Download NR 601 FINAL Study Guide and more Study Guides, Projects, Research Nursing in PDF only on Docsity!
NR601 FINAL EXAM
STUDY GUIDE
Week 5: Glucose metabolism disorders
Types of DM
- Type 1- severe insulin deficiency resulting in reduction or absence of functioning beta cells in the pancreatic islets of Langerhans. This leads to hyperglycemia due to altered metabolism of lipids, carbs, and proteins. Initial s/s of hyperglycemia. Subjective findings- polyuria, polydipsia, nocturnal enuresis and polyphagia with paradoxical weight loss, visual changes and fatigue. Objective-dehydration(poor skin turgor and dry mucous), wt loss despite normal/increase appetite, reduction in muscle mass. DKA-fatigue, cramping, abnormal breathing
- Type 2- Type 2 DM is characterized by the abnormal secretion of insulin, resistance to the action of insulin in the target tissues, and/or an inadequate response at the level of the insulin receptor. A patient may, however, present with pruritus, fatigue, neuropathic complaints such as numbness and tingling, or blurred vision.
- Prediabetic- fasting glucose consistently elevated above the normal range but less than 100-125. Impaired glucose tolerance (IGT) state of hyperglycemia where 2 hr post glucose load glycemic level is 140-
Diagnostic criteria- there are 4 lab-based criteria to confirm DM: A1C, random plasma glucose, fasting plasma glucose, and 2-hr post load plasma glucose
- AIC of 6.5 or higher=diabetes - Random plasma glucose level of 200 WITH classic symptoms of hyperglycemia or a hyperglycemic crisis - Fasting plasma glucose level of 126 or higher on TWO occasions(fasting is defined as no caloric intake for at least 8 hrs - 2-hour post load plasma glucose level of 200 or higher during an OGTT, following consumption of a glucose load containing the equivalent of 75g of anhydrous glucose dissolved in water (OGTT is also used to screen for diabetes during pregnancy)
*** In the absence of unequivocal hyperglycemia results should be confirmed by repeat testing on a new blood sample without delay, preferably using the same type of test.***
*- All above- but confirmation of type 2 diabetes mellitus requires: two fasting blood glucoses ≥126 mg/dL or two random blood glucoses ≥200 mg/dL. - You do not screen for type 1 diabetes but you do screen for type 2 if an individual is overweight or obese, regardless of age, and for all adults aged 45 years and older. Tests should be repeated at a minimum of 3 year intervals
Initial Treatment-
Type 1- FIRST LINE: INSULIN. The initial goal of treatment for type 1 DM is to normalize the elevated blood glucose level. This is best accomplished by intensive insulin regimens to achieve
the following goals: plasma glucose levels of 80 to 130 mg/dL before meals, peak postprandial
SINGLE-DOSE THERAPY
Single Injection
- Intermediate or long-acting insulin with or without regular insulin in the
morning or Intermediate or long-acting insulin at bedtime
- Recommend at a minimum SMBG in the morning and at bedtime
CONVENTIONAL SPLIT-DOSE THERAPY
Two Injections
- Mixture of NPH and regular insulin in the morning and evening
- Recommend at a minimum SMBG before each dosing and at bedtime
INTENSIVE INSULIN THERAPY
Medication Side Effects
-Type 1:
Hypoglycemia is a common occurrence in patients with type 1 DM and occurs for a variety of reasons: excessive exogenous insulin, missed meals or inadequate food intake, excessive exercise, alcohol ingestion, drug interactions, or decreases in liver or kidney function. Signs and symptoms: diaphoresis, tachycardia, hunger, shakiness, altered mentation (ranging from an inability to concentrate to frank coma), slurred speech, and seizures. The ADA classifies hypoglycemia as a plasma glucose level of < 54 as serious, clinically significant hypoglycemia. A blood glucose level of 70 is considered a threshold level that requires intervention. Examples of appropriate foods: #1 choice: pure glucose, ½ cup fruit juice, 6oz regular soda (not diet or sugarless), 1 cup milk, or glucose tabs. Candy is only a last resort. Recheck glucose 15 minutes after treatment. Additional carbs can be given if glucose is still less than 70
-Type 2:
Metformin can cause: hypoglycemia esp in older adults, adverse reactions such as GI disturbances and metallic taste, and is contraindicated in renal disease so assess renal function prior to prescribing.
