of prescribed and over-thecounter medications person is taking, and health status Excellent physical health- walking, dancing, biking etc Impaired physical health- presence of one or more illnesses and disabilities

Activities of Daily Living -ADLs eg. Getting out of bed, bathing, combing hair, shaving, dressing, eating -IADLs eg. Dialing a telephone, driving a car, hanging up clothes, groceries, taking medications correctly

PROMOTING HEALTHY AGING

Overdiagnosis or underdiagnosis occurs when the normal age changes are not considered; both physical and biochemical changes

Underdiagnosis is far more common in the care of the elderly; many symptoms are ascribed to normal aging rather than to a disease entity that may be developing

Ch 8 Laboratory Values and Diagnostics Hematological Testing RBC Count 120 day lifespan, produced primarily in bone marrow speed at which RBC's can be produced is reduced in old age, decreased marrow reserve NORMAL AGING Recovery from blood loss takes longer, increases risk for falling, delirium, and other geriatric syndromes Hemaglobin and Hematocrit- elevations may be pathologic, but often are early markers of hypovolemia saturated gram of Hb carries 1.39 mL oxygen Hb <5gr/dL or >20 defines "critical values" requiring urgent intervention Anemia= Hb <12gr/dL men <11 women Hematocrit about 3x Hb level. Critical values <15% or >60% White Blood Cells granulocytes- neutrophils, basophils, eosinophils Agranulocytes-monocytes,lymphocytes

13-20 day lifespan, produced in bone marrow & thymus, stored in lymph nodes, spleen, and tonsils 5000-10,000 WBC- ELEVATED WHITE COUNT MAJOR CONCERN IN ELDERY often caused by bacteremia Critical values <2,500 or >30,000 Younger adults you see elevated temperature, lymph node enlargement, increase in total WBC count BUT NOT NECESSARILY IN OLDER ADULTS *Change in aging* "left shift" immature band cells, precursors to neutrophils, may be only elevated value in labs to indicate early infection implications for gerontological nurse: waiting for usual signs may result in death (THIS IS FUCKING BAD) must be sensitive to more subtle signs i.e. increased confusion, falling, or incontinence WBC count should remain the same in a healthy older adult, the response to elevate is whats slow. High or low WBC count is often a reaction of medications, NOT A NORMAL RESULT OF AGING Neutrophils produced in 7-10 days in bone marrow in circulation for about 6 hours; phagocytize bacteria neurtrophilia, increas ein neutrophils, may be indicator of infections Lymphocytes T-Cells: produced by thymus: make up 80% of lymphocytes. NORMAL AGING slight decrease in T and increase in B cells

Monocytes largest of leukocytes, mature into macrophages. macrophages migrate to site in body and phagocytize the bad things (all that shit, dead RBC's microorganisms, foreign debris, you know, all that bad shit) Eiosinophils involved in allergic reactions, ingest antigen-antibody complexes, attack allergens and parasites Basophils transport histamine and heparin, play a role in allergic reactions, do not fight viruses or bacteria Platelets thrombocytes, formed in bone marrow, lungs, and spleen. arrive at injury site and activate becoming sticky and helping trigger 'clotting cascade' PLATELET COUNT DOES NOT CHANGE WITH AGING, though clotting enzymes may increase 150k-400k/mm3 normal value thrombocytopenia <100k thrombocytothemia >1million critical values <20k spontaneous hemorraging can occur <40k serious risk in elderly, if they fall internal bleeding may not stop and can cause death, other related risks involving bleeding more significant Measures of Inflammation Erythrocyte Sedimentation Rate rate at which RBC's fall in saline soltion/time, highly nonspecific cannot diagnose any disease may be slightly elevated in older persons due to chronic disease, NOT healthy aging C-Reactive Protein-produced by liver, strong predictor/indicator of cardiovascular events/inflammation. No mention of normal or abnormal values or concerns for the elderly Iron Studies-include iron, ferritin, total iron binding capacity TIBC, transferrin measures anemia-reduced # of RBCs, NOT A NORMAL PART OF AGING but it is a common pathology in older adults 3 most prevelant in older adults are anemia from: chronic disease and inflammation, blood loss, protein deficiency ferritin reflects iron body stores; TIBC measures iron and transferrin available to transport it Vitamins mild deficiencies common BUT NOT NORMAL in later life. May cause cognitive impairment, delayed wound healing, or anemia B Vitamins folic acid and B12 two most important of 8 folic acid decrease NOT NORMAL but common B12 decrease NORMAL but still may need to be treated

Tests of B12 and folic acid part of standard workup for dementia Vitamin D critical values 20ng/mL deficient 20-30 insufficient >30 sufficient, essential for healthy aging and proper amount of calcium in body Blood Chemistry Studies used both for screening and monitoring; glucose, proteins, amino acids, nutritive materials, excretion products, hormones, enzymes, vitamins, and minerals many done in panels Hormones Thyroid hormones receive most attention in older adults T3, T4, Thyroid stimulating hormone TSH Changes in thyroid function NOT A NORMAL PART OF AGING but are frequent, hypothyroidism most common in older adults, both hyper and hypo often iatrogenic in older adults (related to medical procedure or treatment) screening for thyroid disease is part of primary care for older adults esp. women, ppl w/ depression, anxiety, dementia, arrhythmias THS produced by pituitary to stimulate thyroid to make T3 which is converted to T4 hyperthyroidism less common in older adults, often not the same etiology as in younger people Electrolytes minor electrolyte imbalnce may have no effect in younger adult but have profound effect in older adult, dehydration is the most common cause in older adults most common concerns in older adults include sodium, potassium, chloride, calcium, phosphorus, glucose Sodium and Chloride balance influenced by renal filtration, blood flow, cardiac output, glomular filtration rate GFR. Changes in sodium accompanied by changes in chloride Hyponatremia <130mmol/L common in long term care facilities can cause coma secondary to brain edema; one common cause of delirium in older adults Hypernatremia >145mEq/L mortality rate 40% in elders associated w/ seizures, delirium, coma, death Potassium found primarily inside cells hypokalemia <3.5 mEq/L mild cases assymptomatic <2.5 mEq/L critical value causes confusion, cramps, weakness, sudden death all bad things can lead to renal problems if chronic hyperkalemia >5mEq/L usually only in advanced kidney disease, or over supplementation. may be assymptomatic until its lethal

I dont want to type all of this but box 8-2 on pg 122 is very important. It lays out lab values that are expected to change with age. I recommend making flashcards. It lists those that increase with age on one side, and those that decrease with age on the other. I don't think the exam will be that specific, but it will be nice to have under your belt when it's time for taking boards.

