Jump to content

Topics About 'Elder Patients'.

These are topics that staff believe are closely related. If you want to search all posts for a phrase or term please use the Search feature.

Found 3 results

  1. This is Part 2 of a two-part series of articles on caring for the elderly in the ED setting. Sanders (1996) developed 11 principles of geriatric emergency care that should be used when assessing older adults. These precepts are as follows: Complex Presentation Older adults, those at least 65 years of age, often present as complex patients for a number of reasons that extend beyond physical disease. It may be difficult to distinguish which symptoms are the patient's chief complaint, as well as which symptoms are the most important, as the elder may have multiple complaints. In fact, the clinician may feel overwhelmed by the deluge of complaints. The nurse needs to take the time to listen carefully, record each complaint, and ask insightful questions. For instance, late one evening, an infirm older adult came to the ED with complaints of back pain, indigestion, and headache. Upon further questioning, the patient mentioned that he was also experiencing chest discomfort, tightness, and pressure. It was interesting that "chest pain" was not even mentioned in his initial litany of complaints. Teasing out this vital information took quite a bit of time and effort. Atypical Symptomology The elderly patient often presents atypically. Because illness in older adults is complicated by the normal changes of aging and multiple chronic conditions, many older adults do not display the usual signs and symptoms of illness. Atypical presentation of illness in older adults includes absence of fever and cough, anorexia, confusion, dizziness, falls, fatigue, new-onset incontinence, lethargy, level of consciousness changes, malaise, self-neglect, and unexplained weight loss. For instance, the typical symptoms of pneumonia include chills, fever, cough, chest pain, labored breathing, fatigue, and bloody sputum. In the older adult patient, many of these signs and symptoms may be absent. The elder with pneumonia may simply present with level of consciousness changes and anorexia. Depression may be masked by nonspecific somatic complaints, such as multiple "aches and pains." Falls may signify serious illness in the frail patient. Confusion, lethargy, new-onset incontinence, and/or anorexia may signal a urinary tract infection or urosepsis. Atypical presentation often delays the diagnosis of acute illness with a resultant higher rate of mortality. It is essential for nurses to conduct careful and thorough assessments of older adults to consistently recognize vague presentations of illness and ensure appropriate and early treatment. Multiple Pathology (Comorbidities) The majority of the elderly contend with two or more chronic medical conditions, or comorbidity. Chronic diseases are more common than acute illnesses in the older age group. The chronic disorders most prevalent in the older population are ones that can have a significant impact on independence and the quality of daily life. Examples of comorbid conditions are cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), diabetes, arthritis, hypertension, and Alzheimer's disease. Elderly patients with multiple chronic conditions often have worse outcomes and increased mortality. Indeed, chronic conditions account for 70 percent of all deaths in the U.S. Older adults usually visit the ED for an acute exacerbation of chronic disease such as heart failure or COPD. Polypharmacy The elderly are more likely to take multiple medicines. People aged 65 and over comprise 13 percent of the population but account for 34 percent of all prescriptions. On any given day, the average senior takes four or five prescription drugs and two over-the-counter (OTC) medications. Because they take more medications than younger people, the elderly have a higher risk of adverse reactions. As a matter of fact, 5 percent of all elder hospital admissions are related to an adverse drug event. It is vital to have an effective method of medication reconciliation in the ED. This includes accounting for all prescription medications, OTC products, herbals, and supplements. Cognitive Impairment An estimated 40 percent of all elderly ED patients have some form of cognitive impairment (i.e., dementia or delirium). Older patients with cognitive impairment are vulnerable, since they may be unable to make decisions for themselves or function independently when they visit the ED. This can pose many challenges for ED clinicians during admission, assessment, and treatment. Delirium is the most common cognitive impairment, and it is often under recognized and overlooked. Also known as an acute state of confusion, delirium is a medical emergency, with a fatality rate as high as acute MI or sepsis. It can present as lethargy, agitation, or a fluctuation between these two transient states. Correctly identifying cognitive impairment is critical for medical testing, effective treatment, and to facilitate safe and realistic discharge planning. Physiological Efficiency Aging results in a diminished ability to maintain homeostasis and regulate body systems. Organ function becomes less efficient with age, correlating with laboratory values. For instance, the glomerular filtration rate (GFR) of a ninety-year old is normally half that of a twenty-year-old. Other alterations include alkaline phosphatase, cholesterol, PSA levels, and sed rate values, which increase somewhat in seniors. To provide safe and effective care in the geriatric population, clinically significant changes in lab values need to be recognized and accurately interpreted. Decreased Functional Reserve As a result of the effects of aging on the physiological processes, the elderly have less functional reserve. While performing normal activities, the elderly may function well. When stressed by illness or injury, however, their functional reserve may be depleted quickly. As people age, functional reserve diminishes so that a stressful event can have much more severe consequences. Older people who develop acute illness or suffer a trauma usually require longer periods of recovery and have more complications from these conditions. Importance of Family or Community Support Does the older adult require assistance with performing daily activities? Are caregivers available to help him or her? Correctly assessing an elder's support system is critical to discharge planning. Baseline Premorbid Health Status It is important to know the older person's baseline health status to discern cognitive and functional decline and assist diagnosis and treatment. A simple strategy is to compare the presenting signs and symptoms with the elder's normal baseline that preceded this occurrence. Medical history provided by the family can provide important clues as to what is normal and abnormal for the patient and what may be the underlying cause of the presenting signs and symptoms. Psychosocial Impact of Illness and Trauma Social and personal concerns of the elderly are frequently not addressed in ED encounters. Emotional problems, such as depression, often influence somatic complaints and can disguise underlying health problems. The Need for Comprehensive Assessment Some specific areas that ED nurses can focus on include a more comprehensive approach to assessment and discharge planning, improved communication with the patient and their informal caregivers, substance abuse, and elder abuse and neglect. Failure to consider the possibility of abuse and neglect will mean that the appropriate diagnosis is not made and the older adult is returned to an unsafe environment. Danger signals are sudden weight loss, dehydration, medication over dosing or under dosing, injury marks, personal neglect, car accidents, forgetfulness, extreme suspiciousness, fires in the house, bizarre behavior, or disorientation. Emergency department nurses are challenged to meet the needs of older patients, who have complex presentations and require comprehensive assessment and referral. Problems such as atypical presentation, chronic health conditions, altered cognitive state, and polypharmacy can complicate diagnosis and management. These 11 principles can assist clinicians in meeting these challenges and help ensure that older adult patients receive appropriate care in the ED setting. References Aging Effect on Laboratory Values The Unlikely Geriatricians
  2. tokebi

