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PHYSIOLOGICAL BASIS FOR THE CARE OF THE ELDERLY CLIENTNeurological system

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Scenario….• J.H.’s granddaughter returns 3 months after her last visit.

J.H. is more physically active now and her joint pain has improved.

• J.H. has on 2 occasions driven on errands and forgotten how to return home.

• The granddaughter states J.H. no longer complains of her joints hurting but she is even more mean and still won’t listen to her.

• The granddaughter is exhausted and is afraid to leave J.H. alone. She has had to miss work several times.

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Age related changes• Decreased number of neurons• Decrease in brain size• Decreased brain blood flow• Decrease in short term memory• Increased pain threshold• Increased reaction time• Decreased sensation to touch, pain

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Assessing mental status is complex• Cognitive ability• Level of consciousness• Appearance, behavior• Speech and language• Mood• Affect• Perception• Thought content• Insight • Judgment

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Common neurologic disorders of the elderly

Dementia Depression Delirium

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Delirium vs dementia• Delirium

• Temporary mental confusion, agitation• Disorientation • Fluctuating consciousness• Delusions• Sleep-wake disturbances• May be caused by fever, intoxication, shock

• Dementia• Deterioration of intellectual capacities• A syndrome, chronic and terminal• Caused by organic disease or brain disorder

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Depression • Apathy is common in depression, not necessarily in

dementia• Depression is common in dementia• Geriatric Depression Scale is invaluable!

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Geriatric depression scale• > 5 suggestive

of depression• > 10 depression

very likely

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THE SYNDROME OF DEMENTIA• Compromised ability to function at work or home• Decline in usual abilities• Not explained by other causes• Verified by history and cognitive

assessment• Includes at least 2 of the following:

• Inability to acquire new information• Impaired ability to manage complex tasks• Inability to recognize• Impaired language function• Changes in personality

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Types of dementia

Dementia

Alzheimer’s

Vascular

Lewy Body (Parkinson’s)

Fronto-temporal

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Comparison of types of dementia• Alzheimer’s

• Most common form of dementia• Causes include genetics, environment,

lifestyle

• Vascular • Second most common form• Caused by cardiovascular factors

• Lewy body• Protein bodies present in the brain• Can occur late in Parkinson’s disease

• Frontotemporal • Personality change• Frontal brain atrophy occurring in mid-50s

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Mild cognitive impairment vs dementia• Transition between normal aging and dementia• Memory problems without deficits in ADLs• Associated with increased

risk of death• If found in conjunction with

depression, risk of converting

to AD is greater

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Alzheimer’s disease• Before the 1950s, misidentified as alcoholism or

some other presentation• From ages 65 to 74, risk is about 2%• Risk increases with age (42% at age 85)• Risk increases with family history of AD• Medical risks

• Head trauma• Diabetes• Frailty• High cholesterol• Obesity• Low physical activity• Low vitamin D• Clinical depression

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Incidence of Alzheimer’s disease• Twice as common in women• Common in people whose

mothers had the disease

(the “maternal effect”)• Age is greatest risk factor• Associated with low

education level

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Cultural considerations• Symptoms begin on average 7 years earlier in US Latinos

than in non-Latino whites.• Affects African Americans 3 times more than European

Americans.• Japanese American men have higher prevalence that

Japanese men living in Japan.

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Diagnosis of Alzheimer’s disease• No definitive diagnostic test• Physical examination• Formal mental status exam• Onset after age 40, most after age 65• Postmortem examination of brain tissue is only way to

confirm diagnosis

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Prognosis of Alzheimer’s disease• Cognitive decline is inevitable• Average survival time from time of diagnosis is 7-8 years• May last more than 20 years

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Signs and symptoms of Alzheimer’s• Brain changes may begin up to 20 years before

symptoms are obvious• Loss of short term memory is often the first sign• Disease progresses gradually but may plateau for long

periods of time• Distinct symptoms for early, intermediate and late stages.

