Gerontological & Community Based Nursing:

1. Gerontological & Community Based Nursing: Psychosocial Theories Cognitive and Social Changes Family roles & Relationships in Aging

2. Psychosocial Needs of Older Adults

3. Chronologoic, Biologic,Psychological & Social aging • Lifecycle- of aging

4. Social Theories of Aging • Disengagement Theory (Cummings & Henry 1961) • Activity Theory (Maddox 1963) • Continuity Theory (Havinghurst et. al. 1968) • Link between personality traits & how one ages- Bernice Neugarten et. al 1968)

5. Social Theoriescont’d • Age-Stratification Theory-Historical contest- cohort groups(Marshall 1996) • Challenges activity & disengagement theories: Structuring of ages- Young-old; middle-old; Old-old • Encompass social & cultural expressions of aging • Social Exchange Theory- i.e. intergenerational programs ( Social exchange- elders give back to society/family

6. Psychosocial Theories of Aging • Jung’s Theories of Personality • “Last half of life has purpose of it’s own” • Time for inner growth, self-awareness & reflection.

7. Developmental Theories • Eric Erikson’s- 8th stage of life (Ego Integrity vs. Despair)- later reconsidered the either /or concept. Peck(1968) Identified specific developmental task of old age: • Ego differentiation VS. role preoccupation • Body transcendence VS. Body preoccupation • Ego transcendence VS. ego preoccupation • Havinghurst’s Developmental Tasks Middle-age & Later Maturity (Box 7-2) • Theory of Gerotranscendecnce – similar to Erikson’s concept of integrity& Maslow’s Self-actualization

8. Spirituality & Aging • Ability to experience /integrate meaning & purpose in life • A connection with music, art, nature, or a greater power • Assess /identify elders at risk for Spiritual distress

9. Cognition & Aging Normal vs. abnormal changes

10. Memory & Cogniton • Memory • Long term memory remains intact • Short term memory diminished • Processing affected by stress

11. Cognition in the older adult • Learning • Use simple association rather than analysis • Verbal and abstract abilities are approximately equal • Basic intelligence unchanged • Creative thought declines • Factors that affect learning: • Motivation • Attention span • Delayed transmission • Perceptual defecits • Illness

12. Normal Age-Associated changes of the Neurological System • Brain changes • Neurochemical • Structural • Neuropsychological changes • Small decrease in brain weight • 7-8% decrease • Loss of neurons in selective brain structures • Accumulation of neuritic plaques and neurofibrillary tangles • Neurochemical changes • Decreased activity of catecholamine synthesis • Decrease amounts of neurotransmitters: serotonin, noradrenaline, and dopamine

13. Normal Age-relatedMemory Changes • Memory peaks between the ages of 20-30 • Followed by a subtle decline until age 60 • After 60, memory difficulties become more pronounced

14. Memory Storage and Retrieval • Short-term memory: lasts 7-10 seconds and can only hold 4-7 items at once • Intermediate memory: Lasts 24-48 hours. • Long-term memory: What happened beyond 48 hours • Successful memory relies on all three

15. Normal Age-Related Memory Changes • Slower Thinking • All body systems become less efficient with age, including thinking and problem-solving abilities. • The speed of learning and recall decreases, so it may require more time to learn new things or retrieve information. • Difficulty Paying Attention • Many memory problems are due to problems of attention, not retention • Reduction in the ability to concentrate as a person ages makes it harder to remember • More susceptible to distractions and interruptions

16. Normal Age-Related Memory Changes cont’d • More memory cues may be required for recall • Memory cue can be a word, picture, smell, rhyme or anything associated with information/events • Physical Changes of the Brain that may affect memory • Enlargement of the ventricular system • Ventricles enlarge, possibly because the cells surrounding the ventricles are lost. • Widening of the sulci (the grooves) on the surface of the brain • Reduced brain weight and brain volume • Probably caused by the loss of neurons

17. Normal Age-Related Memory Changes cont’d • Other factors that interfere with basis memory • Visual changes • Hearing changes • Sleep • Pain • Medications • Depression and other mood disorders

18. Age associated memory changes • Forgetting specific details and names of people, but remembering them later • Able to learn new material but may have difficulty with information retrieval • General awareness of memory impairment • Memory impairment does not interfere with daily functioning

19. Cognitive Impairment • Currently estimated that over 4 million American have some form of dementia • This number will grow to 14 million by 2050 unless a cure or prevention is found • Each year in the US more than a million people are newly diagnosed with a chronic brain disease or disorder • Currently 10% of people > 65 yo and nearly 50% of those >85 yo have dementia

20. Disorders of the Neurological System • Alzheimer's • Non-reversible and progressive form of dementia that reduces the ability to think, remember, reason, judge and concentrate • Eventually prevents performance of ADLs • Personality and language abilities decline • Accounts for ~66% of dementias

21. Alzheimer’s • Prevalence • 4 million Americans have been diagnosed with Alzheimer’s type dementia • 10% of people >75 y.o. are affected • 47% of people > 85 y.o. are affected • Risk factors • Advanced age • Family history of first-degree relatives diagnosed with AD

22. Alzheimer’s Disease • Clinical presentation • Progression of symptoms and time appearance is unique to the individual • Very early stage • Usually considered questionable dementia • Forgets names, events, phone numbers • Gets lost in familiar surroundings • Early/Mild stage • Loss of recent memory • Forgets bills, misplaces items

23. Alzheimer’s Disease • Middle/Moderate stage • Increased memory loss • Makes up stories to compensate • Wandering • Gait changes to small steps • Late/Severe stage • Inability to perform ADLs • Little response to stimuli • Loss of body weight, bodily functions • Susceptibility to infection

24. 10 Warning signs of Alzheimer’s • Memory Loss • Difficulty perfuming familiar tasks • Problems with language • Disorientation to time and place • Poor or decreased judgment • Problems with abstract thinking • Misplacing things • Changes in mood or behavior • Changes in personality • Loss of initiative

25. Pharmacologic Treatment of Alzheimer’s • Medications should be used when all other methods of management have failed and the benefits outweigh the risks • Psychotropic medications i.e. • Aricept • Donepezil is used to treat mild to moderate confusion (dementia) related to Alzheimer's disease. • An enzyme blocker that works by restoring the balance of natural substances (neurotransmitters) in the brain.

26. Other Common Problems r/t Alzheimer’s • Wandering • Nutrition/Hydration • Home Safety

27. Non-Alzheimer’s Dementia • Development of multiple cognitive impairments, including the loss of memory • Attributable to • Metabolic disorders • Thyroid, renal failure, liver failure • Toxins • Infections and neoplasms • s/e of drugs • Nutritional deficiencies • Degenerative neurological diseases • Cerebral vascular injuries, ischemias,(vascular dementia) or trauma

28. Delirium • AKA acute confusional state, acute brain syndrome, toxic psychosis, etc. • Transient cognitive disorder with a rapid onset and brief duration • Typical clinical presentation • Reduced ability to maintain attention • Disorganized thinking • Difficulty in focusing

29. Interacting with Patients with Dementia • Positive interactions can prevent frustration for all parties, and help in understanding and meeting the needs of the patient. • Techniques to enhance interaction and prevent problem behaviors • Approach the pt from the front, establishing eye contact, speaking slowly, and using short sentences and simple words

30. Interacting with Patients with Dementia cont’d • Ask yes/no questions. An open-ended question is difficult to answer for a cognitively impaired patient • Repeat, restate and paraphrase as needed, to help the patient understand • Speak literally and in concrete terms. Abstract thought is difficult for a patient with dementia to interpret • Break down directions or tasks into simple steps and the cue the patient s needed at each step • Refrain from arguing or attempting to use logic • Reduce environmental stimulus • Allow the patient the time to do as much as he/she can for him/herself

31. Stroke • Intracerebral hemorrhage • Ischemic stroke • TIAs • Acute focal neurological signs than symptoms lasting <24 hours • Brief stroke-like event resulting in block of blood flow to brain • Precedes stroke in 50 -70% of cases • 1/3 will have a stroke within 5 years

32. Parkinson’s Disease • Early stage PD • First symptoms: mild, slight tremor in had at rest. • Purposeful movements such as brushing teeth become slow and difficult • Medications: Symmetrol, Elderpryl, Parlodel, Permax • Mid-stage PD • Increased symptoms • Decreasing affect of medications • Add levodopa (Sinemet)

33. Parkinson’s Disease • Late-stage PD • Decreasing effects of medications • Increasing difficulty with balance, increased muscle contractions, problems initiating movement, involuntary abnormal posture, nightmares, orthostatic hypotension, constipation, rigid face, depression, dementia • Newer therapies: Requip, Mirapex

34. Cognitive Assessments • Instrumental activities of daily living (IADL) • Bathing • Dressing • Toileting • Transferring • Continence • Feeding

35. Cognitive Measures • Mini-Mental State Exam (MMSE) • 30 item instrument used to screen for cognitive deficiencies • Used in determination of dementia or delirium • Tests orientation, short-term memory, calculation ability, language and construction • Must be administered exactly as written

36. Roles & Relationships in Older Adults Close sustaining relationships have a positive effect • ↓ stress • ↑ mental health • ↑ life satisfaction • Married people have better support system • Married people have better income • Married people have better nutrition

37. Relationships • Friends • Shrinking social network • Organizations & neighborhoods • Promotion of social contacts • Factors that affect social network • Family members • Friends • Health • Independence • “Gerontological orphan”

38. Families • Roles • What are they? • What have they been? • How are they changing?

39. Caregivers • May include • Family • Friends • Paid/unpaid workers • “giving back” • Can be very stressful

40. Caregivers • May include • Family • Friends • Paid/unpaid workers • “giving back” • Can be very stressful