Background

Urinary tract infections (UTIs), also called cystitis (inflammation of the bladder), are common among older adults and are more frequent in women. They are a primary cause of urinary incontinence and delirium. Catheter-associated urinary tract infections (CAUTIs) are more common among older adults (Fakih et al., 2012) and is mainly attributed to the use of indwelling urinary catheters. Many indwelling catheters are thought to be unnecessary (Cochran, 2007) and one study noted that physicians were often not aware of the purpose for which their patients had a catheter inserted (Saint, Meddings, Calfee, Kowlaski, & Krein, 2009). UTIs have been show to increase morbidity and mortality, length of hospital stay, and cost of hospitalization (Kleinpell, Munro, & Giuliano, 2008). CAUTI is considered preventable and is not reimbursed by Medicare. Therefore, hospitals will largely assume the financial costs for preventable infections of this type.

Risk factors/Signs and symptoms

Several risk factors are associated with UTIs in general. These include being female, having an indwelling urinary catheter, the presence of urological diseases, and hormonal changes associated with menopause in women. Signs and symptoms of UTIs include urinary frequency and burning or stinging felt during voiding. Pain may be felt above the pubic bone, and a strong urge to void but with small amounts of urine expelled. The most significant risk factor for CAUTI is prolonged use of an indwelling catheter. In hospital-acquired UTIs, 75% are associated with the use of an indwelling catheter (CDC, 2012). In women, signs and symptoms of CAUTI may be more severe than those reported by women by patients in the community who do not have an indwelling catheter. Lethargy, malaise, onset or worsened fever, flank pain, and altered mental status have been associated with CAUTI (Hooton et al., 2010).

Diagnosis

A thorough assessment should be done of the patient’s urinary output, including amounts, color, odor, appearance, frequency of voiding, urgency, and episodes of incontinence. A urine specimen should be obtained if UTI is suspected. Laboratory results will show the type of organism causing the infection, and the sensitivity will tell what medication the organism is susceptible to. These results should be reported promptly to the physician or nurse practitioner caring for the patient and so that a diagnosis and treatment plan can be made.

Treatments

Prevention of UTIs is considered a primary nursing strategy. Elderly female patients can be instructed to make lifestyle modifications such as: increasing their fluid intake; emptying the bladder after sexual intercourse; practicing good perineal hygiene, including wiping front to back after toileting; getting enough sleep; and avoiding stress (PubMed Health, 2011). Although many of these common sense strategies are recommended by primary care providers, there is a lack of scientific evidence to support some of them. Many UTIs will clear up on their own, particularly if the person increases oral fluid intake during early symptoms. However, with many older adults, antibiotic treatment may be needed. In general, a course of three 3 days for healthy adults is thought to be sufficient, but for more resistant bacteria, a longer course more than five 5 days may be needed (PubMed Health, 2011). For those with repeated or chronic UTIs, a low dose of antibiotics taken for 6– 12 months may be indicated (Hooton et al., 2010). If the underlying cause is CAUTI, treatment will be more aggressive. Monitor the patient’s temperature at least every 24 hours (Carpenito, 2013). Encourage fluids. Evaluate the necessity of continuing an indwelling catheter if one is in place.

Alternatives to indwelling catheters should be considered for appropriate patients. Intermittent catheterization, if appropriate, is preferred over indwelling catheter use, especially for long- term maintenance of bladder management (CDC, 2009; Hooton et al., 2010). Condom catheters may be an appropriate choice for some males. If an indwelling urinary catheter is necessary, the catheter should be removed as soon as possible, per the physician or nurse practitioner’s orders, to reduce the risk of CAUTI.

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. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

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Portrait of a happy old couple sitting on quay by sea

For seniors, getting old is the new black. You can ask them yourself. Because according to a recent survey, 68% of seniors never feel offended for being treated like one, while 70.3% feel being called ‘old’ is hardly offensive. The truth is, getting old is blessing – not a curse.

For starters, age brings wisdom. By the time the grey hairs start popping up, you’ve had your fair share of experiences. You’ve likely travelled around a bit, held a few jobs, been through good and bad relationships, started a family, and made some life-changing decisions. But when it comes down it, you’re all the wiser for it. Going forward you can make better, more informed decisions, and even give your two cents to the younger generation.

As you mature, so too will your relationships. You’ll likely cut out the friendships that didn’t mean much, and work on the ones that do. Essentially, you’ll start seeking quality, not quantity, across all areas of your life – which isn’t a bad philosophy to live by. Plus, who said getting old isn’t fun?