- Metformin also has a boxed warning in its FDA-approved prescribing information for lactic acidosis, although this side effect is very rare. Metformin should be discontinued 24 to 48 hours before diagnostic and surgical procedures due to the risk of decreased kidney function, and its administration should not be resumed for at least 6 hours after these procedures or until the patient is adequately hydrated. Initial dosing is 500 mg once a day with breakfast or dinner for 1 week, then twice daily with breakfast and dinner. Several weeks of therapy may be needed to achieve maximum effects of the given dose. Common adverse reactions include diarrhea, nausea, anorexia, and abdominal discomfort, which usually resolve with a gradual increase of dosage. Metformin has been shown to cause decreased vitamin B 12 absorption, and patients on long-term metformin therapy should undergo periodic testing for B 12 deficiency, especially if the patient complains of peripheral neuropathy. At the maximum dose, the monthly cost of metformin in the United States is approximately $4 on many generic formularies. Metformin is currently found in 20 combination formulations with other medications.
For other noninsulin agent adverse reactions see pg 929 Dunphy book
Treatment goals for older adults (Kennedy table 14-2).
- Healthy (few chronic illnesses) A1C <7.5, Fasting glucose 90-130, Bedtime 90-150, BP < 140/90, for lipids use statin unless contraindicated or not tolerated
- Complex (multiple chronic illnesses, ADL impairment, cognitive impairment) A1C <8.0%, fasting 90-150, bedtime 100-180, BP same as above, for lipids use statin unless contraindicated or not tolerated
- Very complex (LTC or end stage illnesses) A1C <8.5%, fasting 100-180, bedtime 110-200, BP <150/90, consider likelihood of benefit with statin (secondary prevention more so than primary)
Hbg A1C goals based on complications
- An A1C value of less than 7% indicates a strong control however, a value of less than 6.5% has been shown to significantly decrease the occurrence of complications, provided this can be achieved without hypoglycemia or other adverse effects
- Maintaining an A1C of less than 6.0% during pregnancy is recommended to prevent adverse fetal outcomes, although this goal increases the risk of hypoglycemia
Weight loss recommendation : Lifestyle modifications of weight loss and exercise are particularly important in lowering Hb A1c. exercise of even a modest nature can be beneficial in decreasing insulin resistance.
- modest weight loss of 5% can improve glycemic control
Risk factors -
Dm Type 1
- Autoimmune,
- Genetics (chromosome 6p)
- 1-5% of monogenic forms Diabetes Mellitus Type 2
- Family history (first-degree relative)
- Body mass index >25 kg/m^2 (lower for Asian Americans)
- Age >45 years
- Impaired fasting glucose or A1C >5.7%
- History of gestational diabetes
- Hypertension (> 140/90 mm Hg or on antihypertensive therapy)
- Hyperlipidemia (high-density lipoprotein <35 mg/dL, triglycerides >250 mg/dL) - Women with polycystic ovarian syndrome Race/Ethnicity
Three Injections
- NPH and regular insulin in the morning; regular insulin at dinner; NPH insulin at bedtime
- Monitor for increased risk of hypoglycemic episodes
Four Injections
- Regular or lispro insulin before meals and long-acting insulin to maintain basal insulin levels
- Monitor for increased risk of hypoglycemic episodes
gallbladder, and leukemia are also associated with obesity. Obese patients are also more likely to develop obstructive sleep apnea, gallbladder disease, fatty liver disease, and osteoarthritis. They will often have symptomatic varicose veins or GERD.
- Obesity is defined as a BMI >30 with morbid obesity as a BMI >40. Overweight is defined as a BMI of 25 to 29. The CDC provides a BMI calculator on their Healthy Weight Web site (CDC, 2015b).
