Kristen Mauk

Background

This type of cancer occurs mainly in older adults, with an average age at diagnosis of 73 years, with 9 out of 10 cases of bladder cancer diagnosed in persons over age 55. The American Cancer Society (ACS)(2012) reported that over 73,000 cases were diagnosed in 2012 and that this diagnosis rate has been relatively stable over the last 20 years. Men are three times as likely to get cancer of the bladder as women (American Foundation for Urologic Disease, 2008) and the incidence increases with age.

Risk Factors

Risk factors include chronic bladder irritation and cigarette smoking, the latter contributing to over half of cases. Male gender and age are also risk factors.

Warning signs

The classic symptom of bladder cancer is painless hematuria (blood in the urine). Older adults may attribute the bleeding to hemorrhoids or other causes and feel that because there is no pain, it must not be serious.

Diagnosis

Assessment begins with a thorough history and physical. Diagnosis may involve several tests including an intravenous pyelogram (IVP), urinalysis, and cystoscopy (in which the physician visualizes the bladder structures through a flexible fiber-optic scope). This is a highly treatable type of cancer when caught early. In fact, the ACS (2012a ) estimates that there were more than 500,000 survivors of this cancer in 2012.

Treatment

Once diagnosed, treatment depends on the invasiveness of the cancer. Treatments for bladder cancer include surgery, radiation therapy, immunotherapy, and chemotherapy (ACS, 2012). Specifically, a transurethral resection (TUR) may involve burning superficial lesions through a scope. Bladder cancer may be slow to spread, and less invasive treatments may continue for years before the cancer becomes invasive or metastatic, if ever. Certainly chemotherapy, radiation, and immune (biological) therapy are other treatment options, depending on the extent of the cancer.

Immune/biological therapy includes Bacillus Calmette-Guérin (BCG) wash, an immune stimulant that triggers the body to inhibit tumor growth. BCG treatment can also be done after TUR to inhibit cancer cells from re-growing. Treatments are administered by a physician directly into the bladder through a catheter for 2 hours once per week for 6 or more weeks (Mayo Clinic, 2012a). The patient may be asked to lay on his/her stomach, back, and or sides throughout the procedure. The patient should drink plenty of fluids after the procedure and be sure to empty the bladder frequently. In addition, because the BCG contains live bacteria, the patient should be taught that any urine passed in the first six 6 hours after treatment needs to be treated with bleach: One cup of undiluted bleach should be placed into the toilet with the urine and allowed to sit for 15 minutes before flushing (Mayo Clinic, 2012a).

If the cancer begins to invade the bladder muscle, then removal of the bladder (cystectomy) is indicated to prevent the cancer from spreading. Additional diagnostic tests will be performed if this is suspected, including CT scan or MRI. Chemotherapy and/or radiation may be used in combination with surgery. When the cancerous bladder is removed, the person will have a urostomy, a stoma from which urine drains into a collection bag on the outside of the body, much like a colostomy does. Bleeding and infection are two major complications after surgery, regardless of type, whether a TUR or cystectomy is performed. Significant education of the patient related to intake/output, ostomy care, appliances, and the like is also indicated.

Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L.
Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Sudbury, MA: Jones and Bartlett Publishers. Used with permission.

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Background

Stroke, also known as cerebrovascular accident (CVA) or brain attack, is an interruption of the blood supply to the brain that may result in devastating neurological damage, disability, or death. Approximately 795,000 people in the United States have a new or recurrent stroke each year (American Stroke Association [ASA], 2012a). Stroke accounts for 1 in 18 deaths, making it the fourth leading cause of death in the United States. A death from stroke occurs every 4 minutes and the cost of stroke treatment and disability was over $73 billion dollars in 2010. Death from stroke is generally higher among females, with higher rates in Black males (67.7/100,000) and females (57.0/100,000) than in Caucasians (ASA, 2012a). In Canada, stroke is the fourth leading cause of death, affecting 50,000 people each year (Heart and Stroke Foundation of Canada, 20059).
There are two major types of stroke: ischemic and hemorrhagic. The vast majority of strokes are caused by ischemia (87%), usually from a thrombus or embolus (ASA, 2012a). The symptoms and damage seen depend on which vessels in the brain are blocked. Carotid artery occlusion is also a common cause of stroke related to stenosis

Risk Factors

Some risk factors for stroke are controllable and others are not. The most significant risk factor for stroke is hypertension. Controlling high blood pressure is an important way to reduce stroke risk. Those with a blood pressure of less than 120/80 have half the lifetime risk of stroke as those with hypertension (ASA, 2012a). Smoking 40 or more cigarettes per day (heavy smoking) increases the stroke risk to twice that of light smokers. If a person quits smoking, their risk after 5 years mirrors that of a nonsmoker, so older adults should be particularly encouraged to stop smoking.