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Stage 1 dementia (mild)• Memory difficulties• Spatial disorientation Learning and retaining new

information becomes difficult• Language difficulties (word finding)• Mood swings—hostility, irritability, agitation• Personality changes• Progressive difficulty

with activities of normal living• Abstract thinking, insight,

judgment impaired

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Tasks at time of diagnosis• Preparation for progressive decline• Establishing DPAHC• Establish interventions to address

functional impairment

Tasks apply to both family and patient!

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Stage 2 dementia (moderate)• Aphasia• Apraxia• Confusion, inability to initiate meaningful activities• Agitation• Insomnia • Remote memory reduced, but not lost• May require help with basic ADLs• Personality changes may progress• Behavior problems• Sense of time and place is lost; wandering • Risk of falls, accidents• Disorganized sleep patterns

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Stage 3 dementia (severe)• Resistiveness to care• Incontinence• Eating difficulties• Motor impairment• Cannot walk, feed self, other ADLs• Unable to swallow• Recent and remote memory lost

• Problems include…• Immobility• Pressure ulcers• Nutrition

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Mental changes to anticipate• Changes create increasingly

difficult behavior….• Depression• Anxiety• Hallucinations • Paranoia due to

• Confusion• Inherent personality• Unique coexisting mental disorder• Brain physiological changes

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Goals of treatment of dementia

Treatment is focused on 4 areas:• Maintain physical/functional abilities• Environmental measures• Drugs• Caregiver assistance

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Patient safety• Evaluate home for safety• Signal monitoring systems for wandering• Unplug the stove, remove the car, confiscate the keys• Install alarms?• Ultimately requires assistance or change

in environment• Patient care goals:

• Prevent accidents• Manage behavior disorders• Plan for change as disease progresses• Transfer of responsibility…

• From patient to family…• From family to others?

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Drugs for Alzheimer’s disease• Limit drugs with CNS activity• Sedation worsens dementia• Antipsychotics may be used to control behavior disorders• Signs of depression treated with anti-depressants

(preferably SSRIs—Paxil, Zoloft, Lexapro)• Mild to moderate disease—cholinesterase inhibitors

(Donezepil [Aricept], Rivastigmine [Exelon])• Moderate to severe disease—

Memantine (Namenda)

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Specific difficult behaviors• Resistiveness• Repetitiveness • Sexual inappropriateness• Aggression• Food refusal

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Non-medication management of resistiveness

• Task too difficult—break into small steps• Caregiver impatience—allow ample time• Can’t follow directions—simplify request• Modesty causes embarrassment—respect privacy• Fear of task—reassure,

comfort, distract with music

or conversation

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Non-medication management of food refusal

• Make meal times a measure of the day’s progression• Create an inviolable routine• Incorporate patient preferences• Eliminate any source of discomfort• Maximize dense calories• Use finger foods• Avoid dry foods• Keep patient upright

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Non-medication management of inappropriate sexual behavior• Misinterpreting caregiver interaction—no mixed sexual

messages• Decreased judgment, lack of social awareness—do not

overreact, confront• Uncomfortable—check for irritants• Need for attention—increase basic need for

touch and warmth, offer soothing objects• Self-stimulating—offer privacy,

remove from inappropriate place

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Antidisrobing clothing

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Factors in caregiver burdenScreaming Repetitive questions

Verbal and physical Reckless or careless aggression behavior

Personality clashes Not sleeping at night

Wandering Suspiciousness

Accusations Sexual actions

Depression Resistance

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Caregiver burden interventions• Design strategies for sharing responsibility• Emphasize importance of caring for oneself• Establish priorities• Education regarding disease• Support groups• Caregiver respite

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Terminal stage of Alzheimer’s disease

• Bedridden• Dysphagia• Eventually mute• Completely dependent• Risk of undernutrition,

pneumonia, pressure ulcers• Eventual death usually from

infection

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Issues associated with terminal stage• Finding appropriate environment or facility• Address guilt associated with transfer• Important to discuss placement early on in process• Address four important concepts

• CPR • (should not be offered)

• Transfer to acute care facility • (not in patient’s interest)

