Care Of Older Adults Exam #6

Front 1

Geriatric depression scale - overview, scoring, targeted population

Back 1

Series of questions that assess how the older individual has felt over the past week (does not assess S/I).
15 questions - how many bold/positive answers were chosen? Score of 0-4 is normal, 5-8 mild depression, 9-11 moderate depression, 12-15 severe depression. Any score above 5 should prompt and in-depth psych eval for S/I.
Targeted pop = healthy, medically ill and mild to moderately cognitively impaired older adults

Front 2

PLISSIT Model

Back 2

P - Permission to initiate sexual discussion
LI - limited information shared with older adult (enough to function sexually)
SS - specific suggestions are provided to improve sexual health
IT - intensive therapy for clients whose sexual concerns go beyond the scope of nsg management

Front 3

Elder mistreatment assessment aka EAI (Elder Assessment instrument)

Back 3

Provides a way for nurses to screen older adults for possible mistreatment, can be used in most clinical settings. Subheadings= general assessment, possible abuse indications (brusing lacerations, fx, statements), possible neglect indicators (decubiti, dehydration, diarrhea, impaction, malnutrition), possible exploitation indicators (misuse of memory), possible abandonment indicators (evidence that the caretaker has withdrawn)

Front 4

Forms of mistreatment (4)

Back 4

1. abuse
2. neglect
3. financial exploitation
4. abandonment

Front 5

Bladder Diary

Back 5

Fluid intake, time and volume of voiding, incontinent episodes

Front 6

Hendrich II fall assessment

Back 6

7 conditions - points allotted for each varies (0-12 total). Confusion/disorientation, symptomatic depression, altered elimination, dizziness/vertigo, male gender, anti epileptics, benzos. Last part is a get up and go test (0-4).
A score of greater than 5 = high fall risk

Front 7

Accidental bruising vs intentional bruising (from handouts)

Back 7

accidental bruising: 90% on extremities, don't remember how they got them, meds could cause higher risk of bruising
intentional bruising: on the back, arms and head/face, large >5cm, can tell you how they got the bruises

Front 8

Statistics about HIV in older adults...

Back 8

17% of HIV pts are over age 50 (2007)
Older adults are more apt to develop AIDS less than 12 mo after dx of HIV
1/3 of HIV infected adults have unprotected sex

Front 9

What would be an acceptable question to ask for the "P" in the PLISSIT model? (3)

Back 9

Permission to initiate discussion:
1. Can you tell me if you feel comfortable discussing issues of concern regarding your sexual health?
2. What concerns you about your experience with intimacy?
3. How have your intimacy needs changed as you have aged?

Front 10

What is functional incontinence?

Back 10

occurs as a result of inability to reach the toilet d/t environmental barriers, physical limitations, impaired cognition, institutional living, restraints, no assistance. It is an external problem.

Front 11

What is stress incontinence?

Back 11

involuntary loss of urine during activities that increase intra abdominal pressure. Lifting, laughing, sneezing, etc. Common cause is urethral spinster deficits, includes pelvic floor muscles.

Front 12

What is urge incontinence?

Back 12

associated with strong abrupt desire to void and inability to inhibit leakage in the time it takes to reach toilet.
Bladder contractions d/t central nervous system disorders/caffeine

Front 13

What is reflex incontinence?

Back 13

variation of urge incontinence resulting from bladder contractions, with no sensation of needing to void or urgency. Most often in spinal lesions transecting cord above T10-T11

Front 14

What is overflow incontinence?

Back 14

over-distention of the bladder d/t abnormal emptying
increase in bladder pressure
results from an atonic bladder from anticholinergics
diabetes, spinal cord injury or mechanical obstruction can cause this.

Front 15

What is mixed incontinence?

Back 15

combination of 2 or more types at the same time. Usually urge and stress. Urge + functional is common in dementia pts.