    A Bathroom Reminiscence

    I love nursing. No, I am not one of those who finds self-worth through the notion of "helping others." It's actually the opposite, as I get helped by those I nurse whether they know it or not. Their vitality, their spirit, their dedication to living, replenish my otherwise colorless inner world. So often people tell me, "Oncology! That must be so depressing!" Only if they knew... I know what depressing is. My work is anything but; fighting for one's life, enduring the agony of brutal therapy with an unwavering hope, or the solemn moment of coming to terms with one's mortality... That's not depressing. It's uplifting. So I listen to them, lapping up whatever pieces of wisdom they offer, and the world seems a little brighter when I step out of the hospital. But enough with the meandering introduction. I actually want to tell you a story of an elderly gentleman whom I had the pleasure of taking care of for a few nights. We knew he was a Holocaust survivor from reading his history. He was also one of those "pleasantly confused" patients, inducing smiles on everyone who came in contact with him. If you asked how he was doing, he would flash the brightest grin you have ever seen and declared with arms spread, "Simply wonderful! Everyone's so kind here! Thank you, thank you!" If you gently reminded him to finish the apple sauce suspended in his hands forgotten, he would raise his eyebrows in surprise, "Oh, I can eat this? How kind of you. Hmm mm... it's delightful!" On this particular night, I found myself squeezed inside the cramped bathroom holding his shoulder so that he will not tip forward while he sat on the toilet. I stood there, my idle hand rubbing his back, wishing his grunting effort will produce result soon. Suddenly, he looked up at me and asked, "Do you know what this means?" I looked down and saw the old tattoo on his arm - the mark of an unspeakable horror of the past. I nodded yes, feeling my heart thump at this sudden start of a conversation. He contemplated his arm for a bit longer, and with an unusual lucidity, he began his story: "You know, life is a very precious thing. I do not take anything for granted, and I am so happy and appreciative for all the things I have. You know, I would not be here if it weren't for my mother. She taught me everything. I was just a boy when we were sent to the camp. It was horrible. Horrible. Do you know what a commandant is? I would never forget this commandant. He would put on his fancy, shiny uniform. He had two guns... one on each side. He would walk down the rows of prisoners..., and shoot as he walked... I was so scared of him. After we were liberated, I was there at his trial. I still remember what he said. He said, 'Yes, I killed them. But I do not regret it.' Can you believe it? That's what he said. Oh, I was so angry... What did I know? I was only a boy. But my mother told me not to hate. My mother... she was an amazing woman. My brothers died in the camp. We lost everything. And yet, my mother taught me that there is no use hating. You know what she did? She would always have candies with her when she went out and give them out to German children. I asked her why. She said, 'Because children are innocent.' Can you believe it? A woman who lost her own children! She had so much love, and she taught me how to live. You know, life is so short. It is too short and precious to waste on hating. Be happy! Life is full of beautiful things if you look." Disclaimer: Just wanted to mention, there were more to his story but I am omitting all the possible descriptions that could potentially identify him. So it is impossible to convey the degree of outrage and awe that I felt at the time.
  3. I rang the doorbell a second time-holding it just a fraction of a second longer than usual. I could hear the chiming inside and I knew the elderly couple were at home. But the dog barked loudly and I suspected that they had trouble hearing. After several more minutes, Mr. P cracked open the door, smiling widely when he recognized me as the Parish Nurse from his church. "Hello, Mr. P! How are you? How is Millie* doing? Do you mind if I come in a visit a little while?" I had come to visit after a church member called to say that Mr. and Mrs. P had stopped attending Sunday School and seemed confused the few times they came. Previously very active, the couple seemed unkempt and unable to answer basic questions. "Oh, she's right in here. Come this way. I'm so glad you are here. We are just in here watching TV." I stepped over a pile of feces and noticed the dog penned in the kitchen, barking frantically. He did not looked pleased with my intrusion and barred his teeth with a growl, so I made a point of staying clear and followed Mr. P into the family room where I was met with more dog waste odors, along with piles of newspapers scattered on the floor, and leftover paper plates, smeared with the remains of forgotten dinners, piled up on a coffee table. I sat down beside Millie and introduced myself, gently taking her hand. She looked over vacantly at me. I told her I had brought a casserole from the church and chatted a little while with them before getting up to put the food in the refrigerator. Mr. P held the dog while I placed the dish beside a nearly empty gallon milk jug. Besides condiments and a small bag of wrinkled carrots, there was little else. I asked Mr. P about his son and how to contact him. While Millie was initially quiet, she warmed up and began telling me about her job and how she planned to go back to work, though I knew she had retired many years prior. Mr. P smiled. He answered questions that let me know he was still aware of date, time and general information but before I said any more he volunteered, "We are having a hard time. Millie can't remember much of anything at all and I'm not much better off myself." I asked permission to call their son and he said that would be fine. "But," Mr. P added, "he's so busy with his job. He don't come around much. And he lives away off." I called the son from my car. He lived several hours away and had not been to visit in six months. Meanwhile, he talked with them on the phone every Sunday. I could tell that he really had no idea how much things had deteriorated in that interval. I told him a little of what was going on and he assured me he would come in that week-end and take care of their needs. "So what do you think I should do? Is it time to move them out of the house? You know, Daddy built that place and he has told me that he won't move out until the hearse comes by to get him." As a Parish Nurse or a nurse that is working with a family like this, what do you do? Of course each situation is different, but there are some general principles that help us help families who face this type of situation: Making a financial assessment when possible helps to determine direction. Without having too many specifics, a nurse can help . Financial resources do play a considerable role in options for elder care. Empowering the family to work together to make decisions that make sense to them. They know their family culture, values, circumstances. Providing as many feasible options as possible and let people make decisions as long as they can. Keeping in mind that while safety and cleanliness are worthwhile goals, there are many ways to achieve these goals where people can still maintain some autonomy. State assistance programs vary widely from state to state and location to location so it is important to know how to access and refer to available social service programs. If families are unable or unwilling to provide eldercare then Adult Protective Services must be notified. As nurses, we are often called into difficult family, neighborhood and professional situations simply because we are medical and in a helping profession. Helping families through these difficult times of adjustment can be a real gift to them so it's important for us to know how to prioritize and plan. In a situation such as the one I described, it is so tempting to want to pull them out of their setting and into a more "safe" environment. As nurses we can lean toward wanting to "fix" things for them, but studies show that people are happier longer staying in their familiar surroundings (nia.nih.gov). In this particular case, the son came and was horrified at what he found. He was able to pay for a professional cleaning service to come in; he gated the back yard for the dog and provided some outside shelter; and he hired a neighbor to come in three times a week to cook a meal and do some grocery shopping. These simple interventions put Mr. and Mrs. P back on a path to well-being and better coping. They still continued to decline and experienced repeated hospital and ER visits, but with the neighbor there, the son was able to monitor things from a distance and make adjustments as needed. I also stayed in touch with all of them and provided assistance from time to time. In this setting, the son had limited financial resources, but he was able to obtain legal power of attorney and function as a supervisory caregiver for his parents. They owned their home, so even though they did not have a lot of savings, their social security income was adequate to keep them aging in place. But what if the son had not been willing or able to help out? When that is the case, the care becomes much more complicated. Generally, the levels of care include the following in order from least care to most: At home, independent, able to do all ADL's. At home but requiring cues and reminders, assistance with meals, ADL's appointments. Sometimes a maid or an occasional companion. At home with regular care coming in for several hours a week. Dependent for ADL's, meals, all medication management and transportation. Facility for independent living with meals provided but little assistance in the individual apartments. Facility with assisted living. Private pay. Must be able to transfer and do some ADL's but some assistance provided with all needs. Nursing home facility. Paid for on a limited basis when for rehabilitative services. Otherwise, private pay. Maximum assistance provided. Higher level of complexity cared for. I visited Mr. and Mrs. P again several months later. Mr. P opened the door and told me the Meals on Wheels volunteer had just left. He pointed toward the kitchen where two styrofoam containers sat side-by-side. The house was still cluttered but now leaned toward "homey" instead of hazardous. What about you? Have you had some eldercare successes and some not so successful outcomes? *Name and some facts changed to protect privacy.