Calcium and Phosphorus Serum Ca levels DO NOT change with age, but calcium metabolism does.result is decreased bone stores. when enough occurs, osteoporosis occurs half of serum calcium is bound to albumin, so if nutrition is poor and albumin is low, Ca serum will be artificially low; this artificial low is common in medically fragile persons true hypocalcemia <8.5 mg/dL most commonly caused by hypoparathyroidism hypercalcemia >12mg/dL calcium levels inversely related to phosphorus Glucose fasting glucose 70-110mg/dL DOES NOT CHANGE WITH AGING but signs and symptoms might. slightl changes in elderly may cause confusion and other problems. older adults have a reduced sensitivity to insulin 7% of Hb in RBC can combine with glucose, 120 lifespan of RBC gives good idea of blood glucose nondiabetics 4-5.9% is normal; <7 good diabetic control >9% poor diabetic control URIC ACID- usually measured in serum chemistry but also found in urine elevation is >7.5 mg/dL and hyperuricemia >13, varies btw men and women serum levels INCREASE SLIGHTLY WITH AGE (no numbers provided) affected by many e.g. medications such as diuretics factors

Prostate Specific Antigen- along with digital rectal exam are the two primary screening tools for prostate cancer. many false positive, controversial, only recommended for men over 75 or at high risk. Chages in PSA levels over time >5%-8% more meaningful than absolute number in serum

LAB TESTS FOR CARDIAC HEALTH Creatinine Kinase (CK), specifically one of its isoenzymes (subgroup) CK-MB associated with cardiac tissue. CK-MB rises 3-6 hours after an acute myocardial infarction AMI (heart attack), returns to normal after 12-48 hours. used to diagnose AMI, unstable angina, shock, malignant hyperthermia, myopathies, and myocarditis. many drugs commonly used by elderly can give false highs MEDICATION HISTORY IS VERY IMPORTANT WITH THIS TEST this test is used in combination with troponin values for diagnosis

Troponin I and Troponin T- gold standard for diagnosis of heart injury, become elevated as early as 3 hours after incident. Troponin I remains elevated for 7-10 days, Troponin T for 10-14 days Normal values Troponin I <0.03 ng/ml Troponin T <0.2 ng/ml Homocysteine -If you are confident enough, every zoo is a petting zoo. - a natrually occuring amino acid, promotes atherosclerosis (bad) normal findings 4-14 micro mols/L elevated values are a predictor of coronary, peripheral, and cerebral vascular disease; also elevated with b12 and folic acid deficiencies and is used to monitor nutrition elevated values put person at 5x risk for stroke, dementia, and alzheimers. also a risk factor for osteoporotic fractures Brain Natriuretic Peptide BNP neuroendocrine peptide secreted by the ventricles in response to excess pressure identify congestive heart failure, hypertension, and atherosclerosis Lipids major predictor of coronary heart disease typically includes cholesterol and triglycerides; used as health screen and to monitor response to treatments, must fast 12-15 hours before tests Cholesterol- stabilizes cell membranes, metabolized in liver where it combines with Low density lipoproteins LDL and high density lipoproteins HDL and very low density lipoproteins VLDL Men's Cholesterol slowly increases from puberty until 60, stabilizes until 80, then rises again While the cholesterol levels of women remain stable until menopause then start to rise THIS IS A NORMAL PART OF AGING!! cholesterol levels also change throughout the day and is influenced by position low serum cholesterol <200mg/dL could be malnutrition is indicative of further evaluation total cholesterol is in whole blood not just serum <160mg/dL in a frail elder is a risk factor for increased mortality Triglycerides are primary lipids found in blood and are bound to protein; produced in liver, excess blood levels deposited in fatty tissue abnormally low suggests malnutrition, elevated could mean chronic renal failure, poorly controlled diabetes. Severely elevated >2000mg/dL strong risk factor for pancreatiti. Lipid panel values Total cholestrerol <200 is desirable >240 is high LDL <100 optimal, 160-189 high, >190 very high HDL 40-60 tightly in this range, above or below is problematic Triglycerides <150 normal, 200-500 high, >500 very high

Total Protein- amount of albumin and globulin in serum, a SLIGHT decrease is a NORMAL PART OF AGING

neither sensitive nor specific; prealbumin has a shorter half life and is a more sensitive marker for change Normal Findings Total Protein- 6.4-8.3 g/dL; Globulin 2.3-3.4 g/dL; Prealbumin 15-36mg/dL RENAL HEALTH early signs of kidney disease are asymptomatic, urinalysis results important early indicator Blood Urea Nitrogen BUN urea end product of protein metabolism critical value of >100mg/dL indicates serious renal dysfunction azotemia is an elevation in BUN; but normal adult values are 10-20 mg/dL Creatinine-used to diagnose and monitor impaired renal function, but can overestimate renal health in older adults; BUN/Creatinine ratio is a good indicator of GFR Cockcroft-Gault equation estimates creatinine clearance, used to estimate drug dosages in elders with probable diminished renal function, esp drugs that are potentially a strain on the kidneys (140-age)x(weight in kg)/(72xserum creatinine) for men, in women value is 85% of this value due to smaller muscle mass REDUCED MUSCLE MASS OF NORMAL AGING WILL RESULT IN DECREASED CREATININE LEVELS

