Chapter 13: Management of Common Illnesses, Disease, and Health Conditions: CV and Resp.

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Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions CV and Resp.

• Bonnie M. Wivell, MS, RN, CNS

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Statistics

• 27 million Americans age 65 or older have some
  form of CVD
• 32 of all deaths in 2008 were attributed to CVD
  (AHA, 2008)
• Major diseases (AHA, 2005)
• Hypertension
• CHD
• MI
• Angina
• CHF
• Stroke

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Hypertension Background

• 65 million Americans have HTN
• In 2004, 63.6 of men and 73.9 of women ages
  6574 were diagnosed with HTN
• Of those age 75 or older, 69.5 of men and 83.8
  of women had HTN
• African American males have highest incidence
• Have a 1.8 times greater risk than whites of
  having a fatal stroke, and a 4.2 times greater
  chance of developing end stage renal disease
  (AHA, 2008)
• Number one risk factor for stroke
• Significant cause of ESRD
• Goal 120/80 or less consistently ideal BP
  determined with physician

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Hypertension Risk Factors

• Heredity
• Race (African American)
• Increased age
• Sedentary lifestyle
• Obesity
• Male gender
• High sodium intake
• Excessive alcohol intake
• Diabetes or renal disease
• Pregnancy
• Oral contraceptives or other meds

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Hypertension Control

• Limit alcohol intake to one drink per day
• Limit sodium intake
• Stop smoking
• Maintain a low fat diet that still contains
  adequate vitamins and minerals through adding
  leafy green vegetables and fruits
• Exercise
• Weight management
• Regular BP checks
• Take meds as directed

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Coronary Heart Disease (CHD) Background

• Also called CAD or ischemic heart disease
• Atherosclerosis resulting in an impaired blood
  supply to the myocardium
• Older females after menopause are more than twice
  as likely to have CHD than those before menopause
• Over 82 of people who die with CHD are age 65
  years and over (AHA, 2008)
• Myocardial infarction and angina are two results
  of CHD

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Angina Background

• Chest pain caused by lack of oxygen to heart
  muscle
• Higher incidence in females, Mexican American
  males and females, and African American females
• Stable managed with meds and lifestyle changes
• Unstable usually requires hospitalization
• Related to exercise or stress and is relieved
  with rest and NTG
• Symptoms in elderly
• Dizziness
• Dyspnea
• Confusion
• Chest pain

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Angina Control

• Teaching patients and families
• Weight management
• Stress management
• Limiting caffeine
• Smoking cessation
• Regular exercise
• Control of hypertension
• Medical management of any co-existing endocrine
  disorder (such as hyperthyroidism)

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Angina Medications

• Beta blockers and calcium channel blockers are
  often prescribed to decrease the oxygen demand on
  the heart
• Side effects
• Fatigue
• Drowsiness
• Dizziness
• Slow heart rate

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MI Background

• 365,000 new and 300,000 recurrent heart attacks
  each year
• In the USA
• Risk increases with age
• Men more at risk until age 70 then risk equalizes
• Average age for a persons first MI of 65.8 for
  men and 70.4 for women (AHA, 2005)

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MI Risk factors

• Hypertension
• Race (especially African American males with HTN)
• High fat diet
• Sedentary lifestyle
• Diabetes
• Obesity
• High cholesterol
• Family history
• Cigarette smoking
• Excessive alcohol intake
• Stress

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MI Warning signs

• Chest pain appearing as tightness, fullness, or
  pressure
• Pain radiating to arms
• Unexplained numbness in arms, neck, or back
• Shortness of breath with or without activity
• Sweating
• Nausea
• Pallor
• Dizziness
• Unexplained jaw pain
• Indigestion or epigastric discomfort, especially
  when not relieved with antacids
• (of particular significance in the elderly)

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MI Treatment

• Antithrombolytics if given early decreases
  morbidity and mortality
• Rest
• MONA (Morphine, Oxygen, NTG q 5 mins x 3, ASA
  chew, if not contraindicated)
• ECG
• Angiogram and/or Cardiac Cath
• Angioplasty
• CABG
• Medications
• Beta blockers, ACE inhibitors, Antihypertensives

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MI Patient Education

• Exercise regularly
• Do not smoke
• Eat a balanced diet with plenty of fruits and
  vegetables avoid foods high in saturated fats
• Maintain a healthy weight
• Manage stress appropriately
• Control existing diabetes by maintaining healthy
  blood sugars and taking medications as prescribed

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MI Patient Education (contd)

• Limit alcohol intake to 1 drink per day for women
  and 2 drinks per day (or less) for men
• Visit the doctor regularly
• After a heart attack, participate fully in a
  cardiac rehabilitation program
• Involve the entire family in heart-healthy
  lifestyle modifications
• Report any signs of chest pain immediately
• Be involved in and buy into the prescribed
  medication regimen

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Congestive Heart Failure (CHF) Background

• Incidence varies by age, gender, and races
• Lifetime risk for persons is 1 in 5
• The risk in older adults doubles for those with
  blood pressures over 160/90
• 75 of those with CHF also have HTN
• The major risk factors are diabetes and MI
• Often occurs within 6 years after an MI

AGE W Men W Women AA Men AA Women
65-74 15.2/1,000 8.2/1,000 16.9/1,000 14.2/1,000
75-84 31.7/1,000 19.8/1,000 25.5/1,000 25.5/1,000
gt85 65.2/1,000 45.6/1,000 50.6/1,000 44.0/1,000
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CHF Signs and Symptoms

• Shortness of breath
• Edema
• Coughing or wheezing
• Fatigue
• Lack of appetite or nausea
• Confusion
• Increased heart rate
• Older adults decreased appetite, weight gain,
  insomnia

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CHF Treatment

• Check O2 saturation - less than 90 requires
  intervention
• Daily weight at same time, clothes, scale
• Threshold wt. gain between 1 and 3 pounds
• Potential medications
• ACE inhibitors, diuretics, vasodilators, beta
  blockers, blood thinners, angiotensin II
  blockers, calcium channel blockers, potassium
• Digoxin rarely used any more