BMI DEFINITION
<18.5 Underweight
18.5–24.9 Normal
25.0–29.9 Overweight
30.0–34.9 Class I obesity
35.0–39.9 Class II obesity
>40.0 Class III extreme obesity
Week 6:
Urology and aging
UTI
- Urethritis and cystitis usually occur together - Infections can be acute, chronic, recurrent, complicated, or uncomplicated. - UTIs become chronic because of obstructions, antibiotic-resistant bacteria, or the presence of multiple strains of bacteria that are not susceptible to the antibiotic therapy prescribed. - A complicated UTI is either an acute or chronic infection that is accompanied by factors that predispose a patient to the infection or make treatment more difficult such as instrumentation (ie indwelling, suprapubic, or intermittent cath), underlying chronic disease, systemic symptoms, or pregnancy.
Risk factors- Predisposing factors to the development of cystitis in older adults include indwelling catheters, urethral or condom catheters, incontinence (urinary and fecal), cognitive impairment, neurological conditions that impair bladder emptying, and diabetes (high pH=more alkaline), which can lead to neurogenic bladder. Poor hygiene, unprotected anal intercourse, sexual intercourse, immunosuppression, functional disability, sickle cell disease, prior antibiotic therapy, genetic predisposition, and functional or structural genitourinary tract abnormalities (including urethral strictures, uterine or bladder prolapse, ureteral weakness, and vesicoureteral reflux or renal calculi)
Gender:
▪ UTI rarely occurs in men younger than 50yo unless caused by urinary caths, anatomical abnormalities, of urinary tract, unprotected anal intercourse, or vaginal intercourse with a woman who has a bacterial infection. ▪ Cystitis is rare in men because the increased length and drier environment around the urethra contribute to less frequent bacterial colonization. In addition, prostatic fluid has inherent antibacterial prosperities. Thus, when UTI does occur, it is often associated with abnormal urethral anatomy or inadequate treatment of prostatitis ▪ - Men have a 20% incidence of UTI, with lifetime prevalence of 1%. After age 65 years, the rate of cystitis in men significantly increases, but is still approximately one-half that of. ▪ Incidence in postmenopausal women can range from 0.07/women/year to 0.13/women/year in women greater than 85 years old with great degrees in prevalence. ▪ -Community-dwelling men 70 years of age and older have a prevalence rate of ASB from 3.6% to 19%, whereas their institutionalized counterparts have a prevalence rate from 15% to 40% ▪ -Community-dwelling women 70 years of age and older have a prevalence rate of ASB from 10.8% to 16%, whereas their institutionalized counterparts have
Patho & Common bacteria
- Cystitis is a pathogenic invasion of the wall of the bladder, usually resulting from an ascending infection via the urethra, of bowel flora organisms from the perineum - The most common organism in adults of all ages is E. coli, which transcends across community dwelling and long-term care residing older adults. In women, approx. 80-90% of cases of uncomplicated UTI are a result of E.Coli. - The second most common cause (5-20%) of uncomplicated bacterial infections=Staphylococcus saprophyticus - Other less common bacteria but more prevalent in complicated UTI’s: Proteus mirabilis, Klebsiella, Enterobacter, Serratia, and Pseudomonas
Diagnostic Criteria
- Diagnosis of lower UTI is made based on the subjective complaints of the patient and a clean- catch midstream urine sample showing the presence of bacteria, especially if more than 100, organisms/mL of the same morphology are present in a sample from a female patient. - UTI is currently defined as a urine sample with greater than 100 organisms/mL in the presence of characteristic clinical symptoms. - Although urine culture is considered the gold standard with the greatest sensitivity for lab confirmation of URI, urinalysis with microscopy is also helpful and provides rapid results. UA typically indicates pyuria (>10 neutrophils per hpf on microscopic exam) and often the presence of RBC. Hematuria is common in UTI but not with urethritis or vaginitis, however blood in the urine is not a marker of complicated infection. - Bacteriuria and pyuria are the main laboratory clinical manifestations of cystitis - older adult, the presence of localized genitourinary symptoms (see Signal Symptoms) and pyuria on urinalysis are required for diagnosis - The presence of greater than 10^ 5 colony-forming units/mL of a single bacterium in a culture of freshly voided urine is generally considered to be a significant bacteriuria
Treatment
o Tx: Assess for cause ie. medication usage and fluid intake. Double voiding to empty residual urine from bladder
- Functional: the inability to hold urine due to reasons other than neurological and lower urinary tract dysfunction including delirium, psychiatric disorders, UTI, impaired mobility o Tx: treat underlying cause
Risk factors: pelvic muscle weakness, multiparity, estrogen depletion, pelvic organ prolapse, diabetes, stroke, multiple sclerosis, Parkinson’ s disease, spinal cord injury, benign prostatic hyperplasia, UTI, fecal impaction, poor fluid intake or excessive fluid intake, smoking, cognitive impairment, depression, immobility or impaired mobility, environmental barriers, impaired dexterity, visual impairment, obesity, and high-impact physical activities. Incontinence can be a side effect of many medications, including cholinergics, anticholinergics, diuretics, antispasmodics, opiates, hypnotics, calcium channel blockers, ACE inhibitors, alcohol, and caffeine.