Front 16

Normal age-related changes that occur in the GU system that may cause problems with incontinence. (8)

Back 16

• Bladder retains tone, but decreases in volume it can hold
• Sphincter weakens
• Increase of involuntary bladder contractions causing more urine produced at night → increase in nocturnal awakenings
• Increase in voiding frequency
• Increase in susceptibility to dehydration
• Decrease in estrogen levels after menopause affect pelvic floor muscle tone
• Thinning of urethral mucosa causes urgency to urinate

Front 17

Normal age-related changes that occurs with the kidneys and hydration of the older adult. (7)

Back 17

• Reduced ability to respond to a fluid overload → need to slowly rehydrate
• Loss of water content + more body fat = impairment in drug/metabolite excretion
o Recommended to spread out the fluid intake throughout the day to reach 1500-2000 mL per day
• Kidneys are less able to concentrate urine
• Kidneys are less responsive to circulating hormone levels (antidiuretic hormone)
• Urine has lower specific gravity
• Atrophy in vessels carrying blood to kidneys
• Decrease in GFR (<50%) – measured by creatinine clearance

Front 18

Planning care of the older adult with impaired GU system.

Back 18

Bladder diary
Scheduled toileting q 2 hrs
prompted voiding
Habit training - patterned urge response
Pelvic floor muscle exercises
Caregiver education
Prevention of UTIs
Skin care/barrier cream
Measure I&Os
Avoid use of catheters
Eliminate or restrict caffeine
Hydration management (75-80% at meals, 20-25% non meals)

Front 19

What does TOILETED stand for?

Back 19

T - Thin, dry vaginal and urethral epithelium
O - obstruction, stool impaction, constipation
I - infection
L - limited mobility
E - emotional, psych, depression
T - therapeutic medication
E - endocrine d/o
D - delirium

Front 20

What does the TOILETED tool assess for?

Back 20

the possible causes of transit urinary incontinence. Reveals the possible underlying causes of urinary incontinence. Helps the healthcare worker to pinpoint the problem.

Front 21

Symptoms suggestive of a UTI in the older adult?

Back 21

change in mental status (this could be the only sx!)
becoming weaker and more fatigued
dysuria
urgency
frequency
hematuria secondary to damaged bld vessels
fever, chills, flank tenderness

Front 22

The older adult's perception of a mental health problem?

Back 22

Depressed mood, trouble remembering, trouble staying focused/concentration
Belief that symptoms are not treatable or curable and a reluctance on the part of the older adult to admit a need to seek treatment from a mental health professional.
Stigma

Front 23

What is the LEARN model?

Back 23

LEARN Model
• L Listen to what the patient has to say
• E Explain your perception of the problem
• A Acknowledge the similarities and differences of perception
• R Recommend a plan of action that takes into account both perspectives
• N Negotiate a plan that is mutually acceptable.

Front 24

What are the symptoms of depression?

Back 24

1. Depressed mood
2. Diminished interest
3. Loss or gain of >5% body weight within one month
4. Insomnia, excessive sleeping/fatigue
5. Psychomotor agitation or retardation
6. Impaired concentration
7. Feelings of worthlessness
8. Recurrent thoughts of suicide or death

Front 25

Characteristics of an older adult victim of neglect/abuse?

Back 25

• Age: median age = 77.9 years (1996 data excluding self-neglecting elders); self-neglecting elders = 77.4 years (same study)
• Race/ethnicity: 66.4% Caucasian; 18.7% African-American; 10.4% Hispanic; <1% Asian-American, Native American, Pacific Islander
• Gender: 67.3% female, 32.4% male (NCEA, 1996): Important to remember that men are also abused
• Severity of injuries greater in women; higher mortality rates; could be due to the inability to strike back
• Cognitively impaired and disabled
• Women over 80 mistreated 2-3x their proportional numbers (NCEA, 1998)
o Women statistically live longer than men and therefore, live alone and are vulnerable

Front 26

Characteristics of the abuser?

Back 26

• Mental illness
• Alcohol and substance abuse, gambling
• Son in late 30’s or early 40’s
• Lives at home with dependent elder parents
• Unemployed (dependence of abuser on victim)
• Caregivers

Front 27

Risk factors for abuse of an older adult?