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CHF Patient Education

• Teach lifestyle modifications as discussed for
  promoting a healthy heart
• Limit or eliminate alcohol use
• Maintain a healthy weight
• Stop smoking (no tobacco use in any form)
• Limit sodium intake to 2 3 g per day
• Take medications as ordered do not skip doses
• Exercise to tolerance level
• Alternate rest and activity learn energy
  conservation techniques

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Stroke and TIAs Background

• Cerebrovascular accident (CVA)
• Interruption of blood supply to the brain that
  may result in devastating neurological damage,
  disability, or death
• Transient ischemic attack (TIA)
• Symptoms similar to stroke but go away with in
  minutes to 24 hours and leave no residual effects
• 780,000 new or recurrent strokes per year
• Third leading cause of death in US
• 10 of all strokes are preceded by a TIA
• CVA is the 1 diagnosis for hospital discharge to
  LTCF
• 2/3 happen to those over 65 years of age

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Types of Stroke

• Ischemic (86)
• Thrombotic occurs when a blood clot forms in an
  artery that supplies the brain, causing tissue
  death (carotid artery stenosis) develops over
  time
• Embolotic occurs suddenly when a blood clot
  (embolism) forms in one part of the body, travels
  through the bloodstream, and lodges in and
  obstructs a blood vessel in the brain
• Hemorrhagic

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Stroke and TIAs Risk Factors

• Controllable
• HTN 1
• High Cholesterol
• Heart Disease
• Smoking (quit and risk equalizes after 5 years)
• Obesity
• Stress
• DM
• Depression
• A Fib

• Uncontrollable
• Age
• Gender (males gt females until menopause)
• Race (AA gt White)
• Heredity

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Stroke and TIAs Warning Signs

• Sudden numbness or weakness of face, arm, or leg,
  especially on one side of the body
• Sudden confusion trouble speaking or
  understanding
• Sudden blurred or decreased vision in one or both
  eyes
• Sudden trouble walking, dizziness, loss of
  balance or coordination
• Sudden severe, unexplainable headache -- often
  described as the worst headache of my life
  (more common with hemorrhagic)

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3 Easy Assessment Signs

• Facial droop
• Motor weakness
• Language difficulties

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Stroke Treatment

• H P, esp. neuro exam
• Vital signs
• ECG, CXR, CBC, PT, PTT, Lytes, Glucose
• Diagnostic testing
• CT scan and/or MRI
• Arteriography
• US of carotids

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Stroke Acute Management

• Determine cause/type of stroke
• Hemorrhagic ? surgery to evacuate blood
• Ischemic ? t-PA (tissue plasminogen activator)
• Gold standard
• Must be given within 3 hours after the onset of
  stroke symptoms
• Some patients will not be candidates
• May reduce or eliminate symptoms in over 40 of
  pts who receive it within time frame

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Stroke Acute treatment

• Manage hypertension, hyperthermia, and
  hyperglycemia
• To prevent recurrence Medications
• ASA
• Ticlid
• Plavix
• Persantine
• Heparin
• Coumadin
• Lovenox

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Effects of Stroke

• Effects and degree of recovery vary
• Hemiplegia
• Hemiparesis
• Visual /perceptual deficits
• Language deficits
• Emotional changes
• Swallowing dysfunction
• Bowel/bladder problems

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Stroke Rehabilitation

• Maximize function
• Prevent complications
• Promote QOL
• Encourage adaptation
• Enhance independence
• Emphasize abilities NOT disabilities

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Stroke Mauk Model
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Phase/Concept Characteristics
Agonizing Fear, shock, loss, questioning, denial
Fantasizing Mirage of recovery, unreality
Realizing Reality, depression, anger, fatigue
Blending Hope, learning, frustration, dealing w/changes
Framing Answering why, reflection
Owning Control, acceptance, determination, self-help
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Stroke Patient Education

• PREVENTION is KEY
• Know the warning signs of stroke
• Call 911 if experiencing warning signs
• TIA is a warning sign
• Manage high blood pressure
• Take medication as scheduled
• Visit the doctor regularly

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Peripheral Vascular Disease Background

• Peripheral artery disease (PAD) is most common
  type of PVD
• Affects 8 12 million Americans, 12 20 of
  those over the age of 65

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PVD Risk Factors/Symptoms

• Same as those for CHD
• Diabetes and smoking are the greatest risk
  factors (AHA, 2005)
• More at risk of MI or CVA
• Symptoms
• Leg cramps with activity but alleviated at rest
  (intermittent claudication)
• None

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PVD Treatment

• Heart healthy lifestyle and modifications as
  those discussed previously with CAD
• Left untreated can lead to decreased quality of
  life
• Sometimes results in gangrene and amputation

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Respiratory

• Pneumonia
• COPDs
• Chronic bronchitis
• Emphysema
• TB
• Lung cancer

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Pneumonia Background

• Leading cause of death among the elderly
• Those over age 65 have 5 10 times the risk of
  death from pneumonia than young adults
• Causes bacterial, viral, aspiration
• More at risk if COPD, CHF, or immune-suppressing
  disease

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Pneumonia Signs/Symptoms

• Viral (less severe)
• Fever, non-productive hacking cough, muscle pain
  (chest), weakness, shortness of breath, anxiety,
  crackles in lungs
• Bacterial (sudden or gradual onset)
• Chills, chest pain, sweating, productive cough,
  or dyspnea
• Older adults may not present with these typical
  symptoms
• Confusion, disorientation, or delirium in the
  elderly

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Pneumonia Treatment

• CXR
• CBC
• Sputum culture to determine type and causal agent
• HP
• Viral no tx self-limiting
• Bacterial antibiotics

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Pneumonia Treatment (contd)

• Hydration, rest
• Tylenol/ASA if not contraindicated
• Monitor for worsening of symptoms
• Hospitalization often required in frail elderly
• Vaccines recommended
• Pneumonia once in life time
• Flu annually

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COPDs Background

• Obstructed airflow
• Emphysema and chronic bronchitis
• Fourth leading cause of death in the US
• 118,000 deaths in 2004
• Nearly 24 million American adults have some type
  of impaired lung function
• Slightly more females than males are affected
• Female smokers have a 13 times greater chance of
  death from COPD than nonsmoking females