Warning Signs

Several warning signs are common. These include:
SUDDEN numbness or weakness of face, arm or leg – especially on one side of the body.
SUDDEN confusion, trouble speaking or understanding.
SUDDEN trouble seeing in one or both eyes.
SUDDEN trouble walking, dizziness, loss of balance or coordination.
SUDDEN severe headache with no known cause (National Stroke Association, 2013)

Diagnosis

There are several tools for assessing for signs and symptoms of stroke. One easy acronym is FAST:
F stands for facial droop. Ask the person to smile and see if drooping is present.
A stands for arm. Have the person lift both arms straight out in front of him. If one is arm is drifting lower than the other, it is a sign that weakness is present.
S stands for speech. Ask the person to say a short phrase such as “light, tight, dynamite” and check for slurring or other abnormal speech.
T stands for time. If the first F-A-S checks are not normal, then one is to remember F-A-S-T that Time is important and the emergency medical system should be activated (National Stroke Association, 2012).
Older adults experiencing the warning signs of stroke should note the time on the clock and seek immediate treatment by activating the emergency response system in their area calling 911 (American Stroke Association, 2012). Transport to an emergency medical facility for evaluation is essential for the best array of treatment options. A history and neurological exam, vital signs, as well as diagnostic tests including electrocardiogram (ECG), chest Xx-ray, platelets, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, and glucose are routinely ordered. Diagnostic testing imaging may include computed tomography (CT) without contrast, magnetic resonance imaging (MRI), arteriography, or ultrasonography to determine the type and location of the stroke. The CT or MRI should ideally be done within 90 minutes so that appropriate emergency measures may be initiated to prevent further brain damage.

Treatment

The first step in treatment is to determine the cause or type of stroke. A CT scan or MRI must first be done to rule out hemorrhagic stroke. Hemorrhagic stroke treatment often requires surgery to evacuate blood and stop the bleeding.
The gold standard at present for treatment of ischemic stroke is t-PA (tissue plasminogen activator). At this time, t-PA must be given within 3 hours after the onset of stroke symptoms. This is why it is essential that older adults seek treatment immediately when symptoms begin. Only about 3 – 5% of people reach the hospital in time to be considered for this treatment (ASA, 2012d). t-PA may be effective for a select group of patients after the 3-hour window (up to 4.5 ½ hours), and this treatment window has been approved in Canada (Heart and Stroke Foundation of Canada, 2009). The major side effect of t-PA is bleeding. t-PA is not effective for all patients, but may reduce or eliminate symptoms in over 40% of those who receive it at the appropriate time (Higashida, 2005). Other, much less common procedures such as angioplasty, laser emulsification, and mechanical clot retrieval may be options for treatment of acute ischemic stroke.
To prevent recurrence of thromboembolic stroke, medications such as aspirin, ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), heparin, warfarin (Coumadin), and enoxaparin (Lovenox) may be used to prevent clot formation. Once the stroke survivor has stabilized, the long process of rehabilitation begins. Each stroke is different depending on location and severity, so persons may recover with little or no residual deficits or an entire array of devastating consequences.
The effects of stroke vary, and some persons may recover with no residual effects. But more often, stroke survivors may have problems that include hemiplegia or hemiparesis (paralysis or weakness on one side of the body), visual and perceptual deficits, language deficits, emotional changes, swallowing dysfunction, and bowel and bladder problems. Ninety percent of all dysphagia (swallowing problems) results from stroke (White, O’Rourke, Ong, Cordato, & Chan, 2008).

Poststroke Rehabilitation

Rehabilitation after a stroke focuses on several key principles. These include maximizing functional ability, preventing complications, promoting quality of life, encouraging adaptation, and enhancing independence. Rehabilitation emphasizes the survivor’s abilities, not disabilities, and helps him or her to work with what he or she has while acknowledging what was lost.
Stroke survivors go through a unique recovery process. This model shows the process of stroke recovery where forward progress after stroke lead to acceptance and adaptation:

If significant functional impairments are present, evaluation for transfer to an intensive acute inpatient rehabilitation program is recommended. Inpatient rehabilitation units offer the survivor the best opportunity to maximize recovery, including functional return. An interdisciplinary team of experienced experts, including nurses, therapists, physicians, social workers, and psychologists, will help the survivor and the family to adapt to the changes resulting from the stroke. Outcomes for geriatric stroke survivors are enhanced by intensive rehabilitation programs, whether offered in rehabilitation units or in skilled nursing facilities (Duraski, Denby, Danzy & Sullivan, 2012; Jett, Warren, & Wirtalla, 2005).
A large amount of teaching is often done by stroke rehabilitation nurses who work with older survivors and their families. These include knowing the warning signs of stroke and how to activate the emergency response system in their neighborhood, managing high blood pressure, understanding what medications are ordered as well as how often to take them and why, the importance of regular doctor visits, preventing falls and making the home environment safe, available community education and support groups, and the necessity of maintaining a therapeutic regimen and lifestyle to decrease the risk of complications and recurrent stroke. All survivors will need assistance in re-integrating into the community. This is generally begun in the rehabilitation setting.

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Background

There are three major types of skin cancer: basal cell, squamous cell, and malignant melanoma (MM). Basal cell carcinoma is the most common skin cancer, accounting for 65–85% of cases (Kennedy-Malone et al., 2000). According to the American Cancer Society (2013), more than 3.5 million cases of basal cell and squamous cell skin cancer are diagnosed every year. Squamous cell carcinoma is more common in African Americans and is also less serious than malignant melanoma. Malignant melanoma accounts for only 3% of all skin cancers, but it is responsible for the majority of deaths from skin cancer. Older adults are 10 times more likely to get MM than adults under age 40 (Johnson & Taylor, 2012). About 8,420 people were estimated to die from malignant melanoma in 2008. The American Cancer Society (2013) estimated that in 2013 there would be over 76,000 new cases of malignant melanoma in the United States.

Risk Factors

Older adults are more susceptible to skin cancers because of a variety of factors. These include exposure to carcinogens over time (such as through sunburn or tanning booths) and immunosenescence, or a decline in immune function. Family history of skin cancers, multiple moles (more than 100), and pale skin also put a person at higher risk. The major risk factor for all types of skin cancer is sun exposure.

Warning Signs

The ABCDE method can help people remember the warning signs of skin cancer:
A = Asymmetry (if a line is drawn down the middle of the lesion, the two sides do not match)
B = Border (the borders of the lesion tend to be irregular)
C = Color (a variety of colors is present; the lesion is not uniform in color)
D = Diameter (MM lesions are usually larger)
E = Evolving (note any changes in shape or size, or any bleeding)

Diagnosis

Annual physical examinations should include inspection of the skin for lesions. Older adults should be taught to report any suspicious areas on their skin to the physician. Persons should particularly look for changes in shape, color, and whether a lesion is raised or bleeds.

Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common kind of skin cancer. It is often found on the head or face, or other areas exposed to the sun. Although there are different forms of BCC, the nodular type is most common, and appears as a raised, firm, papule that is pearly or shiny with a rolled edge. (Johnson & Taylor, 2012). Patients often complain that these lesions bleed and scab easily. When treated early, it is easily removed through surgery and is not life threatening, though it is often recurring.

Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) also appears as lesion on areas of the body exposed to the sun, or from other trauma such as radiation. HPV is a risk factor of SCC, and metastasis is more common than with BCC. The lesions of SCC appear scaly, pink, and thicker than BCC. Their borders may be more irregular and the lesions may look more like an ulceration.

Malignant Melanoma

Malignant melanoma MM has a more distinctive appearance than other types of skin cancer. The areas appear asymmetric with irregular borders, a variety of colors (including black, purplish, and pink), and size greater than 6 mm. Malignant melanoma MM is often identified with the ABCDE method and MM accounts for the vast majority of deaths from skin cancer. The good news is that MM is almost always curable when found early. A skin check should be part of an older person’s yearly physical.

Treatment

The best treatment for skin cancer in the elderly is prevention. All older persons, especially those with fair skin who are prone to sunburn, should wear sunblock and protective clothing. Most skin cancers, when treated early, have a good prognosis.

All skin lesions larger than 6 mm, or those with any of the ABCDE signs, should be referred for biopsy. There are many nonsurgical interventions. These include cryotherapy, radiotherapy (for superficial BCC or SCC), electrodessication and curettage, and topical treatments. Topical treatments are generally not as effective as more aggressive interventions, but research is ongoing in this area.

The prognosis for MM depends on the extent and staging of the tumor, but when caught very early, the cure rate is nearly 100%. Malignant melanoma MM presenting in older adults is often more advanced and aggressive. Malignant melanoma MM metastases sites are typically the lymph nodes, liver, lung, and brain (Johnson & Taylor, 2012). Surgical treatment is required in malignant melanoma, with chemotherapy and radiation. Adjuvant treatments for MM are also often used.

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