Gender: UI is twice as prevalent in women as in men, and the incidence increases with age, with institutionalized individuals, and those who have at least one deficit in ADLs ( Wagg et al., 2015 ; da Silva et al., 2012 ). Women are at higher risk for stress incontinence; however, overflow incontinence is more prevalent in men as a result of hyperplasia of the prostate gland.
Pathophysiology: The causes and management of UI are multifactorial, depending on the type of incontinence and also the severity and impact on quality of life for the individual. Anatomical changes, factors related to the individual ’ s medical history, lifestyle, and acute and chronic illnesses, in addition to medications, can result in incontinence that can be either reversible or a permanent condition. Cognitive as well as chronic mental illness, depression, and functional barriers to continence can also affect an individual’ s ability to maintain urinary continence
Dx and when to treat: urinalysis to rule out infection and renal abnormalities. presence of nitrites and leukocyte esterase in the urinalysis is usually indicative of an infectious process. culture and sensitivity should be ordered to ensure appropriate antimicrobial therapy.
Incontinence Mnemonic:
- DRIP ■ Delirium ■ Restricted mobility ■ Infection ■ Pharmaceuticals, polyuria - Mnemonic: DIAPERS ■ Delirium ■ Infection, impaction, inflammation ■ Atrophic vaginitis ■ Psychological, pharmaceuticals, psychotropics ■ Endocrine problem ■ Restricted mobility ■ Stoolimpaction
Causes of hematuria and proteinuria:
- Proteinuria: glomerular disease
- Hematuria: may indicate a tumor
- Hematuria may indicate a number of differential diagnoses, including infection, obstruction, kidney stones, or malignancy. Proteinuria is revealing for renal disease and is often associated with poorly controlled diabetes.
Urologic changes in male/female:
- Incontinence is common in older men because of their enlarging prostate
- Age-related changes that may affect urological functioning are decreased bladder capacity, increased postvoid residual urine volume (>50mL), increased disinhibition of bladder contractions (overactive bladder), increased nocturnal sodium and fluid excretion (nocturia), urinary overflow phenomena resulting from increased urethral resistance in men related to BPH, and weakness of the pelvic floor in women. Postmenopausal estrogen deficiency in women can result in decreased competence of the internal and external sphincters via atrophy of the urethral mucosa epithelium resulting in atrophic urethritis, loss of compliance, and a diminished urethral mucosal seal. It is important to note that normal aging does NOT cause UI.
Sexuality and aging
STIs/Age related changes:
- Assumptions regarding lack of sexual expression in the healthy older adult are unfounded. With the possibility of pregnancy eliminated, many mature adults feel less restraint. As a result of divorce or widowhood, they may seek satisfaction with new partners yet lack the knowledge to protect themselves from sexually transmitted diseases, especially HIV. More than 42% of those living with HIV in the United States in 2013 were in people more than 50 years old; 39% of deaths from HIV in 2014 were in adults older than 55yo. Older adults need to be taught methods for safe sex with use of a barrier to avoid sexually transmitted diseases, including HIV and hepatitis B. Using the patient’s sexual history, explore patient needs, preferences, and medical or psychological obstacles to sexual expression. This exploration facilitates counseling and interventions to promote healthy sexual behavior.