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COPDs Risk Factors

• Smoking 80-90 of COPD deaths
• Air pollution
• Second-hand smoke
• Heredity
• History of respiratory infections
• Industrial pollutants
• Environmental pollutants
• Excessive alcohol consumption
• Genetic component (alpha1-antitrypsin deficiency)

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Chronic Bronchitis

• 8.5 million Americans diagnosed as of 2005
• Females 2x more likely than males
• Recurrent inflammation and mucus production
  produces blockage and eventual scarring that
  restricts airflow
• S/S Increased mucus production, shortness of
  breath, wheezing, decreased breath sounds, and
  chronic productive cough
• Can lead to emphysema

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Emphysema

• Alveoli are irreversibly destroyed lungs lose
  elasticity, air comes trapped in alveolar sacs
  resulting in CO2 retention and impaired gas
  exchange
• Nearly 4 millions Americans have it
• Males more than females
• S/S Shortness of breath, decreased exercise
  tolerance, and cough
• Diagnosed PFTs and HP

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COPDs Treatment

• Control symptoms and minimize complications
• Lifestyle modifications
• Stop smoking
• Respiratory therapy
• Medications
• Pulmonary rehabilitation
• Oxygen therapy required as disease progresses

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COPDs Patient Education

• Involve the family and plan for long term
• Lifestyle modifications reduce factors that
  contribute to symptoms
• Appropriate use of meds
• Alternating rest and activity (energy
  conservation)
• Stress management
• Relaxation
• Supplemental oxygen
• Work with respiratory therapist and physician on
  home maintenance program

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Tuberculosis Background

• Infection that can attack any part of body but
  targets lungs and is spread through air droplets
• Number of cases in US steadily decreasing over
  last 10 years
• Asian Americans, Pacific Islanders, African
  Americans, American Indians, Hispanics, Whites
• 8 times greater incidence in non-US born
• Spread common in less developed countries related
  to immune suppression associated with AIDS
• Nursing home residents at risk TB testing prior
  to admission

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Tuberculosis Signs and Symptoms

• Severe cough lasting more than 2 weeks
• Chest pain
• Bloody sputum
• Weakness
• Fatigue
• Weight loss
• Chills, fever, night sweats (May not be present
  in elderly)

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Tuberculosis Diagnosis Treatment

• Skin test
• CXR
• Sputum culture
• Infected with no symptoms no tx
• Positive skin test tx with isoniazid (INH) x 6
  months for prevention
• Active TB Combination drug regimen for many
  months, isolation, rest, adequate nutrition,
  hydration, breathing exercises
• Monitor LFTs due to drug therapy toxicity
• From another country? Language barrier?

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Lung cancer Background

• Second most common cancer
• Smoking is the number one cause
• 87 of lung cancers caused by smoking (ALA, 2005)
• Radon exposure
• Industrial Exposure
• Genetics
• Affects both men and women

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Lung Cancer Signs and Symptoms

• A cough that doesn't go away and may get worse
• Constant chest pain
• Coughing up blood
• Shortness of breath, or wheezing
• Loss weight and loss of appetite
• Frequent lung infections, such as bronchitis or
  pneumonia
• Hoarse voice
• Unexplained fever

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Lung Cancer Treatment and Patient Education

• Surgery, radiation, chemotherapy or combination
• Surgery generally indicated and most effective
• Prevention is best!
• Encourage smoking cessation
• Link with support groups
• Avoid second hand smoke and exposure to
  environmental toxins
• For those living with lung disease, employ all
  the strategies above for those with COPDs

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Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions GI
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Gastrointestinal Disorders

• GI problems common among most frequent complaints
  in elderly
• Gastroesophageal reflux (GERD), peptic ulcer
  disease (PUD), diverticulitis, constipation, and
  several types of cancers discussed here

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GERD

• Acid or other stomach contents back up into the
  esophagus
• Can be chronic disorder affecting QOL
• Associated factors
• Decreased LES tone and increased pressure in
  stomach and abdomen
• Decreased peristalsis
• Delayed gastric emptying
• Common cause H. Pylori

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GERD Symptoms

• Heartburn 1
• Noncardiac chest pain
• Dysphagia
• Hoarseness
• Coughing
• Wheezing, respiratory problems, asthma
• Complications
• Esophagitis
• Barretts esophagus
• Cancer

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GERD Treatment

• Diagnosis HP, endoscopy with biospies
• Treatment
• Medications
• Mild Antacids H2 blockers (Tagamet, Zantac,
  Pepcid AC, Axid)
• Proton pump inhibitors (PPIs) (Nexium, Prevacid)
• Elderly have fewer complaints of heartburn but is
  more severe with more complications

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GERD Patient Education

• Lifestyle modifications
• Smaller, more frequent meals
• Avoid food and drink within 3-4 hrs of lying down
• Elevate entire HOB
• Lose weight
• Avoid tight fitting clothes
• Take meds properly

• Avoid
• Caffeine
• Chocolate
• Nicotine
• Alcohol
• Peppermint
• Spicy and tomato-based foods
• Acidic products
• Carbonated beverages
• Stress

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Peptic Ulcer Disease Background

• Direct cost exceeds 2 billion/year
• Indirect cost exceeds 500K annually
• Incidence increases with age
• Occurs more often in Hispanics and African
  Americans
• Can be a complication of COPD (increase in
  stress) so tx prophylactically

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Peptic Ulcer Signs/Symptoms

• Causes
• NSAIDS
• H. Pylori infection
• Decrease protection of GI mucosa
• Early symptoms may not occur in elderly r/o
  cardiac etiology as may present as indigestion
• Epigastric pain esp. after meals
• Bowel changes
• Bloating
• Anorexia

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Peptic Ulcer Risk factors Diagnosis

• Risk factors
• Smoking
• Drinking alcohol
• Caffeine
• Stress
• Helicobacter pylori infection
• Diagnosis HP, barium swallow, endoscopy with
  biopsy

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Peptic Ulcer Treatment Patient Education

