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Health Challenges and Solutions for the Elderly: A Comprehensive Guide, Exams of Nursing

Miami University - MiddletownNursing

An in-depth analysis of various health issues faced by the elderly, including vision problems, hearing loss, oral health issues, neurocognitive disorders, polypharmacy, dehydration, falls, failure to thrive, and elder abuse. It also offers solutions and management strategies for these conditions. Particularly useful for healthcare professionals, students, and caregivers seeking to understand the unique health needs of the elderly.

Typology: Exams

2023/2024

Available from 05/07/2024

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Module 3 Guided
Questions
Lesson 1: Geriatrics for the PCP
1. What are the physiologic changes of aging? What kinds of problems are caused by these
changes?
ā€¢Vision : Presbyopia is caused by loss of elasticity of the lenses. Close vision is markedly
affected. Onset is during early to mid-40s. Can be remedied with ā€œreading glassesā€ or bifocal
lenses. Cornea less sensitive to touch. Arcus senilis, cataracts, and glaucoma are more common.
Annual eye exams,
assess ability to read (driving, Rx
bottles) Arcus Senilis- check lipids
ā€¢Hearing : Presbycusis (Sensorineural Hearing Loss) Screen with audioscope or whisper test.
Refer to audiology if failed. Higher risk for cerumen impaction. Be aware of temp. hearing
loss inducing meds: ASA, Lasix
ā€¢Mouth : Receding gums and xerostomia (dry mouth) Decreased sensitivity of taste buds results in
decreased appetite. Dentures- do they fit?
Leukoplakia- check bottom lip, cheilitis, glossitis
ā€¢Neck : probably is not supple, masses are likely cancer. Check thyroid and TSH level, check
carotids
ā€¢Chest : BP
š–³
r/t
š–³
vascular resistance. Baroreceptors less sensitive to changes in position.
Decreased sensitivity of the autonomic nervous system. Blunted BP response. Decrease in
maximum heart rate. Higher risk of orthostatic hypotension. S4 heart sound a ā€œnormal ļ¬ndingā€
in the elderly if not associated with heart disease. The left ventricle hypertrophies with aging (up
to 10% of thickness). ā†“ Cough reflex, ā†“ mobility= risk for PNA
ā€¢Extremities : Edema- does it resolve at night? Discoloration of lower extremities r/t chronic
edema.
Assess pulses, Heberden nodes,
foot abnormalities
š–³
risk of falls.
ā€¢Abdomen/GI : Decreased efļ¬ciency in absorbing some vitamins and minerals by the small
intestines. Delayed gastric emptying. Higher risk of gastritis and GI damage from decreased
production of prostaglandins. Diverticula common. Large bowel (colon) transit time is
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Module 3 Guided

Questions

Lesson 1: Geriatrics for the PCP

1. What are the physiologic changes of aging? What kinds of problems are caused by these

changes?

  • Vision: Presbyopia is caused by loss of elasticity of the lenses. Close vision is markedly affected. Onset is during early to mid-40s. Can be remedied with ā€œreading glassesā€ or bifocal lenses. Cornea less sensitive to touch. Arcus senilis, cataracts, and glaucoma are more common. Annual eye exams, assess ability to read (driving, Rx bottles) Arcus Senilis- check lipids
  • Hearing: Presbycusis (Sensorineural Hearing Loss) Screen with audioscope or whisper test. Refer to audiology if failed. Higher risk for cerumen impaction. Be aware of temp. hearing loss inducing meds: ASA, Lasix
  • Mouth: Receding gums and xerostomia (dry mouth) Decreased sensitivity of taste buds results in decreased appetite. Dentures- do they fit? Leukoplakia- check bottom lip, cheilitis, glossitis
  • Neck: probably is not supple, masses are likely cancer. Check thyroid and TSH level, check carotids
  • Chest: BP š–³ r/t š–³ vascular resistance. Baroreceptors less sensitive to changes in position. Decreased sensitivity of the autonomic nervous system. Blunted BP response. Decrease in maximum heart rate. Higher risk of orthostatic hypotension. S4 heart sound a ā€œnormal findingā€ in the elderly if not associated with heart disease. The left ventricle hypertrophies with aging (up to 10% of thickness). ā†“ Cough reflex, ā†“ mobility= risk for PNA
  • Extremities: Edema- does it resolve at night? Discoloration of lower extremities r/t chronic edema. Assess pulses, Heberden nodes, foot abnormalities š–³ risk of falls.
  • Abdomen/GI: Decreased efficiency in absorbing some vitamins and minerals by the small intestines. Delayed gastric emptying. Higher risk of gastritis and GI damage from decreased production of prostaglandins. Diverticula common. Large bowel (colon) transit time is

