Depression

How do we tx it?

What is the most common side effect of SSRI?

What are common side effects of TCA?

1. Depression

2. SSRI & TCA /SSRI for acute depression - less side effects that TCA

3. SIADH & EPS (drug induced parkinsons)

4. anticholenergic effects - constipation, dry mouth, urinary retention, decreased memory & attention, delirium, orthostatic HOTN, sedation, cardiac condunction

Delirium

What is it?

How do we tx it?

1. Acute consution, occurs more often in pt with dementia. 

2. Determine underlying cause: ie meds, infection, metabolic, neuro

Dementia

Define dementia?

What is apraxia?

What is agnosia?

What is the tx?

What are some of the most commons side effects of med tx?

1. Memory impairment with one or more of the following: langange impairment, apraxia, agnosis, and or impaired executive function

2. Apraxia: inabilitily to preform previously learned task

3. Agnosia: inability to recognize objects

4. AChEI - Acetylocholinesteracse inhibitors: aricept, galantamine, rivastigmine

5. SE: diarrhea, nausea, anorexia, wt loss

Urinary Incontinence

Waht rea some transient causes?

What meds can cause it?

What are estabilished causes?

1. Delirium, infection, atropic urethritis & vaginitis, psychologic factors, restricted mobility, meds

2. diuretics, anticholenergics, psychotropics, opioid, alpha blocker in women, alpha agonist in mean, CCB

3. Detrusor overactivity (urge incont) (#1 cause in elderly)/Uretheral incompetence (2nd more common - rare in men)/Detrusor underactivity (poor contractility)

BPH

How do we treat it medically?

1. Alpha blockers

terazosin 1-10 mg qd

prazosin 1-5 mg daily

tamsulsoin 0.4-0.8 mg po daily

saw palmetto

Pressure Ulcers

As we age our skin loses what?

What may a pressure ulcer be an indicator of?

How much does a pressure ulcer increase mortality?

How would you describe a pressure ulcer?

Name some of the scales used to identify those at risk for pressure ulcers?

1. Sensation & immune respone

2. Malnutrition, impaired dermtological function and comorbidities

3. 4 times, & 6 times in non-healing pts

4. Location, color, shape, distrubution, size, type

5. Braden, Norton, APACHE II

Stage 1 - nonblanchable erthma of intact skin

Stage 2 - partial-thickness lesions extending into the epidermis and dermis

Stage 3 - full-thickness loss involving the SQ tissue

Stage 4 - extensive tissue damange extends to muscle, bone

FYI: staging is not possible when eschar is present - much debride first

What lab is a reliable indicator of pressure ulcer development?

How do we tx pressure ulcers?

What dietary supplement help to promote wound healing?

1. Albumin

2. remove ishcemic tissue

clean moist wound - keep surrounding tissue dyg

dressings

topical antibiotics for ulcers failing to heal more than 2 wks

For stage 2 and higher NS irrigation

Systemic antibiotics for higher staged ulcers

Stage 3-4 require surgery

rehabilitation and PT required

3. Vitamin C & A, riboflavin, iron, zinc, O2 and growth factors

Elderly Abuse

General Demagraphics

 3.2 % of elderly report abuse and approx 5 times as many are unreported

Women more at risk than men

90% of time the victum knows the abuser

Embarrasment, feeling overwhelmed, intimdation, and isolation - reasons for not reporting

Early interventions for proventions add: stress by edu, conseling, and referral to communtiy agencies

Physical

Emotional

Sexual

Finanical exploitation

Caregiver neglect

Self-neglect

Lack of close family ties

increasing age

physical or mental impairment

poverty or financela distress

psychopathology of caregiver

shared living arrangement

caregiver stress

isolation

unsafe housing

cultural pressure not to seek help

What Federal act requires reporting of elder abuse in nursing home?

Who requires that hospitals report elder abuse?

1. Federal Older Americans Act of 1976

2. JCAHO

Frame ?'s in non-threatening, non-judgemental manner

Note any signs of defensiveness

Has anyone tried to hurt you?

Have you had any recent injuries?

How did that mark get there?

Is there stress at home?

Tell me about your caregiver?

How are your financies handled?

Is anyone making you do anything you don't want to?

injuries

papilledema

malnutrition

person hygiene

appropriate dress

dehydration

pain

pressure ulcers

mobility and ROM problems

Genital/rectal trauma, infection,STD

Serum levels of meds

Screen for depression, anxiety, mental do, dementia and delirium

Evaluate mood, behavior, affect

Yes as of 1997

except for in Colorado, Illinois, New Jersey, New York, North Dekota, Pennsylvania, South Dekota, & Wisconsin

Pain

Is pain a normal part of aging?

