geriatric nurse

Medications and Older Adults  CHAPTER 7 133 medications. The more medications taken, including to medication-related problems. It is increasingly OTCs, supplements, and herbs, the greater the risk for common for an older person to have two or more spe- untoward reactions, drug interactions, and drug toxici- cialists providing their care. When more than one care ties. Drug interactions and toxicities in older adults are provider writes prescriptions, the risk for medication likely to result in behavioral or cognitive changes, reactions and overmedication increases dramatically. often mistaken for dementia. If a care provider does not know what medications and OTC products the patient is already taking, he or she Clinical Situation cannot consider those drugs when determining the safety of another prescription. Every prescribing care   provider must be aware of all medications the older adult is taking, no matter who prescribed them, as well For an easy way to quickly discover potential drug interactions as all OTC medications, supplements, and herbs being in your patient, go to http://reference.medscape.com/drug- used, as many of the popular herbs have potentially interactionchecker. Type in the medications and supplements, serious interactions with prescription medication one by one, and receive a list of interactions in order of (Table 7-2). Many older adults use herbs and supple- seriousness. ments as an alternative to prescription medications, sometimes because they are less expensive, and some- Many factors contribute to the increased usage of med- times because they are marketed as “natural,” which ication among older adults, including an increased implies “safe.” Remember: digoxin is an herb! It is likelihood of multiple acute or chronic disease condi- important to carefully question the older adult about tions; increased availability of a variety of prescription supplements and herbs they are taking. medications, OTC medications, supplements and herbs; changes in patient expectations; and changes in Clinical Situation the health care delivery system.   Newer, better, and more potent medications are developed every day. Medical conditions of older Medication Side Effects adults that were once considered untreatable are A patient who was using timolol eye drops that were pre- now treated routinely using medications. Because scribed by an ophthalmologist for glaucoma began to experi- older adults tend to have more physical complaints or ence joint pain. Not seeing any connection between his eye diseases than do younger individuals, medication problems and his aching joints, the patient sought the advice usage increases exponentially. of his rheumatologist. Fortunately, the rheumatologist asked the patient whether he was taking any other medications. Older adults seek medical intervention for many When timolol was identified, the rheumatologist recognized the reasons. Some live with their problems and seek possibility of a drug-induced problem and contacted the oph- medical attention only when they have serious con- thalmologist, who then changed the medication. The joint pain cerns. By the time such a person seeks medical disappeared without further medical intervention. attention, his or her condition may have seriously deteriorated, requiring the prescription of multiple POTENTIALLY INAPPROPRIATE MEDICATION medications. Other older people make frequent visits USE IN OLDER ADULTS to their primary care providers, seeking reassurance that nothing is seriously wrong. Rather than spending The fact that older adults respond differently than the time needed to reassure older adults, some provid- younger adults has been long recognized. Until 1991, ers issue a prescription as a way to terminate the visit. there were no specific guidelines to aid the physician Unfortunately, this medical practice occurs too often in the selection of medications least likely to cause and can result in older adults taking unnecessary or adverse reactions. In 1991, the Beers criteria, a list of marginally necessary medications. drugs that should usually be avoided by older adults, was developed. This list was improved and expanded Still other older people expect their primary care in 1997, 2002, and again in 2012, and is frequently used providers to be able to eliminate all of their problems in the United States. Two separate lists now exist, and and ailments with medications. Every television show, both are extensive in nature. Part I identifies medica- magazine article, or recommendation from a friend tions best avoided by older adults independent of extolling the benefits of a new medication sends some diagnoses or conditions. Part II uses diagnoses or con- older adults to their primary care providers’ offices to ditions as the primary consideration for which medica- request or even demand the new medicine. They tions should be avoided in the older adult. expect the provider to prescribe a medication to relieve their ailments, and they often perceive that the pro- Did You Know? vider is not doing anything for them unless this happens. Some older adults even go from provider to   provider until they get what they want. Under these pressures, some care providers prescribe medications Over 100 medications that are potentially inappropriate for that they otherwise would not have ordered. older adults are listed in the Beers criteria, as well as numerous medications and categories of medications with recommenda- Changes in health care delivery, particularly tions for lowered dosages or use in selective disorders only. increased medical specialization, have contributed

134 UNIT II  Basic Skills for Gerontologic Nursing Table 7-2  Selected Herbal and Supplement Considerations for Older Adults HERB OR SUPPLEMENT HEALTH CLAIM OLDER ADULT CONSIDERATIONS Black Cohosh Increases the effects of digoxin and antihypertensives Decreases hot flashes and other menopause symptoms Ginkgo biloba Improves memory; improves blood Can cause excessive bleeding, especially if on circulation in the brain anticoagulants St. John’s Wort Relieves depression Reduces the effect of at least a dozen cardiac medications; interferes with numerous other medications, including medications for transplant rejection, cancer, respiratory disorders, and antidepressants Chamomile Calms upset stomach; helps with sleep Increases bleeding for people on warfarin; intensifies effect of sedatives Echinacea Shortens duration of colds and flu Slows metabolism of certain medications, potentially leading to liver toxicity Ginseng Boosts immune system; lowers blood Alters drug effectiveness for numerous medications sugar; improves learning including anticoagulants, diabetes drugs, corticosteroids Green tea Numerous claims including prevention of Reduces effectiveness of warfarin cancers, promotion of weight loss, alleviates stomach disorders, and many others Kava Relieves anxiety; promotes sleep Prolongs effects of sedatives; can lead to liver toxicity Soy Helps with high cholesterol, hypertension, Decreases effectiveness of warfarin diabetes, and other claims Glucosamine sulfate Helps relieve joint pain and arthritis Blocks the effects of insulin Data from Ahn J (reviewer). Caution: Herbs are also drugs, 2013. Albuquerque Journal. http://health.abqjournal.com/HealthFeature.aspx?id=1032; Rochon PA. Drug Prescribing for Older Adults, 2013. www.uptodate.com/contents/drug-prescribing-for-older-adults; Merck Manual. Overview of dietary supplements. 2012. www.merckmanuals.com/professional/special_subjects/dietary_supplements/overview_of_dietary_supplements.html#v1126015; and Kee JL, Hayes ER, McCuistion LE: Pharmacology: A Nursing Process Approach, ed 7, 2012, St. Louis: Saunders. Medicare and Medicaid have developed regulations To protect older adults, physicians and others who for skilled nursing facilities that are heavily based on have legal authority to prescribe medications should the Beers criteria. Skilled care facilities are required to remember six basic guidelines: (1) Start low and go have protocols that ensure that care providers’ orders slow; (2) start one drug and stop two; (3) do not use a are in compliance. Citations are issued to facilities that drug if the adverse effects are worse than the disease; fail to comply. A mobile app is available to make pre- (4) use as few drugs as possible and use nonpharma- scribing health care providers’ job easier in avoiding cologic approaches whenever possible; (5) frequently potentially inappropriate medications for older adults assess the patient’s response; and (6) consider drug under their care. holidays. Another commonly used tool used in other parts RISKS RELATED TO COGNITIVE OR of the world is called the STOPP (Screening Tool of SENSORY CHANGES Older Person’s Prescriptions)/START (Screening Tool to Alert doctors to Right Treatment) criteria. The Cognitive and sensory limitations increase the risks STOPP/START criteria were developed in the UK in for medication errors in older adults. Cognitive response to perceived content gaps and disagreement problems come in several forms, including a lack about Beers content; moreover, many of the Beers of the literacy skills needed to read the labels and medications are not included in the European Drug directions, the inability to understand and comply Index manuals (Yayla et al., 2013). Furthermore, with directions, and the inability to make correct judg- STOPP/START emphasizes both sides of medication ments about medications. In severe cases of cognitive prescription in older adults: the examination of medi- impairment, older individuals may not even recognize cations to be considered for prescription as well as that they have to take medication. If they do attempt examining medications already prescribed that might be to take medication, serious and potentially harmful inappropriate. Examples of medications in the STOPP errors are often made. Cognitively impaired older and START criteria can be found in Tables 7-3 and 7-4, adults should not be responsible for medicating respectively.

