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Geriatrics 2. KNR 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

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today porter burlingame 2006
Today (Porter & burlingame, 2006)
  • Diabetes Mellitus
  • Cerebrovascular Accident (Stroke)
  • Dementia
diabetes mellitus not just older adults
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 mellitus 4 primary classifications
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
diabetes mellitus 4 primary classifications1
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 mellitus 4 primary classifications2
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 mellitus 4 primary classifications3
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
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
diabetes mellitus secondary problems
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 mellitus secondary problems1
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
  • 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.
tr interventions
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 stroke1
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 stroke2
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 stroke3
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 stroke4
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 stroke5
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
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 affected1
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 stroke6
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
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 interventions1
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 interventions2
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
  • 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
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 apa1
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 apa2
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 apa3
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)
  • 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
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
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
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
MDS 3.0 (2009)
    • All very helpful
    • See MDS 3.0 and Recreational Therapists
    • Copy of form
    • New Manual 10/2013 (see website)
bandi rt assessment
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
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
evidence based practice1
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
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

  • 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
  • National Council of Certified Dementia Practitioners
  • Love, Loss, and Laughter