• Antibiotics
• Antacids and other medications to control acid
  production
• Dietary changes
• Avoidance of risk factors
• Combination therapy if H. pylori present
• Teach
• Risk reduction
• Adhere to medication regimen
• Bleeding may result

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Diverticulitis Background

• Inflammation or infection of the pouches of the
  intestinal mucosa
• 65 of older adults will develop diverticulosis
  by age 85
• Most common in elderly men
• Perforation of one or more pouches of intestinal
  mucosa
• Certain foods may irritate condition (seeds)

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Diverticulitis Signs/Symptoms

• Elderly may not present with typical symptoms
• LLQ pain
• Nausea
• Fever
• Constipation
• Diarrhea
• Mucus and/or blood in stool

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Diverticulitis Risk factors Diagnosis

• Risk Factors
• Obesity
• Chronic constipation
• Hiatal hernia
• Family history
• Diagnosis
• H P
• Barium enema

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Diveritulitis Treatment

• Antibiotics
• Avoid irritating foods
• Extreme cases
• May require surgery to remove diseased bowel
• May result in bowel obstruction leading to
  colostomy
• Teach dietary changes, adhere to medication
  regimen

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Cancers

• GI cancers account for gt 25 of all cancer deaths
  in older adults
• 2 cause of cancer next to lung disease
• Types
• Esophagus
• Stomach
• Colorectal
• Pancreas

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Esophageal Cancer

• Squamous cell type most common in black males
  with a history of alcoholism and heavy smoking
• Adenocarcinoma more often in white males,
  particularly resulting from Barretts esophagus
• Early detection is key
• Poor prognosis
• S/S weight loss, difficulty swallowing
• In older adults, symptoms may not appear until
  advanced stage
• Avoid smoking and alcohol
• Tx Chemotherapy, radiation, possible surgery

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Stomach Cancer

• Common in older men age 65 74
• Greater incidence among Hispanics, African
  Americans and Asians/Pacific Islanders than
  Whites
• Rates are high among Japanese men living in Japan
  (American Cancer Society, 2005)
• Men have twice the risk of women
• Good prognosis if caught early
• S/S epigastric pain, anorexia, nausea, and
  difficulty swallowing
• Early signs may not be present in elderly
• Tx Surgery, radiation, and chemotherapy (often
  combination)

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Colorectal Cancer

• Most common yet treatable
• Most common is adenocarcinoma secondary to polyps
• Screenings recommended for early detection, esp.
  in high risk persons
• Hispanics and AA at higher risk
• Good prognosis when detected early
• Risk factors upper socioeconomic groups, high
  fat intake, alcohol, smoking, sedentary
  lifestyle, environmental toxins
• S/S depend on location of lesion, rectal
  bleeding, anemia, fatigue, abd cramping, changes
  in bowel pattern
• DX HP, Hemoccult, barium enema, endoscopy
• Tx Surgery, chemotherapy, radiation

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Pancreatic Cancer

• Found more often in elderly (60-80 yo) and is
  leading cause of death for this age group
• 10 x greater risk in men gt 75 yo
• Risk factors smoking, family hx, DM
• Poor prognosis
• Difficult to detect due to lack of symptoms
• S/S nausea, vomiting, anorexia, wt loss,
  depression, excessive belching
• Tx Palliative, surgery, chemotherapy

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Constipation Background

• Most common bowel problem in elderly6
• Causes decreased peristalsis, decreased fluids
  from decreased thirst, decreased activity, lack
  of fiber in diet, side effect of meds, neurogenic
  bowel or other disease
• May lead to fecal impaction or bowel obstruction
• Treatment depends on cause use all natural
  means first start with a clean bowel

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Factors to Consider in Bowel Management

• Uncontrollable Factors
• Neurogenic bowel disorder
• Family history
• Environment
• Previous bowel disease

• Controllable Factors
• Diet
• Fiber
• Fluids (1500-2000 mL per day)
• Timing
• Activity
• Positioning
• Medications

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Nursing strategies Oral medications

• Bulk formers
• Metamucil
• Stool softeners
• Colace
• Peristaltic stimulators
• Pericolace
• Senna
• Rectal
• Glycerin or bisacodyl suppository

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Enemas

• Avoid if at all possible
• If must use, try a Fleets
• Should not be part of a regular bowel program for
  older adults can distend the bowel, make it
  lazy, cause dependence
• CVA, dementia, PD, MS, TBI, SCI may need
  comprehensive bowel program developed by rehab
  nurse

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Genitourinary problems

• Bladder cancer
• Vaginitis
• Breast cancer
• Cervical cancer
• BPH
• Prostate cancer
• Erectile dysfunction

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Bladder Cancer Background

• Incidence increases with age
• Men 3x more likely than women
• Risk factors
• Chronic bladder irritation
• Cigarette smoking
• Classic symptom
• Painless hematuria

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Bladder Cancer Diagnosis Treatment

• Dx IVP, UA, Cystoscopy with biopsies
• Treatment
• Burning through scope when superficial
• BCG washes
• If invasive into bladder muscle, then removal of
  bladder is indicated
• Chemotherapy and/or radiation

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Bladder Cancer Patient Education

• Urostomy
• Several types
• Urine empties into a bag on the outside
• Stoma looks much like a colostomy
• Indiana pouch
• Teach self-cathing
• Care of urostomy
• Appliances
• I O
• Skin care

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Female Reproductive System

• Vaginitis
• Cervical cancer
• Breast cancer

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Vaginitis

• Vaginal canal fragile due to atrophy
• Decreased lubrication
• Alkaline pH due to decreased estrogen
• Symptoms itching, foul-smelling discharge
• Tx topical estrogen cream
• Pt. Education
• Avoid douching, feminine deodorant sprays,
  powders, or perfumes
• Cotton undergarment
• Water-soluable lubricant during sex

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Cervical Cancer

• Incidence peaks in women ages 50-60
• Treated less aggressively with poorer outcome in
  elderly
• Pap smear annually until age 70
• Risk factors smoking, onset of sex prior to age
  18, multiple sex partners
• Symptoms post-menopausal bleeding no pain
• Prognosis good if detected early
• Tx Laser and/or cryo surgery, chemotherapy,
  radiation