Medications and Older Adults  CHAPTER 7 135 Table 7-3  Examples from STOPP Criteria PHYSIOLOGIC SYSTEM NUMBER OF CRITERIA EXAMPLES OF THESE CRITERIA (MEDICATIONS THAT MAY BE INAPPROPRIATE Cardiovascular System FOR THIS BODY SYSTEM UNDER CERTAIN CIRCUMSTANCES, AND PERHAPS SHOULD BE “STOPPED”) 17 • Digoxin at a long-term dose greater than 125 mcg/day in a patient with impaired kidney function Central Nervous 13 System 5 • Loop diuretic for dependent ankle edema only • Thiazide diuretic in patient with gout Gastrointestinal System 3 • Beta-blocker in a patient taking verapamil 8 Respiratory System 6 • Tricyclic antidepressants (TCAs) with any of the following: dementia, Musculoskeletal 4 glaucoma, cardiac conduction abnormalities, or constipation 5 System 3 • Long-acting benzodiazepines for greater than one month Urogenital System 1 • Diphenoxylate, loperamide, or codeine phosphate for diarrhea of Endocrine System unknown cause Drugs That Adversely • Full-dose proton pump inhibitors (PPIs) for peptic ulcer disease for Affect Fallers > 8 weeks Analgesic Drugs • Systemic corticosteroids for maintenance of COPD Duplicate Drug Classes • Nebulized ipratropium in patient with glaucoma • NSAIDs for peptic ulcer disease, unless given concurrently with H2 receptor agonist, PPI, or misoprostol • NSAIDs with moderate to severe hypertension or heart failure • Antimuscarinic drugs with dementia, glaucoma, chronic constipation • Alpha-blockers in males with urinary incontinence of more than once daily • Estrogen with history of breast cancer or thromboembolism • Beta-blockers in people with diabetes experiencing hypoglycemia more than once a month • Benzodiazepines • Neuroleptic drugs • Long-term opiates • Long-term powerful opiates for first-line pain therapy • Opiates longer than 2 weeks with chronic constipation • Any drug category with more than one medication prescribed Modified from Ryan C. (2011). The basics of the STOPP/START criteria. Available at: http://www.pcne.org/upload/ms2011d/Presentations/Ryan%20pres.pdf Table 7-4  Examples from START Criteria PHYSIOLOGIC SYSTEM NUMBER OF CRITERIA EXAMPLES OF THESE CRITERIA (MEDICATIONS THAT OUGHT TO BE CONSIDERED, FOR THIS BODY SYSTEM OR STARTED, IN CERTAIN SITUATIONS) Cardiovascular System 8 • Warfarin in the presence of chronic atrial fibrillation • Antihypertensives for systolic BP chronically above 160 mmHg Respiratory System 3 • Beta-blockers with chronic stable angina Central Nervous 2 • Regular beta2 agonist or anticholinergic for mild-moderate asthma or COPD System 2 • Inhaled corticosteroid for moderate-severe asthma or COPD 3 Gastrointestinal • L-dopa for Parkinson disease with functional impairment System • Antidepressants for moderate-severe depression greater than 3 months Musculoskeletal • PPI for severe acid reflux or stricture System • Fiber for diverticular disease with constipation Endocrine System 4 • Disease-modifying antirheumatic drug (DMAR) for moderate-severe rheumatoid disease longer than 12 weeks • Biphosphonates for patients on corticosteroids • Calcium and vitamin D for osteoporosis • Metformin for type 2 diabetes • ACE inhibitor or angiotensin receptor blocker for diabetic nephropathy Modified from Ryan C. (2011). The basics of the STOPP/START criteria. Available at: http://www.pcne.org/upload/ms2011d/Presentations/Ryan%20pres.pdf

136 UNIT II  Basic Skills for Gerontologic Nursing create or mask symptoms of disease. Use of these themselves but should be supervised by a family drugs can make it difficult for the primary care pro- member or nurse. vider to recognize changes in their health status. Older adults must be taught to consult with their Sensory changes, particularly visual and, to a lesser primary care provider or pharmacists before taking extent, hearing changes, present problems for older any OTC medication and to carefully keep track of adults. When vision changes render an older person and inform their primary care provider of all prescrip- unable to read a medication label or to recognize the tion and OTC medications, herbs, and supplements different sizes, shapes, or colors of the various medica- they take. tions, serious problems can arise. Many older adults essentially guess what medications they are taking, Alcohol is the most commonly consumed nonpre- often taking the wrong medication at the wrong time scription drug used by adults. Many older adults do and in the wrong amount because they are unable to not think of alcohol as a drug, so they do not consider read the directions. Liquid medications, particularly it when taking medications. Alcoholic beverages can injectable medications such as insulin, are commonly cause adverse reactions when taken in conjunction overdosed or underdosed because of poor vision. with many prescription and OTC drugs. It is prudent Many of these risks can be reduced by assessing the to check with the primary care provider or pharmacist person’s ability to read labels accurately, by proper before drinking alcohol. Today, most prescription teaching, and by using special labels or magnifying drugs are labeled if there is a risk for interaction with devices that facilitate safe administration. alcohol, but these labels are not always given adequate attention. In addition to OTC medications, herbal or RISKS RELATED TO INADEQUATE KNOWLEDGE natural remedies are being used with increased fre- quency; as many as 33% of Americans use herbs, and Lack of knowledge about medications can result in most are reluctant to tell their primary care provider serious problems for older adults. This knowledge (University of Maryland Medical Center, 2013). deficit, which can relate to both prescription and non- Considering possible interactions between these sub- prescription medications, has many causes and mani- stances and more traditional prescription and OTC fests in different ways. medications is important. One common sign of lack of knowledge involves Older adults often lack adequate knowledge regard- sharing medications with friends or relatives. This ing their prescription medications. They are often practice is common and persists because many people given one or more prescriptions and simply told to are unaware of the dangers. When older adults find a take them according to the directions. The directions medication that makes them feel better, they may provided may be very clear to a health care profes- attempt to share the medication with friends who have sional, but they are easily misinterpreted by older similar problems. The intention of helping friends is adults. Even simple misunderstandings can lead to good, but the consequences can be serious or fatal. All improper self-medication, leading to serious conse- people must be aware that it is not safe to take a medi- quences. To reduce the risks, older adults often require cation prescribed for someone else. If an older adult additional instruction to take their prescriptions safely. believes that a certain medication will help, that person Because this is a common problem among older adults, should get the name of the medicine and then contact self-administration of medication is addressed in detail his or her primary care provider. The care provider, not later in the chapter. a friend, is best able to determine whether the drug will be safe and beneficial. Clinical Situation Many older adults have misconceptions about OTC   preparations. It is estimated that up to 90% of older adults use at least one OTC preparation (Zwicker & Polypharmacy Fulmer, 2012). In fact, 40% of all OTC medications are consumed by older adults (Iowa Poison Control Center, Mrs. Smith had been taking a medication for her high blood 2014). Many do not think of OTC medications as “real” pressure. This medication was no longer completely effective drugs because no prescription is needed to purchase in controlling the problem, so her primary care provider ordered them. Because they do not consider OTC medications a newer, more potent antihypertensive. Approximately 25 to be “real” drugs, older adults are not likely to consult tablets of the original medication were left in the bottle, which with a physician, pharmacist, or nurse regarding their Mrs. Smith left in her medicine chest. After taking the new use. Many simply go to the drug store or grocery store prescription for a month, Mrs. Smith happened to check her and purchase whatever preparation looks helpful. This blood pressure with one of the automatic machines located in uneducated use of OTC drugs can be hazardous to a drugstore. She found that her blood pressure was just a little older adults, particularly those taking prescription bit higher than she thought it should be. Remembering that medications. OTC medications are capable of potenti- she had another medicine for blood pressure at home, she ating or interfering with prescription medications, decided (without consulting the care provider) to take a few of possibly resulting in serious harm. OTC drugs can also the “less potent” old tablets. Only when she began to feel dizzy and almost fainted did she call the care provider.