slower. Constipation more common. Increased risk of colon cancer (age greater than 50 years is strongest risk factor). Fecal incontinence common due to drug side effects, underlying disease, and/or neurogenic disorders. Fecal impaction may lead to small amount of runny soft stool. Laxative abuse more common.

  • GU/reproductive: Starting at the age of 40 years, the GFR starts to decrease. By age 70, up to 30% of renal function is lost. Renal clearance of drugs is less efficient. The serum creatinine is a less reliable indicator of renal function in the elderly due to the decrease in muscle mass, creatine production, and creatinine clearance. Serum creatinine can be in the normal range even if renal function is markedly reduced. Risk for UTI š–³ r/t prostatic enlargement, atrophic vagina, constipation, mobility issues. Remember early sign of UTI in geriatrics is confusion! Ask about sexual activity, may need pharmacological support, may need STD education.
  • MSK: Kyphosis: Compression fractures of vertebrae (a sign of osteoporosis). Deterioration of articular cartilages common after age of 40. Stiffness in the morning. Osteoarthritis very common. Muscle mass and muscle strength markedly decrease, with more muscle loss on the legs compared with the arms. Osteoporosis and osteopenia common. Slower healing of fractures due to decrease in the number of osteoblasts. Bone resorption is more rapid than bone deposition in women compared with men (4:1). Remember to observe for symmetry in changes. Sarcopenia- age related loss in muscle mass. o Osteoporosis: deterioration of bone tissue caused by hormonal changes, calcium/vitamin d deficiency, risk factors- patients on PPI, patients with anorexia/bulimia females, family history, age; estrogen and testosterone deficiency (Turnerā€™s), post-menopausal, kyphosis, Caucasians and Asian, small frame people, cigarette, alcohol, caffeine, medication- steroids anticonvulsants, thyroid supplements, eating disorder, sedentary life, Dx bone mineral density >-2.5 osteoporosis, -1 to -2.5 is osteopenia- thinning bone TX first line is bisphosphonates alendronate, Fosamax (sit upright for 30 min), calcium500 mg, vitamin D thru food and supplementation, testosterone, wt bearing exercise
  • Neuro: Cranial nerve testing may show differences in ability to differentiate color, papillary response, and decreased corneal reflex. Decreased gag reflex. Deep tendon reflexes may be decreased, watch for symmetry. Neurological testing may be impaired by medications causing slower reaction times. Benign essential tremor more common. Tremor with rigidity- think Parkinsons. Neuro exam is predictor of fall risk.
  • Skin: Skin atrophy. Thinner epidermis, dermis, and subdermal fat. Less collagen (less elasticity). Fragile skin and slower healing. Slower nail growth. Lower oil production and drier skin (xerosis) due to decrease in sebaceous and sweat gland activity. Fewer melanocytes leading to graying of hair and vitamin D synthesis. Decrease in the skinā€™s sensory ability. o Seborrheic Keratoses Soft wart-like skin lesions that appear ā€œpasted on.ā€ Mostly seen on the back/trunk. Benign. o Senile Purpura Bright purple-colored patches with well-demarcated edges. Located on the dorsum of the forearms and hands. Lesions eventually resolved over several weeks. Benign. o Lentigines Also known as ā€œliver spots.ā€ Tan- to brown-colored macules on the dorsum of the hands and forearms. Due to sun damage. More common in light skinned individuals. Benign. o Stasis Dermatitis Affects primarily lower legs and ankles secondary to chronic edema (from PVD). o Senile Actinic Keratosis Secondary to sun exposure; potential for malignancy.

