Geriatrics 2KNR 365

Today (Porter & burlingame, 2006)•Diabetes Mellitus

•Cerebrovascular Accident (Stroke)

•Dementia

Diabetes Mellitus (Not just older adults)•Occurs when insulin production is too low

or when the body is unable to effectively use the insulin it produces

•Normally the body makes insulin to transport sugar (glucose) to cells. Cells use sugar for energy

•Symptoms:▫Excessive thirst, extreme hunger, frequent

urination, unusual weight loss, increase fatigue, irritability, & blurry vision

Diabetes Mellitus4 Primary Classifications•Type 1 Diabetes (T1D)

▫Insulin dependent & juvenile-onset diabetes

▫Body destroys cells that make insulin▫Primary occurs in children & young adults▫Risk factors include autoimmune, genetic,

and environmental factors▫No known methods to prevent or cure▫Will need to take insulin via injections or

insulin pump for their entire lives

Insulin Pump

Diabetes Mellitus4 Primary Classifications•Type 2 Diabetes (T2D)

▫Non-insulin dependent & adult-onset diabetes▫Most common form (90-95%)▫Body does not produce enough insulin or cells

don’t use insulin properly so there is a build up in the blood stream

▫If glucose levels not reduced, damage can impact eyes, kidneys, nerves, & heart

▫Associated with older age, obesity, family history of diabetes, prior hx of gestational diabetes, physical inactivity, race/ethnicity

Diabetes Mellitus4 Primary Classifications•Type 2 Diabetes

▫90% of newly diagnosed are overweight▫Usually control with diabetic diet, regular

exercise program, achieve & maintain ideal body weight, taking oral medication, insulin

▫Sometimes if enough weight is loss, T2D will go away

▫Increasingly being diagnosed in children

Diabetes Mellitus4 Primary Classifications•Gestational Diabetes (GD)

▫During pregnancy

•Pre-diabetes ▫Glucose levels are higher than normal but

not enough for dx of T2D▫Can prevent with diet & exercise

30 mins./day of moderate exercise 5-10% reduction in body weight

Diabetes Mellitus•5th leading cause of death

•Secondary problems▫Hypoglycemia (blood sugar too low)

Symptoms: shakiness, dizziness, sweating, hunger, headache, pale skin color, sudden moodiness or behavior changes, clumsy or jerky movements, confusion, tingling sensations around mouth

Treated: 3 glucose tablets, ½ cup of fruit juice, 5-6 pieces of hard candy

Clients carry blood sugar testing supplies

Testing Equipment

Diabetes MellitusSecondary Problems•Hyperglycemia (blood sugar too high)

▫Symptoms: High levels of sugar in urine, frequent urination, increased thirst

▫Treated: Exercise unless ketones are present

▫Urine stick•Ketoacidosis (build up of ketones in urine)

▫Mostly in clients with T1D▫Fruity odor on breath, confusion, ▫Life threatening & requires immediate

attention

Diabetes MellitusSecondary Problems•Heart disease and stroke (~65% of

deaths)•Kidney disease•Nervous system disease

▫Impaired sensation or pain in feet or hands•Amputations (+60% non-traumatic lower-

limb)•Dental disease•Blindness (diabetic retinopathy)

Diabetic Retinopathy• Diabetic retinopathy is caused by damage to blood

vessels of the retina. The retina is the layer of tissue at the back of the inner eye. It changes light and images that enter the eye into nerve signals that are sent to the brain

• Symptoms of diabetic retinopathy include:▫ Blurred vision and slow vision loss over time▫ Floaters▫ Shadows or missing areas of vision▫ Trouble seeing at night▫ Many people with early diabetic retinopathy have no

symptoms before major bleeding occurs in the eye.