Medications and Older Adults  CHAPTER 7 137 RISKS RELATED TO FINANCIAL FACTORS Box 7-2  CARE Acronym for Medication Assessment Medications are expensive. A single prescription can C—Caution/compliance: Assess benefits and risks. easily cost $100 or more a month. If an aging person Remember, there are many reasons an older adult requires more than one medication, the cumulative may not be compliant (adherent). cost can be overwhelming. To save money, older adults living on limited incomes may fail to take their medi- A—Adjust: The dose may change based on age and cations or they may make changes in the amount or condition. “Start low, go slow” is the rule for older frequency to conserve their supply. Because these adults. “A little goes a long way.” changes do not follow the recommended therapeutic schedule, a wide variety of untoward responses can R—Review regimen regularly: Polypharmacy is common occur. Even with insurance coverage, some prescrip- in older adults. Each new medication increases risk for tions may not be filled. Older adults may say, “I don’t interactions. like to take pills.” Others will get a prescription filled once to see whether it is “worth the price.” If the ben- E—Educate: Be sure older adults know their drugs, how efits gained from taking the medication are not readily and when to take them, and when to notify the obvious to older adults, they may not refill the pre- primary care provider. scription. Because medications are expensive, many frugal older adults save medications that were pre- Modified from Fordyce M: Geriatric Pearls, 1999. Philadelphia: FA Davis. scribed in the past, even if the drugs are no longer part of their therapy. Older adults are often reluctant to • Normal route or routes of administration discard costly medications, holding on to them “just in • Any special precautions related to administration case” they are needed again. This practice can bring • Common side effects or adverse effects of the medi- serious harm if the medications become outdated. Outdated medications can undergo chemical changes cation (see Clinical Situation, p. 133) that make them hazardous. Saving old medications • Signs of overdose and toxicity also increases the risk for problems if the older person thinks the drug is appropriate and takes it without NURSING ASSESSMENT AND MEDICATION checking with the primary care provider. Thoroughly assess the older adult before administer- MEDICATION ADMINISTRATION IN ing any medications. After administration, monitor the AN INSTITUTIONAL SETTING older adult continually to determine whether or not the medication is having the desired effect. Perform this It is obvious that medications can present a wide range after administering both scheduled and as-needed of problems for older adults. Nurses working with medications. Also, observe for any untoward effects or older adults must consider each of these risks when significant changes in medical condition or behavior determining a plan for safe administration. Medication (Box 7-2). administration is a common part of nursing care of older adults in hospitals, extended-care facilities, and Because normal physiologic changes and the effects home settings. Approaches and methods may vary of disease place the older person at an increased risk according to the setting, but the safety of the older for drug-related problems, be particularly watchful for adult remains the primary concern. A great deal of any signs of overdose or toxicity. Special age-related nursing time in facilities is spent on medication-related risk factors and observations for the more common activities. Because medications play an important drug classifications are summarized in Table 7-5. role in the health care of many older adults, nurses must take special precautions to ensure safe drugs Cultural Considerations administration.   Safe drug administration begins with a thorough knowledge and understanding of each medication. Assessment and Ethnicity Clarify and resolve any questions regarding medica- Ethnicity is one factor that should be considered when tion therapy before administering a medication. you assess a patient’s use of and response to medication; Information regarding medications is contained in however, it should not be used to stereotype any group. Some many reference books, which should be readily avail- ethnic variations that have been identified include the able to nurses. Before administering a medication, following: have the following information: • African Americans do not respond as well as whites to • Therapeutic effects of the medication • Reasons this individual is receiving the medication propranolol (Inderal) or to the angiotensin-converting- • Normal therapeutic dosage of the medication enzyme (ACE) inhibitors, such as captopril (Capoten). Because of an enzyme deficiency, some African Americans may be more resistant to chemotherapy. • Codeine and similar drugs are more likely to be effective in individuals of Chinese, Japanese, Thai, and Malaysian descent. Individuals of Asian descent are also more likely to experience alcohol intolerance and may demonstrate excessive responses to antianxiety medications. Use of

138 UNIT II  Basic Skills for Gerontologic Nursing   Table 7-5  Common Drug Categories with Precautions Related to Aging TYPE OF MEDICATION RISK FACTORS ASSESS FOR Cardiac Medication Digoxin, propranolol Dehydration, hypothyroidism, decreased Visual spots, dizziness, headaches, fatigue, renal excretion, and hypoxia increase drowsiness, mental changes, numbness around the risk for toxicity. lips or of hands, altered pulse rate or regularity, loss of appetite, nausea, vomiting, diarrhea, weight loss Diuretics Bumetanide, furosemide May result in dehydration. May Signs of dehydration, hypotension, weight loss, precipitate urinary incontinence or lethargy, dizziness, lightheadedness, and retention in older men with prostate confusion hyperplasia. May result in altered electrolyte balance (K+ and Na+), which predisposes patient to digitalis toxicity. Antihypertensives Captopril, clonidine, High doses may aggravate existing Bradycardia, postural hypotension, weakness, hydralazine, methyldopa problems in cerebral, coronary, and headaches, palpitations, nausea, vomiting, renal circulation. Hot weather, diarrhea or constipation, difficulty urinating, and alcohol, and exercise are likely to edema increase the risk for hypotension. Psychotropics (Including Antianxiety Agents, Antidepressants, and Antipsychotics) Flurazepam, triazolam, Older persons usually require smaller Apathy, confusion, drooling, lip smacking, diazepam, haloperidol doses to achieve therapeutic grimacing, difficulty swallowing, decreased chlorpromazine, response. Tardive dyskinesia is a mobility, skin reactions, jaundice, impaired sense thioridazine significant risk with long-term therapy. of balance, alteration in gait, falls, drowsiness, fainting, hypotension, palpitations, constipation, hypothermia, and complaints of feeling cold Antiinfectives Cephalosporins, penicillins, Standard dose may result in higher Nausea, vomiting, diarrhea, dehydration, signs of sulfonamides, blood levels in older adults. Increased oral or vaginal yeast infection, urticaria, and tetracyclines risk for allergic reactions or tinnitus superimposed yeast infections with aging. Damage to cranial nerve VIII is particularly common in older adults. Nonsteroidal Antiinflammatory Agents Aspirin, ibuprofen, Increased risk for gastrointestinal and Signs of gastrointestinal upset including nausea, tolmetin, naproxen central nervous system problems vomiting, tarry stools, diarrhea or constipation, with aging and occult blood loss; central nervous system side effects including dizziness, confusion, mood swings, depression, and tinnitus Bronchodilators and Spasmolytics Theophylline Older adults taking allopurinol, Tachycardia, arrhythmias, anorexia, nausea, propranolol, and cimetidine are at headaches, or insomnia increased risk for toxicity. Antiulcer Medications Cimetidine, ranitidine, May affect the absorption of other Confusion, dry mouth, gynecomastia, impotence, aluminum hydroxide and medications constipation, and diarrhea magnesium hydroxide herbal remedies is common among the Chinese. Implementation of computerized records as part of the Common herbs, such as ginseng, may affect the Minimum Data Set 3.0 (see Chapter 8) provides better linkage absorption and elimination of other drugs. between nurses and pharmacists. It is hoped that this interdis- • Hispanics are more likely to experience significant side ciplinary approach to medication will promote early recognition effects from antidepressants and need to be monitored of problems or areas of concern regarding the medication closely. regimen.