2. How do the changes impact the function of the elder?

(Source: Kaplan & Sadockā€™s Psych Book p. 1336)

3. How is function assessed by the PCP? Why is function important?

  • The geriatric assessment begins with a review of the two key divisions of functional ability: activities of daily living (ADL) and instrumental activities of daily living (IADL). o ADL are self-care activities that a person performs daily (e.g., eating, dressing, bathing, transferring between the bed and a chair, using the toilet, controlling bladder and bowel functions). o IADL are activities that are needed to live independently (e.g., doing housework, preparing meals, taking medications properly, managing finances, using a telephone). o Two instruments for assessing ADL and IADL include the Katz ADL scale and the Lawton IADL scale o Deficits in ADL and IADL can signal the need for more in-depth evaluation of the patient's socioenvironmental circumstances and the need for additional assistance. o Mental status should be a part of the functional assessment. Dementia = significant decline in 2 or more areas of cognitive functioning. Dementia is major cause of loss of ADL/IADL function. Screening is Folstein MMSE, MCOA, or Mini Cog.
  • The degree of functional competence in their everyday behaviors is an important consideration in formulating a treatment plan for these pts.

4. What are the geriatric syndromes? How are they managed? (Primary Care textbook, p 87- 93)

  • Polypharmacy o Definition: Use or misuse of multiple drugs (>5), both prescription and OTC o Mgmt ā–Ŗ Review all meds at each pt contact ā–Ŗ Maintain good communication w consultant ā–Ŗ Use tools to evaluate use of drugs (ie Beers list; and I donā€™t mean Budweiser, Miller, or Corona;) ā–Ŗ Encourage pt to carry an up-to-date list of their meds ā–Ŗ Determine drug risk/benefit ration when considering use of any new drug (ā€œstart low and go slowā€)
  • Cognitive impairment (See NCD tx)
  • Dehydration o Definition: a state of fluid intake deprivation and/or excess fluid loss

syndromes is frequent testing at an eye doctor and the use of prescription glasses or bifocals, when prescribed

  • Sleeping Difficulties- Warning Signs : Difficulty concentrating during the day, drowsiness, persistent insomnia. Solutions : An overnight stay in an observational sleep lab is the best way to get a comprehensive diagnosis of sleep patterns, which can then be cross-examined by a doctor against current medications and patient lifestyles to determine if sleep medication is an appropriate solution.
  • Hearing Loss / Presbycusis- Warning Signs : Difficulty following or contributing to a conversation, frequent requests for words to be repeated, lack of reaction to sounds in the immediate area. Solutions : An examination is necessary to determine if the cause is, in fact, something serious and not an easily remedied condition such as impacted earwax. If a serious issue is discovered, a hearing aid may be prescribed to assist the userā€™s natural hearing capability. Mental Function:
  • Dementia- Warning Signs : Strange or unusual declarations, confusion, inability to remember short-term events. Solutions : see neurocognitive disorders below.
  • Depression- Warning Signs : Withdrawing from social activities, a preoccupation with death or dying, a general lack of energy or enthusiasm. Solutions : see neurocognitive disorders below.
  • Paranoia / Psychosis- Warning Signs : Frequent accusations of misdeeds such as stealing or attempting to inflict harm, an overwhelming feeling of being watched, experiencing sights

and sounds that arenā€™t present. Solutions : Anti-psychotic medication can be very

effective in controlling the disruptive properties of these syndromes

  • Substance Abuse- Warning Signs : Consciously taking more pills than prescribed, frequent alcohol drinking, disproportionately negative reactions when an addictive substance is

controlled or taken away. Solutions : Just as their younger counterparts might turn to others

for help, group therapy has been shown to assist elderly substance abusers with

regaining sobriety and responsible medication handling.

6. How is a functional assessment performed in the primary care visit?

  • Musculoskeletal and foot assessment; mobility
  • Activities of daily living- Katz ADL scale
  • Instrumental activities of daily living- Lawton IADL scale
  • Mental status- Folstein MMSE, MCOA, or Mini Cog, & Clock test *Geriatric Depression Scale or Patient Health Questionnaire (PHQ2)*