Take LATA 65 for example, an art organisation in Portugal that’s destroying age stereotypes in the street art scene. By giving senior citizens the tools and knowledge to create their own stencils, the organisation’s goal is to connect the older and younger generations through art, as well as help the elderly get out and about to engage in contemporary culture.

But that’s just one example of how seniors are making the most of their retirement. What else are they getting up to?

How Aussies are living it up in their golden years

Gone are the days of knitting, card games and staying put. Seniors these days are proving to be one the most lively and radical bunch of seniors to date. According to the Golden Years Report, 85% of seniors consider themselves happy, while 80% are doing the things they really want to do.

In fact, most feel younger than they actually are. This can be attributed to being more physically active, learning new things, travelling to new places, having new experiences, being sociable, and having hobbies.

Seniors are also busting ‘old age’ stereotypes. For example, as technology becomes more prominent in our lives, Aussie seniors are no longer relying on others to show them the ropes. Instead, many are now technically savvy and spend plenty of time online. They also have no problem dressing like younger generations, speaking the same lingo (#YOLO), or even getting tattoos.

While they might not be huge spenders, today’s retirees are also spending more money than earlier generations. So instead of slowing down and disappearing modestly into retirement, they’re choosing to fork out just as much money (sometimes more) on their later lifestyles. And why not? Retirement isn’t an expiry date – it’s an excuse to live life to the fullest.

It’s safe to say, Australian seniors are reinventing the concept of ‘getting older’. They’re not confined to the activities and stereotypes usually associated with old age, and are instead open-minded, tech-savvy and progressive. They’re not just comfortable with the modern world, they’re enthusiastically making the most of it. So if there’s one take home message here, it’s this – there’s still plenty to look forward to.

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Background

Once thought to be mainly a disorder of children, recurrent seizures or epilepsy is thought to be present in about 7% of older adults (Spitz, 2005) and is usually related to one of the common comorbidities found in older adults (Bergey, 2004; Rowan & Tuchman, 2003). Epilepsy affects up to 3 million Americans of all ages (Velez & Selwa, 2003). Davidson & Davidson (2012) summarized findings of most studies on epilepsy in older adults with these main points:

Seizures can be caused by a variety of conditions in older persons, but “the most common cause of new-onset epilepsy in an elderly person is arteriosclerosis and the associated cerebrovascular disease” (Spitz, 2005, p. 1), accounting for 40–50% of seizures in this age group (Rowan & Tuchman, 2003). Seizures are associated with stroke in 5–14% of survivors (Spitz, 2005; Velez & Selwa, 2003). Other common causes of epilepsy in the elderly include Alzheimer’s disease and brain tumor.
There are three major classifications of epilepsies, although there are many additional types. Generalized types are more common in young people and associated with grand mal or tonic-clonic seizures. A number of cases have an un¬determined origin and may be associated with certain situations such as high fever, exposure to toxins, or rare metabolic events. In older adults, localized (partial or focal) epilepsies are more common, particularly complex partial seizures (Luggen, 2009). In contrast to young adults, Rowan and Tuchman (2003) cite other differences in seizures in the elderly: low frequency of seizure activity, easier to control, high potential for injury, a prolonged postictal period, and better tolerance with newer antiepileptic drugs (AEDs). Additionally, older adults may have coexisting medical problems and take many medications to treat these problems.

Risk Factors/Warning Signs

Risk factors for seizures in older adults include cerebrovascular disease (especially stroke), age, and head trauma. The most obvious signs and symptoms of epilepsy are seizures, although changes in behavior, cognition, and level of consciousness may be other signs. Also, note that exposure to toxins can cause seizures that are not epilepsy. Complex partial seizures in older adults may include symptoms such as “confusion, memory loss, dizziness, and shortness of breath” (Davidson & Davidson, 2012, p. 16). Automatism (repetitive movements), facial twitching with following confusion, and coughing are also signs of the more-common complex partial seizure (Luggen, 2009).

Diagnosis

Diagnosis is made by careful description of the seizure event, a thorough history, and physical. Eyewitness accounts of the seizure incident can be quite helpful, although many community-dwelling older adults go undiagnosed because their seizures are never witnessed. In addition, complete blood work, neuroimaging, chest X-ray, electrocardiogram (ECG), and electroencephalogram (EEG) help determine the cause and type of seizure (National Institute for Health and Clinical Excellence {NICE}, 2012).