Medications and Older Adults  CHAPTER 7 139 MEDICATION AND THE NURSING CARE PLAN FIGURE 7-2  Before administering any medications, the nurse should check the resident’s identification bracelet to be sure the right Medications are only one part of the overall care of the person receives the right drug. (From Kostelnick C: Mosby’s older person and should be included as such. For Textbook for long-term care nursing assistants, ed 7, 2015, example, the administration of laxatives should be St. Louis: Mosby.) only a part of a more comprehensive plan to assist respond promptly and appropriately with the correct bowel elimination, and the administration of analge- name. A response to hearing the nurse call a name that sics should be only a part of a larger nursing care plan involves a head shaking or a “yes” from a patient is for pain control. not enough to ensure identification. Many older adults suffering from hearing or cognitive impairment give Nursing interventions and precautions related to some sort of response to any name. When an older medications should be addressed in the care plan. This person is not oriented to a person, bracelets or pictures could include the use of safety devices, call signals, must be used (Safety Alert). behavior monitoring, or any other specific precaution related to medications. The care plan should indicate Safety Alert when it is necessary to check vital signs, monitor labo- ratory values, or make any other special observations.   All parameters specified by the prescriber should be readily identified in the care plan—for example, “Hold Check identification, following agency policies, each time a digoxin if apical pulse is below 60” or “Give 6 units medication is administered. Failure to do this can result in regular insulin at bedtime if the fingerstick blood serious errors and harm to older adults. glucose is over 150.” Do not attempt to identify a resident by room and bed number because cognitively or perceptually impaired The care plan should indicate any individual prefer- individuals often wander into the wrong room or lie ences of the older person. Many older adults use a down in someone else’s bed. Be careful to avoid the particular order or method to take their medication. trap of insisting that you “know the residents.” Check This information should be in the care plan so that all identification with each medication pass; no matter staff nurses can be consistent. how long you have been caring for the patient. Serious mistakes can and do occur when nurses take shortcuts NURSING INTERVENTIONS RELATED with safety procedures. As a method of ensuring accu- TO MEDICATION ADMINISTRATION rate identification in accredited agencies, The Joint It is often necessary to modify procedures and tech- Commission (TJC) requires the use of two identifiers niques of medication administration when working before the administration of medications. with older adults. Despite modifications, the tradi- Right Medication tional “rights” of medication administration remain Before administering a medication, ensure that the essential to the process. drug provided by the pharmacy is the correct one. This is not as easy as it seems. Because each medication Right Resident has a generic name and one or more trade names, Proper identification of the resident or patient is an and, because the appearance of a medication can vary essential part of safe nursing care. This simple task can depending on the manufacturer, nurses must use a be a challenge to nurses who work in extended-care reference source to verify that the right drug is, in fact, facilities. Whenever a large number of residents are available. Orders should be checked carefully, and the up and about, accurate identification becomes more pharmacy should be contacted if any questions arise. difficult. Many drug names look or sound alike; therefore, it is important to check spellings carefully. The most accurate way to verify identity is to compare the medication record with the identification bracelet (Figure 7-2). Whenever possible, these brace- lets should be used for identification checks. However, not all long-term residents wear identification brace- lets, and if they do wear them, the bracelets are often old and blurred. When reliable bracelets are not avail- able, alternative methods must be used. A resident’s picture is sometimes used as a means of identification. However, pictures that are old or bear little resemblance to the individual are useless. Pictures used for identification must be kept up to date and must be readily available when medications are distributed. Identification can also be accomplished by asking the resident to state his or her full name. Most people

140 UNIT II  Basic Skills for Gerontologic Nursing • cc (can be mistaken for the letter “u” if poorly written): use mL or milliliters instead If telephone medication orders are permitted, repeat the entire order back (“read back”) to the physician, • µg (can be mistaken for mg, resulting in 1,000- taking care to clarify the spelling of the drug to avoid fold dosing overdose): instead, write mcg or the possibility of error. micrograms Right Amount Health Promotion The goal of drug therapy in older adults is to achieve the maximal therapeutic benefits with the smallest   amount of medication necessary (Health Promotion). Therefore, the dosage prescribed for an older adult is Guiding Rule for Medication Administration in Older Adults often lower than what would be prescribed for a Achieve the maximal therapeutic benefits while giving the younger adult. To achieve therapeutic levels without smallest necessary amount of medication: “Start low and go overdosing the older adult, the primary care provider slow!” may order lower doses or less frequent administration of a medication. With lower doses, as with all medica- Right Dosage Form tion doses, it is imperative to verify the strength of the Problems arise when the older person is unable to medications (checking decimal points closely). All swallow tablets or cannot swallow at all and relies measurements, particularly for liquids, must be made on a gastric or nasogastric tube for nourishment. For with great care. Decreased frequency in administration these patients, nurses must consider safe alternatives. can result in medications that are administered every If the medication is available in liquid form, discuss other day or every third day. Nurses must pay close the possibility of an order change with the physician. attention when administering medication to avoid Because liquids might be absorbed more rapidly than administering it on a day when the drug should be solids, all changes in medication form require a new withheld. Any questions regarding the dosage should order. Many times when the drug form is changed, the be clarified with an approved reference, the pharma- dosage is also changed. If a liquid form is not available, cist, or the prescribing care provider before the medi- the tablet or capsule may have to be crushed or broken cation is administered. To prevent errors caused by to facilitate swallowing. Not all medications can be misinterpretation of orders, TJC has published an offi- crushed or broken, because these activities can alter cial “Do Not Use” list of symbols, abbreviations, and the action of the drug (Box 7-3). Consult the pharmacy mathematical expressions (Table 7-6). In addition to if there is any question of whether or not a medication the “Do Not Use” list, it is also important to avoid should be crushed. Lists of common medications that certain symbols that can easily be misread when should not be crushed or chewed are available from handwritten: many sources and should be kept on the nursing unit • > and < symbols (can easily be confused with the for reference. number 7 and capital letter L): instead, use the Right Route words “greater than” and “less than” Most medications are prescribed for oral administra- • Abbreviations for drug names: instead, use the full tion. When an oral medication is being administered, name the importance of the medication, the preferences of • Apothecary units: use metric units instead the older person, and his or her capabilities must be • @ sign (can be mistaken for the number 2): instead, considered. write the word “at” Table 7-6  The Joint Commission’s Official “Do Not Use” List* DO NOT USE POTENTIAL PROBLEM USE INSTEAD U, u (unit) Mistaken for “0” (zero), “4” (four), or cc Write “unit” Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit” IU (international unit) Mistaken for each other Write “daily” Period after the Q mistaken for “I” and the “O” Write “every other day” Q.D., QD, q.d., qd (daily) Q.O.D., QOD, q.o.d., qod (every mistaken for “I” Write X mg Decimal point is missed Write 0.X mg other day) Write “morphine sulfate” Can mean morphine sulfate or magnesium sulfate Write “magnesium sulfate” Trailing zero (X.0 mg)† Lack of leading zero (.X mg) Confused for one another MS MSO4 and MgSO4 *Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on pre-printed forms. †Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation. The Joint Commission, 2014. Reprinted with permission.

Medications and Older Adults  CHAPTER 7 141 FIGURE 7-3  Many tablets are scored and can be split for easier refused all oral medications, including those for his diabetes swallowing. (From Kee JL, Hayes ER, McCuistion LE: Pharmacology: and hypertension. A nursing process approach, ed 7, 2012. St. Louis: Saunders.) • Why do you think is he refusing his medication? • How can you determine what is going on in this particular Box 7-3  Medications That Should Not Be Chewed or Crushed situation? • What actions should you take? • Enteric-coated tablets (Many appear to have a “candy coating.”) Crushed medications should not be mixed into a serving of food during mealtime. This practice is • Capsules (Some may be opened and the contents unsafe as it often results in a partial missed dose dissolved; others may not; be sure to check with because the entire serving of food may not be con- pharmacy.) sumed and also because the nursing assistant assigned to feed the patient is not qualified to administer medi- • Time-release tablets or capsules (These often have cations. Again, use of a small amount of applesauce, names with suffixes, such as LA [long-acting], SR pudding, or ice cream to facilitate swallowing of a [sustained-release], ER [extended-release], etc.) crushed medication is an acceptable practice. Crushing medication and hiding it in food to administer a medi- • Sublingual or buccal tablets cation that the patient has refused violates the person’s • Medications with a bitter taste right to choose and is considered unethical. Administer • Medications that can irritate oral mucous membranes unpleasant tasting medications after all other medica- tions. Offer a sip of ice water before the medication or Many older adults receive numerous medications. refrigerate unpleasant-tasting liquid medications to Administer the most important medications first, so if make them more palatable. Facility policies should the person refuses to take them all, at least the most provide directions as to how to proceed when a patient essential ones will have been administered. Whenever refuses medications as a result of dementia or other a person refuses to take his or her medication, it should cognitive problems. be noted in the chart and notify the nurse in charge, as the primary care provider may need to be informed in Administration of medication through a feeding a timely manner. tube is often necessary and must be done correctly. Request the liquid form of a medication when avail- Some older adults are capable of and prefer swal- able. Large particles of a medication can block the lowing several tablets at one time to “get it over with.” feeding tube, requiring tube replacement. To prevent If they experience no difficulty taking their medica- blockage, finely crush each tablet and then place tions this way, there is no reason to try to make them in a plastic medication cup, where it should be thor- change their habits. Other people prefer to take their oughly dissolved in a small amount of warm water. medications one tablet at a time. If this is their prefer- Once completely dissolved, administer the medica- ence, the nurse should oblige. Still others have trouble tions through the feeding tube. Administer each swallowing any solid medications. medication separately. Flush the feeding tube with a small amount of water before giving the first Tablets, particularly large ones, are likely to cause medication, again after each medication, and once the greatest problems. Dryness of the mouth related to more before reconnecting the tube with the feeding aging often makes swallowing difficult and results in solution. Never mix medications together or with complaints of pills sticking in the throat. Encouraging feeding solutions. older adults to take a drink of water or some other beverage before they try to swallow the tablet may Transdermal delivery is becoming an increasingly make swallowing easier. Coating the tablet with a popular route for drug administration. Transdermal spoonful of pudding, ice cream, or applesauce might medications are administered using a “patch” consist- also help the patient swallow it more easily. Only small ing of a center that contains the medication surrounded amounts of these foods should be used to facilitate by a skin overlay, which secures the patch to the skin. swallowing. Ask the pharmacist if larger pills can be Transdermal medications are typically readily accepted split in half; if they are scored, this will be possible by older adults, because they are easy to apply and are (Figure 7-3). effective for extended periods of time. This route is convenient and has a high rate of compliance because Critical Thinking it is painless, tasteless, and eliminates the need to con- sider the timing of application in relation to meals.   Transdermal patches cause few GI problems and are able to maintain more stable plasma levels of medica- When a Patient Refuses Medication tions, so there are fewer side effects. An additional A 78-year-old male patient in the hospital for pneumonia has benefit is that drug delivery can be stopped immedi- taken his medication without problems in the past. Today, he ately by removal of the patch.