Caution with psychoactive agents

Use opioids with low side effects for sedation

Start at half the adult dose

SSRI if depression present

Advoid meds contraindicated for glaucoma

Instruct pts to report vision problems

Begin with nonopioid agents

NSAIDS for inflammatory pain

Opioids for long term pain

Supplemental analgesia for activity-related pain

Evaluate liver and renal function

Exercise and PT

Caution with opioids & other analgesics that cause sedation

Start at 1/2 the dose and increase

Use NSAIDS with caution

Avoid TCA depressants

assess worsening cardiac functioning

ECG for monitor of dig tox

Assess for dizziness/syncope

Avoid NSAIDS with h/o PUD and on anticoags

Caution with opioids in dehydrated pts

Avoid long acting agenst and long half lives

Monitor liver function

400 mg Ibuprofen TID to reduced renal tox

caution in meds being excreted by kidney

Monitor renal function

Opioid naive pt are at risk for renal retention

anticholenergics may cause urinary retention

monitor I&O

Monitor for preexisting BPH or bladder problems potentiating urinary retention

Use low dose Marcaine to prevent HOTN & lower ext weakness

Monitor resp status

Assess cognitive status

Monitor I&O

• "start low and go slow"
• consider combo opioid meds: codeine + tylenol, Vicodin, Percocet
• Consider short acting opioids: oxy IR, dilaudid
• Consider long acting opioids: oxycodone, hydrocodone, Fent patch
• Use non-opioid analgesic and tylenol for mild to mod pain
• Steroids
• TCA for neuropathic pain
• Anticonvulsants for shooting, electric or lacing neuropathy
• Topical agents: Capsaicin - may increase pain at first/ELMA cream for neropathic pain

• Hot and cold packs
• Menthol
• Message tx
• Transelectricl stimulation
• cognitive & behavioral tx
• exercise & PT
• immobilization: splintin/bracing
• Distracting: music/imagery
• Relaxation
• Meditation

The study and managment of pts with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is on the quality of live

Active, total care of pts whose disease is no longer responsive to curative tx

Dignity and respect

alleviate pain

F - Faith or spiritual practice

I - improtance of the practice

C - community

A - assist

Anxiolyitcs, O2, opioids, bronchdilators

non-pharm managment

? about environment

BM as infreq as every 3 days

Distress & pain assessment

Review med and diet

Tx as appropriate

May be sign of inadequate care/abuse

Careful with enternal and parental nutrition - cause discomfort

Force feeding may lead to possible suffering

review and modify diet restrictions

Discontinue offending meds

Alcohol, crytoheptadine

cisipride, metaclopramide

megstrol acetate

prednisone, dexamethasone

cannabionoids

Edu pt on conservation of energy

PT to maintain mobility

review meds

Steroid tx

Hydration and electrolyte tx

Psychostimulants - methylphenidate, dextroamphetamine, pemoline methyphenydate

• Yoga
• Play
• Meditation
• Animal/pet therapy
• Breathing exercises
• Biofeed back
• Drumming
• Game playing
• Expressive art therapy
• Body - mind oriented therapies - ie: Rechian/Hakomi
• Exercise
• Aroma tx
• Massage
• PT
• Herbal remedies
• Homeopathics
• Acupuncture
• Chiropractic
• Eastern med practice
• Energy alignment
• Polarity tx

Fatigue/Weakness

Immobility

Pain

Risk for aspiration

Dehydration

Neurological decline

Appearance changes - mottled skin

Los of ability to swallow

Changes in breathing pattersn

Pacemakers

Name the components of a pacemaker?

What precautions do pts have after surgery?

What are some more general precautions to having a pacemaker?

• 1. Battery, electrodes, timer
• 2. do not raise are closest to pacemarker above head for 2 wks
• Do not swim, golf, play tennis for 4 wks
• Seek med attention if site red/swollen/fever
• Do not shower for 5 days around pacer site
• 3. seek med attention if dizziness, CP, palpitations, swelling in legs & ankes, fainting spells, SOB
• Do not hold electric razor over the pacer
• Stay away from high electricity contents: MRI, power plants
• Stay 4-5 ft away from operating Pre-1980's microwaves
• Do not use digital cell phones

Allergic Reactions

Waht are some of the most common reactions?

How do we tx allergic reactions?

1. Allergic Uticaria - Hives/allergic eczematous - contact dermatis/Allergic drug eruption - most common

2. Withdrawl any med causing reaction/antipruitic agents/antihistamine

What is Senile Pruritis?

What are some of the causes?

How do you tx it?