Back 27

• Invisibility (socially isolated)
• Physiologic impairment
• Cognitive impairment, disabled
• Psychosocial factors (transgenerational violence)
• Environmental factors (shared living arrangements, unsafe conditions)
• Psychopathology of caregiver or perpetrator
• Caregiver stress
o Assess and address if the patient has been abused or neglected in any way and make sure the care giver has support to prevent extra stress
• Elders caring for elders
• Institutional factors
• Lack of training of caregiver especially in care facilities
• Financial stress
• Inability to adhere to treatment and medication regimens; Pt. may need assistance setting up medications or administering medications
• Dependence of abuser on victim for housing and finances
• Dependence of elder on abuser
• Poverty
• Substance abuse in family/caregivers
• Cultural sanctions against seeking help to care for elder

Front 28

What is a silver alert?

Back 28

when an older adult wanders out of a facility on their own/ gets lost
not an abduction

Front 29

Appropriate intervention for an alleged elder abuse?

Back 29

Interventions
• Approaches will depend on the client’s cognitive status and decision-making capabilities.
• Determine capacity to make decisions.
• Geriatric/psychiatric evaluations
• The nurse relies on close observation of physical and emotional cues of cognitively-impaired elders.
Clinical Interventions
• Complete history and physical exam
• Laboratory studies: CBC, chemistry, U/A, urine drug screen, ethanol level, serum levels of relevant medications
• Imaging studies: x-rays of relevant body parts to detect unusual fractures; head CT scan to detect intracranial bleeding or possible explanation for injuries/altered mental status.
• Pelvic exam with forensic evidence collection in cases of sexual abuse. Follow facility policies and procedures.
• Emergency department care: treat physical manifestations of abuse and assure safety of client; photograph findings.
• Social service referral
• Contact Adult Protective Services
• psych eval/support groups/education

Front 30

Assessment of exploitation of the older adult.

Back 30

Questions to ask: “Who pays your bills? Do you ever go to the bank with this person? Does this person have access to your account? Does this person have power of attorney? Have you ever signed papers you didn’t understand? Are any family members showing an interest in your assets? Has anyone ever taken anything without asking?”

Front 31

Assessment of elder physical abuse.

Back 31

• Bruising, black eyes, welts, lacerations, rope marks, fractures, burns, untreated injuries, use of physical restraints, sudden change in behavior, bleeding
• Note if a caregiver refuses an assessment of the victim alone. Note inconsistent stories (caregiver may be lying about what may have occurred)
• Review laboratory tests. Note any low or high serum levels for prescribed drugs.
• Note any reports of being physically mistreated; any delay in seeking care
• Questions to ask: “Has anyone ever tried to hurt you in any way? Have you had any recent injuries? Has anyone ever touched you or tried to touch you without permission? Have you ever been tied down? How did that bruise occur? When did it happen? Did someone do this to you? Are there other areas on your body like this? Has this ever occurred before?”

Front 32

Assessment of elder psychological abuse.

Back 32

• Questions to ask: “Are you afraid of anyone? Has anyone ever yelled at you or threatened you? Has anyone been insulting you or using degrading language? Do you live in a household where there is stress and frustration? Does anyone care for you or provide regular assistance? Are you cared for by anyone who abuses drugs or alcohol? Are you cared for anyone who has been abused as a child?”

Front 33

Assessment of caregiver neglect.

Back 33

• Malnourishment and dehydration
• Pressure ulcers
• Poor hygiene, fecal/urine smell
• Inappropriate/inadequate clothing for weather
• Unaddressed health problems
• Non-adherence to medication regimen
• Insect infestation
• Unsafe/unclean living conditions
• Questions to ask: “Are you alone a lot? Has anyone ever failed you when you needed help? Do you receive your medication on time? Are you made to remain in a room all day with no one to talk to? Do you have enough groceries in the house? Who does your shopping? Who helps you with bathing, toileting, and dressing?”

Front 34

Assessment of self-neglect in the older adult.

Back 34

• Dehydration, malnutrition
• Poor hygiene
• Unsafe living conditions
• Inappropriate clothing
• Fecal/urine smell, lice
• Non-adherence to medication regimen
• Questions to ask: “How often do you bathe? Have you ever refused to take prescribed medications? Have you ever failed to provide yourself with adequate food, water, clothing? Who does your grocery shopping? Are you friendly with your neighbors? Do you find yourself wandering alone in your neighborhood?”