Monitoring for Therapeutic Blood Levels- drugs that have a narrow therapeutic window (too low ineffective, too high adverse affects) Anticoagulents, warfarin (Coumadin) and heparin elderly ppl often on these, must have coagulation time monitored closely due to narrow therapeutic windows prothrombin- produced by liver, key component in blood clotting, in clotting prothrombin is converted to thrombin at the beginning of the coagulation cascade. Body must have adequate vitamin k intake and absorption to produce prothrombin Prothrombin Time PT is a sensitive measure of deficiencies in vitamin K-dependent clotting factors II, VII, IX, and X. It is not sensitive to Heparin or fibrinogen deficiencies. Partial Prothrombin Time PPT is used to monitor patients on heparin PT is among tests gerontological nurses will see most often. It is evaluated by a set Internationalized Normal Ratio INR. too high an INR can result in life threatening bleeding PT of 20 seconds= INR >5.5 is considered a panic level Too low an INR means the drugs are not working and the patient is probably in a hypercoagulative state

Antiarrhythmics: DIGOXIN (Personally I'd take particular care to commit this section to memory, Dr. O loves to talk about it, I think it's safe to assume it will appear not just on this test, but many tests). Digoxin (Lanoxin) is a drug commonly used to control ventricular response to chronic atrial fibrillation. normal therapeutic range is 0.9-2.0 ng/mL; TOXICITY occurs at levels above 3.0ng/mL a dose of 0.125 mg can be quite effective in older adults blood levels can miss problems with toxicity, so they are only a guide for nurses. clinical presentation must be monitored carefully even when blood levels are normal.

URINE STUDIES urinalysis done by nurse macroscopically at bedside (color, odor, clarity, and urine dips, using dipsticks that react to certain elements outside specific concentrations and comparing to a standard dipstick) and microscopically in lab. Both measure specific gravity, pH, presence of urine protein, glucose, ketones, blood, bilirubin, nitrates, and leukocytes results should be the same REGARDLESS OF AGE, but frequently have abnormalities due to complications common in the elderly. THIS IS NOT NORMAL AGING. clean catch or catheterization to collect, should be sent to lab immediately but may be refridgerated up to two hours. You should never leave it unlabeled as it can be confused with lemonade rather easily leading to lawsuits in the hospital. specific gravity in adults is usually between 1.005 and 1.030. These values decrease with aging because of the 33-50% decline in nephrons. THIS IS A NORMAL PART OF AGING. Nephron function measured by GFR which is determined by creatinine clearance

Urine pH indicates acid base balance. Does not provide normal range in text. protein- proteineuria is defined as albumin level >150mg/dL in a 24 hour period glucose- can be affected by ascorbic acid or aspirin ketones may be high from crash diets high protein diets or starvation Nitrates and leukocytes often found in infection. if urinalysis suggests infection a further analysis, probably a culture of the urine, is necessary due to danger of infection in elderly, clinical evidence of infection may require treatment before test results can be obtained, often taking 3 or 4 days

Implications for Gerontological Nurses

screening is important we may find that normal values for the population over 65 may be different than the younger population, but this has not yet been determined. (IT DEPENDS? I pulled this word for word from the book, pg 130. Sooo which values change as a normal part of aging? apparently they don't actually know yet.) Many elderly are on many medications which may affect lab values. It is a nurses job to watch for empirical clinical evidence and interpret lab values. Deep thoughts: If death is a natural result of aging, and death needs a cause, aren't all changes a natural part of aging? Somehow I doubt that argument is gonna fly on the exam.

GERO CHAPT 9 Geropharmacology: Persons 65 years and older are the largest users of prescription and OTC medications. They consume about one third of all prescription drugs and one half of available OTC. The most commonly prescribed and used drugs in the ambulatory older populations are cardiovascular drugs, diuretics, nonopioid analgesics, anticoagulants, and antiepileptic. Gastrointestinal preparations and analgesics are the most used OTC medications, followed by cough products, eye washes, and vitamins.

Pharmacokinetics: It is the study of the movement and action of a drug on the body. It determines the concentration of drugs in the body, which in turn determines effect. The concentration of drug at different times depends on: Absorption; this is how the drug is taken into the body. A drug must first be absorbed into the bloodstream for it to be effective. The amount of time between the administration of the drug and its absorption depends on these factors a. Route of administration: most common are intravenous, oral, enteral, parental, transdermal and rectal. Drug is delivered immediately to the bloodstream with intravenous, quickly through parental, transdermal, and rectal routes. Orally and rectally administered drugs are absorbed the most slowly and primarily in the small intestine. Liquid drug dosage forms for oral use come as solutions, suspensions, tinctures, and elixirs. Solid oral drug dosage forms are tablets, capsules, powders and pills.

 Factors affecting the rate at which a medication is dissolved are the amount of liquid in the stomach, the type of coating the tablet has, the extent of tablet compression used in making the tablet, the presence of expanders in the tablet, the solubility of the drug in the acid environment of the stomach, and the rate of peristalsis. Presence of food in the stomach may or may not delay absorption b. Bioavailability: the degree to which a drug or other substance becomes available to the target tissue after administration. c. The amount of drug that passes through the absorbing surfaces in the body. Effects of aging process on drug absorption: 1. Diminished salivary secretion and esophageal motility may interfere with swallowing some medications.

2. Decreased gastric acid, common in the elderly will retard the action of acid-dependent drugs. 3. Delayed stomach emptying may diminish or negate the effectiveness of short-lived drugs that could become inactivated before reaching he small intestine.

4. Some enteric-coated medications which are specifically meant to bypass the stomach may be delayed so long in the older adults that their actions begin in the stomach and may produce undesirable effects such as gastric irritation or nausea. 5. Slowed intestinal motility, frequently seen with aging, can increase the contact time and increase drug effect because of prolonged absorption, significantly increasing the risk for adverse reactions or unpredictable effects 6. Drugs that are extensively metabolized as they pass through the liver are said to have a large first-pass effect. Such drugs usually require much larger oral doses than the same drug given by injection. Normally, the liver mass and blood flow decreases significantly as one ages resulting to reductions in the metabolism rate with potential but unknown implications. 7. Drying of the mouth is a common side effect of many of the medications taken by older adults and it may reduce or delay buccal absorption on the older adults. In such cases, rectal administration may be useful. Transdermal Drug Delivery System (TDDS): a. Used for topical application of drugs such as nitroglycerin b. Has developed significantly and is now used for many fat-soluble drugs, usually a medicationimpregnated patch (e.g. estrogen, nicotine, fentanyl, and nitroglycerin). c. Overcomes any first-pass problems

d. Is more convenient, acceptable and reliable than other routes especially in the outpatient setting and for some persons with cognitive disorders e. Provides more constant rate of drug administration and eliminates concern about gastrointestinal absorption variation, gastrointestinal intolerance, and drug interaction. f. The skin must be intact, the patch must remain in place for the designated amount of time, and the previous patch must be removed before a new one is applied.

g. The characteristic thinning, dryness, and roughness of older skin may affect absorption of the intended dose. h. It is indicated when a slow, time-release delivery into the tissue and the bloodstream is desired. i. The risk for an allergic reaction to the patch is increased with the normal immune changes with aging.