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Breast Cancer

• Second leading cause of death in women
• Half of all breast cancers are diagnosed in women
  over age 65
• Screening Mammogram yearly until age 75 , SBE
  monthly, CBE annually
• Risk Factors family hx, late menopause, 1st
  child after age 30, high fat diet, alcohol
• S/S breast mass or lump, breast asymmetry,
  dimpling of skin, nipple discharge
• Dx mammogram, US, MRI, biopsy

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Breast Cancer Treatment

• Surgery, radiation, chemotherapy or combination,
  depending upon stage
• Elective surgery done in some younger women with
  strong familial history
• Older women undergoing mastectomy may require
  more time for recoery
• PT to regain ROM
• Psychosocial and emotional support

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Male Reproductive System

• BPH
• CA of prostate
• Erectile dysfunction (ED) or Impotence

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Benign Prostatic Hyperplasia (or hypertrophy)
(BPH)

• Non-CA enlargement of prostate associated with
  age
• Affects 50 of men 51-60 and up to 90 of men
  over age 80
• Can be precursor to CA, so must be monitored
• Symptoms Decreased urinary stream, frequency,
  urgency, nocturia, incomplete emptying,
  dribbling, weak stream, incontinence
• Dx UA, PVR, PSA, Urodynamic studies, US,
  Cystoscopy
• Tx Meds and surgery

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Prostate Cancer

• Second leading cause of cancer death in US males
• Incidence increases with age
• Over half men 70 and over show some histologic
  evidence, though only small percent die from
  disease
• S/S urinary urgency, nocturia, painful
  ejaculation, blood in urine or semen, pain or
  stiffness in back or thighs
• Risk Factors advanced age, high fat diet, family
  hx, AA higher risk, Asians lower risk
• Dx DRE, PSA, biopsy
• Tx depends on stage, radical prostatectomy,
  radiation therapy, surveillance

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Erectile Dysfunction

• Defined as inability to achieve and sustain
  erection for intercourse
• Prevalent in approx. 70 of men age 70
• Increases with age but not inevitable and is
  treatable
• Causes DM, HTN, MS, SCI, thyroid disorders,
  alcoholism, renal failure, hypogonadism, other
  diseases, medications, psychological factors
• Tx Oral meds, vacuum pump, penile implant,
  penile injections
• Oral meds contraindicated in those with heart
  disease

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Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions Neurological
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Dementia Background

• 4 million older adults have some form of dementia
• How is dementia different from depression and
  delirium?
• Slower onset
• Progressive, not variable
• Irreversible
• Different causes
• Lowest MMSE

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Other Types of Dementias

• Vascular dementia results from multiple
  cerebral infarctions
• more rapid and more predictable than AD
• risk factors HTN, hyperlipidemia, history of
  stroke, smoking
• Lewy body dementia presence of Lewy body
  substance in cerebral cortex many
  gerontologists consider this the same type of
  dementia as AD

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Other Types of Dementias

• Creutzfeld-Jacob disease (Mad Cow)
• Rare brain disorder
• Rapid onset and progression
• Slow virus
• Familial tendency
• Destruction of neurons in cortex
• Symptoms more varied than AD
• Death with 1 year

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Other Types of Dementias

• Parkinsons disease
• Small percentage of those with dementia are this
  type
• Degeneration of neurons due to lack of
  neurotransmitter, Dopamine

96
Alzheimers Disease (AD)

• The most common type of dementia seen in older
  adults
• Advanced age is the single most significant risk
  factor
• Estimated 5.2 million Americans affected in 2008
• 5 million over age 65
• Estimated to reach 7.7 million in 2030
• Projected 11 16 million by 2050

97
Alzheimers Disease (AD)

• May live from 3 20 years or more after
  diagnosis
• Seventy percent of people with AD live at home
  until the latest stages, being cared for mainly
  by family members (Alzheimers Association, 2005
• Costs 61 billion annually
• Expected to exceed 163 billion/yr by 2050
• Characterized by progressive memory loss
• Average life span of 8 years after dx

98
Alzheimers Disease (AD)

• Two types of abnormal lesions in the brains of
  individuals with Alzheimer's disease
• Plaques
• Neurofibrillary tangles
• Definitive diagnosis is still through biopsy
• Dx early dx is important to maximize function
  and QOL as long as possible

99
AD Stages

• Early
• Loss of STM (Safety concerns)
• Inability to perform math calculations and to
  think abstractly
• Middle
• Bodily systems begin to decline
• Confused to date, time, and place
• Communication skills become impaired
• Personality and/or emotional changes
• Wandering
• Screaming
• Delusions/hallucinations
• Suspiciousness
• Depression
• Personal hygiene suffers

100
AD Stages (contd)

• Final
• Completely dependent upon others
• Severe decline in physical and functional health
• Loses communication skills
• Unable to control voluntary functions
• Death occurs from body systems shutting down and
  may be accompanied by infectious process

101
AD Warning Signs

• Ten warning signs of Alzheimers Disease
• Memory loss
• Difficulty performing familiar tasks
• Problems with language
• Disorientation to time and place
• Poor or decreased judgment
• Problems with abstract thinking
• Misplacing things
• Changes in mood or behavior
• Changes in personality
• Loss of initiative

102
AD Treatment

• Medications (Aricept, Namenda) may help slow
  progress but does not change disease course
• Symptom management
• Behavior
• Safety
• Nutrition
• Hygiene
• As dementia progresses, likely to be
  institutionalized
• Support for family/caregiver
• Support groups
• Respite
• Be aware of caregiver strain

103
Parkinsons Disease (PD) Background

• One of the most common neuro diseases
• Both men and women
• Generally 50 - 60 years of age at onset
• Originally called the shaking palsy
• Degenerative, chronic, and slowly progressing
  disease
• No known etiology though several causes are
  suspected
• Specific pathological marker is the Lewy body
  (under microscope round, dying neuron)
• No specific test to diagnose