Diabetic Retinopathy

TR Interventions•Teach to manage diabetes in real-life settings

▫How to maintain glucose levels when eating out (suggested 80-120 mg/dl)

▫How to problem solve for diabetic complications like low blood sugar

▫Insulin can’t be exposed to extreme heat or freezing temperatures

•Teach exercise basics (pp. 554-556)▫Doctor’s clearance

•Stress management and relaxation training

Cerebrovascular Accident (Stroke)

Cerebrovascular Accident (Stroke)

•3rd leading cause of death in elderly•A leading cause of severe, long-term

disability

•Form of brain injury that originates in brain itself▫Occurs when portion of brain deprived of

oxygen-rich blood▫Results in neurological impairments

Higher incidence in African-Americans Few people under 40 have stroke

Cerebrovascular Accident (Stroke)• Major cause = hypertension

• Most common form = cerebral thrombosis Blood clot in artery that supplies blood to brain

• Cerebral embolism Blood clot travels to brain from another part of body

• Cerebral hemorrhage Blood vessel bursts in brain Most serious form of stroke

Cerebrovascular Accident (Stroke)• Often no warning that stroke will occur

• If warning:▫ Sudden, temporary weakness or numbness of face, arm

or leg▫ Temporary difficulty or loss of speech or trouble

understanding speech▫ Sudden dimness or loss of vision, especially in 1 eye▫ An episode of double vision▫ Unexplained headaches or a change in headache

patterns▫ Temporary dizziness or unsteadiness▫ Recent change in personality or mental ability

Cerebrovascular Accident (Stroke)•Some may have a series of small strokes

before Transient ischemic attacks

•Degree of injury depends on type & location of damage

Hemiplegia

Cerebrovascular Accident (Stroke)• Right-brain stroke

▫Left side of body▫Visual deficits▫Memory loss, impulsive behavior▫Inappropriate reflex crying or laughter or

anger

• Left-brain stroke▫Right side of body▫Memory loss, speech & language problems▫Slow cautious behavior style

Cerebrovascular Accident (Stroke)Systems Affected

•Motor▫Hemiplegia, motor planning, coordination

•Cognitive▫Orientation, concentration, problem solving,

organizing, planning, time management, judgment, insight, sequencing, safety

•Sensory ▫Sensory awareness and processing

•Affect▫Emotions, lability, depression

Cerebrovascular Accident (Stroke) Systems Affected

• Vision▫Field cuts, double vision, depth perception▫Visual neglect (brain problem not vision)

Half of visual field disappears Eat from only 1 side of plate Talk to people standing on 1 side Can’t see car on left when crossing street

• Language (Aphasia)▫Receptive: No longer understand spoken or

written language▫Expressive: Can understand what is said or

written but can not respond

Cerebrovascular Accident (Stroke)• Stroke is preventable

▫Decrease hypertension, heart disease, high cholesterol, sleep apnea, smoking, alcohol use, and body weight

• Recognize a stroke▫S: Ask person to smile▫T: Ask person to talk▫R: Ask person to raise both arms

Call 911

Team Interventions

•Enhance independence•Restore functional skills & adapt for

functional losses•Prevent secondary complications•Encourage a healthy adjustment to

disability•Train family member or caregiver

TR Interventions•Neuroplasticity (pp 605-610)

▫Cognitive retraining Recovery (restore lost skills)

Gradual stepping Cueing Reinforced practice

Compensation (develop adaptations for lost skills) Memory books Recorders Alarms Placement of items

TR Interventions

•Visual neglect (pp. 190-191)▫Visual clues▫Bright colored tape so knows when turns

head far enough to see neglected area•Physical activity•Community accessibility & problem-

solving training•Energy conservation training

Dementia

Dementia• Multiple disorders where client experiences

decreased cognitive functions• Long-term, progressive, often lasting 10-20 years with

average of 3-8 years• Primary reason for admission to LTC• 5 primary types

▫ Alzheimer’s▫ Vascular▫ Due to other general medical conditions (tumors,

diabetes, hypothyroidism, vitamin B12 deficiency, infection)

▫ Substance-induced▫ Multiple etiologies

Alzheimer’s Criteria (APA) • Manifested by both impaired memory (long

or short term) & learning (can’t learn new information or can’t recall information previously learned) with 1 or more:▫ Aphasia (language disturbance)▫ Apraxia (impaired ability to carry out motor

activities despite intact motor function)▫ Agnosia (failure to recognize or identify objects

despite intact sensory function)▫ Disturbance in executive functioning (e.g.,

planning, organizing, sequencing, abstracting)

Alzheimer’s Criteria (APA)

•Cognitive deficits cause significant impairment in social or occupational functioning & represent significant decline from previous functioning

•Cognitive decline begins gradually & worsens steadily

Alzheimer’s Criteria (APA)

•Cognitive deficits are not due to any of the following:▫Other central nervous system conditions

(e.g., CVA, Parkinson’s, Huntington’s, subdural hematoma, brain tumor)

▫Systemic conditions that cause dementia (e.g., hypothyroidism, vitamin B-12 or folic acid deficiency, HIV infection)

▫Substance-induced conditions

Alzheimer’s Criteria (APA)

•The deficits do not occur exclusively during the course of a delirium

•The disturbance is not better accounted for by another Axis 1 disorder (e.g., Major depressive disorder, Schizophrenia)

Delirium• The symptoms of delirium come on quickly, in hours or days, in

contrast to those of dementia, which develop much more slowly.• Delirium symptoms typically fluctuate through the day, with periods

of relative calm and lucidity alternating with periods of florid delirium.

• The hallmark of delirium is a fluctuating level of consciousness. Symptoms may include:▫ decreased awareness of the environment ▫ confusion or disorientation, especially of time ▫ memory impairment, especially of recent events ▫ hallucinations ▫ illusions and misinterpreted stimuli ▫ increased or decreased activity level ▫ mood disturbance, possibly including anxiety, euphoria or depression ▫ language or speech impairment

◦ Free Medical Dictionary

Global Deterioration Scale (GDS)

• 1: No cognitive decline• 2: Very mild cognitive decline

Age associated memory impairment• 3: Mild cognitive decline• 4: Moderate cognitive decline

Mild dementia• 5: Moderately severe cognitive decline

Moderate dementia• 6: Severe cognitive decline

Moderately severe dementia• 7: Very severe cognitive decline

Severe dementia

Also see text pp. 54-55

Secondary Problems

•Agitation and aggression▫Combativeness, hyperactivity, disinhibition

related to socially acceptable behaviors•Decubitus ulcers (pp. 635-637)•Depression•Pacing•Psychosis

▫Delusions, hallucinations (e.g., stealing, seeing or hearing someone from past)

•Sleep disturbance

Geriatric Assessment Tools• Caregivers• Dementia and Delirium• Functional Assessment /

ADLs• Gait and Immobility / Fall

Risk• Nutrition / Weight Loss• Oral Health• Sensory Perception• Urinary Incontinence

• Depression▫ Geriatric Depression

Scale▫ Long & short scale

• Pain• Pressure Ulcers

• See course website for links

MDS 3.0 (2009)

•http://www.uncg.edu/ctr/mds3/mds3

▫All very helpful▫See MDS 3.0 and Recreational Therapists

•http://semerwp.saluddigital.net/wp-content/uploads/2010/09/seccal-mds30.pdf ▫Copy of form▫New Manual 10/2013 (see website)

BANDI-RT Assessment

•Buettner, Connolly & Richeson, 2011•Designed to follow MDS 3.0 to help CTRS

review all relevant areas of function to design care plan

•Instructions & instrument in American Journal of Recreation Therapy, vol 10, no 3, 2011

•Instrument on ATRA website (members only)

Evidence-based Practice•Dementia Practice Guideline for Recreational

Therapy: Treatment of Disturbing Behaviors▫Buettner & Fitzsimmons, 2003▫Trainings at conferences

•Falls Protocols (linked on class web site)▫Walking, air mat therapy ($1,700), exercise

group▫Buettner

•Wheelchair Biking for Treatment of Depression▫Fitzsimmons, 2010▫http://www.guideline.gov/content.aspx?id=34019

Duet Bike (cost $4,750)

Evidence-based Practice

•Cognitive Stimulation for Apathy in Probable Early-Stage Alzheimer’s▫Journal of Aging Research, 2011▫Buettner, Fitzsimmons, Atav, & Sink

•Brain Fitness▫Fitzsimmons, 2008

Care Plans

•Quality of Life Outcomes for People with

Alzheimer’s Disease and Related Dementia

•Promoting Positive Behavior Health: A Non-pharmacologic Toolkit for Senior Living Communities

Linked on class web page

Resources

•Activities Director’s Quarterly for Alzheimer’s & Other Dementia Patients

•ATRA Geriatric Treatment Network•Geriatric Recreational Therapy (GRT)

Certificate▫University of North Carolina at Greensboro▫15 credit hours all online▫Geriatric specialization by NCTRC▫Buettner▫http://www.uncg.edu/ctr/GRTCert.pdf

Resources

•National Council of Certified Dementia Practitioners

•Love, Loss, and Laughter