Best Nursing Practices in Care for Older Adults

1. Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School of Nursing Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

2. Session 2 Topics: • Functional Assessment of Older Adults • Sleep/Rest in Older Adults Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

3. Topic 1: Functional Assessment of Older Adults • Functional Assessment….What is it? A comprehensive evaluation of physical and cognitive abilities required to maintain independence. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

4. What tools can we use to help? • Objective Assessment Tools • Can be well known, or something your agency has created Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

5. Activities of Daily Living (ADLs) • Use of Katz Activities of Daily Living Tool • Bathing • Dressing • Toileting • Transferring • Continence • Feeding Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

6. Instrumental Activities of Daily Living (IADLs) • Basic daily activities needed to live independently in the community: • Shopping • Cooking • Using the phone • Laundry • Housekeeping • Finances • Maintaining home and property • Performing duties for job or volunteer • Traveling Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

7. Lawton Scale for IADL • Based on score from 8 – 28 • The lower the score, the more independent • Compare scores over time Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

8. PULSES Profile • P: Physical condition • U: Upper limb function • L: Lower limb function • S: Sensory components • E: Excretory functions • S: Support factors Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

9. SPICES • S: sleep disorders • P: problems with eating or feeding • I: incontinence • C: confusion • E: evidence of falls • S: skin breakdown Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

10. Psychological Function • Need to measure cognitive mental and affective functions independently Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

11. Social Functioning • Includes • Social interaction and resources • Subjective well being and coping • Person-environment fit Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

12. What happens to function over time? • Chronic conditions increase with age • Arthritis • Hypertension • Heart disease • Hearing impairment • Orthopedic impairment • Cataracts Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

13. ADL’s • 20% of people over 65 require assist with ADLs • 45% of people over 85 require assist with ADLs Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

14. How is the USA changing? • 1990: 7 million older adult in the USA were over age 80 • Estimation: By 2025: 14 million older adults will be over age 80 Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

15. How prepared are we? Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

16. Topic 2: Sleep/Rest for Older Adults Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

17. Age Related Sleep Changes: • Total sleep time decreases until age 80, then increases slightly • Time in bed increases after age 65 • Onset to time of sleep is lengthened(>30 min) • Awakenings are more frequent • Sleep is lighter Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

18. Fact: • With age, more time is spent awake in bed because of frequent sleep interruptions. • (ie: wake up and can’t fall back asleep) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

19. Fact: • Frequent arousals reduce the amount of nocturnal sleep. • Napping during the day may increase the total sleep time over a 24-hour period. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

20. Frequent Complaints • Difficulty falling asleep • Sleep interruptions • Daytime fatigue Some changes in sleep may be due to changes in circadian rhythms. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

21. 4 Categories of Sleep Disturbances Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

22. Category 1: Dyssomnias: disorders of initiating and maintaining sleep and of excessive sleepiness Example of a cause: sleep apnea Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

23. Apnea & Hypopnea • Breathing disorders can cause sleep arousals • The older adult may not recognize that the disorder is disturbing sleep Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

24. Category 2 • Parasomnias: unusual behavior during sleep • Older adults may not relate these behaviors to sleep-related complaints Examples: Sleep walking, Nocturnal myoclonus (PLMS) Restless leg syndrome, Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

25. Periodic Limb Movements in Sleep PLMS: may cause sleep disturbances in older adults, but they may not recognize that this condition is disturbing their sleep Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

26. Category 3 • Disorders associated with medical or psychiatric disorders • Examples: • Anxiety, • Depression • Medical problems Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

27. Medical Problems That May Lead to Sleep Disturbances • Cardiovascular: nocturnal ischemia • Diabetes: nightmares; waking early due to blood glucose fluctuations • GI: reflux • Arthritis: pain • COPD: dyspnea while prone • Parkinsons: decreases REM sleep • Alzheimers: nighttime wandering, agitation Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

28. Category 4 • Proposed sleep disorders (other various disorders that continue to be studied, in an effort to make them better defined) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

29. Other Causes of Sleep Disturbances • Onset of acute illness • Progression of chronic illness • Pain • Nocturia • Dementia • Alcoholism • Depression Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

30. How do I assess sleep? 4 Areas to Assess Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

31. #1: Assess sleep history • Include impact of sleep complaint on the individual’s daily life • Get a 24 hour sleep diary over 1-2 weeks to see patterns • Remember to get observations of partners or caregivers Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

32. #2: Obtain a medical history • Various medical conditions can contribute to sleep disturbances Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

33. #3: Get a Drug History • Include prescription and nonprescription medications • Include alcohol, caffeine, and nicotine Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

34. #4: Get a Psychosocial history • Begin with psychiatric illness (anxiety, depression, dementia) • Follow with social history (grieving, illness, loss, translocation) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

35. Nursing Interventions • Pharmacologic • Nonpharmacologic Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

36. Refer: • If they have PLMS or sleep related breathing problems, they need further assessment Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

37. 1st Line of Treatment • Remove contributing factors • Examples: • Treat a medical condition • Reassess drugs that may be cause • Counseling for alcohol, caffeine, nicotine use • Reduce fluid intake in the evening Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

38. More strategies • Develop a sleep-preparation routine • Change into night clothes, wash face, go to bathroom • Establish a regular bedtime • Use bedroom for sleep only, not for other daily activities • Develop a sleep story that soothes • Discourage daytime napping • Daily exercise • Sexual activity Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

39. Pharmacologic Interventions • Recommended for short term use only for elderly • Benzodiazepine with short or intermediate acting action (ex: temazepam, triazolam) • Two week maximum Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

40. Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

41. Reference: The content covered in this presentation is provided by the John A. Hartford Foundation Institute for Geriatric Nursing (2001) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

42. Reference: Various slides in this presentation, courtesy of Mathers Lifeways Mather Institute on Aging , 2002 Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858

43. Power Point Presentation Created by: Diana R. Mager, CRN, MSN Fairfield University School of Nursing ELDER Project Director Supported by DHHS/HRSA/BHPr/Division of Nursing Grant #D63HP06858