142 UNIT II  Basic Skills for Gerontologic Nursing muscle remains large enough for injection even in very slender people. Furthermore, it is well away from Box 7-4  Precautions When Using areas of possible contamination if the older person is Transdermal Patches incontinent. 1. Check the dosage strength of the patch. Choose needle length with caution, depending on 2. Verify the correct site or sites for administration. the injection site. The deltoid muscle is usually a poor 3. Remove any protective liner so that the medication is site for all but very infrequent administrations of very small volumes. To avoid striking the bone of an emaci- in contact with the skin. ated older person, a shorter-length needle (e.g., 1 inch 4. Wear gloves when applying and removing instead of 1.5 inches) may be needed. transdermal patches to avoid skin contact with the Right Time medicated portion. Some medications are more effective or better toler- 5. Document where each patch is applied. Be sure to ated if given under specific conditions. For greatest rotate sites. effect, medications that are ordered before meals 6. Apply patch to dry, hairless patch of skin. Avoid should be given when the stomach is empty. areas of irritation and bony areas. Medications that are ordered after meals should be 7. Remove all old patches, and clean the skin before given only after the person has eaten. applying a new one (pay special attention for clear patches that are difficult to see on the skin). Activities of daily living can be affected by medica- 8. Avoid use of heat over a patch because this causes tions. Medications should be administered when the vasodilation, which increases the rate of absorption. drugs will interfere as little as possible with normal Do not apply tape over the patch. activities. For example, administer a diuretic medica- 9. Dispose of old patches by folding sticky edges tion early in the day to prevent the older person from together and placing in the sharps container. If having to get up several times at night to urinate. the old patch contains a controlled substance, Administer steroids in the morning, because they can a second nurse must witness the folding and give the person an energy “boost,” but which could disposal, and both will document, according to lead to insomnia if given in the evening. agency policy. 10. Teach patient safe application, removal, and disposal The timing of eye-drop administration becomes an of patch. Also, teach patients to report use of a issue when an aging person requires more than one patch, as well as any other medications, when type of medication in the same eye. Some eye medica- seeking medical attention, particularly during tions are compatible and can be given together, whereas emergency care or when magnetic resonance others cannot. Clarify the timing and order of admin- imaging (MRI) is anticipated, because many patches istration for eye drops with the pharmacy, and clearly contain metal and can cause skin burns during the indicate the schedule in the medication administration MRI procedure. record. The major disadvantage of the patch is skin irrita- Right Documentation tion caused by either the active ingredient or the adhe- Use care when documenting medications. Facilities sive used to secure the patch. Newer techniques have use a variety of different forms and records to docu- reduced these problems, and the risk can be reduced ment various aspects of care, including medication by rotating the application site and cleaning the skin administration. To ensure that all medications are thoroughly following removal (Box 7-4). administered properly, the rules of charting must be followed. The inhalation route is also used for the administra- tion of medication. Inhalation drugs are typically Medications cannot be charted as having been administered using metered-dose inhalers and nebu- administered until they are actually taken. This means lizers. The older adult who has arthritis in the hands that you must stay in the room and watch the older or lacks coordination may need some assistance using adult take the medication. It is not safe practice to these devices. Effectiveness of drugs administered by leave medication at the bedside unless the resident has inhalation is often affected by the diminished lung specific orders that permit self-medication. capacity and decreased depth and strength of inhala- tion typically seen with aging. Include special observations regarding the patient’s or resident’s response in the daily nursing notes and When a parenteral medication is ordered, other narrative summaries. Identify the reasons for admin- precautions must be taken. Because older adults gener- istration of as-needed medications each time one is ally have less muscle mass and subcutaneous tissue administered, and document the effectiveness of these than do younger people, injection sites should be medications. When a medication is refused or with- selected carefully. Intramuscular injections are best held, clearly document the reasons and notify the administered using the ventrogluteal site, which is primary care provider so that the plan of care can be easily accessible without excessive repositioning adjusted if necessary. and is free from major nerves or blood vessels. This

Medications and Older Adults  CHAPTER 7 143 PATIENT RIGHTS AND MEDICATION Coordinated Care Older adults have the right to know what medication   they are receiving and why they are receiving it. Nurses should provide this information when questioned and Delegation when a new medication is prescribed. MEDICATION ADMINISTRATION Older adults also have the right to refuse to take Many long-term care institutions now use specially trained medication. If a person refuses to take medication, nursing assistants as medication assistants to administer nurses cannot use force. A positive attitude and encour- routine oral and some topical medications to stable patients. agement may help encourage the individual to cooper- The responsibility for monitoring the patient’s response, ate. However, when a medication is still refused, you however, remains your responsibility. must determine and document the reasons for refusal, notify the nurse in charge, and communicate any prob- IN THE HOME lems to the primary care provider. Taking medications correctly can be a complex problem Provide privacy for the older person during injec- for older adults. Because medications are a significant tions or any other procedures. Close the doors and part of the medical plan of care, older adults who live curtains. Failing to do this violates residents’ rights. independently must learn to take them properly. The responsibility of assessing medication-taking behav- Administering psychotropic drugs as chemical iors and teaching safe self-administration often falls restraints presents a risk to the rights of older adults. to the home health care nurse (see Home Health The Omnibus Budget Reconciliation Act (OBRA) of Considerations box). 1987 mandates that nursing home residents be “free from physical or chemical restraints imposed for the Home Health Considerations purposes of discipline or convenience” (Health Services Advisory Group, 2012). You must follow specific   guidelines carefully regarding the administration and monitoring of behavior when an older person is receiv- Medications ing a psychotropic medication. Each abnormal behav- ior that is an indication for administration of such Nurses who work in home health have a great opportunity to drugs must be individually identified in the plan of evaluate patients’ medication knowledge and adherence to care. During each shift, you must document the medication therapy. The number of drugs prescribed and the number of times these identified behaviors occur. If no risk for drug-drug interactions increase when a patient is being symptoms occur at a given dosage of psychotropic seen by more than one specialist. Adherence issues are also medication, the prescriber will attempt to decrease the likely with multiple medications. Here are some steps to dose. This process continues as long as the older person increase patient awareness and adherence: receives these medications. 1. Explain why it is important to do a thorough medical SELF-MEDICATION AND OLDER ADULTS history and review of medications to gain the older adult’s cooperation. IN AN INSTITUTIONAL SETTING 2. Determine what drugs (prescription, OTC, and herbal) are Under OBRA legislation, residents of care facilities kept in the house. If possible, go around with the older should have the option of self-medication if they are adult and identify where medications are stored. Be sure capable of doing so safely. An order stating that self- to check places, such as medicine cabinets, the kitchen medication is permitted is usually required. table, counters or cabinets, on top of and inside the refrigerator, at the bedside, and in purses. Self-medication by a resident can be time-consuming 3. Check whether there are any other “old medications” because you remain responsible for monitoring the stored in a shoebox, bag, or anywhere else. resident’s adherence and response to the medications. 4. Gather all medications in the house and go through them When self-medication is anticipated, you must assess one at a time. Ask the patient to identify which ones are the older adult’s ability to understand and comply taken daily, occasionally, and as needed. If more than one with the medication regimen. This assessment should older adult lives in the home, separate the medications, include the resident’s ability to read labels, follow and evaluate each separately. Watch for drugs that do directions, and measure dosages accurately. After it not relate to any identified health problems, for any drug has been determined that the person can safely assume duplications caused by orders under both generic and responsibility for self-medication, the nurse should trade names, for potential drug-drug interactions develop a plan, including (1) delivery of adequate (including OTC and herbs), and for inappropriate drug amounts of medication; (2) safe storage of medications dosages. that will be kept at the bedside; (3) record-keeping of 5. Review each medication to determine whether the patient medications taken; and (4) follow-up assessments of knows why he or she is taking it, when to take it, and any medication’s effectiveness or side effects. precautions to use regarding the drug. 6. Discuss what method (if any) the older person uses to verify that the appropriate doses of all medications are taken each day (e.g., Does the person use a daily or weekly pillbox?). 7. After obtaining the patient’s consent, discard any expired drugs.