Front 35

Assessment of sexual abuse.

Back 35

• Bruises around breasts and genital and breast area
• Sexually transmitted infections
• Vaginal/anal bleeding/discharge
• Torn, stained, bloody clothing/undergarments
• Note any reports of being sexually assaulted or raped.
• SAFE will collect physical evidence
o We always need to get a forensic specialist who is well skilled at preserving evidence
• Questions to ask: “Are you afraid of anyone? Has anyone ever touched you or tried to touch you without permission? Have you ever been tied down? Has anyone ever made you do things you didn’t want to do? Does anyone care for you or provide regular assistance? Are you cared for by anyone who uses alcohol and drugs?

Front 36

How do you assess for abuse of the cognitively impaired older adult?

Back 36

assess for hair loss
bruising chart
malnutrition
poor hygiene

• Bruising, black eyes, welts, lacerations, rope marks, fractures, burns, untreated injuries, use of physical restraints, sudden change in behavior, bleeding
• Note if a caregiver refuses an assessment of the victim alone. Note inconsistent stories (caregiver may be lying about what may have occurred)
• Review laboratory tests. Note any low or high serum levels for prescribed drugs.

Front 37

What is the EAI (Elder Assessment Instrument)?

Back 37

A tool used to determine if any type of abuse may be going on - a tool to use during assessment.
Uses 5 categories to assess:
general assessment (clothing, etc)
possible abuse indications (brusing lacerations, fx, statements)
possible neglect indicators (decubiti, dehydration, diarrhea, impaction, malnutrition)
possible exploitation indicators (misuse of memory)
possible abandonment indicators (evidence that the caretaker has withdrawn)

Front 38

What is the IOA? (Indicators of Abuse Screen)

Back 38

Purpose is to screen for abuse and neglect at the clients home - to be completed by a trained practitioner.
2-3 hr comprehensive in-home assessment
Includes possible problems for both the caregiver and care receiver to be rated on.

Front 39

Risk assessment instruments - scoring and how it is used to assess

Back 39

When using the EAI, there is no "scoring". Social services should be contacted if:
1) if there is any positive evidence without sufficient clinical explanation, 2) whenever there is a subjective complaint by the older adult of elder mistreatment, or 3) whenever the clinician deems there is evidence of abuse, neglect, exploitation, or abandonment

Front 40

What is the caregiver strain index?

Back 40

Determines the level of strain on caregivers - 13 aspects:
1. disturbed sleep
2. caring fro incontinent
3. when caring is physical strain
4. caregiving is confining
5. family adjustments
6. changes in personal plans
7. other demands on time
8. emotional adjustments
9. behavior is upsetting
10. pt going downhill
11. work adjustments
12. financial strain
13. feeling overwhelmed
Scoring: regular basis =2, sometimes = 1, no = 0
Scoring ranges 0-26

Front 41

Elder abuse suspicion index

Back 41

developed to raise doctor suspicion about elder abuse and to pose referral to social services. Five questions asked referring to the last 12 mo.
Questions about pt is reliant, preventing needs being met, pt becoming upset, pt forced, pt fearful.
Doctor determines based on answers if pt should be referred to social services.

Front 42

When to refer a pt to social services? (4)

Back 42

1. Pt verbalizes abuse/neglect is occurring
2. Elder abuse suspicion index, EAI, IOA tools reveal a positive result
3. Nurse sees obvious bruises/wounds that cannot be explained clinically
4. Whenever the clinician deems there is evidence of abuse, neglect, exploitation, or abandonment

Front 43

What is the mandated reporting per the Welfare and Institutions Code?

Back 43

o “Phone call within 24 hours, then in writing within 2 days to:”
o Adult Protective Services (will report to the larger agency), Social Services (experts knowing how to work with outside agencies and how to report), and/or Law Enforcement
o Facilities call Ombudsman, report to DHHS
o Mandatory Reporting in all 50 states

Front 44

What is an Ombudsman program?

Back 44

Usually appointed by the government
Serves the interest of the public by addressing and investigating c/o maladministration of rights/abuses
one that investigates, reports on, and helps settle complaints

Front 45

What are some nx interventions for elders with fall risks?