• Insertion of feeding tube • (does not enhance quality of life)

• Treatment of infections • (does not promote comfort)

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Common neurologic disorders of the elderly: Parkinson’s disease

• Chronic, progressive neurologic disorder• Does not include cognitive impairment• Risk increases with age• More common in men, more often after 50s• Faint tremor in hand often 1st sign• Tremor decreases with purposeful

movement (tremor at rest vs intention

tremor)• Muscle weakness and rigidity• Characteristic gait• Related to loss of dopaminergic cells

in the midbrain

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Festinating gait

• From Latin festinare (to hurry)• The patient’s speed increases

in an unconscious effort to

"catch up" with a displaced

center of gravity• Patient has difficulty starting• Difficulty stopping after

starting

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Therapy for Parkinson’s disease• Directed at replacing dopamine• Levodopa is metabolic precursor of dopamine• Maintenance of function• Risk for falls is great

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Secondary Parkinson’s disease• Symptoms are similar to Parkinson’s disease• Caused by certain medicines

• Antipsychotics (haloperidol)• Metoclopramide• Phenothiazine medications

• May be caused by another illness• AIDS• Encephalitis• Meningitis• Stroke

• Confusion and memory loss may be more likely in secondary parkinsonism

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Common neurologic disorders of the elderly: cerebrovascular accident• High risk in patients with HTN, severe

arteriosclerosis, diabetes, gout, anemia, silent MIs, TIA, dehydration

• Most caused by partial or complete cerebral thrombosis

• Warning signs: • light-headedness• dizziness• headache• drop-attack• memory and behavior changes

• Can occur without warning

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Stroke risk factors• Prior stroke• Advanced age• Family history• Alcoholism• Male• Hypertension• Cigarette smoking• Hypercholesterolemia• Diabetes• Recreational drugs

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Common neurologic disorders of the elderly: transient ischemic attack

• Caused by any situation that reduces cerebral circulation: • Positioning• Anemia • Diuretics • Antihypertensives• Cigarette smoking

• Lasts from minutes to hours • Resolves within < 24 hours• Symptoms are the same as CVA

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Symptoms of TIA• Hemiparesis• Aphasia• Unilateral loss of vision• Diplopia• Vertigo• Nausea, vomiting• Dysphagia

• Dependent on site of ischemic area!

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Treatment of acute CVA

Ischemic stroke• Maintain blood flow to brain

• Aspirin • tPA

• Surgical intervention• Carotid endartrectomy• Angioplasty and stents

Hemorrhagic stroke• Stop bleeding• Surgical vessel repair

• Clipping• Coiling (promotes clot)• AVM removal

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Antithrombolytic therapy• Used for acute ischemic stroke (thrombus or embolus)• Blood pressure not decreased unless exceeds 220

systolic or 120 diastolic to promote perfusion of site• tPA (tissue plasminogen activator)—

• protein involved in breakdown of clots

• Most are not candidates for tPA; • Give ASA (81-325mg) within

24 to 48 hours

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Common neurologic disorders of the elderly: seizures• Obtain accurate patient history• Prevent injury

• Maintain airway• Suction equipment• Bite block• Prevent aspiration—side-lying position• Oxygen and IV access• Pad side rails

• Observe seizure and document progression of symptoms

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Observation during a seizureWHAT HAPPENED DURING THE EVENT • Alert or confused • Able to speak? Think? Remember?• Changes in seeing, hearing, smells, tastes, feelings? • Facial expression – staring, twitching, eye blinking or rolling, drooling• Changes in muscle tone or movements• Automatic, repeated movements – lipsmacking, chewing• Changes in color of skin, sweating, breathing• Loss of urine or bowel control

PART OF BODY INVOLVED – where started, spread

WHAT HAPPENED AFTER EVENT • Awareness of name, place, time• Memory for events

HOW LONG IT LASTED

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Formal evaluation• What is your nursing diagnosis for J.H.?• What is your desired outcome?• What are appropriate interventions

pertinent to your desired outcome?