144 UNIT II  Basic Skills for Gerontologic Nursing Box 7-5  Information to Include on Medication Teaching Sheets TEACHING OLDER ADULTS ABOUT MEDICATIONS • Name of the medication (trade and/or generic) Older adults and their families or significant others • The time or times when the medication should be should be given complete information about the pre- scribed medications and the proper method for taking taken them. Explanations should be given well in advance of • Whether the medication should be taken before, with, the older adult leaving the office, clinic, or hospital. If possible, nurses should select a time when the older or after meals adult’s anxiety level is low, because the individual will • Any precautions to take with medication preparation be more likely to remember the important points when • How much of the medication to take calm. If the directions are complex, extra time may be • The reason why the person is receiving each needed to ensure that they are understood completely. Commonly, older people fail to ask questions because medication (desired effects) they are afraid of being judged as ignorant or bother- • Common side effects some. This information should be reviewed and • Action to take if these side effects occur repeated if necessary at subsequent visits. Provide all • What to do if the person forgets a dose of the information in written form in addition to the verbal instructions. medication • What to do if the person experiences nausea or Most medications are taken orally, but increasingly drugs are administered using alternative routes. When vomiting and is unable to take oral medication medication is taken in any way other than the oral route, verify that the older person understands and is updated each time a medication is added or discontin- able to demonstrate safe self-administration. This ued. If the person is not capable of keeping the record includes transdermal patches, suppositories, eye drops up to date, the nurse or family should provide assis- or eardrops, and injections. Remember, many things tance. This record should be taken along each time the that seem obvious or simple to nurses are complex for individual receives health care services so that all care others. providers have the necessary information. A written record relieves the older person of the burden of trying In addition to teaching independent older adults to remember too many details, which is particularly about their prescription medications, teach the impor- difficult when the person is under stress. tance of consulting with the physician or pharmacist before using alcoholic beverages or taking any OTC or Nurses can assist older adults by preparing medica- herbal medications. Remind independent older adults tion cards or sheets that identify and give the impor- never to take medication prescribed for someone else tant information about each medication (Box 7-5). without first consulting the primary care provider. Teaching aids should be kept simple and clear; writing should be large and legible. Family members should Patient Teaching be included in the teaching so that they are able to assist if necessary.   SAFETY AND NONADHERENCE Independent Older Adults and Medications (NONCOMPLIANCE) ISSUES Older adults who live independently need to know the Nonadherence with prescribed medication regimens is following: common among older adults. Choosing to not take • Alcohol and nonsteroidal antiinflammatory drugs medication as prescribed can result in poorer health, adverse reactions, emergency department visits, hos- (NSAIDs), such as ibuprofen, can increase blood pitalization, and even death. The financial cost of non- pressure and interfere with the action of antihypertensive adherence with medication therapy is estimated to be medications. as high as $100 billion a year. • Excessive use of acetaminophen (Tylenol) can damage the kidneys; if the patient uses alcohol heavily, it can also Several factors can increase the risk for nonadher- damage the liver. ence. Cognitive and sensory limitations increase the • Antacids do not protect the stomach from aspirin or risk for medication errors. Keeping track of multiple NSAIDs. medications can be confusing to anyone, but it is more • Antacids, calcium supplements, and significant amounts likely to present problems for older adults. One or two of dairy products should be taken at least two hours medications do not seem to cause many problems, but apart from other medications. a significant number of older adults become confused • The combination of NSAIDs and angiotensin-converting- and nonadherent when three or more medications are enzyme inhibitors increases the risk for renal failure, ordered. Special precautions and complicated time especially when the patient is also taking a diuretic. schedules compound the problems. To reduce the risk for nonadherence, encourage older adults to talk to the Each older person who lives independently should primary care provider and/or the pharmacist to see have an up-to-date record that identifies his or her major physical problems, their care provider(s), any allergies, and all current medications. This list must be

Medications and Older Adults  CHAPTER 7 145 whether there is any safe way to reduce the number of distinguishable. This is particularly important medications or simplify the medication schedule. In because many ear preparations can cause perma- addition, research has shown that depression, belief nent damage to the eye. patterns, and lack of a social support system contribute • Teach older adults to store medications properly. to nonadherence. Medications should be stored away from direct light and moisture, which can cause chemical changes. Techniques that improve safety and adherence The tiny pillboxes used by many older adults can include, but are not limited to, the following: be dangerous and should be avoided. Pills left in the • Associating medication schedules with regular boxes may undergo chemical changes. Nitroglycerin can become totally ineffective if stored improperly. daily events such as meals or bedtime can help Once medications are removed from the prescrip- older adults remember to take their medications. tion bottle, they cannot be readily identified and the Provide additional teaching if medications require older person can easily take the wrong pill. It is special timing (e.g., before or after meals). Unless safest to leave medications in the pharmacy bottles older persons are aware of the reasons and necessity even though they may be bulky. for a schedule, they may not adhere to the schedule • Obtain or devise a system to promote adherence. and may experience untoward effects. When older people are unable to keep their medica- • Explain the importance of preparing medication in tion schedule straight by using the bottles provided a well-lit area. Poor lighting can further reduce by the pharmacy, other approaches may be neces- vision in older adults and increase the chance of a sary. There are several ways nurses can help older mistake. adults remember to take their medications. Medi­ • Ensure that containers are properly labeled. Visually cation reminder systems help some older adults impaired older adults can continue to self-medicate remember to take medications. These systems typi- if measures are taken to compensate for visual prob- cally consist of divided containers that sort the lems. Large, preferably uppercase or printed letter- medications by day of the week or by time. They ing should be used on all labels and teaching can either be purchased inexpensively at a phar- materials. All print or writing should be in dark, macy. A simple check of the box reveals if the medi- bold letters. If there is any chance of moisture on the cation was taken on time. Some individuals require labels, coat them in clear plastic or a wide piece of more medication than fits into these standard con- clear packing tape. This prevents blurring of the tainers or fear that they will drop the container and lettering, which can lead to errors. mix everything up. These individuals may benefit • Apply color codes, tape strips, pictures, or textures from a system using small zip-closure plastic bags such as sandpaper to containers to help older adults that are labeled (using masking tape) with the recognize them. For example, black could indicate appropriate day and time. High-technology solu- medicine to be taken with breakfast, red could indi- tions such as automated pill dispensing systems cate medications for lunch, and a piece of sandpa- with alarms are available, but the cost of most per attached to the bottle could indicate bedtime of these devices is significant, and maintenance of medications. Avoid yellow because many older the system may be too complex for the average adults have difficulty distinguishing this color from older adult. others. Alternatively, place one strip of tape for • Stress the importance of being alert when taking morning administration, two strips for lunch, three medications. Sleepiness can interfere with the ability strips for dinner, and four strips for bedtime. Ensure to read labels. If patients are not completely awake, that the person understands whatever coding they can easily take the wrong medication. It is not system is selected. Mark medication cups with dark advisable for older adults to keep any medications, lines or tape to improve accuracy when measuring particularly those taken to promote sleep, at the liquids, and provide magnifiers for insulin syringes. bedside. Because sleeping pills dull the ability to • Modify containers for ease of use. Impaired physi- perceive things accurately, patients who have cal function can interfere with self-medication. trouble getting to sleep may take extra doses of their Many pill bottles routinely come with safety caps medication and be seriously harmed. that older adults cannot open. If requested, most Older adults can achieve maximal benefits from pharmacies will provide containers that are easier their medication when nurses pay careful attention to to open. all aspects of medication administration. Careful • Establish measures to distinguish and separate assessment, good teaching, and well-planned inter- similar containers. If the older person is receiving ventions can enable many older adults to function eardrops and eye drops, store these containers independently. well away from each other and mark clearly with a large picture of an eye or an ear so that they are