Back 45

o Frequently reorient the patient to the environment.
o Keep personal belongings and other objects in the same position, within reach.
o Ensure the patient has on glasses and/or hearing aids.
o Ask the patient every one to two hours if he/she needs to use the bathroom.
o Teach the patient to change positions slowly, especially from lying to sitting to standing.
o Evaluate the patient’s electrolytes.
o Evaluate for hypoxemia. Measure oxygen saturation as needed.
o Use a bed and/or chair personal alarm.
o Do not expect a pt. to use their call light
o Eliminate potential hazards such as debris or water on floor.
o Keep eyeglasses within reach.

Front 46

Statistics regarding incidence of falls?

Back 46

1/3 of older adults fall each year in their home.
Nursing homes have the highest fall risk incidence (50-75%)
Falls rank at the 8th leading cause of unintentional injury in older adults
Responsible for 16,000 deaths in 2006

Front 47

Intrinsic risk factors for falls

Back 47

Vision, hearing, cardiovascular, musculoskeletal, neurological, drugs

Front 48

Extrinsic risk factors for falls

Back 48

Environmental hazards
• Floor surfaces: waxed or polished floors, throw rugs, clutter
• Edges and curbs: homogenous color; tell the pt. to change the color of the edge
• Lighting: dimly lit rooms, bright lights
• Grab bars or rails: lack of/misplaced
• Assistive device: inappropriate size, poorly maintained

Front 49

What are the normal age-related changes in women?

Back 49

• Loss of estrogen at menopause
• Thinning of vaginal wall
• Reduction in vaginal lubrication
• Atrophy of labia, shortening of vagina
• Less frequent uterine contractions resulting in less pleasurable orgasms
• Longer period of stimulation required
• Decline in ovarian and adrenal androgens preceding menopause, causing loss of bone mass, libido and energy
• Low testosterone = decrease in libido
• Dyspareunia: painful intercourse
• Vaginismus: involuntary spasms of lower vaginal muscles

Front 50

What are the normal age-realated changes in men?

Back 50

• Decrease in pre-ejaculatory fluid; semen is less forceful at ejaculation
• Longer refractory period between ejaculations
• Erection is less firm and shorter acting
• Androgen decline in the aging male (ADAM): decrease in testosterone
• Decrease in pre-ejaculatory fluid; semen is less forceful at ejaculation
• Longer refractory period between ejaculations
• Erection is less firm and shorter acting
• Androgen decline in the aging male (ADAM): decrease in testosterone
• Impotence related to medication side effects

Front 51

What are some medical diseases that can affect sexual functions?

Back 51

• Cardiac
• Endocrine
• Genitourinary
• Immune
• Musculoskeletal
• Neurologic
• Respiratory
• Surgeries, medications

Front 52

What is ED? What are the common causes?

Back 52

• Erectile dysfunction (impotence): inability to develop and sustain an erection in 50% or more attempts at intercourse; under reported
• Causes of ED include structural abnormalities of the penis; adverse effects of drugs; psychiatric illness; vascular, neurologic, and endocrine disorders.
• Not a normal aging change: can be a side effect of meds (antihypertensives)

Front 53

What are some medications that can affect sexual function?

Back 53

• Dopamine agonists (Decreases Dopamine): increase sexual desire
• Diuretics: can cause incontinence
• Anticholinergics: can cause impaired ejaculation
• Antipsychotics: inhibit erection and ability to ejaculate
• Sedatives/hypnotics: depress sexual arousal
• Antidepressants: SSRIs inhibit sexual desire and orgasm
• Antihypertensives: inhibit orgasm, can cause incontinence and ED
• Antianxiety meds: diminish sexual desire and inhibit orgasm
• Anticonvulsants: diminish desire, can cause ED
• Alcohol: ED, impaired function in women

Front 54

What is the impact of disease on sexual function?

Back 54

ED
dyspanuria - painful intercourse
less projector fluid and semen, less forceful ejaculation
vaginismus - involuntary, painful contraction of lower vaginal muscles
Lower testosterone levels from disease? then would have dec libido, dec muscle mass, dec strength, alterations of memory, diminished energy, inc in sleep disturbance