Gero Exam 2

• Changes of aging associated with sleep patterns of older adults

  • Takes longer to fall asleep
  • Spend more time in bed – not actually sleeping
  • Total sleep time and sleep efficiency are decreased
  • Awakenings are frequent
  • Shift in and out of sleep stages
  • More time in Non rem 1 – drowsy but not sleeping
  • Less time in Non rem 3
  • Less time in REM sleep stage
  • Increased daytime sleepiness/need for naps
  • Circadian rhythm changes – sleepy earlier, wake up earlier
  • Abnormal breathing events increased
  • Increased frequency of leg movements
• 1.     Interventions to help an older adult improve sleep. a.     Bedroom restful and comfortable

  b.     Avoid naps

  c.      Get regular exercise

  d.     Avoid eating late in the day

  e.     Limit caffeine and alcohol late in the day

  f.      If can’t sleep, exit room then return when sleepy

  g.     Herbal therapy

  h.     Aromatherapy

  i.       Relaxation therapy

  j.       Prayer or other spiritual practices

  k.     Diphenhydramine (Tylenol PM) contraindicated

  l.       Barbiturates/CNS depressants

  m.   Non-barbiturate sedatives
• Bedroom restful and comfortable:

  Use only for sleep

  Comfortable bed, darkness, temperature
• a.     Avoid naps:If must nap, no longer than 30 minutes before 3 pm
• a.     Get regular exercise: None 4 hours before bedtime
• a.     Herbal therapy: Melatonin
• a.     Aromatherapy: Lavender
• a.     Relaxation therapy: Progressive relaxation and guided imargery
• Diphenhydramine (Tylenol PM) contraindicated in older adults due to anticholinergic side effects.  May have reverse effect.
• Barbiturates/CNS depressants – also not recommended due to the increased risk of adverse reactions
• Non-barbiturate sedatives – longer half life can extend sedation into the daytime.  Safety concerns
• Non-barbiturate sedatives: Only use when absolutely necessary and for short term use
• 1.     Consequences of untreated pain in an older adult.

  a.     Mood changes

  b.     Impaired cognition

  c.      Depression, anxiety, fear

  d.     Helplessness

  e.     Falls

  f.      Increased dependence

  g.     Functional impairment

  h.     Slowed rehabilitation

  i.       Caregiver strain

  j.       Sleep disturbance

  k.     Impaired cognition

  l.       Increased health care costs
• pharmacologic treatment of pain in older adults. 3 classifications of analgesics

  Non-opioid analgesics, Opiates, Adjuvant analgesics
• Non-opioid analgesics:   Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), aspirin
• Acetaminophen

  Effective and initial treatment

  Most common causes of pain (osteoarthritis)

  Use for persistent pain

   “Around the clock” (ATC) dosing

  Maximum dose - 3 gm/day

  Caution

  renal dysfunction

  hepatic dysfunction

   alcohol use
• nonsteroidal anti-inflammatory drugs (NSAIDS)

  Effective

  most common causes of inflammatory pain (rheumatoid arthritis)

  Ibuprofen and Naprosyn most common

  Higher risk for adverse events

  renal disorders

  gastric disorders (GI toxicity increases with age)

  cardiac disorders

  Always use with caution!!!

  COX-2 inhibitors, such as Celecoxib (Celebrex), appear to be as effective as NSAIDS with fewer GI effects
• Opiates

  Short trial is recommended first

      Age-related changes

  Greater analgesic effect

  Higher peak

  Longer duration

  Adverse effects (often transient)

  Sedation

  Altered mental status

  Impaired cognition

  Convert to longer-acting opioids after trial complete

  Medications for breakthrough pain

  Titrate long-acting medications accordingly
• Adjuvant analgesics

  Most effective for neuropathic pain management

  Include:

  Antidepressants (SSRIs)

  Anticonvulsants - Gabapentin

  Steroids

  Topical analgesics

  Interfere with neurotransmitters

  Interfere with perception of pain

  Usually given in combination with a non-opioid or opioid analgesic
• Ladder:

  
• Pain assessment tools especially for a client diagnosed with dementia. Numeric Rating Scale (NRS)

  Verbal Descriptor Scale (VDS)

  Pain Thermometer

  Faces Pain Scale (FPS)

  Consider visual changes

  Non-verbal: Look at behavior changes (confusion, agitation, aggression, and passivity)
• Pain assessment in impaired adults: Pain Assessment in Advanced Dementia Scale (PAINAD)

  
• Pain assessment in impaired adults: Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC)

  
• Rheumatoid Arthritis

  Autoimmune disease

  Chronic

  Systemic manifestations

  Inflammation of the synovium (joint lining)

  Remissions and exacerbations

  Destruction - joint cartilage and  bone

  Unknown cause: Heredity, Environment, Hormonal factors
• Rheumatoid arthriits: Clinical Manifestations - Joints

  Wrist, knee, ankle, hand

  Erythema

  Pain

  Swelling

  Stiffness

  Joint deformities
• Rheumatoid arthritis

  Clinical Manifestations – Systemic

  Fatigue

  Malaise

  Weakness

  Fever
• Rheumatoid arthritis: Labs

  Increased rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR)
• Impact of RA on older adults

  Chronic pain 

  Joint deformities

  Decreased mobility

  Decreased performance of ADLs
• Osteoarthritis

  Slow progressive non inflammatory disease

  Also know as Degenerative Joint Disease (DJD)
• Osteo Changes

  Cartilage damage

  Scar tissue and calcification

  Joint degeneration
• Osteo Risk factors

  Trauma

  Genetics

  Obesity

  Age
• Osteo Clinical manifestation

  Joint stiffness

  Joint pain with activity

  Pain relieved with rest
• Osteo Complications

  Decreased function of affected joints
• Osteo Diagnosis

  No lab test

  Bone scan, CT or MRI  detect early joint changes

  X-rays confirm disease and used for staging joint damage
• Osteo treatment Low impact exercise program

  Balance activity with rest

  Weight loss

  Vitamin supplements

  Assistive devices

  Decrease pressure on weight bearing joints

  Improve balance

  Improve independent function
• Gout

  Increased uric acid (Uric Acid –>6mg/dL)

  Cytokine-mediated inflammatory response

  Acute or chronic

  Single or multiple episodes

  Unpredictable
• Gout Risk factors

  Age

  Gender -male

  Genetics

  Excessive alcohol consumption

  Lead toxicity

  High purine diet
• Gout Clinical manifestations

   Joint: bright red, hot, very painful

  Fever

  Malaise

  Chills

  Tophi
• Common consequences of falling in the older adult population Moderate to severe injuries –20 to 30% older adults. Major consequences: hip fracutre, TBI, fallophobia
• Hip fractures

  Falls – cause more than 95% of hip fractures in older adults

  Second leading cause of hospitalization for older adults

  Osteoporosis most common related factor

  Negative outcomes: Mortality, Mobility limitations, Chronic pain, Depression

  Only 50-60% recover prefracture ambulation abilities in first year post fracture

  Older adults have a 5-8x increased risk of mortality during the first 3 months following the fracture