104
PD Signs and symptoms

• The four cardinal signs
• Bradykinesia (slowness of movement)
• Rigidity
• Tremor
• Gait
• See page 422 in text
• Advanced PD may result in Parkinsons dementia

105
PD vs. Parkinsonian symptoms

• Drugs and toxins
• Alzheimers
• Vascular diseases
• NPH (normal pressure hydrocephalus)

106
PD Treatment

• Levodopa synthetic dopamine amino acid that
  converts to dopamine when it crosses the
  blood-brain barrier
• Levodopa lessen most of the serious s/s
• Hallucinations
• Sinemet (levodopa/carbidopa)
• Most common combination
• Decreases side effect of nausea seen with levodopa

107
PD Treatment

• Selegiline interferes with one of the enzymes
  that breaks down dopamine
• Dopamine receptor agonists Permax and Parlodel
  synthetic compounds that mimic dopamine not
  as powerful as levodopa
• Anticholinergics earliest used drugs
• Artane
• Cogentin

108
PD Treatment

• New drugs being examined
• Wearing off effect requires higher dose
• Drug holiday to reset itself
• New research
• Fetal tissue/stem cell transplants
• Adult stem cells retinal cells

109
PD Treatment

• Surgery for symptom relief
• Deep brain stimulation
• Thalamotomy (used for tremor destroys group of
  cells in thalamus)
• Pallidotomy destroys group of cells in internal
  globus pallidus, major area where info leaves the
  basal ganglia

110
PD Treatment

• Treat the symptoms
• Support
• Support groups, Parkinsons Foundation
• Preserve strength
• Also, care for the caregiver

111
PD Patient Education

• Medication therapy (side effects, wearing off,
  drug holidays, role of diet in absorption)
• Safety promotion/fall prevention
• Disease progression
• Effects of disease on bowel and bladder, sleep,
  nutrition, attention, self-care, communication,
  sexuality, mobility

112
PD Patient Education

• Swallowing problems
• Promoting sleep and relaxation
• Communication
• Role changes
• Caregiver stress/burden need for respite
• Community resources

113
Dizziness Background

• Affects about 30 of those over age 65
• Most common complaint in those over 75 who are
  seen by office physicians
• Four major types of dizziness
• Vertigo
• Presyncope (light-headedness)
• Disequilibrium
• Ill-defined

114
Dizziness Vertigo

• False sense of motion or spinning caused by
  benign paroxysmal positional vertigo (BPPV)
• Other causes
• Inflammation in inner ear
• Menieres syndrome
• Vestibular migraine
• Acoustic neuroma
• Rapid changes in motion
• More serious Stroke, brain hemorrhage, MS

115
Dizziness BPPV

• Most common cause of dizziness in older adults
• Increased incidence with age
• Brought on by normal calcium carbonate crystals
  breaking loose and falling into wrong part of
  inner ear (otoconia or rocks in the ears)
• Underlying cause unknown
• Degeneration in vestibular system in the inner
  ear that occurs with normal aging
• Should be suspected if vertigo doesnt respond to
  meds, such as Antivert

116
Dizziness BPPV (contd)

• S/S dizziness, presyncope, feelings of
  imbalance, and nausea
• Symptoms begin when person changes head position
• DX with Hallpikes maneuver pt. is laid down
  quickly from sitting position, with head turned
  to side and hung over the back of the exam table
  will produce nystagmus

117
Dizziness BPPV (contd)

• Treatment
• Epley maneuver patient is put into a series of
  specific positions and head turns to promote
  return of otoconia to their proper place in the
  ear

118
Dizziness Presyncope

• Feels faint or light-headed
• Associated with drop in BP
• Can be caused by
• Meds
• Hypotension
• Hypovolemia
• Low blood sugar
• Lack of blood flow to brain

119
Dizziness Disequilibrium

• Loss of balance or the feeling of being unsteady
  when walking
• Causes
• Vestibular problems
• Sensory disorders
• Joint or muscle problems
• Meds

120
Dizziness Ill-defined

• Catch all
• Inner ear disorders
• Anxiety disorders
• Hyperventilation
• Cerebral ischemia
• Side effect of meds
• Parkinsonian symptoms
• Hypotension
• Low blood sugar
• Benign positional vertigo

121
Dizziness Menieres

• Vestibular
• Common in those over 50
• Cause is unknown
• May be a viral or bacterial infection
• Signs and symptoms
• rapid decrease in hearing
• a sense of pressure or fullness in one ear
• loud tinnitus (ringing in the ears) and then
  vertigo

122
Dizziness Treatment Patient Education

• Early diagnosis
• Safety promotion
• Emotional reassurance that condition is generally
  temporary and treatable
• Dizziness is generally treatable by addressing
  the cause

123
Seizures Background

• Present in about 7 of older adults
• Usually related to one of the common
  comorbidities found in older adults
• CVD accounts for nearly 40-50 of seizures in
  elderly
• Seizures are associated with stroke in 5 14 of
  survivors

124
Seizures Potential Causes

• Stroke or other cerebrovascular disease
• Arteriosclerosis
• Alzheimers disease
• Brain tumor
• Head trauma
• Intracranial infection
• Drug abuse or withdrawal
• Withdrawal from antiepileptic drug

125
Seizures Types

• Partial or focal (AKA localized)
• Generalized grand mal or tonic-clonic
• Status epilepticus

126
Seizures Characteristics in Elderly

• Low frequency of seizure activity
• Easier to control
• High potential for injury
• A prolonged postictal period
• Better tolerance with newer antiepileptic drugs

127
Seizures Signs and Symptoms Diagnosis

• S/S
• Seizures
• Changes in behavior, cognition, and level of
  consciousness
• Diagnosis
• Careful description of the seizure event
• Thorough history and physical
• Complete blood work, chest x-ray,
  electrocardiogram (ECG), and electroencephalogram
  (EEG)

128
Seizures Treatment

• Treat causal factors
• AEDs newer medications may be better tolerated
  with fewer side effects
• Tegretol
• Trileptal
• Topamax
• Safety

129
Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions Musculoskeletal
130
Osteoporosis Background