146 UNIT II  Basic Skills for Gerontologic Nursing Review Questions for the NCLEX® Examination Get Ready for the NCLEX® Examination! 1. Following an appointment with the primary care provider, the nurse is teaching an independent living Key Points older adult about a newly prescribed medication. Which factor is most likely to interfere with the effectiveness of • On average, older adults take 14 or more medications this process? each day, not including OTC preparations. 1. The patient wears a hearing aid. 2. The patient has a history of hypothyroidism. • Drug use, misuse, and abuse present serious threats 3. The nurse provided written handouts. to the well-being of older individuals and increase the 4. The nurse is in a hurry. risk for hospitalization resulting from adverse drug reactions. 2. What is an example of a medication that can be crushed? • The chance of adverse reactions is increased by the 1. A potassium tablet normal changes of aging, pathologic changes related to 2. Enteric-coated aspirin the higher incidence of acute or chronic diseases, and 3. Sublingual nitroglycerin numerous other factors. 4. A calcium tablet • Polypharmacy is a significant problem for older adults; 3. You are administering medication through a transdermal OTC medications, herbs, and supplements all need patch. What are some precautions? (Select all to be considered when reviewing prescription that apply.) medications. 1. Remove all old patches before applying a new patch. • The medical community has long recognized that 2. Use the same location each time for consistent children require special considerations with regard to absorption. medication, and we are now aware that the aging 3. Cleanse the skin after removing an old patch. population also requires special considerations. 4. Dispose old patches in the toilet. 5. Verify the dosage strength of the patch. • Geropharmacology, the study of how older adults 6. Wear gloves. respond to medications, is an expanding area of study. 7. Tape over the patch to keep it secure. • Care providers who prescribe medication, pharmacists 4. A resident in a long-term care facility has an order for who dispense medication, and nurses who administer digoxin (Lanoxin) 0.25 mg every morning in tablet form. medication must continue to work together to If the nurse assesses that this resident has been having understand the unique problems and needs of older difficulty swallowing, what should the nurse do? adults with regard to these potentially dangerous 1. Administer the digoxin (Lanoxin) in liquid form. substances. 2. Crush the digoxin (Lanoxin) for administration. 3. Withhold the digoxin (Lanoxin) and document. • Nurses must work diligently to build a knowledge base 4. Discuss the possibility of an order change to liquid of the medications administered to their patients or form with the primary care provider. residents, know how to administer each medication safely, know how to assess the older adult’s need 5. Why are older adults more likely to experience adverse for and response to each medication, and develop an drug reactions? appropriate plan of care that includes safety concerns 1. Because of the number of medications they take and teaching needs. daily 2. Because of physiologic changes in metabolism and Additional Learning Resources excretion 3. Because of higher percentage of body fluid   Go to your Evolve website at http://evolve.elsevier 4. Because of cognitive changes .com/Williams/geriatric for the additional online resources. 5. Because of interactions with foods, OTC preparations, and herbal supplements   Online Resources: 6. Because of decreased sense of taste • Resource for older adults to keep track of medications, herbs, and OTCs used: http://www.americangeriatrics .org/files/documents/beers/MyDrugDiary.pdf • Drug interaction checker: http://reference.medscape .com/drug-interactionchecker • Beers Criteria for Potentially Inappropriate Medications: www.americangeriatrics.org/files/documents/beers/ 2012BeersCriteria_JAGS.pdf • Mobile app for Beers Criteria: http:// www.americangeriatrics.org/publications/ shop_publications/smartphone_products/

Medications and Older Adults  CHAPTER 7 147 6. What should you instruct the independent living older 7. You are caring for a new patient who had a heart person to do? transplant five years ago. She takes seven medications 1. Take most medications with milk or antacids to every day, including antirejection drugs, cardiac avoid stomach upset. medications and inhalers. She mentions feeling 2. Avoid drinking alcohol if taking acetaminophen “depressed,” and wants your advice about trying a new (Tylenol). “natural” remedy she found on the internet. Which of 3. Keep daily medications in the kitchen cabinet near the following would be the best response? the sink. 1. “That might be a good idea. I have heard good 4. Save prescription drugs in case the care provider things about St. John’s Wort.” orders them again. 2. “My Aunt Judy used to take some of those herbal remedies, and she died from liver failure.” 3. “You really should talk with your doctor first, because many things can interfere with your antirejection and heart medications, even herbs and supplements.” 4. “You’re on too many pills already; you should start an exercise program instead and fresh air to help you feel better.”

chapter 8  Health Assessment of Older Adults http://evolve.elsevier.com/Williams/geriatric 6. Discuss modifications to use when preparing an older person for a physical examination. Objectives 1. Identify different levels of assessment. 7. Describe techniques to use when performing a physical 2. Compare and contrast subjective versus objective examination. data. 8. Explain adaptations to use when assessing vital signs in 3. Discuss the importance of thorough assessment. older adults. 4. Describe appropriate methods for structuring and 9. Discuss how the Minimum Data Set affects assessments conducting an interview. of institutionalized older adults. 5. Identify approaches that facilitate a successful physical palpation  (păl-PĀ-shŭn, p. 152) examination. percussion  (pĕr-KŬ-shŭn, p. 152) pulse deficit  (p. 155) Key Terms screenings  (SKRĒ-nĭngs, p. 148) assessment  (ă-SĔS-mĕnt, p. 148) subjective data  (p. 149) auscultation  (ăw-skŭl-TĀ-shŭn, p. 152) inspection  (ĭn-SPĔK-shŭn, p. 152) objective data  (p. 149) orthostatic hypotension  (p. 156) Health assessment of older adults can be done on could be contributing factors. For example, there are several levels, ranging from simple screenings to complex, interrelated factors contributing to different complex, in-depth evaluations. To perform assess- cancer incidence and deaths among various racial, ments accurately, nurses and other health care ethnic, and underserved groups. The most significant providers who interact with older adults must possess of these factors seems to be related to inadequate the necessary knowledge and skill to perform the health care coverage and low socioeconomic status assessments correctly. They must know how to use (National Cancer Institute, 2013). It is hoped that the diagnostic tools and equipment safely. Furthermore, Affordable Care Act will improve this by reducing they must be knowledgeable and sensitive to the financial barriers and expanding insurance coverage unique needs of older adults. (Centers for Disease Control and Prevention [CDC], 2012). Nurses should screen all populations for poten- HEALTH SCREENING tial problems and promote early identification and treatment of problems. Today, Medicare coverage is Health screenings are done to identify older individu- more focused on preventive care. Annual wellness als who are in need of further, more in-depth assess- checkups and colonoscopies, for example, are two ment (Table 8-1). Screening for high blood pressure, screenings covered by Medicare that should be offered hearing loss, foot problems, and challenges with activi- to all appropriate individuals. ties of daily living are commonly performed at senior centers and health clinics. Screening services are often Screenings are not designed to provide treatment. provided by medical and nursing schools or other They are intended to identify significant findings so health groups committed to helping needy older that older individuals who are most in need of care persons. Many screenings are performed by lay indi- can be referred to the most appropriate health service viduals working under the direction of professionals. provider (i.e., physician, social worker, dietitian, or Special screenings for depression and suicide risk, nurse) in a timely manner. Early screenings also help although less common, are recommended for the older reduce frustration in older adults and wasteful use adult population. Some health concerns are more of time and resources. Depending on what is being common among certain ethnic populations, although evaluated, health screenings may be conducted in limited use of screenings and socioeconomic status person, by telephone, online, or, less commonly, by 148 mail surveys (Table 8-1).