- Male microabrasion in outer penis shaft serve as entry point for STI
- Susceptibility is also influenced by aging and the presence of existing infection
- Female pH change can disrupt the natural balance of flora and predispose the reproductive track to infection
- Older women are prone to infection secondary to drying and thinning of the vaginal and vulvar tissue
- Education methods of safe sex with the use of barriers to avoid STI (esp HIV and Hep B)
- More than 42% living with HIV are over 50yo, 39% of deaths from HIV 55yo+
GSM: genitourinary syndrome of menopause
- GSM incorporates VVA (vulvovaginal atrophy aka atrophic vaginitis). VVA really just describes estrogen deficiency changes of the vulva and vagina but GSM is a whole syndrome that involves symptoms of the vagina, the urinary tract, and sexual symptoms.
- Signs and symptoms - main symptoms: pain with intercourse, vaginal dryness, postmenopausal o GSM is the #1 cause of discomfort with intercourse after menopause o All symptoms: vaginal dryness, dysuria, vulvar and vaginal itching, urinary frequency, blood-tinged vaginal discharge, dyspareunia, decreased vaginal secretions ▪ Complaints of urinary frequency, urgency, and stress incontinence are common o On exam: pale, dry, nonrugated vaginal walls with patches of erythema or petechiae or both. The vaginal canal is short and narrow. A watery, white vaginal discharge without foul odor may be found. Estrogen deficiency can lead to loss of uterine support and subsequent uterine descensus. The exam may also reveal sparse vulvar hair, decreased
- Perimenopause refers to the time period before menopause when hormonal, physical,
and emotional changes occur and fertility begins to decline.
- The perimenopause period (which is 2-8 years before and 1 year after the final
menstrual period (FMP) is characterized by waxing and waning of ovarian function (both
ovulatory and anovulatory (estrogen-only) menstrual cycles have unpredictable duration
and intensity) extended periods of estrogen deficiency, and heightened FSH and LH
secretion with occasional follicular development and estradiol production. Estrogen
feedback begins to decline to the hypothalamic-=pituitary axis. Failure of corpus luteum
cysts after ovulation leads to a decrease in progesterone and increased exposure to
unopposed estrogen=abnormal uterine bleeding and endometrial hyperplasia
o Factors that contribute to irregularities and cessation of menses
o The average at menopause has remained remarkably constant since ancient
times however, several factors are known to lower the age at menopause:
smoking (decreases by 2 years), nulliparity, menstrual regularity and a shorter
cycle length, a family hx of early menopause, increased galactose intake,
concurrent type 1 DM, and certain genetic variants in the estrogen receptor and
galactose-1-phosphate uridyl transferase gene.
o (Menopause occurring past 55yo is defined as late menopause-(avg
age=51.5yo) )
Symptom Management
TX: * symptom management*
- Hot flashes (vasomotor) : fans, lowering room temp, dressing in layers, avoiding trigger
(stress, caffeine, ETOH). Women with high BMIs experience more hot flashes so weight
loss and regular exercise can be helpful. Physically active women have 50% fewer hot
flashes than their sedentary counterparts. Regular aerobic exercise (although it may
initially precipitate perspiration and hot flashes, these symptoms will ease as physical
conditioning improves). Diet: low fat, high in complex carbs and fiber, and high
antioxidants (fruits and vegetables) may be beneficial.
- Pharmacology for hot flashes: SSRIs and SNRIs. Menopausal hormone therapy (NO hx of
breast CA and low risk of CAD). Clonidine can be given orally or transdermally to relieve
hot flashes but can cause dry mouth, drowsiness, and hypotension.
- New drugs: Tissue selective estrogen complexes: treats vasomotor symptoms AND
osteoporosis: Duavee combines: SERM(bazedoxifene 20mg) with estrogen 0.45mg.
- Alternative options: cognitive behavioral therapy, hypnosis, acupuncture, and oral
supplements: isoflavonoid phytoestrogens (are similar to estradiol), soy products (have
phytoestrogens) like tofu and soy milk. It should be noted however, that the use of soy-
based products is controversial because of their unknown effects on estrogen receptors
located in breast tissue. Due to this, they should be avoided by women with breast,
ovarian, or uterine cancer, endometriosis, and uterine fibroids, black cohosh
- Emotional symptoms : many women experience depression, irritability, and anxiety.