Distribution: The systemic circulation transports a drug throughout the body to receptors on the cells of the target organ, where a therapeutic effect is initiated Organs of high blood flow (brain, kidneys, lungs, liver) rapidly receive the highest concentrations. Distribution to organs of lower blood flow (skin, muscles, fat) occurs more slowly and results in lower concentrations of the drug in these tissues Lipophilic (fat-soluble drugs pass through capillary membranes more easily than do hydrophilic (water-soluble) drugs, resulting in more rapid tissue distribution and a greater volume of distribution. Decrease body water in normal aging leads to higher serum level of water-soluble drugs. Drugs that are highly lipid soluble are stored in the fatty tissue, thus extending and possibly increasing the drug effect, depending on the level of adiposity. Distribution also depends on the availability of plasma protein in the form of lipoproteins, globulins, and especially albumin. Some drugs are bound to protein for distribution. Normally, a predictable percentage of the absorbed drug is inactivated as it is bound to the protein. The remaining free drug is available in the bloodstream for therapeutic effect when an effective concentration is reached in the plasma.

Metabolism: Some drugs exert their therapeutic effect in their absorbed form while others must be metabolized first.

Metabolism is the process wherein the chemical structure of the drug is converted to a metabolite that is more easily used and excreted (a process called biotransformation). As long as a drug remains in its original state or as an active metabolite (s), it will continue to exert a therapeutic effect.

Excretion: Drugs and their metabolites are excreted either unchanged or as metabolites. A few drugs are eliminated through the lungs, as unreabsorbed metabolites in bile and feces, or in breast milk. Very small amounts of drugs and metabolites can also be found in hair, sweat, tears, and semen. Glomerular filtration depends on both the rate and the extent of protein binding of the drug. The process involves passive filtration and only unbound drugs are filtered. Because kidney function declines in many older persons, so does the ability to excrete or eliminate drugs in a timely manner. The glomerular filtration rate, renal plasma flow, tubular function, and reabsorptive capacity decline. Pharmacodynamics: o o o o o o o o o o Refers to the physiological interactions between a drug and the body, specifically, the chemical compounds introduced into the body and the receptors on the cell membrane. Receptors are generally specifically configured cellular proteins that, because of their shape and ionic charge, bind to specific chemicals in the medications. The receptor protein has a specific shape that fits the chemical molecule, like a glove to a hand with complementary ionic charges. When the chemical binds to the receptor, the therapeutic effect is initiated. Drugs are usually similar in configuration to chemicals naturally occurring in the body such that they bind to the same receptor sites. Although the drugs are designed to bind to specific receptor sites for specific purposes, usually they will attach to various other types or receptors as well. The result might be unwanted effects. The older a person gets, the more likely he or she will have altered and unreliable pharmacodynamics. It is not always possible to explain or predict the alteration, several are unknown. Those of special note in the elderly are related to drugs with anticholinergic side effects which significantly increase the risk for accidental injury and associated with geriatric syndromes.

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Baroreceptor reflex responses decrease with age. This causes increased susceptibility to positional changes (orthostatic hypotension) and volume changes (dehydration).

Polypharmacy: Defined as the use of medications, or as the use of multiple medications for the same problem. It is extremely common among older adults and a source of potential morbidity and mortality. May be necessary if the patient has multiple chronic conditions May occur unintentionally Is exacerbated by the combination of a high use of specialists and a reluctance of prescribers to discontinue potentially unnecessary drugs that have been prescribed by someone else; therefore treatments are continued longer than necessary. Two major concerns of polypharmacy are the increased risk for drug interactions and the increased risk for adverse events. Drug Interactions: The more medications that one takes the greater the possibility that one or more of them will interact with each other, a dietary supplement, or other herbal preparation. The more chronic conditions one has, the more likely that a medication for one condition will affect the body in such a way as to influence the other. When two or more medications are given at the same time or closely together, the drugs may potentiate one another, that is when given together the drugs have stronger effects than when give alone, or When two or more medications are given at the same time or closely together, the drugs may antagonize each other, that is when give together one or the more of the drugs become ineffective. Drug-supplement/Drug-herb Interactions: Are the potential interactions of the herbal preparations or nutritional supplements. Because of inadequate labeling requirements, drug interactions may not be listed on the product labels of these supplements.

Drug-food Interactions: Foods may interact with drugs, producing increased, decreased, or variable effects. Foods can bind to drugs affecting their absorption. Certain drugs antagonize the therapeutic action of a drug.

Drug-drug Interactions: Made common due to the polypharmacy that may be a necessary part of health care in later life. When several medications are crushed, mixed together, and then dissolved in water for administration, a new product is created and drug-drug interactions may have already begun. Several drugs may compete to simultaneously bind and occupy the receptor sites needed by the other drug, creating varied bioavailability of one or both of the drugs. Interference with enzyme activity may alter metabolism and cause drug deficiencies or toxicities. Altered distribution may be caused by displacement of one drug from its receptor site by another drug. Altered metabolism can occur when one drug increases (inducts) or decreases (inhibits) the metabolism of another drug.