• Low bone density or porous bones
• 55 of adults age 50 or older
• Women (80) gt men (20)
• Common yet preventable
• Leads to fractures, esp. of vertebral spine, hip,
  and wrists

131
Osteoporosis Risk factors

• Inactivity
• Insufficient calcium or vitamin D intake
• Smoking
• Alcohol
• Lack of exposure to sunlight
• Hormonal imbalances
• Meds, such as steroids or anticonvulsants

132
Osteoporosis Risk Factors

• Surgery related to reproductive organs
• Physical disorders affecting weight-bearing
• Menopause
• Thin, fair-skinned, blonde, European or Asian
  woman

133
Osteoporosis Signs and Symptoms

• Fractures
• Pain
• Kyphosis
• Decreased bone density

134
Osteoporosis Treatment

• Supplements
• biphosphonates (such as Fosamax)
• calcitonin (Miacalcin)
• What about ERT?
• estrogen/hormone replacement medications (such as
  Estratab or Premarin)
• Benefits
• Risks

135
Arthritis

• Affects 66 million Americans
• Number one chronic complaint and cause of
  disability in the US
• Over 100 types of arthritis
• 2 most common
• Osteoarthritis (OA)
• Rheumatoid arthritis (RA)

136
Osteoarthritis (OA) Background

• Degenerative joint disease (DJD)
• Characterized by chronic deterioration of the
  cartilage at the ends of the bones
• Cause unknown

137
OA Signs and Symptoms

• Herberdens nodes (bony enlargements at end
  joints of fingers)
• Bouchards nodes (bony enlargements at middle
  joints of fingers)
• Pain/Aching
• Stiffness esp. in am
• Joint swelling and inflammation
• Limited range of motion
• Crepitus
• Limping
• Frequent fractures

138
OA Signs and Symptoms
139
OA Diagnosis Treatment

• Dx Lab tests, x-rays, MRI or CT scan
• Tx aimed at symptom reduction
• Exercise
• Coping with pain
• Pain meds (NSAIDS, COX-2, Tramadol)

140
Rheumatoid arthritis (RA) Background

• Affects over 2 million Americans
• More common in women than men
• Characterized by remissions and exacerbations of
  inflammation within the joint
• Fingers, wrists, knees, and spine
• Due to chronic inflammation that can cause severe
  joint deformities and loss of function over time
• Cause unknown but researchers believe it may be
  due to virus or hormonal factors

141
Rheumatoid arthritis (RA)
142
RA Risk Factors

• Female
• Predisposing gene
• Exposure to an infection
• Advanced age
• Smoking over a period of years

143
RA Signs and Symptoms

• Malaise/Fatigue
• Symmetrical patterns of joint inflammation
• Pain, stiffness, swelling
• Gelling (joints stiff after rest)
• Elevated sedimentation rate
• Presence of serum rheumatoid factor
• Elevated WBC in synovial fluid of inflamed joint
• Erosion of bone (on radiograph)
• Pain more prevalent
• More debilitation than with OA

144
RA Treatment

• Meds
• Anti-inflammatories
• Immune-suppressing
• Disease-modifying anti-rheumatic drugs (DMARDs)
• Used within 3 mons of diagnosis
• Modify disease process and prevent deformities
  and pain
• May not show results for several months
• Teach pt. to recognize signs of infection
  chills, pain, fever

145
RA Goals of Care

• Independence within limitations
• Pain management
• Education
• Exercise and mobility
• Individual PT/OT
• Independence with ADLs

146
Joint Replacement Background

• Used for
• Fracture
• Immobility
• Intractable pain
• Total hip arthroplasty
• Arthritis or fracture from falling
• Total knee arthroplasty
• Advanced arthritis causing sever pain and
  decreased function

147
Total Hip Replacement
148
Total Hip Replacement Patient Education

• Surgical procedure
• Hip precautions
• Weight bearing status
• Maximum improvement over 1 2 years
• Signs and symptoms of wound infection
• Implications for travel

149
Total Knee Replacement Patient Education

• Indications for replacement
• Bilateral versus unilateral
• General versus spinal anesthesia
• Rehabilitation process
• CPM (settings)
• Wound care
• Pain management
• Expected ROM
• Maximum function return may take 2 or more years

150
Amputation Background

• Loss of limb, typically from disease, injury
  and/or associated surgery
• 135,000 new amputees annually in US
• Two thirds from circulatory problems, especially
  PVD related to diabetes
• Most involve the lower extremities AKA, BKA
• Advanced age and the incidence of diabetes in the
  elderly makes this a potential problem in the
  older age group
• HgbA1c level may be a significant predictor of
  foot amputation

151
Amputation Patient Education

• Stump care preparing the stump to wear a
  prosthesis is one of the best ways to promote
  later independence
• Mobility elders will walk more slowly after
  amputation due to increased energy expenditure
  required
• Adaptation
• Coping
• Self-care
• Managing phantom limb pain
• More common in trauma
• Massage and meds

152
Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions Sensory
153
Common Problems

• Most common visual problems among the elderly
  are
• Cataracts
• Glaucoma
• Age Related Macular Degeneration (ARMD)
• Diabetic retinopathy

154
Cataracts Background

• Common in older adults
• Etiology thought to be from oxidative damage to
  lens protein that occurs with aging
• Clouding of the lens50 of those ages 65-75 have
  them
• Most common in those over 75
• No ethic or gender variations

155
Cataracts Background

• Contributing factors
• Advanced age, DM, HTN, poor nutrition, cigarette
  smoking, high alcohol intake, eye trauma,
  Exposure to UV B, strong family history

156
Cataracts Signs/Symptoms

• No pain or discomfort
• Distorted vision/blurry
• Decreased night vision
• Photosensitivity
• Yellowing of lens
• Pupil changes color to cloudy white

157
Cataracts Treatment Patient Education

• Tx
• Surgery is the only cure outpatient with few
  complications
• Removal of the lens and insertion of intraocular
  lens implant (distorts vision less than special
  cataract glasses do)
• Pt. Ed
• Avoid bright sunlight wear wrap around
  sunglasses
• Avoid straining, lifting, bending