- Pharmacological: SSRIs (paroxetine or venlafaxine) may relieve hot flashes as well as
hormonal therapy
- Nonpharmacologic: regular aerobic exercise improves cognitive function, enhances
mood, and promotes daytime alertness and nocturnal sleepiness. Recent studies have
shown that a brisk daily walk enhances wellness and promotes a sense of well-being
- Hormone Therapy (HT): useful for prevention of osteoporosis, relief of vasomotor
symptoms, and the treatment of vulvovaginal atrophy associated with menopause. HT is
the most effective tx for vasomotor symptoms and genitourinary symptoms of
menopause. There is an increased risk of heart disease, stroke, venous
thromboembolism, and breast cancer with the use of HT. HT is contraindicated in pts
with hormone dependent cancers, such as breast, endometrial, and ovarian cancer, and
undiagnosed vaginal bleeding. Patients with liver disease, active thrombosis, or history
or stroke should not take estrogen, and progestin should be used with caution.
Pregnancy is an ABSOLUTE contraindication to HT. Migraine headache is a relative
contraindication to HT.
o Estrogen-only therapy (ET) is used in women who do not have a uterus or are
treating genitourinary symptoms with low-dose topical preparations.
o Estrogen plus progestin therapy (EPT) is used in women who HAVE a uterus to
prevent endometrial hyperplasia.
Erectile Dysfunction
Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance. ED can also manifest as a lack of sexual desire or an inability to ejaculate. ED can result from many causes, including physiological, psychological, endocrinological, vascular, and neurologic etiologies. It is characterized as the inability to achieve an erection sufficient for intercourse for at least 3 months. In a broader sense, ED encompasses problems with arousal, libido, orgasm, sensation, and relationships
Diagnosis :
- Initially, lab tests to r/o various causes of ED should be done. These tests include: fasting blood sugar (r/o DM), lipid profile (r/o dyslipidemia), TSH, and testosterone level. If the testosterone level is below 300, serum prolactin level is warranted. - Several specialized tests can be done but usually only if the cause of the ED is not apparent following the standard testing regimen. Most useful: Inocturnal penile tumescence and rigidity (NPTR) test (physical ability to achieve erection) and color doppler sonography (asses vascular causes-integrity of arterial influx in the cavernous artery during erection by measuring the peak systolic blood flow velocity in this artery)
Treatment:
- If an organic cause cannot be found, these men will most likely benefit from behavioral based sex therapy - Nonpharmacologic interventions : vacuum constriction devices (takes 2 minutes, use pump, then put ring around base of penis to maintain erection), vasoactive therapy, penile prostheses (surgically implanted into the penis), and penile revascularization (mainly for men <45 yo whose impotence is mainly caused by severe pelvic trauma)
negligent act performed by a caregiver or another person that may cause harm or risk of harm to an older adult who is vulnerable.
Types of abuse:
- Physical abuse: causing physical pain or injuring a vulnerable elder
- Sexual abuse: sexual contact with a vulnerable elder without his or her consent
- Neglect: failing to provide food, shelter, health care, or protection for a vulnerable elder
- Exploitation: the taking of funds, property, or any assets of a vulnerable elder without legal consent and not for the benefit of the elder
- Emotional abuse: using verbal or nonverbal means to cause mental pain, anguish, or distress in an elder
- Abandonment: deserting the vulnerable elder once someone has assumed responsibility for that individual
- Self-neglect: the elder fails to perform the needed activities to protect his or her own health and safety (lacks food/utilities, refuses medications, hoards, lives in unsafe conditions, neglects his or her grooming/appearance, is unable to handle finances, is isolated, is disoriented, develops a dependence on drugs and/or alcohol)
Risk Factors:
- Common features of perpetrators committing elder abuse are partners or spouses living with the victim, history of alcohol or drug abuse, history of mental illness, history of unemployment, and being socially isolated. - The abused elder is more likely an older female who generally has a physical impairment and is in poor health. She may either live alone or with the abuser, or in a household with many members. - The abuser is generally found to be a male who has a history of past or current substance abuse, has mental health issues, is socially isolated, and has a history of past trouble with law enforcement - In 90% of cases (of abuse of adults aged 60 or older) the culprit is a family member. - These cases result in an increased risk of death for the vulnerable elder involved in the abuse Provider responsibilities in suspected abuse - If elder abuse is suspected, it is the health-care professional’s responsibility—and in most cases his or her legal obligation—to report this to either 911 or the state elder abuse hotline. Carefully collect information regarding the patient, using physical findings, patient’s functional abilities, testing results, and verbal information from the patient and his or her caregivers. Use the interdisciplinary team and speak with social workers, nursing staff, and others who may have interacted with the patient and caregiver. Document all findings, because they may be required to be presented in court later. Photograph suspicious injuries and measure or compare size of injury to familiar objects if ruler is not available. Be sure to f/u with case workers to determine outcome. It may take several reports before the true picture of abuse/neglect/etc can be investigated thoroughly and the elder moved to a safe environment.