Adverse Drug Reactions (ADR): Occur when there is a noxious response to a drug. Ranges from a minor annoyance to death and are common causes of hospitalization, especially for persons more than 80 years of age. Such medication categories include cardiovascular agents, diuretics, nonopioip analgesics, hypoglycemic, and anticoagulants (especially anticoagulants). Sometimes they can be predicted from the pharmacological effects of the drug such as in bleeding form coagulants, other times they are unpredictable such as in an allergic reaction to antibiotics. Allergic reactions become more common in the older adults as the immune system changes, many drug reactions are deemed serious, may even be fatal, and most of them are preventable. To minimize the likelihood of ADR, the dose can be slowly increased until it safely reaches a therapeutic level. Implications for Gerontological Nursing: i. ii. iii. iv. The nurse is the key person in ensuring that the medication used is appropriate, effective, and as safe as possible. The nurse is knowledgeable about drug interactions and signs ans symptoms of ADR. The nurse promotes the actions necessary to prevent drugs from becoming toxic and to treat toxicity promptly. The nurse initiates assessment of medication use, evaluate outcomes, and provide the necessary teaching.

Assessment:

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The initial step in ensuring that drug use is safe and effective is to conduct a comprehensive drug assessment. Brown bag approach is the gold standard of assessment in a medicine history. The nurses analysis of the assessment data is centered on identifying unnecessary or inappropriate medications, establishing safe usage, determining the patients self-medication management ability, monitoring the effect of current medications and other products and evaluating effectiveness of any education provided.

Education: Most common intervention used to promote medication adherence. The nurse should; Find out who manages the persons medications, help the person, or assist with decision-making; and with the elders permission, make sure that the helper is present when any teaching is done. Minimize distraction, and avoid competing with television or others demanding the patients time; make sure the person is comfortable and is not hungry, thirsty, tired, too warm or too cold, in pain, or in need of the toilet. Provide the teaching during the best time of the day for the person. Ensure that you will be understood. Encourage the person to use techniques which have worked in the past or develop new strategies to ensure correct and timely medication use when needed. Psychotherapeutics in Later Life: Antidepressants: Selective serotonin reuptake inhibitors (SSRIS) have been found to be highly effective antidepressants. They are the drugs of choice for first-line use in older adults. Most adults are sensitive to it while some are not. Anxiolytic agents: drugs developed to treat anxiety. Examples are benzodiazepines and buspirone (BuSpar). Antipsychotics (Neuroleptics): are tranquilizing medications used primarily to treat psychoses and off-label as mood stabilizers fro bipolar disorder. o Movement disorders Acute dystonia: an acute dystonia reaction is an abnormal involuntary movement consisting of a slow and continuous muscular contraction or spasm Akathisia: is a compulsion to be I motion, a sense of restlessness, being unable to be still, having an unrelenting desire to move, and feeling like crawling out of my skin. The patient is seen pacing, fidgeting, and markedly restless.

Parkinsonian symptoms: the use of antipsychotics may cause a collection of symptoms that mimic Parkinsons disease. A bilateral tremor (as opposed to unilateral tremor in true Parkinsons), bradykinesia, and rigidity may be seen, which may progress to the inability to move. The patient may have inflexible facial expression and appear bored and apathetic and be mistakenly diagnosed as depressed. Tardive dyskinesia: Irreversible movement disorder that occurs when antipsychotics have been used continuously for at least 3 6 months. Symptoms appear as wormlike movements of the tongue; other facial movements include grimacing, blinking, and frowning. Slow, maintained, involuntary, twisting movements of the trunk, limbs, neck, face, and eyes. No treatment reverses its effect.

Gero- Chapter 10 Herbs & Supplements in the Elderly Use of Herbs and Supplements in United States o o o o o o 38% of American adults use these and other forms of complementary and alternative medicine (CAM) Several popular examples of nonherbal supplements used by older adults are: melatonin for sleep coenzyme Q10, sometimes advised for Cardiac strengthening Glucosamine for painful arthritic joints Saw palmetto for prostate hypertrophy

Herbs are considered dietary supplements Echinacea, garlic, ginseng, Ginkgo biloba, and glucosamine with or without chondroitin were herbs/supplements used most often. o o o o Glucosamine to be the most frequently used supplement with ginkgo, chondroitin and garlic following. A large national survey found that 49% of older adults taking herbs never report them to the provider 84% were using self-paced OTC medications and dietary supplements Many believe that they are derived from harmless natural plants or substances and therefore were not concerned about, or aware of, any dangers

The increasing use of herbs and supplements by older adults is related to their hopes of preventing illness, promoting and maintaining health, treating a particular health problem, or replacing some currently missing dietary component. Elders with chronic conditions and symptoms of a health problem are more likely to use supplements and herbs in addition to their traditional therapies People perceive that such products will give them more control of their health and bodies Obtain specific information related to use---reason, form, frequency, duration, dose, any side/adverse effects, plans for continuing, and communication with providers about use.

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Lack of Standards in Manufacturing o o Any substance consumed that affects the body should be considered drug and potentially harmful Herbal manufacturers label herbs as foods Not regulated by FDA like drugs are Regulated by Dietary Supplement Health and Education Act (DSHEA) By regulation, herbs and other supplements may not be labeled for prevention, treatment, or cure of a health condition of any kind unless the claim has been substantiated by research and recognized by the FDA. Of all the identified herbs, only a handful are FDA approved, such as aloe, psyllium, capsicum, witch hazel, cascara, senna, and slippery elm. Because herbs are not typically under the protection of patent laws, companies have been less inclined to participate in clinical trials to determine their effectiveness, although the market for herbs and supplements is growing so fast that some companies now are conducting more scientific study of safety and efficacy. However, the lack of consistency among the methods different companies use to produce herbal products makes analytical analyses of them difficult. Despite the fact that few dietary supplements are FDA approved, not every such product is unsafe or ineffective for use Mixed herbal supplement therapies, such as some weight loss products, can cause hazardous effects on blood pressure and heart rate and rhythm and can be particularly risky because actually determining what the product contain may be difficult

For example, bitter orange (Citrus aurantium) was used to replace ephedra in many weight loss products after its removal from the market by the FDA in 2004, but bitter orange has synephrine (epinephrine-like) effects that can lead to cardiac arrest and ventricular fibrillation, and thus is unsafe for use.