158
Glaucoma Background

• Group of degenerative eye diseases in which optic
  nerve is damaged by High intraocular pressure
  (IOP)
• Blindness due to nerve atrophy
• Leading cause of visual impairment
• 10-20 of all blindness in the U.S.
• Increased incidence with age
• Blacks develop earlier than Whites
• Women more often than men
• Cause is unknown

159
Acute Glaucoma

• Also called closed-angle or narrow-angle
• S/S
• Severe unilateral eye pain
• Blurred vision
• Seeing colored halos around lights
• Red eye
• Headache
• Nausea/Vomiting
• Symptoms may be associated with emotional stress
• Medical Emergency Permanent vision loss within 2
  5 days if untreated

160
Chronic Glaucoma

• Open angle or primary open-angle
• More common than acute
• Occurs gradually
• Peripheral vision slowly impaired
• S/S
• Tired eyes
• Headaches
• Misty vision
• Seeing halos around lights
• Worse symptoms in the morning

161
Chronic Glaucoma Diagnosis Treatment

• Dx
• Tonometer to measure IOP (normal is 10-21 mm Hg)
• Gonioscopy (direct exam)
• Treatment
• No cure
• Reduce the IOP
• Medications to decrease IOP (topical eyedrops)
• Surgery iridectomy

162
Age-related Macular Degeneration (ARMD)
Background

• Most common cause of blindness for those over 60
• Damage or breakdown of macula
• Loss of central vision
• Associated with aging process
• Can also result from injury, infection

163
ARMD Risk Factors

• High cholesterol
• Hypertension
• Diabetes
• Smoking
• Overexposure to ultraviolet light
• Heredity

164
ARMD Two Types

• Dry (nonexudative)
• 90 are this type
• Better prognosis
• Slower progression
• Wet (exudative)
• 10 are this type
• More sudden onset
• More severe loss of vision

165
ARMD Treatment

• No cure at present
• New research
• Photodynamic therapy uses a special laser to seal
  leaking blood vessels in the eye
• Antioxidant vitamins (C, D, E, and Beta-carotene)
  and zinc also seemed to slow the progress of the
  disease
• Retinal cell transplantation or regeneration

166
Diabetic Retinopathy Background

• Leading cause of blindness resulting from
  breakage of tiny vessels in the retina
• Generally affects both eyes
• No early outward warning signs
• Early diagnosis and treatment can prevent much of
  the blindness that occurs
• 4 stages

167
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168
Diabetic Retinopathy Diagnosis Treatment

• Pt. complains of seeing floating spots
• Dx
• Visual acuity
• Dilated eye exam
• Tonometry
• Tx
• Scatter laser treatment shrinks vessels
• Vitrectomy removal of vitreous gel containing
  blood

169
Diabetic Retinopathy Patient Education

• PREVENTION is key
• Regular checkups for older adults with diabetes
• Visual loss can often be prevented
• Control hypertension
• Lower cholesterol
• Monitor blood sugars keep within suggested
  limits

170
Retinal Detachment Background

• Result of trauma
• Symptoms may be gradual or sudden
• May look like spots moving across eye, blurred
  vision, light flashes, curtain drawing
• Keep person quiet
• Seek immediate medical attention
• May require surgery

171
Corneal Ulcer

• More common in elderly due to decreased tearing
• Inflammation of the cornea related to
• Stroke
• Fever
• Irritation
• Dehydration
• Poor diet
• Difficult to treat may leave scars
• S/S bloodshot eye, photophobia, c/o irritation
• Seek prompt assistance from physician

172
Chronic Sinusitis Background

• One of the top ten chronic complaints of the
  elderly
• Irritants block drainage of the sinus cavities,
  leading to infection
• Acute 1 day 3 weeks prior to reporting
  symptoms
• Chronic 6 weeks to 3 months of symptoms

173
Chronic Sinusitis Signs/Symptoms

• Severe cold
• Sneezing
• Cough that is worse at night
• Diminished smell
• Hoarseness
• Colored nasal discharge

• Postnasal drip
• Headache
• Facial or upper teeth pain
• Fatigue
• Malaise
• Fever

174
Chronic Sinusitis Diagnosis Treatment

• Diagnosis H P, CT sinuses
• Treatment
• Antibiotics
• Decongestants
• Analgesic
• Nasal irrigation with NS
• Inhaled corticosteroid
• Increase fluids
• Avoid environmental pollutants

175
Chapter 13 Management of Common Illnesses,
Disease, and Health Conditions Integumentary
176
Integumentary

• Skin cancer
• Herpes zoster (shingles)

177
Skin Cancer

• Three major types
• Basal cell
• Squamous cell
• Malignant melanoma (MM)
• The major risk factor for all types of skin
  cancer is sun exposure.
• Most skin cancers, when treated early, have a
  good prognosis
• Prevention is key

178
Basal Cell Carcinoma
179
Skin Cancer (Basal Cell)

• Most common skin cancer
• Accounts for 65 - 85 of cases
• Found on the head or face, or other areas exposed
  to the sun
• When treated early, easily removed through
  surgery
• Not life threatening, though it is often recurring

180
Skin Cancer

• Squamous Cell
• More common in African American
• Less serious than malignant melanoma
• Malignant Melanoma
• Accounts for only 3 of all skin cancers
• Responsible for the majority of deaths from skin
  cancer
• Tx Surgery, chemotherapy, radiation therapy

181
Malignant Melanoma
182
Skin Cancer Patient Education

• The best treatment in the elderly is prevention
• All older persons, especially those with fair
  skin who are prone to sunburn, should wear sun
  block and protective clothing
• Annual physical examinations should include
  inspection of the skin for lesions
• Report any suspicious areas on the skin to the
  physician
• Check shape, color, and whether or not a lesion
  is raised, or bleeds

183
Herpes Zoster (Shingles) Background

• AKA Shingles
• Same virus that causes chicken pox
• Latent varicella virus after initial exposure
• Reactivated due to immunosuppression
• Painful vesicles along the sensory nerves
• Herpes zoster occurs in both men and women
  equally
• No specific ethnic variations
• More common in the elderly

184
Herpes Zoster Risk Factors

• Age o