Treatment

Treatment for epilepsy is aimed at the causal factor. The standard treatment for recurrent seizures is antiepilepsy drugs (AEDs). The rule of thumb, “start low and go slow,” for medication dosing in older adults particularly applies to AEDs. The elderly tend to have more side effects, adverse drug interactions, and problems with toxicity levels than younger people.
Research has suggested that older adults may have better results with fewer side effects with the newer AEDs than the traditional ones, though about 10% of nursing home residents are still medicated with the first-generation AEDs (Mauk, 2004). The most common older medications used to treat seizures include barbiturates (such as phenobarbital), benzodiazepines (such as diazepam/Valium), hydantoins (such as phenytoin/Dilantin), and valproates (such as valproic acid/Depakene) (Deglin & Vallerand, 2005; Resnick, 2008).
Several newer drugs are also used, depending on the type of seizure. Second-generation AEDs, including gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazepine (Trileptal), levetiracetam (Keppra), pregabalin (Lyrica), tiagabine (Gabitril), and topiramate (Topamax), are generally recommended over the older AEDs; however, older AEDS such as phenytoin (Dilantin), valproate (Depakote), and carbamazepine (Tegretol) are the most commonly prescribed treatment options (Resnick, 2008). Each of these medications has specific precautions for use in patients with certain types of medical problems or for those taking certain other medications. Regarding side effects in older patients, watch for potential stomach, kidney, neurological (especially poor balance or incoordination), and liver problems. Additionally, some newer extended-release AEDs are thought to be better tolerated and have a lower incidence of systemic side effects (such as tremors) (Uthman, 2004).

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.Burlington, MA: Jones and Bartlett Publishers. Used with permission.

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This time of year, many people pause to give thanks for the good things in their life, but did you know that giving thanks is good for your health?

Having an optimistic outlook on life and using positive coping skills to manage stress has been linked in numerous studies to a longer and happier life. One of the common themes among people over age 85 who report very good to excellent health (in spite of dealing with chronic illnesses) is just that – thinking positive. Norman Vincent Peale, in his famous book, “The Power of Positive Thinking” said:

The way to happiness: Keep your heart free from hate, your mind from worry. Live simply, expect little, give much. Scatter sunshine, forget self, think of others. Try this for a week and you will be surprised.

But what if you are not naturally a positive thinker, but more of a “the glass is half empty” kind of person? The good news is that you can begin to change your thinking to improve your health. If you are not sure where to start, consider some of these suggestions as a place to begin:

Count your blessings. There is an old hymn that was sung when I was girl. When I felt down and discouraged, I would sing this song. It went like this:

When upon life’s billows you are tempest-tossed. When you are discouraged thinking all is lost. Count your many blessings every doubt will fly. Then you will be singing as the days go by. Count your blessings. Name them one by one. Count your many blessings. See what God has done.

Sometimes it helps to list what you are grateful for on paper. If you need a place to start, an excellent resource is the book “One Thousand Gifts: Reflections on Finding Everyday Graces” by Ann VosKamp. Through a series of 60 short devotionals, the author walks you through a journey to greater appreciation and thankfulness for all that you have.

Learn to be content with what you have.  At the holidays, especially, it is easy to get caught up in thinking about what we wish we had and those things we don’t have. Try looking at it the other way- even in relationship to your health. For example, several years ago I had a catastrophic skiing accident, breaking my leg and tearing all of my knee ligaments. A subsequent blood clot complication meant that I couldn’t have surgery to repair the knee right away. After being in a wheelchair, on crutches, and in awful pain for months, with the help of countless hours of painful therapy and surgery a year later, I was finally able to walk almost normally again. Every day since then, when I am tempted to complain that I will never ski again, cannot kneel or squat, or do not have complete range of motion in that knee, I remind myself of those months when I couldn’t walk at all without help and how it felt to be completely dependent on others for everything. Each step I take, each walk in the sunshine, each little jaunt to the car, and the ability to ride a bicycle is a blessing. Every movement without pain is a bonus I never thought I would have again. Take time to recall when your situation was worse, and express joy that things are better than they were then.