Nurses must maintain current knowledge about herbs and other supplements so that when they assess older persons about their drugs and substance intake, potential and actual harmful effects may be recognized.

Herb Forms Different parts of herb may have uses and actions that are unrelated Manufactured in several forms o o Capsules, extracts, oils, tablets, salves, teas, tinctures An extract is a fluid or solid form of the herb that is concentrated. It is made by mixing the crude herb with alcohol, water, or some other solvent that is then distilled or evaporated. Essential oils are aromatic, volatile, and can be derived from varies parts of the fresh plant Infused oils, on the other hand, are developed when the volatile oil of one herb is mixed with that of another. Herbal oils are often used in massage therapy or aromatherapy. Tincture is when an herb is soaked in water, alcohol, vinegar, or glycerin for a specific time and the liquid is then strained to dispose of the plant remains. Salve is a type of ointment---a semisolid substance that is used topically.

o o o o Teas o o o o o

Teas are both foods and herbs, not regulated, may be highly concentrated if grown at home, may be mixed with other substances Consumption of more than recommended amounts of certain teas may cause illness or death Some teas may have very positive effects especially related to cardiovascular disease. Antioxidants in tea and raspberry juice may decrease plaque formation and help the risk of atherosclerosis. Green tea has also been associated with a decreased risk of some cancers, such as prostate cancer in men and breast and stomach cancers in women.

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For instance, senna leaf tea many cause serious fluid and electrolyte imbalance effects if used in excess and for a prolonged period. For example, comfrey tea has been linked with serious liver disease and drinking very hot tea too fast is associated with an increased risk of esophageal cancer

Commonly Used Teas, Herbs, and Supplements Chamomile o o o o o Usually taken in tea form Primary uses: anti-inflammatory and antispasmodic and to relieve gastrointestinal upset, sleep disorders, and anxiety In large doses it may cause gastrointestinal (GI) upset, and contact dermatitis and hypersensitivity reactions have been reported Use with benzodiazepines and other sedative-causing drugs is not advised Taking it with warfarin may increase warfarins effect and increase the risk of bleeding

Echinacea o o o o o Cold and flu therapy Taken in tea form, but can be used as tincture Study results indicate that Echinacea decreases the risk of developing the common cold and decreases the duration of a cold by at least 1 day Seems to have immune-stimulant qualities but significant benefits are unclear Persons allergic to daisy family plants or who have human immunodeficiency virus/acquired immunodeficiency (HIV/AIDS) or an autoimmune disease should use this herb with caution. Combining Echinacea with acetaminophen and other drugs or herbs that could cause liver damage is discouraged because it may cause liver inflammation.

Ginseng o o o o Improves well-being and helps with stress adaptation Capsules, extracts, tinctures Ginseng may benefit persons with heart disorders by reducing LDL cholesterol, lower blood sugar levels in type 2 diabetes, and enhance the immune system. Belief that ginseng is possibly effective in improving mood in postmenopausal women and some cognitive functions.

Side effects are many in Older Adults: Tachycardia Hypertension Hypotension Edema Diarrhea Mania (for persons with bipolar illness)

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Person with hypertension, cardiac problem, or diabetes must use ginseng with significant caution. Ginseng can increase blood pressure and may interact with other medications and products, (Table 10-1) page 153. Person who have had strokes may have increased bleeding if they take ginseng and blood-thinning medications at the same time. American ginseng is said to decrease blood glucose levels in type2 diabetes and also may help decrease the risk of upper respiratory infections, such as cold or flu, in older adults. Siberian ginseng may be helpful in decreasing herpes virus type 2 infections. There is not enough evidence to support its use for improving memory, feeling of wellbeing, hyperlipidemia, arrhythmias or stroke outcomes, as some resources suggest.

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Commonly Used Teas, Herbs, and Supplements Garlic o o o o o Thought to protect against stroke and atherosclerosis Use associated with decreased blood clots by keeping platelets from sticking together Two meta-analyses showed that garlic use reduces blood pressure in persons with hypertension Garlic may have some anticancer activity particularly gastrointestinal No standard dose or accepted standard for which form is bestoil, powder, deodorized extract

Glucosamine Sulfate (chitosamine) o o Used orally for glaucoma and as anti-inflammatory and antiarthritic Capsules, tablets, liquids

Two newer productsPrimarine and Relamine---- may have some ability to improve symptoms when used with glucosamine sulfate and chondroitin sulfate, but more study is needed. Not effective for hip osteoarthritis Persons with diabetes, asthma, or shellfish allergy should use glucosamine with caution.

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Commonly Used Teas, Herbs, and Supplements Ginkgo Biloba o o o o Capsules, extracts, tablets May improve cognitive function associated with mild or moderate memory impairment Will not help normal mental ability or forgetfulness A positive finding from a small component of the Ginkgo Evaluation of Memory (GEM) Study is that peripheral arterial disease (PAD) improved in the ginkgo versus placebo users. However, Ginkgo is implicated as causing dangerous interactions with heart medications. One serious side effects of ginkgo is bleeding. Persons taking drugs that increase bleeding risk or who have bleeding disorders should take ginkgo with caution and with provider oversight, and report any abnormal response such as bleeding, bruising dizziness, headache, and blurred vision. Pre-surgery, ginkgo needs to be stopped according to surgeon directions, generally at least one week or more before the surgery to prevent excessive bleeding during and after surgery. Ginkgo seeds can be toxic, and consumption may lower the seizure threshold.

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Saw Palmetto o o o o Offers mild to modest symptom improvement for benign prostatic hyperplasia (BPH) The herb is associated with some mild side effects, such as dizziness, fatigue, rhinitis, decreased libido, headache, and GI upset. May prolong bleeding time, so use with anticoagulant/antiplatelet drugs, supplements, or herbs is advised with caution and under supervision. The herb must not be taken with drugs for the treatment of benign prostatic hyperplasia (BPH) or prostate cancer, or with any drug or herb/supplement that can affect male sex hormones or that can increase bleeding.

Commonly Used Teas, Herbs, and Supplements Hawthorn, o o o o Extracts, teas, capsules Believed to have positive effects on congestive heart failure and coronary circulation May work by increasing cardiac output, and it also is said to have effects as an antispasmodic, diuretic, sedative, and anxiety reducer. Benefits were significant for chronic heart failure.

Red Yeast Rice o Gaining popularity in Western medicine, has always had a strong support in Eastern Medicine as a drug to lower low-density lipoprotein cholesterol (LDL-C), especially in individuals with dyslipidemia who cannot tolerate statins. The FDA does warn that the public should but red yeast products from respected sources, and avoid purchases through the internet because products may be adulterated. Persons need to know the potential side effects of red yeast rice, similar to those of lovastatin, such as muscle pain, kidney damage, heartburn, bloating and gas, dizziness, and asthma.

St. Johns Wort (SJW) (Demon chaser and goatweed) o o o Used to treat mild or moderate depression and seasonal affective disorder (SAD) May have antiviral properties This list of possible drug-drug, drug-herb/supplement, herb-disease, and anesthesia interactions is long, which is the primary reason for caution with SJW use and provider oversight. When taking this herb, people should be warned not to take medications containing monoamines, such as medications for nasal decongestants, hay fever, and asthma, because this combination may cause hypertension. It may take up to six weeks for SJW to reach its full effect; it should be discontinued slowly. Herbs & Supplements in Select Conditions

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Use of herbs and Supplements for Select Conditions Organ Transplantation o o Drug-herb interactions can occur when persons are taking medications for immunosuppression Transplant team members need to educate patients on hazards of herb and supplement use

Hypertension o o o o o o Hawthorn used as treatment for hypertension Reduction in blood pressure for persons already taking beta-blockers or calcium channel blockers may precipitate dangerous hypotension with HAWTHORN! Because therapeutic levels are not established, overtreatment and under treatment can occur when hawthorn alone is used. Caution is urged when erectile dysfunction drugs are used concomitantly with hawthorn because hypertension may result. Coenzyme Q10, garlic, green tea, melatonin, and magnesium have some positive effects in lowering blood pressure Herbs & Supplements in Select Conditions

Human Immunodeficiency Virus o o Persons with HIV-related symptoms are known to use alternative therapies, including herbs, to assist with symptoms Of concern is the potential that some herbal products may alter the metabolic action of antiretroviral drugs used in treatment. For example, SJW is commonly used for depression, but research indicates it may lower blood level of antiretroviral medications when taken together.

Gastrointestinal Disorders o o o Chinese have used herbal therapies for thousands of years to treat irritable bowel syndrome Chronic alcohol-induced and fulminate hepatitis have both been positively affected by use of milk thistle Herbs & Supplements in Select Conditions

Cancer o o o o Many herbs have potential to be used in treatment of cancer None has met goals for use in biomedicine Claims are often made that substance or herb will cure or help cancer patient, even though no data support such claims. Calcium, garlic, ginkgo, and psyllium are possibly helpful for decreasing colorectal and gastric cancer risk

Alzheimer's Disease o o o o Ginkgo used by older persons with dementia because it increases blood supply to brain. Improves memory and attention There is some scientific support for modest improvement in Alzheimers and dementia symptoms. Sage significantly improved cognitive outcomes as measured by the cognitive subscale of the Alzheimers Disease Assessment Scale and on the clinical to moderate Alzheimers disease. Moderate to heavy physical activity levels, drinking sage tea one to four times per day, and not being deficient in vitamin D have all been associated reducing brain decline risk.

Diabetes o o o o Herbal approaches to diabetes management in place before discovery of insulin in 1921 Approximately 400 different plants affect blood glucose; many still in use Fenugreek, a seed powder, when consumed as a cup of tea three times daily or taken orally in a capsule, can induce a hypoglycemic response A number of possible adverse effects may occur with increased caffeine intake, including headache, insomnia, anxiety and nervousness, hypertension, and heart rhythm disturbance. Cinnamon is another herb that has been linked with lowering blood glucose, but scientific evidence is mixed. Other herbs or supplements linked with some scientific evidence of lowering blood glucose are chromium, ginseng, gymnema, and stevia.

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Some supplements do not help or may even be harmful, such as selenium, fish oil, or coenzyme Q10, particularly if the patient stops taking prescribed medications for diabetes.

Herb & Supplement Interactions with Standardized Drugs Many herb and supplement products interact with prescription or over-the-counter medications, foods, and/or other herbs and supplements The more herbs and other drugs that the client is taking, the more likely it is that an interaction will occur Misuse of Herbal and Dietary Supplements Patients often do not reveal use of herbs and supplements to provider Failure to share important health information can severely jeopardize client o o Many products may have serious consequences of misuse based on actions or interactions with individuals current health status The interaction may cause alterations in absorption, distribution, or metabolism. For example, aloe and rhubarb have been found to bind to medications such as digoxin or warfarin, reducing their effectiveness by limiting absorption. SJW has significant interactions with many conventional drugs that may decrease the drugs concentration by inducing cytochrome P450s (CYPs) and Pglycoprotein, the major drug transporter, and lead to adverse reactions. Meadowsweet and black willow together may interact with warfarin and carbamazepine. Black licorice can decrease corticosteroid action. SJW decreases plasma concentrations or increases clearance of many drugs including alprazolam, amitriptyline, atorvastatin, digoxin, erythromycin, simvastatin, verapamil, and warfarin Ginkgo Biloba decreases plasma concentrations of omeprazole, ritonavir, and tolbutamide; it can unpredictably interact negatively with antiepileptics, aspirin, diuretics, and ibuprofen, and in some instances has an additive effect when taken with warfarin

Because the content of active herb or herbs in products by different manufacturers varies considerably, the therapeutic outcome and potential for herb-drug interactions varies greatly.

Implications for Nursing Once the conversation has begun, both the nurse and the elder can begin to evaluate the existing knowledge about and safety in the use of the substance. Knowledge of its potential side effects and interactions and it is helpful to know what the person hopes to accomplish by using the herb/supplement.

Assessment o Perioperative: Including herbs and supplements in the perioperative or emergency surgery assessment is of vital importance. Hypertension, excessive and prolonged bleeding, increased chance for interactions between herb and other drugs may occur Herbs that affect bleeding and clotting time, such as garlic, ginger, ginkgo, and ginseng, should be especially noted and reported to surgical team

Interventions o o o o Check for side effects, adverse reactions, and interactions among herbs, supplements, medications, foods, and illness Urge discontinuance of possibly harmful products Refer to persons usual health care provider The main reasons given for the use of alternative therapies by elders: 1-dissatisfaction with traditional medicine 2-The need for more autonomy and control in ones own health care 3-Incongruence with the elders concept of health and illness

Check for side effects, adverse reactions, and interactions among herbs, supplements, medications, foods, and the illness; and urging discontinuance of possibly harmful products.

Education Scientific data and information about the safe use of herbs must be provided in the context of the persons age and particular learning needs.

Elders should be helped to understand the importance of reporting the use of all herbs and supplements to their health care providerherbs and supplements are still drugs

Regarding product safety

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There is no standardization among manufacturers, so the amount of active ingredient per dose among brands is inconsistent Herbs and supplements should be purchased from reputable sources Herbs are available in different forms, making accurate closing difficult Research on both the untoward effects and the benefits of most herbs and supplements inadequate, making recommendations about specific herbs and supplements difficult Persons who have allergies to certain plants may have allergies to herbs in the same plant family.

Herbs and supplements taken with other such products may cause unpredictable effects Lastly, the nurse has a responsibility for maintaining a sound knowledge base, as well as having readily available sources of changing current data, regarding the treatments used by the patient, including those both prescribed and used in self-care. At the same time making recommendations for or against the use of herbs and supplements may be considered a form of prescribing in some settings, such as long-term and acute care. The nurse is cautioned to be aware of both organizational policies and state nurse practice regulations.

Implications for Nursing Dr. Os PowerPoint Notes Evaluation o o Review of herb-supplement-medication-drug-food interactions Outcomes of all teaching should be evaluated, as well as effectiveness of herbs and supplements used in select conditions

Prescription Drugs Older adults account for 1/3 of prescription drug use, while they only account for 13% of the population Older adults living in the community fill between 9-13 prescriptions a year (new and refills) Average of 5.7 prescription medicines per patient

Average nursing home patient on 7 medicines

Costs of Drugs Medicare does not pay for prescription drugs Average prescription drug cost for an older person is $500/year, but highly variable Nonprescription drugs and herbals can be quite expensive Many Medicare Managed Care Plans have dropped or severely limited drug coverage Drugs cost more in US than any other country New drugs cost more

Non-prescription Drugs Surveys indicate that older adults take an average of 2-4 nonprescription drugs daily Laxatives are used by 33% to 50% of older adults NSAIDs, antihistamines, sedatives, and histamine 2 (H2) blockers are all available without a prescription, and all have potential major side effects and possible drug-drug interactions

Adverse Drug Reactions About 15% of hospitalizations in the elderly are related to adverse drug reactions The more medications a person is on, the higher the risk of drug-drug interactions or adverse drug reactions The more medications a person is on, the higher the risk of non-adherence

Drug-Drug Interactions Common cause of ADEs in elderly Almost countless good role for pharmacist and computer or on-line programs Some common examples o o o Statins and erythromycin and other antibiotics TCAs and clonidine or type 1Anti-arrythmics Warfarin and multiple drugs

ACE inhibitors increase hypoglycemic effect of sulfonylureas

Drugs and Cognitive Impairment Common cause of potentially reversible cognitive impairment Individuals with dementia are particularly prone to delirium from drugs Anticholinergic drugs Other offenders cimetidine, steroids, and non-steroidal anti-inflammatory agents (NSAIAs)

Drugs and Falls Largest risk drugs are long acting benzodiazepines and other sedative-hypnotics Both selective serotonin reuptake inhibitor (SSRI) antidepressants and Tricyclic antidepressants (TCAs) associated with increased risk of falling Mild increase in fall risk from diuretics, anti-arrythmics, and digoxin

Drug-Food Interactions Interactions between drugs and food o o o warfarin and Vitamin K containing foods (remember green tea, as well) Phenytoin & vitamin D metabolism Methotrexate and folate metabolism

Drug impact on appetite o o Digoxin may cause anorexia ACE inhibitors can alter taste

Drugs and Dosages to Avoid in Older Adults Meperidine Diphenhydramine Most anticholinergic tricyclics Long acting benzodiazepines such as diazepam Iron: 325 mg once daily is enough

Anticipate Known Side Effects Narcotics o o May need lactulose or sorbitol and a stimulant laxative Colace is often insufficient

Steroids o o Think about osteoporosis prevention Be aware of the possibility of steroid induced diabetes

Levothyroxine o Calcium interferes with absorption of levothyroxine

Severe Adverse Drug Events (ADEs) in LTCFs Cardiovascular 36% o o Digoxin Furosemide 11% 7% 13% 11% 19% Phenytoin 9% 7%

Analgesics o Ibuprofen

CNS o

ASA

High Risk Situations Patient seeing multiple providers Patient on multiple drugs Patient lives alone and/or has cognitive impairment Discharge from hospital or any change in venue

Hospitalization: A Time of High Risk At hospitalization:

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40% of admission medications stopped 45% of discharge medications were started Serious prescribing problems in 22% Other prescribing problems in 66%

Nonadherence Lack of understanding of how to take o High risk times: Hospital discharge, new meds added, complex regimens

Unable to take Conscious nonadherence o o o Side effects Lack of understanding of benefits of drug Financial

Herbals and Supplements: Regulation Demonstration of safety is NOT required prior to marketing Manufacturing standards are not required Can have health claims, but not claims about treating, preventing, or curing For glucosamine/chondroitin, on third of combinations did not contain listed ingredient

Using the Beers Criteria http://vimeo.com/4852321

Resources Medication Use Safety Training (MUST) for Seniors Program http://www.mustforseniors.org/index.jsp

Summary Older adults take more medications than any other age group

Pharmacokinetics and pharmacodynamics are altered in the elderly Adverse drug reactions are common Risks go up with the number of drugs used Nonprescription and herbal therapies are common Patient & family teaching are critical