Alzheimers most common form of dementia
Alzheimer’s disease (AD) is a progressive, neurodegenerative condition and the most common form of dementia. Progressive and irreversible cognitive decline; and an array of emotional and behavioral problems that result from cognitive decline. Impaired ability to learn new information or recall
previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function.
Distinguishing features-
- AD is characterized by an insidious onset; slow, progressive cognitive decline, and an array of emotional and behavioral problems that result from cognitive decline.
- The cognitive decline in AD manifests as an impaired ability to learn new information or recall previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function.
- Most cases are sporadic but there are rare familial forms of AD.
- Pathologic changes in the brains of pts with AD include neuritic plaques and neurofibrillary tangles
Subjective
- The patient usually presents with an initial complaint of memory problems. Often it is a family member who mentions this because patients with AD do not typically have insight into their memory difficulties.
- Recognition of cognitive difficulty on from the family is often due to a change in pattern (getting lost in familiar places, etc.)
- Eventually, the person loses the capacity to converse, walk, sit, or hold up the head.
- 80% of pts in nursing homes with AD have behavioral problems including: hostility, aggression, suspiciousness and paranoia, delusions, agitation, sundowning, incontinence, and inappropriate or impulsive sexual behavior
Objective
- Concern about cognitive decline expressed by the pt or family or changes in behavior or cognition should trigger an initial assessment for dementia. Cognitive assessment is central to diagnosis and management of dementias and should be performed on all patients.
- Routine social conversation and questions that can be answered automatically will not elicit symptoms of early AD. Instead, the provider should probe the pt’s memory further with questions such as “Do you remember what you did last Sunday? Or “What did you eat for breakfast this morning?”
- It is very important to maintain the pts dignity by examining the pt alone before interviewing others and inform the pt if others are being interviewed. And be alert to the possibility that family members are overexaggerating or minimizing symptoms depending on motives
- Signs and Symptoms for further assessment:
- Learning and memory: the pt becomes repetitive; in daily life the pt has trouble remembering recent conversations, events, appointments, or frequently misplaces objects.