Lesson 2: Neurocognitive Disorders

1. What cognitive changes are seen in the elderly patient?

  • Regarding neurocognitive domains, NORMAL changes with aging are:

o Attention: slow decline with age seen in selective attention, divided attention, &

working memory

o Executive function: decline with age especially after age 70

o Memory: episodic memory shows lifelong declines while semantic memory shows

late life decline; unlike declarative memory, nondeclarative memory remains

unchanged across the lifespan

o Language: overall language ability remains intact with aging; vocabulary remains

stable and even improves over time

o Visuospatial Abilities: visual construction skills decline overtime, in contrast,

visuospatial abilities remain intact

o Processing speed: fluid ability begins to decline in the 3 rd^ decade of life and continues

throughout the lifespan

2. What are neurocognitive disorders?

  • NCD Defined:

o formerly known as dementia

o A reduction or impairment of multiple cognitive abilities, including memory,

sufficient to interfere with self-maintenance, work, or social relationships

o Progressive & disabling episodic memory shows lifelong declines while

o NOT an inherent aspect of aging

o Different from normal cognitive lapses

  • DSMV Criteria: Major vs Minor Cognitive Disorder

o Major NCD

ā–Ŗ Cognitive deficits interfere w independence in AD activities (minimally

requiring assit w complex IADLs)

ā–Ŗ Cognitive deficits do NOT occur exclusively in the context of a delirium

ā–Ŗ Cognitive decline is not better explained by a mental disorder (i.e. major

depressive disorder, schizophrenia)

o Minor NCD (AKA mild cognitive impairment)

ā–Ŗ Memory problem w/o deficits in other domains

ā–Ŗ NO fxn impairment

ā–Ŗ 10-12%/yr progress to dementia

  • Dx NCD

o Examination of neuro, mental, & fxn status using screening tools

ā–Ŗ Cognitive screening tools

āž¢ Folstein MMSE

āž¢ Mini-cog

āž¢ MOCA

āž¢ SLUMS

āž¢ Clock Test

ā–Ŗ Fxn screening tools

āž¢ Lawton IADL Scale

āž¢ Katz (Basic ADLs)

āž¢ KELS Evaluation (independent living status)

o Laboratory testing

ā–Ŗ CBC, Blood chemistries, LFTs, renal fxn tests, other serology (TSH/free T$,

Vit B 12 /folate levels, serum drug levels, VDRL/RPR, NH 4 level

o Neuroimaging

ā–Ŗ Consider non-contrast head CT, MRI, PET scan

3. How are the neurocognitive disorders diagnosed and treated?

  • Tx

o Primary goals of tx are to improve quality of life and maximize fxn performance by

enhancing cognition, mood, and behavior.

psychomotor agitation or retardation, fatigue, loss of energy, feeling of

worthlessness(poor self-image), inappropriate guilt, recurrent thoughts of death(suicide),

difficulty thinking or concentrating/indecisiveness Dx labs CBC, TSH, Vit B12 TX rule

out other disease refer psychotherapy ,first line SSRI

  • Cofabulation- lying due to not remembering event
  • Dyskinesia- abnormal involuntary muscle rigidity
  • Dystonia- involuntary and repetitive muscle movements, muscle spasms
  • Abstract thinking- when asked to interpret a proverb

FYI- Geriatric Medication Tips

Drugs: Higher risk of adverse effects (avoid with frail/elderly)

  • Antihistamines: diphenhydramine (Benadryl) is the most sedating antihistamine. Avoid antihistamines, if possible. Claritin less likely to cause sedation.
  • Tricyclic antidepressants: amitriptyline (Elavil) is the most sedating. Also causes confusion, delirium, hallucinations. All tricyclic antidepressants (TCAs) cause sedation. Given at bedtime.
  • Benzodiazepines: confusion, dizziness, ataxia resulting in falls, other accidents.\
  • Hypnotics: avoid long-acting (e.g., Halcion). Prefer shorter duration (e.g., Ambien).
  • Narcotics: start at lower doses; lasts longer in the elderly.
  • Propranolol, others (beta blockers): depression, fatigue, slowing, hypotension.
  • Digoxin, warfarin sodium: high doses cause visual changes, fatigue, depression.
  • Muscle relaxants (Soma, Skelaxin, Norflex): drowsiness, confusion, delirium.
  • High anticholinergic effects (antihistamines, antipsychotics, atropine, Ditropan, etc.).
  • Atypical antipsychotics: Black Box Warning of the high risk of mortality in elderly (from long- term care facilities) with dementia who are treated with atypical antipsychotics