Help others.  One of the best ways to stop feeling sorry for yourself and cultivate an attitude of gratitude is to serve others, especially those who are less fortunate than you. Volunteer to help serve food at the community Thanksgiving dinner or participate in Operation Christmas Child by making a shoebox for a boy or girl in a developing country who would otherwise have no gifts. Take food to your local food pantry. Mow the lawn or shovel snow for your widowed neighbor. Invite the single and lonely person to share Thanksgiving dinner with your family. Buy gifts through the Angel Tree Ministry for children of those in prison. Adopt a needy family. Even if you are homebound, you can encourage others by simple but meaningful tasks such as sending birthday or holiday cards to the people in your church or community group. A simple encouraging phone call can change a person’s day. By giving to others, you focus on positive parts of life and meaningful activities that in turn promote your positive mental health.

So, this Thanksgiving, push the pause button for a little while and take a moment to reflect on what you are grateful for. You may just find that Thanksgiving is good for your health.

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Alzheimer’s disease (AD) is the most common type of dementia seen in older adults. An estimated 5.4 million Americans of all ages had Alzheimer’s disease in 2012. Nearly half (45%) of people over the age of 85 have AD. By 2050, the number of individuals age 65 and over with Alzheimer’s could range from 11 million to 16 million unless science finds a way to prevent or effectively treat the disease. One in eight older adults has AD, and it is the sixth leading cause of death in the United States (Alzheimer’s Association, 2012). Those affected with AD may live from 3–20 years or more after diagnosis, making the life span with this disease highly variable.

Risk factors

Advanced age is the single most significant risk factor for AD (Alzheimer’s Association, 2012). More women than men have AD, but this is because women live longer than men, not because gender is a risk factor. Family history and heredity are also identified risk factors for AD, as are head trauma and poor cardiac health.

Warning Signs

Alzheimer’s disease is characterized by progressive memory loss. The person affected by AD is gradually less able to remember new information and memory lapses begin to affect daily function. It is a terminal disease that over its course will eventually leave a person completely dependent upon others for care.

Diagnosis

Initially, the clinical progression of the disease is slow with mild decline; however, deterioration increases the longer the person lives, with an average life span of 8 years after diagnosis (Cotter, 2002; Fletcher, Rapp, & Reichman, 2007). The underlying pathology is not clear, but a growth of plaques and fibrillary tangles, loss of synapses, and neuronal cell loss are key hallmarks of AD that interfere with normal cell growth and the ability of the brain to function. Absolutely definitive diagnosis is still through autopsy, although clinical guidelines make diagnosis easier than decades ago when less was known about the disease. Primary care physicians generally make the diagnosis through a thorough history, physical exam, cognitive testing, and labs. New criteria for diagnosis include staging the disorder and biomarkers (beta amyloid and tau in the cerebrospinal fluid and blood) (Alzheimer’s Association, 2012b). An MRI of the brain may be ordered to rule out other causes of symptoms.

The clinical course of AD is divided into several stages, depending on the source consulted. In the early course of AD, the person may demonstrate a loss of short-term memory. This involves more than common memory loss, such as where the keys were put, and may involve safety concerns such as forgetting where one is going while driving. The inability to perform math calculations and to think abstractly may also be evident. In the middle or moderate phase, many bodily systems begin to decline. The person may become confused as to date, time, and place. Communication skills become impaired and personality changes may occur. As cognitive decline worsens, the person may forget the names of loved ones, even their spouse. Wandering behavior as well as emotional changes, screaming, delusions, hallucinations, suspiciousness, and depression are common. The person with AD is less able to care for her- or himself and personal hygiene suffers. In the most severe and final phase, the person becomes completely dependent upon others, experiences a severe decline in physical and functional health, loses communication skills, and is unable to control voluntary functions. Death eventually results from body systems shutting down and may be accompanied by an infectious process. Although there is no single test, and the diagnosis may be one of exclusion, early diagnosis is important to maximize function and quality of life for as long as possible. Persons experiencing recurring and progressing memory problems or difficulties with daily activities should seek professional assistance from their physician.

Treatment

Treatment for AD is difficult. There are several medications (such as Aricept, Namenda, Razadyne, and Exelon) that may help symptoms (such as memory), but they do not slow the course of the disease. There is currently no cure; however, research continues to occur in pharmacology, nonpharmacology, and the use of stem cells to manage symptoms and perhaps one day eradicate the disease.

Treatment will focus on symptom management, particularly in the areas of behavior, safety, nutrition, and hygiene. Behavioral issues such as wandering and outbursts pose a constant challenge. Many long-term care facilities have special “memory care” units to care for Alzheimer’s patients from the early to late stages of the disease. These units provide great benefits such as consistent and educated caregivers with whom the patient or resident will be familiar, a safe and controlled environment, modified surroundings to accommodate wandering behaviors, and nursing care 24 hours a day. Additionally, nurses are present to manage medications and document outcomes of therapies. However, many family members wish to care for their loved ones at home for as long as possible.