- Handling complex tasks: trouble following complex set of tasks that require many steps ie. organizing bills or following a recipe
- Reasoning ability: pt unable to respond with a reasonable plan to challenges at work or home ie knowing what to do if the kitchen sink is plugged (shows poor judgement)
- Spatial relationships: pt has trouble remembering direction or driving to what was once familiar places, organizing objects around the house, unfamiliarity with familiar objects and places
Seizures, dysphagia Incontinence Groaning, moaning, grunting
Treatment:
- The principles of management of AD are directed toward slowing progression of the disease pharmacologically, protecting physical health, providing emotional support, and maintaining optimal function through prevention or reduction of excess disability - Maintaining as much normalcy as possible in relationships and everyday activities may be the most effective way to prevent the development of excess disability (defined as the difference between the observed function and the actual underlying impairment). - Both patient and family need assistance in understanding and coping with AD. - Support group attendance can be helpful but should be relevant to the stage of the disease. - Anxiety and depression should be recognized and treated vigorously. - Legal and financial planning and discussion of future care options should take place early in the disease course. - Attention to good nutrition, exercise, and preventive care (imms, dental, vision, hearing care) is important. - A comprehensive, multidimensional treatment plan for dementia includes biological, psychotherapeutic, social, family, and pharmacological interventions - Biological Interventions: Treat underlying medical disorders with medications, medical or surgical procedures, and ongoing evaluation and management as indicated. - Psychotherapeutic Interventions: Include behavioral management, reminiscence therapy, validation therapy, supportive psychotherapy, sensory integration, simulated presence therapy, reality orientation, skills training, recreation and art therapy, exercise, and aromatherapy. - Social Interventions: Include a functional and safety assessment, environmental modifi cations, assessment for abuse and neglect, provision of supervision and home health care, cleaning and meal services, assessment for appropriate level of care, fi nancial and estate planning, and legal provisions for power of attorney. - Family Interventions: Include caregiver education, training and support, respite care, and support groups. - Pharmacological : - Medications may improve cognitive function in mild to mod AD - At the time of dx: treat with cholinesterase inhibitors - Antipsychotics should be used with caution and reserved for pts who exhibit persistent disruptive or dangerous behavior - The failure to institute timely pharmacologic management in pts with AD may result in a more rapid need for institutionalization, an increase in aggression, further difficulty with ALDs, and further cognitive decline - Pharmacotherapy: Cholinesterase inhibitors (ChEIs) are the cornerstone of pharmacological therapy, with the aim to enhance or preserve cognitive and behavioral status. o Acetylcholine is important for the functioning of brain cells involved in memory, thought, and judgment, and brain levels are significantly decreased in those with AD.
o ChEIs inhibit breakdown of acetylcholine, which increases levels within the brain; this mechanism of action may improve or delay a decline in memory. ChEIs are effective in approximately 30% of patients and are not curative, preventive, or disease-reversing agents. o The choice of ChEI is based on the patient ’s clinical presentation and comorbid conditions. The three commonly prescribed ChEIs are donepezil, rivastigmine, and galantamine o ChEIs are nausea, vomiting, dyspepsia, anorexia, diarrhea, insomnia, vivid dreams, fatigue, increased urination, and cramps
- Another medication approved to treat dementia is memantine (Namenda), an N -methyl-D- aspartate (NMDA) receptor antagonist. Memantine assists in regulating high levels of glutamate in the brain, typically found in AD. o Common side effects include headache and constipation, and an uncommon side effect is confusion. o Memantine is excreted through the kidneys, and caution is advised in patients with renal impairment. o Combination therapy of memantine with a ChEI is a good strategy, because these medications work differently
Dementia- Dementia is a neurocognitive disorder. Dementia is defined as a clinical syndrome with global cognitive decline from a previous level of baseline function that interferes with activities of daily living (ADLs)
Distinguishing features:
- Cognitive changes include confusion, disorientation (as to time, place, person), and impaired short term memory. Personality changes psychiatric symptoms, problem behaviors, and changes in daily functioning. - Symptoms vary from person to person, and cognitive deficits cause significant impairment in social and occupational functioning, impaired ability to care for oneself, and altered behavioral patterns. - Signs/symptoms progress from memory loss to impaired executive functioning, language deficits, coordination, and perception with total or partial loss of the ability to recognize familiar people or objects. - Impairment in memory and learning (amnestic) is the typical presentation for AD and neuropsychiatric symptoms almost always occur. - Noncognitive Behavioral Symptoms of Dementia: Apathy, Agitation, aggression, Combativeness, Delusions, hallucinations, Depression, anxiety, Disinhibition/sexual behaviors, Emotional lability, Irritability, Wandering, Sleep disturbances, Sundowning - Onset is insidious, course long and progressive, duration months to years, awareness clear, alertness normal, orientation is impaired. thought process: poor, abstract thinking, diminished thoughts; poor judgment, difficulty with word finding/verbalizing. Perception frequent misperceptions. Psychomotor behavior normal, apraxia. Sleepwake cycle fragmented, disturbed and revered. Associated features affected superficial, labile, inapproatied, may be in attempt to conceal deficits. mental status test increase effort to find appropriate replies, frequent near miss answer, word searching - Common: Alzheimer’s disease (AD) is the most common cause of dementia Etiology:
