Common Risk Factors in the Elderly Falls Anxiety Urinary Incontinence Sleep Disorder Pressure Ulcer Dysphagia I.

FALLS

e.g. cognitive impairment, medcn/alcohol, impaired mobility, fall hx, acute or chronic illness, elimination problem, sensory defects, frailty, postural hypotension B. Extrinsic Factors - related to environmental hazards and challenges

Haloperidol (Haldol) is a drug chemically unrelated to benzodiazepines and is also popular for chemical restraint, without the potentially dangerous side effects of benzodiazepine drugs. However, Haloperidol has its own set of serious side effects, some of which can be fatal. II. ANXIETY Normal adaptive reaction to new situations or perceived threats &can manifest as tachycardia, palpitations, GIT disorders, insomnia and tachypnea

Eg. poor lighting, poor color distinction, unfamiliar envt, stairs, throw rugs, unsuitable footwear, restraints, side rails Interventions/Strategies for Fall Prevention

Notes: Anxiety is a generalized mood condition that can An event which results in a person unintentionally coming to rest on the ground or another lower level; not as a result of a major intrinsic factor or overwhelming hazard. Notes: Fractures are the most serious health consequence of a falls; falls that do not result in injury could result to fear of falling again w/c can lead to reduced mobility. 5. Restraint Use Falls among older adults are not a normal consequence of aging; rather, they are considered a geriatric syndrome most often due to discrete multifactorial and interacting, predisposing (intrinsic and extrinsic risks), and precipitating (dizziness, syncope) causes Risk factors for Falls: A. Intrinsic Factors - changes associated with aging and with disorders of physical functions needed to maintain balance. Eg. Physical Restraint - physical or mechanical device that involuntarily restrains a pt as a means of controlling physical activity. Example: waist or wrist restraint or geriatric chair Chemical Restraint - use of psychopharmacological drug for the purpose of discipline or convenience & not to treat medical symptoms; Drugs that are often used as chemical restraints include benzodiazephines (such as Lorazapem (Ativan), Midazolam (Versed), or Diazepam (Valium), 2. Evaluate gait and balance 3. Review medications Additionally, fear is related to the specific behaviors of 4. Develop a Fall Prevention Plan escape and avoidance, whereas anxiety is related to situations perceived as uncontrollable or unavoidable. Another view defines anxiety as "a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events",suggesting that it is a distinction between future vs. present dangers which divides anxiety and fear Example: a student may experience this during a class final exam or while performing a skill on a patient for the first time Interventions/Strategies for Anxiety care As such, it is distinguished from fear, which is an emotional response to a perceived threat. 1. Modify the environment often occur without an identifiable triggering stimulus.

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1. Decrease environmental stimuli 2. Stay with the patient

the pelvic floor muscles.; triggered by laughing, sneezing, coughing 2.Urge Incontinence - strong, abrupt desire to void and the

communicating that prevent them from reaching a toilet. A person with Alzheimer's Disease, for example, may not think well enough to plan a timely trip to a restroom. A person in a wheelchair may be blocked from getting to a toilet in time. Conditions such as these are often associated with age and account for some of the incontinence of elderly women and men in nursing homes.Disease or biology is not necessarily the cause of functional incontinence. For example, someone on a road trip may be

3. Make no demands, & do not ask the pt to make decisions

inability to inhibit leakage in time to reach the toilet. - is involuntary loss of urine occurring for no apparent

4. Speak slowly in a soft, calm voice III. Urinary Incontinence Involuntary leakage of urine. (UI) is any involuntary leakage of urine. It is a common and distressing problem, which may have a profound impact on quality of life. Urinary incontinence almost always results from an underlying treatable medical condition but is underreported to medical practitioners. There is also a related condition for known as fecal incontinence. Types of urinary incontinence 1.Stress Incontinence - refers to involuntary loss of urine during activities that increase intra - abdominal pressure. - no bladder distention or contraction; occurs due to hypermobility of the bladder neck and urethral sphincter defects. Weakness of the pelvic floor muscles leads to loss of support from the bladder neck and disrupts the normal pressure gradient between the bladder and urethra resulting to leakage of urine. also known as effort incontinence, is due essentially to insufficient strength of

reason while suddenly feeling the need or urge to urinate; sudden unexpected need to void 3.Overflow Incontinence - results from a weak or areflexic bladder, neurologic condition such as DM spinal cord injury below T10-11 or obstruction of the bladder outlet or urethra. Sometimes people find that they cannot stop their bladders from constantly dribbling or continuing to dribble for some time after they have passed urine. It is as if their bladders were constantly overflowing, hence the general name overflow incontinence. Over distention of the bladder due to abnormal emptying. 4.Functional Incontinence - refers to the problems from factors external to the lower urinary tracts.

between rest stops and on the highway; also, there may be problems with the restrooms in the vicinity. 5.Mixed Incontinence - existence of the symptoms of urge and stress incontinence at the same time. - is not uncommon in the elderly female population and can sometimes be complicated by urinary retention, which makes it a treatment challenge requiring staged multimodal treatment. 6.Reflex Incontinence - No warning to void Urinary Incontinence Assessment 1. History Taking

occurs when a person recognizes the need to urinate but cannot make it to the bathroom. The urine loss may be large. Causes of functional incontinence include confusion, dementia, poor eyesight, poor mobility, poor dexterity, unwillingness to toilet because of depression, anxiety or anger, drunkenness, or being in a situation in which it is impossible to reach a toilet. People with functional incontinence may have problems thinking, moving, or - presence f voiding problems 3. Physical Exam 1.History Taking - focus on usual # of voids during the day and through the night. 2. Bladder Diary

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- daily food and fluid intake 2.Bladder Diary - recording that outline the timing, amount & type of fluid intake with the timing, amount, & continence status for each void. ; 3 days period recording voiding status

c. Bladder Training - Focus on the ability to delay urination and suppress urgency; scheduled voiding & reinforcement to provide pts with the skills to improve the ability to control urgency, decrease frequency, and incontinent episodes & prolong the interval bet voiding d. Pelvic Muscle Relaxation (Kegel Exercises)- Increases

and relieving symptoms. Doxazosin mesylate (Cardura), Tamulosin hydrochloride (Flomax), Terazosin hycrochloride (Hytrin), 3. Devices & Products - protective undergarments - toileting equipment & collection devices (Urinals and bedpans, urine bag) - moisture barriers (skin care is essential in the care of a person with incontinence, so it is important to gently dry the

3.Physical Exam- abdominal assessment, genitourinary assessment, rectal assessment and general examination that could detect conditions that could contribute to incontinence
Time Fluid intake amou nt (oz.) Void amount (oz.) Leak ? (S, M,L) Urge prior to leak ? ---Activity

the strength, tone, & control of the pelvic floor muscles to facilitate a persons ability to voluntarily control the flow of urine &suppress urgency. e. Pelvic Floor Electrical Stimulus - Application of electrical current to sacral & pudendal afferent fibers via non implantable vaginal or anal probes.

skin after cleaning and apply moisturizer) - catheters (Pts whose incontinence is caused by obstruction and no other intervention is feasible, for

7:00 AM

8 oz. coffee

180 ml. 6 ml.

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awakening

2. Pharmacological Approaches a.Stress I. - alpha adrenergic agonist

terminally ill incontinent pts,) IV. Sleep Problems Types of Sleep Disturbances 1. Insomnia - difficulty falling & staying asleep genetic and environmental factors contribute to insomnianoise and unfavorable room temperature

7:20 AM

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----

yes

washing my hands & face

- pseudoephedrine,epinephrine, ephedrine; Alphaadrenergic agonists reduce symptoms by improving the strength of the sphincter.

Interventions/strategies for Urinary Incontinence 1. Behavioral Approaches a. Managing Hydration - Focuses on maintaining fluid balance b. Prompted Voiding - Scheduling regimen that initially focuses on the caregivers behavior in order to change the incontinent persons behavior; monitoring, prompting, praising

b. Urge I. - anticholinergic or antispasmodic - Anticholinergics work in the following ways:Inhibit the involuntary contractions of the bladderIncrease capacity of the bladderDelay the initial urge to void; example Propantheline (ProBanthine) Oxybutynin (Ditropan, Oxytrol)Tolterodine (Detrol)Hyoscyamine (Levbid, Cystospaz)Trospium (Sanctura c. Overflow I. - Alpha antagonist - Alpha blockers relax striated and smooth muscle, decreasing urethral resistance

2. Sleep Apnea - periods of breathing cessation associated with snoring. during the episode of apnea, the soft structures of the throat relax and the airway is closed off, oxygen level decrease, carbon dioxide increases and the blood ph becomes more acidic.

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3. Restless Leg Syndrome - neurological disorder characterized by an uncontrolled urge to move to relieve paraesthesias in the legs. paraesthesia- abnormal sensations in the legs, it is triggered by lying down to relax

Lavender produces sedative effect and considers the safest with no irritation; once inhaled, it enters the olfactory buld then to the limbic system where GABA is increased in response similar to diazepam ingestion

1. Stage 1 - The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple Notes: Nonblanchable erythema of intact skin, the

5. Herbal Therapy - - herbal prep containing Valerian, Sleep Assessment 1. History Taking 2. Cartoon Face Sleepiness Scale - measures sleepiness uncontaminated by emotional state or pain 3. Epworth Scale - self completion report of the likelihood of the pt falling asleep during several daytime activities Assessing Pressure Ulcer Interventions/Strategies for Sleep Problems 1. Braden Scale for Pressure Ulcer Risk Assessment 1. Sleep Hygiene - caffeine avoidance; late afternoon to evening avoidance; caffeine life has 3-7hrs 2. Environmental Restructuring - lights off or natural light, colors mixed tone of blue, green, and violet through flowers; environmental noise Notes: Scoring: the lower the Braden, the higher the Risk of 3. Relaxation (Music Therapy) - music therapy can promote relaxation, decrease anxiety and pain perception, improves sleep quality and decreases heart rate and systolic pressure 4. Aromatherapy - oils such as lavender oil has calming effect and decreases insomnia. True pressure devt Score of 16 - high risk in general popn Score of 18 or less - high risk in the older popn Stages of ulcer formation - determines the risk of pressure ulcer development - assesses sensory perception, skin moisture, activity, mobility, nutrition & friction 6. Medications V. Pressure Ulcers Lesions caused by unrelieved pressure with damage to the underlying tissue a root extract that enhances sleep by influencing GABA, adenosine, and serotonine levels which regulate normal sleep

heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, or hardness may also be indicators. A Stage I pressure ulcer is an observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). Stage I pressure ulcer. Intact skin with non-blanching redness 2. Stage 2 - Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. If you've ever had a blister on your heel that has opened, revealing the reddish tissue beneath it, you have seen a stage 2. Stage II pressure ulcer. Shallow, open ulcer with red-pink wound bed 3. Stage 3 - Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

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The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. This is when the layers of skin have been completely eroded, and you are in the subcutaneous fatty tissue. It is a full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. You will also see epibole in this type of ulcer, which is the growth of epithelium around the edges of a wound. Stage III pressure ulcer. Full-thickness tissue loss with visible subcutaneous fat

Notes: If nutritional intake is not enough tube feeding shuld be used with 35 calories/kg/day and 1.5 grams of protein/kg/day

Dressing selection is dictated by clinical judgement and wound characteristics Notes: Wound cleansing with antiseptic agents (e.g.,

Zinc & Protein - promote cell production & tissue healing Arginine - formation of collagen & elastin

povidone-iodine [Betadine], hydrogen peroxide, acetic acid) should be avoided because they destroy granulation tissue. Notes: Dressings that maintain a moist wound environment

Vitamin A - promote tissue healing & resistance to infxn Vitamin B - Required for protein synthesis Vitamin C - formation of strong blood vessels Food Sources Protien - peanut butter, high protein shakes, yogurt, egg

facilitate healing and can be used for autolytic debridement.Synthetic dressings reduce caregiver time, cause less discomfort, and potentially provide more consistent moisture.These dressings include transparent films, hydrogels, alginates, foams, and hydrocolloids. Transparent films effectively retain moisture, and may be used alone for partial-thickness ulcers or combined with hydrogels or hydrocolloids for full-thickness wounds. Hydrogels can be used for deep wounds with light exudate. Alginates and foams are highly absorbent and are useful for wounds with moderate to heavy exudate. Hydrocolloids retain moisture and are useful for promoting autolytic

4. Stage 4 - Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). A very troubling stage. It is described as full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers.

custard Zinc - whole milk, cheese, cocoa, wheat bread, cereal Arginine - walnuts & peanuts Vit A - carrots, apricots, Pink Grapefruit Vit B - egg salad, Chicken Vit C - oranges, strawberries, cantaloupe

debridement. Dressing selection is dictated by clinical judgment and wound characteristics; no moist dressing (including saline-moistened gauze) is superior. VI. Dysphagia - is the medical term for the symptom of

Stage IV pressure ulcer. Full-thickness tissue loss with exposed muscle and bone. Interventions/Strategies in Treating Pressure Ulcers Nutrition - assess pts intake of Protein, Arginine, Zinc, and Vitamins A, B, C. Dressings that maintain a moist environment facilitate healing and can be used for autolytic debridement Wound cleansing with antiseptic agents should be avoided

difficulty in swallowing. It is derived from the Greek dys meaning bad or disordered, and phago meaning "eat". It is a sensation that suggests difficulty in the passage of solids or liquids from the mouth to the stomach.

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Deglutition - risk factor for dysphagia, occurs before, after, and during the swallow Types of Dysphagia 1. Oropharyngeal Dysphagia - related to neuromuscular dysfunction affecting the tongue, pharynx, & upper esophageal shpincter s/Sx: difficulty initiating swallow, cough early in the swallow & nasal regurgitation

- complaints of food sticking after a swallow & coughing late in the swallow

- using the National Dysphagia Diet - changing the consistency of the food, usually pudding to

Assessing Dysphagia (a) review of medical history or record for surgeries, physical conditions, or medications that place the patient at risk for dysphagia (b) (b) interviews of the patient and/or significant others describing difficulties in feeding or swallowing, or changes in mealtime behaviors

liquid consistencies food. 2. Environment Adjustment - Conversation during meals should be minimized - keeping suction equipment close 3. Compensatory Measures a. glos-sectomy spoons that facilitate placing food further

(c) physical assessment of the mouth, throat, and chest 2. Esophageal Dysphagia - results from motility problems, neuromuscular problems &/or obstruction that interferes with the movement of food bolus. 1.Diet Modification Managing Dysphagia

back in the mouth b. "grazing" (eating small amounts of food at frequent intervals).

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