Thus, another important aspect of care in AD is care for the caregivers. Howcroft (2004) suggested that “support from carers is a key factor in the community care of people with dementia, but the role of the caregiver can be detrimental to the physical, mental, and financial health of a carer” (p. 31). She goes on to say that the caregivers of persons with AD would benefit from training in how to cope with behaviors that arise in these patients and how to cope with practical and legal issues that may occur.

Research has shown that ongoing skills are needed by family caregivers to deal with the progressive decline caused by AD. In fact, “a 63% greater risk of mortality was found among unpaid caregivers who characterized themselves as being emotionally or mentally strained by their role versus noncaregivers” (National Conference of Gerontological Nursing Practitioners & National Gerontological Nursing Association, 2008b, p. 4). Adapting to stress, working on time management, maximizing resources, and managing changing behavior were all skills caregivers needed to develop in order to successfully manage home care of their loved ones. When interventions and resources were not used by caregivers in the early stages of the care recipient’s AD, the risk of a healthy patient being institutionalized due to caregiver burden was higher (Miller, Rosenheck & Schneider, 2012). Caregivers needed not only to acquire knowledge and skills, but also to make emotional adjustments themselves to the ever-changing situation.

Such findings suggest that nurses should focus a good deal of time on educating caregivers of persons with AD to cope with, as Nancy Reagan put it, “the long good-bye.” Scientists continue to explore the causes of AD and hope in the near future to be able to isolate the gene that causes it. In the meantime, results from a fascinating longitudinal study (called the Nun study) on aging and AD, which used a group of nuns who donated their brains to be examined and autopsied after death, has suggested that there is a connection between early “idea density” and the emergence of AD in later life. That is, essays the nuns wrote upon entry to the convent were analyzed and correlated with those who developed AD. It was found that those with lower idea density (verbal and linguistic skills) in early life had a significantly greater chance of developing AD (Grossi, Buscema, Snowdon, & Antuono, 2007; Snowdon, 2004). The nun study has allowed researchers to examine hundreds of brains so far in nuns who died between 75 and 107 years of age and discover other important facts such as a relationship between stroke and the development of AD in certain individuals, and the role of folic acid in protecting against development of AD (Snowdon, 2004). Scientists from a number of fields continue to research the causes and possible treatments for AD and the Nun study project is continuing at the University of Minnesota. Snowdon’s research suggests that early education, particularly in verbal and cognitive skills, may protect persons from AD in later life.

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

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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Consider these facts about stroke from the American Stroke Association (2013): Be informed about stroke.

• Nearly 800,000 Americans annually suffer a new or recurrent stroke.
• A stroke occurs about once every 40 seconds. About every 4 minutes, someone dies of a stroke.
• Stroke is the 4th leading cause of death in the United States, killing more than 137,000 people a year.
• Risk of stroke death is higher for African American males and females than for whites. Females have a higher rate of death from stroke than males.
• In 2010, Americans paid about $73.7 billion for stroke-related medical costs and disability.

Stroke is simply defined as an interruption of the blood supply to the brain. It is most often caused by a clot that either originated in the brain or traveled from another part of the body. Warning signs of stroke include (National Stroke Association, 2013):
• Sudden weakness or paralysis, usually on one side of the body
• Sudden confusion, speaking or understanding
• Sudden changes in vision
• Sudden dizziness, incoordination, or trouble walking
• Sudden severe headache with no known cause

If you or someone you love experiences any of these symptoms, call 911 immediately. Do not delay. New medical treatments may be able to reverse the effects of stroke, but time is critical. Note the time that the symptoms started so that you can inform the medical professionals who are providing treatment.
The effects of stroke depend on the area of the brain that is damaged. Some common results of stroke are weakness or paralysis on one side of the body, difficulty walking or dressing oneself, aphasia, trouble eating or swallowing, bowel and bladder changes, cognitive changes such as memory problems, and emotional issues such as depression and mood swings. Stroke affects the entire family, so be sure to seek out resources and support in your community if a stroke has touched your family.

For stroke survivors, treatment in an acute rehabilitation facility with an interdisciplinary team approach is highly recommended and results in more positive outcomes. The rehabilitation team works together with the survivor and family to accomplish personal goals and achieve the highest level of function possible. Although some of the effects of stroke may be long-lasting or permanent, there is hope of continued progress and good quality of life after stroke.