1. Most common dermatological problem in the elderly

Percipitated by any condition that dries the skin

2. DM, hepatic, uremia, cancer, pernicious anemia, arterosclerosis, psychatric more at risk

3. correct and identify underlying cause.  Bathoils, moisturizing lotions, massage, antihistamines, topical steroids

Stage 1 - edema, hyperemia, skin peeling, mild cyanosis

Stage 2 - redness, swelling, vesicles, skin sloughing

Stage 3 - edema, vesicles, shriveling toes, hard, dry eschars

Stage 4 - gangerene

Do not touch, rub or put pressure on it

Assess for hypothermia

Rewarm tissue slowly - do not run hot water or place hot compresses on skin

Exposure the area & may soak in 100F water

Treat the pain

Tissue take as long as 12 mons to recover and sensation can be lost

May require surgery

Remove stinger

Grasp tick at head - test for tick-borne illness

topical or intralesional/corticosteroids topical antipruritis/topical anesthetics

How would you tx a brown recluse spider bite?

How would you tx a black widow bite?

Apply ice to bite

use surgical debridement conservatively

use meds mentioned in previous slide

Pts present with abd pain like acute abd

Narcs, IV calcium gluconate, BENZOs, antivenin

Burns

What are the classification of a burn?

• First degree - superficial involving only the epidermis
• Second degree - partial thickness, involving the dermis ie boiling water burn/blisters
• Third degree - Full thickness, involving the epidermis, dermis, extending inot the subcutanous tissue ie direct flames, chemical, electrical. 

• 1st - analgesic, fld
• 2nd - cold water or compress for at least 5 mins/do not break blisters/analgesic/flds
• 3rd -refer for skin grafting is often required

Cellulitis

What is cellulitis?

What are sometimes that can make pts at risk?

What are common S&S?

What confirms the diagnosis of cellulitis?

How do we tx it?

1. Acute infection of the skin and SQ tissues

2. DM, pedal edema, prior trauma, underlying skin lesions, venous & lyphatic compromise

3. Tenderness, pain, swellling, erythema, fever, chill, malaise/erythemia in indistinct margine, enlarged tender lymoh nodes/linear streaks, patches of erythema and tendernss

4. Lymph node enlargement & lymphatic streaking

5. antibiotics for strep & staph/sepsis pt IV

Corns & Calluses

What are they and how would you tx them?

1. Hypertrophy of the epithelium develops becaue of prolonged pressure

Typically calluses are not painful & corns are painful

2. tx - removal/antibiotis for infection/surgical removal for protruding bone

Measure to promote health prior to the onset of any recognizable problems

Ex: healthy diet, exercise, safety, avoiding tobacco, wearing seat belts

What is secondary prevention?

What is an example?

Focuses on early identification and tx of existing problems

ex: screening

What is tertiary prevention?

What is an example?

Includes rehag and restoration of health

ex: cardiac rehab, PT after MVC

Health Screenings

At what are do we do what to whom?

What age should you have a physical exam?

3 yrs after onset of intercourse, but no later than 21

Than annually to age 30

May discontinue at 65-70 after 2 neg consecutive results

Basic needs before more complex

1. Survival needs

2. Safety & Security

3. Love & Belonging

4. Self-esteem

5. Self - actualization - ones highest potential

What is the Health Belief Model?

What are some of key concepts?

Health is influenced by numerous entites such as age, sex, race, and income

Treats of health ie percieved susceptibility

Outcomes expectations ie percieved benefits

*Must percieve threat or benefit for behavior to change*

Nutritional Considerations

What are the daily recs for calcium for 51 yrs or older?

Men 1000 mg

Women 1500 mg - postmenopause not recieving estrogen

Daily rec needs to be individualized

Calcium absorption decreases with age

Disease to consider:

Certain CA/Kidney stones/Hyperparathyroidism

Men 0.2

Women 0.18

Men 350 mg

Women 280 mg

Men 15 mg

Women 13 mg

Men 60 gms

Women 46 gm

At least 0.8g/kg/day

Albumin below 3.5% indicated malnutrition

Low protein intake slows healing

Men 1.4 mg

Women 1.2mg

Men 70 mcg

Women 55 mcg

Men 1.2 mg

Women 1.0 mg

Men 1000 mcg

Women 800 mcg

Men & Women 2.0 mcg

Absortion problems in the presence of atrophic gastritis, pernicious anemia, diet

Anemia

Depresion

Anorexia

Fatigue

Men 2.0 mcg

Women 1.6 mcg

B6 and folate benefit: CV, immunity, antibody response

Men 10 mcg

Woemn 8 mcg

Men 80 mcg

Women 65 mcg

Men 15 mg

Women 12 mg

Scurvy causes by def

high dosing implicated in anorexia & gastric irritation

Dosing for wound healing not supported

Zinc def causes?

Zinc excess causes?

1. slows wound healing

2. depressed neutropli function, lymphocytic response, and copper deficiency

CV

memory

antioxidant

Immunity

Can act as a blood thinnner caution on pts using anticoagulants and those with platelet issues

Supplementation - 400-1200 mg/day

Supplementation may cause GI irritation

anorexia

constipation

diarrhea

Determine the underlying cause of iron def