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Background

Diabetes mellitus is a common metabolic disorder that affects carbohydrate, lipid, and protein metabolism. It is estimated that about 4.4 to 17.4% percent of adults in the United States have diabetes mellitus (Cory , Ussery-Hall, Griffin-Blake et al., 2010). It is estimated that 11.5 million women and 12.0 million men over the age of 60 have diabetes, but many do not know it. The Indian Health Service reported via the National Diabetes Survey of 2007 that of the 1.4 million Native Americans and Alaska Natives in the United States, 14.2% age 20 years or older have diagnosed diabetes. Rates vary by region, from 6.0% of Alaska Natives to 29.3% of the Native Americans in southern Arizona (CDC, 2007). There are two major types of diabetes, type 1 (T1DM) and type 2 ( T2DM). T1DM is characterized by autoimmune destruction of the insulin-producing beta cells of the pancreas, leading to a deficiency of insulin. New-onset of adult T1DM in older adults rarely happens; however, due to better treatment of T1DM, older adults who have been diagnosed at an earlier age are living longer. About 90% of older adults with diabetes have T2DM, which is often related to obesity. T2DM is characterized by hyperglycemia and insulin resistance; however, impaired insulin secretion may also be present. Diabetes mellitus is a major cause of disability and death in the United States, and is the seventh leading cause of death among older adults.

Risk Factors

The risk of diabetes increases with age (45 years and older). Other risk factors include family history, obesity, race (African Americans, Hispanics, Native Americans, Asian Americans, Pacific Islanders), hypertension, less “good” cholesterol (less than 35 mg/dl), lack of exercise, having a history of delivering large babies (≥9 pounds), personal history of gestational diabetes, and pre-diabetes in men and women (Laberge, Edgren, & Frey, 2011). Type 2 is the most common type in older women (CDC, 2007). The risk of death from DM is significantly higher among older ¬Mexican American, African American, and Native American women when compared to Whites. The Centers for Disease Control CDC (2005) names obesity, weight gain, and physical inactivity as the major risk factors for DM among women.

Diagnosis

The most common presentation for older adults with T1DM is hyperglycemia (high blood sugar). Older adults may not have the classical symptoms such as polydipsia, polyuria, polyphagia, and weight loss. Instead, they may have an atypical presentation (Halter Chang & Halter, et al., 2009). They may first present with falls, urinary incontinence, fatigue, or confusion. Because older adults may have T2DM for years before it is diagnosed, they often have macrovascualar and microvascular complications at the time of diagnosis, so evaluation of these should be considered at that time.

Treatment

Prevention is the best approach to care, which involves identifying those at risk and encouraging lifestyle change. Older adults with diabetes mellitus have a high risk for complications related to macrovascular disease, microvascular disease, and neuropathy. Macrovascular diseases include coronary heart disease, stroke, and peripheral vascular disease, which can lead to amputation. Microvascular diseases are chronic kidney disease, which is the most common cause of end-stage renal disease, and diabetic retinopathy, that which can lead to blindness. Peripheral neuropathy presents as uncomfortable, painful sensations in the legs and feet that are difficult to treat. A lack of sensation may also be present and contribute to the risk of falls. There is no cure for peripheral neuropathy, and it tends to be a complication for which patients experience daily challenges trying to manage the symptoms. A combination of medication to address pain and interventions by a physical therapist seems to be the best current treatment.

Treatment is aimed at helping patients to achieve and maintain glycemic control to decrease risk of complications. The initial treatment approach is to work with the older adult to establish treatment goals aimed at reducing long-term complications. This often requires working within an interprofessional team. Aggressive treatment may be appropriate for most older adults; however the risk of hypoglycemia (low blood sugar) is higher in older adults. Older adults with hypoglycemia may have an atypical presentation with acute onset of confusion, dizziness, and weakness instead of tremors or sweating. The best measure of good blood glucose management and controlled blood sugars is HgbA1c levels (glycosylated hemoglobin). This measure of hemoglobin provides insight into the previous 3 months of blood sugar control. If HgbA1c is elevated, it indicates that the blood sugar has been high over time. For most people, a HgbA1c ≤ 7% indicates optimal glycemic control; however, due to poor health outcomes, for frail older adults or those with a life expectancy ≤ 5 years this may not be the best, and a Hgb A1c of 8% might be more appropriate.

Management is successful when a balance is achieved among exercise, diet, and medications. Medications may be oral hypoglycemics or insulin injection. Insulin injection is used in T1DM and may be prescribed for T2DM because as the person ages, beta-cell function declines. If insulin is needed, it is important to consider if there are visual problems and or hand arthritis that limits the dexterity that is necessary to prepare and inject the medication. For some, a simple regimen, such as premeasured doses and easier injection systems (e.g.,insulin pens with easy-to-set dosages) is the best.

Thorough evaluation of readiness to learn and of the ability of an older person to manage his or her medications must be done. Older adults who need to give themselves insulin injections may experience anxiety about learning this task. Demonstration, repetition, and practice are good techniques for the older age group. Adaptive devices such as magnifiers may help if the syringes are hard to read. A family member should also be taught to give the insulin to provide support and encouragement, although the older adult should be encouraged to remain independent in this skill if possible. Williams and Bond’s (2002) research suggested that programs that promote confidence in self-care abilities are likely to be effective for those with diabetes. A plan for times of sickness and the use of a glucometer to monitor blood sugars will also need to be addressed. Additionally, the dietician may be consulted to provide education for the patient and family on meal planning, calorie counting, carbohydrate counting, and nutrition. Many patients benefit from weight loss, so the nutritionist can assist with dietary planning in this regard also.

Due to the increased risk of infection and slow healing that result from diabetes, foot care is an essential component in teaching older adults to manage DM. Some experts believe that good preventive foot care would significantly reduce the incidence of amputation in the elderly. Older persons with DM should never go barefoot outside. Extremes in temperature should be avoided. Shoes should be well fitting and not rub. Socks should be changed regularly. Elders should be taught to inspect their feet daily, with a mirror if needed. Corns and ingrown toenails should be inspected and treated by a podiatrist, not by the patient. Older persons should see their podiatrist for a foot inspection at least yearly. Patients should be cautioned that even the smallest foot injury, such as a thorn or blister, can go unnoticed and unfelt—and often results in partial amputations that lead to a cascade of lower extremity problems.

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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Pneumonia is an infection of the lung that can be caused by bacteria, viruses, or mycoplasmas. The two most common ways to get pneumonia are through inhalation of droplet particles carrying infectious germs and aspiration of secretions of the nose or mouth areas. Older adults are at higher risk for pneumonia and can get a more serious infection if they also have other chronic diseases such as COPD, heart failure, a suppressed immune system, cerebrovascular disease, and poor mobility (ALA, 2012). The incidence of community-acquired pneumonia (CAP) among people age 65 and older is about 221.3 per 10,000 (ALA, 2008). Streptococcus is the most common bacterial cause, with about 50% of people with CAP requiring hospitalization (Weinberger, 2004). When hospitalized, older people are at risk for poor health outcomes, including respiratory failure requiring ventilator support, sepsis, and longer length of hospitalization, duration of antibiotic therapy and other supportive treatment (ALA, 2012).

Warning signs

The onset of bacterial pneumonia can be sudden or gradual; however, older adults may not present with the typical symptoms of chills, fever, chest pain, sweating, productive cough, or shortness of breath. Instead, they may have a sudden change in mental status (confusion/delirium). Cases of viral pneumonia account for about half of all types of pneumonia and tend to be less severe than bacterial pneumonia. Symptoms of viral pneumonia include fever, nonproductive hacking cough, muscle pain, weakness, and shortness of breath.

Diagnosis

Diagnosis is made through chest x-ray, complete blood count, and/or sputum culture to determine the type and causal agents (if bacterial). A thorough history and physical that includes assessment of swallowing ability and eating (watch for coughing while eating) to evaluate for aspiration risk should be done. Crackles may be heard in the lungs through a stethoscope, and chest pain with shortness of breath may be present.

Treatment

Bacterial pneumonia can often be treated successfully when detected early, and viral pneumonia generally heals on its own (antibiotics are not effective if pneumonia is caused by a virus), though older adults may experience a greater risk of complications than younger adults. Oral antibiotics will significantly help most patients with bacterial pneumonia.

Aspiration pneumonia is caused by inhalation of a foreign material, such as fluids or food, into the lungs. This occurs more often in persons with impaired swallowing. For older adults receiving tube feedings, care must be taken to avoid having the person in a laying position during and immediately after tube feeding because aspiration can occur; it is important to note that tube feedings do not reduce the risk of aspiration. Having the head of the bed elevated or, even better, the person in a sitting position when eating or receiving nutrition through a feeding tube, helps to avoid the potential complication of pneumonia related to aspiration.

When recovering from pneumonia, one should get plenty of rest and take adequate fluids to help loosen secretions (with accommodations made to support the added need to urinate due to the increased fluid intake, a common reason why older adults may not drink adequate fluids). Tylenol or aspirin (if not contraindicated by other conditions) can be taken to manage fever as well as aches and pains. Exposure to others with contagious respiratory conditions should be avoided. Respiratory complications are often what lead to death in the older adults, so they should be cautioned to report any changes in respiratory status such as increased shortness of breath, high fever, or any other symptoms that do not improve. It is important to follow up with the physician or nurse practitioner and get a chest x-ray if ordered, since symptoms may improve with treatment before the pneumonia is actually completely gone.

Prevention of pneumonia is always best. Adults over the age of 65 are advised to get a pneumonia vaccine. Persons younger than age 65 who have higher risk (those with respiratory problems or persons in nursing homes) should get the vaccination. A yearly flu vaccine is also recommended for older adults, because pneumonia is a common complication of influenza in this age group. Medicare will cover these vaccines for older persons.

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Background

Although gastroesophageal reflux disease (GERD) is common among older adults, the true prevalence is not known. Many patients with GERD-related symptoms never discuss their problems with their primary care provider. GERD is thought to occur in 5–7% of the world’s population, with 21 million Americans affected (International Foundations for Functional Gastrointestinal Disorders, 2008). It is found in both men and women.

Signs and symptoms

Pathophysiological changes that occur in the esophagus, hiatal hernia, and certain medications and foods increase the risk for GERD. Obesity (Corely , Kubo, Levin et al., 2007) and activities that increase intra-abdominal pressure such as wearing tight clothes, bending over, or heavy lifting have also been linked to GERD (MedlinePlus, 2005a). The cardinal symptom of GERD is heartburn; however, older adults may not report this, but rather complain of other symptoms such as pulmonary conditions (bronchial asthma, chronic cough, or chronic bronchitis), a hoarse voice, pain when swallowing foods, chronic laryngitis, or non-cardiac chest pain (Pilotto & Franceschi, 2009). The chronic backflow of acid into the esophagus can lead to abnormal cell development (Barrett esophagus) that increases the risk for esophageal cancer.

Diagnosis

Older adults often have atypical symptoms, making the diagnosis of GERD very challenging. As people age, the severity of heartburn can diminish, while the complications, such as erosive esophagitis, become more frequent. Therefore, endoscopy should be considered as one of the initial diagnostic tests in older adults who are suspected of having GERD (Pilotto & Franceschi, 2009). Examination of the esophagus, stomach, and duodenum through a fiber-optic scope (endoscopy) while the person receives conscious sedation, allows the gastroenterologist to visualize the entire area, identify suspicious areas, and obtain biopsies as needed. Helicobacter pylori (H. pylori), a chronic bacterial infection in humans, is a common cause of GERD, affecting about 30% to 40% of the U.S. population. Testing for H. pylori can be done during the endoscopy or by other tests (Ferri, 2011).

Treatments

The objectives of treatment for GERD include: (1) relief of symptoms, (2) healing of esophagitis, (3) prevention of further occurrences, and (4) prevention of complications (Pilotto & Francheschi, 2009). Lifestyle and dietary modifications are important aspects of care. It is widely recommended that persons with GERD should stop smoking, limit or avoid alcohol, and limit chocolate, coffee, and fatty or citrus foods. Medications should be reviewed and offending medications modified, since certain medications decrease the lower esophageal sphincter (LES) tone, allowing acid to backflow into the esophagus. These include anticholinergic drugs, some hormones, calcium channel blockers, and theophylline. Avoidance of food or beverages 3–-4 hours prior to bedtime, weight loss, and elevation of the head of the bed on 6-to-8 inch blocks are some other interventions that may help alleviate symptoms. Pharmacological treatments with antacids in conjunction with histamine 2 (H2) -blockers (Tagmet, Zantac, Axid, and Pepcid) are used for mild GERD. If these are ineffective in controlling symptoms, then the proton pump inhibitors (PPIs) are the next drugs of choice. These include medications like Nexium and Dexilant. With lifestyle modifications and appropriate medications, older adults can manage their GERD symptoms so that quality of life is maintained.

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. Burlington, MA: Jones and Bartlett Publishers. Used with permission.

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