Health Assessment of Older Adults  CHAPTER 8 149 Table 8-1  Preventive Medicine: Screening Recommendations for Older Adults SCREENING TEST RECOMMENDATION Blood Pressure Every clinical examination (USPSTF) Clinical Breast Examination Annually after age 40 (ACS) Mammogram Every 2 years between ages 50 and 74; no recommendation after age 75 (USPTF); yearly as long as a woman is in good health (ACS) Cholesterol Every 5 years (NCEP, USPSTF) Screening for Colorectal Cancer One of the following after age 50: and Polyps • Yearly fecal occult blood testing (USPSTF) • Flexible sigmoidoscopy every 5 years (USPSTF, ACS) + fecal occult blood testing every 3 years (USPSTF) • Colonoscopy every 10 years (USPSTF, ACS) • Double-contrast barium enema every 5 years (ACS) • CT colonography (virtual colonoscopy) every 5 years (ACS) Screening for Obesity At regular intervals (USPSTF) Bone Mineral Density (BMD) Recommended for women age 65 or older (USPSTF, NOF, ACOG) and men over age 70 (NOF) Prostate Examination/PSA Consultation with primary care provider to discuss appropriateness of screening at age 50, or at age 45 if African American OR family history of prostate cancer (ACS) Not recommended (USPSTF) Hearing Screening Test Every 10 years (ASHA) Comprehensive Eye Examination Every 1 to 2 years; yearly if person has diabetes (AAO) Abdominal Ultrasound (screen Once between ages 65 and 75 in men who have ever smoked (USPSTF) for abdominal aortic aneurysm) Hepatitis C Screening Recommended for people at high risk of infection (any history of injection drug use); one time screening recommended for all persons born between 1945 and 1965 (USPSTF) Human Immunodeficiency Virus Recommended for people at increased risk (USPSTF) (HIV) Blood Test Type 2 Diabetes Screening Recommended every 3 years for people with sustained BP of >135/80 mmHg (USPSTF), adults who are overweight, or those with other risk factors such as high cholesterol, family history, high risk race/ethnicity, and physical inactivity (ADA) AAO, American Academy of Ophthalmology; ACOH, American Congress of Obstetricians and Gynecologists; ACS, American Cancer Society; ADA, American Diabetes Association; ASHA, American Speech-Language-Hearing Association; USPSTF, United States Preventive Services Task Force; NOF, National Osteoporosis Foundation; NCEP, National Cholesterol Education Program. HEALTH ASSESSMENTS behavior at any given point in time. Behaviors such as crying, limping, and clutching the abdomen can be In-depth health assessments are time-consuming and verified by anyone who observes the patient. Rashes, must be performed by skilled professionals. Nurses skin lesions, and wound drainage are likewise observ- perform health assessments of older adults in the com- able to anyone. Objective data can be made more munity, in clinics, and in institutional settings. Health precise and specific by using meters, monitors, and assessment includes the collection of all of the impor- other measuring devices. A blood pressure reading, a tant health-related data using a variety of techniques. change in weight, the size of a wound, the volume of Data includes all of the information gathered about a urine, and laboratory test results are all examples of person. This information is used to formulate nursing specific objective data. Whenever possible, objective diagnoses and to plan patient care; therefore, accurate data should be stated using specific information and complete data should be collected. Data can be because accurate and precise data enhance the nurse’s either objective or subjective. ability to determine changes in a person’s health status. For example, it is better to take a temperature reading Objective data include information that can be gath- than to touch the skin and determine that it feels warm. ered using the senses of vision, hearing, touch, and Both are objective observations, but one is more precise smell. Objective information is collected by means of than the other. direct observation, physical examination, and labora- tory or diagnostic tests. Because objective data are con- Subjective data are information gathered from the crete by nature, all trained observers should report older person’s point of view. Fear, anxiety, frus­tration, similar findings about a person or that person’s and pain are examples of subjective inform­ ation.

150 UNIT II  Basic Skills for Gerontologic Nursing FIGURE 8-1  Conducting an interview. (From deWit SC, O’Neill P: Fundamental concepts and skills for nursing, ed 4, 2013, St. Louis: Subjective data are best described in the individual’s Saunders.) own words, such as “I’m so afraid of what is going to happen to me here” or “It hurts so much I could die!” the interview to last, and what will happen after it is completed. When performing a health assessment on an older person, nurses need to modify their usual approaches Focus on and speak directly to the older person and techniques to make them more appropriate for being interviewed (Figure 8-1). This notion may seem older adults. obvious, but it is often disregarded in practice. Often, a younger family member present during the inter- INTERVIEWING OLDER ADULTS view “takes over” the responses for the older person. The conversation then takes place between the nurse Interviews conducted during admission to a facility and the family member while the older adult remains are likely to be planned and conducted in a formal passive. An assertive older person might speak up and manner. Other interviews may be spontaneous, infor- say, “Let me speak for myself,” whereas a nonassertive mal, and based on an immediate need recognized older adult may be left feeling frustrated and unim- by the nurse. Before beginning an interview with an portant. The nurse should continue to direct the con- older adult, plan ways to establish and maintain a versation to the older adult and, if necessary, tactfully climate that promotes comfort and develops trust. This request that the family member allow the older person includes preparing the physical setting, establishing to respond first before he or she adds information. rapport, and structuring the flow of the interview. If the older adult is confused, nonresponsive, or During this planning phase, take into consideration does not speak English, the family member will need the unique needs of the older person. to be more actively included to translate or provide PREPARING THE PHYSICAL SETTING information. Choose the interview environment carefully. Minimize distractions: Noise from televisions, radios, and public Cultural Considerations address systems should not be loud enough to distract the older adult or interfere with his or her ability to   distinguish words and understand questions. Lighting should be diffused, because bright lights or glare may Assessment and Culture make it difficult to see clearly. Furniture should be Americans tend to approach issues directly. This is considered comfortable. Privacy is very important. Conduct the inappropriate in many Hispanic and Asian countries, where interview in a room where there is little chance of inter- more social, tactful, and indirect conversation is thought to be ruption. If such a place is not available, the patient’s proper. It is also culturally appropriate to include family members room may provide sufficient privacy; the curtains and to determine who will answer questions and participate in should be drawn and the door closed. Ensure the room the assessment process. is comfortably warm and free from drafts. Because many older adults experience urinary frequency or During the physical examination, be careful to main- urgency, it is advisable to either assist them to the tain the modesty standards set by each culture. bathroom or inform them that a bathroom is available • In some cultures, it may be desirable for a family nearby should they require it. ESTABLISHING RAPPORT member to be present during this examination. In It is most appropriate to begin the interview by greet- most cases, this should be permitted. ing the older adult and introducing yourself. During • Cultural values may dictate that physical contact this first contact, it is best to address the person using with a nurse of the opposite gender is inappropri- his or her formal name (e.g., “Mr. Smith” or “Mrs. ate. In these cases, the patient or family may request Adams”). Appropriate use of names indicates respect that a nurse of the same gender as the patient and helps build rapport. Use of the individual’s first perform the examination. name only without the person’s consent is presumptu- ous and overly familiar. This familiarity may be resented by the older person even if it is not verbal- ized. If there is any doubt about someone’s preference, it is best to ask the person how he or she wishes to be addressed. Briefly explain the purpose of the interview so that the individual will know what to expect. An explana- tion helps reduce anxiety that otherwise might inter- fere with understanding. Explain how long you expect

Health Assessment of Older Adults  CHAPTER 8 151 When in doubt, consult a knowledgeable expert or an may lose trust and refuse to communicate freely in authoritative reference text about the specific cultural the future. expectations. OBTAINING THE HEALTH HISTORY Enhance rapport by first determining the problems or concerns that most trouble the patient and then Before starting a physical assessment, the nurse focusing on those problems. This helps reduce anxiety will use interviewing techniques to obtain a health and increases the older adult’s perception that the history. This history starts with basic identifying nurse is truly concerned about him or her. Begin the data followed by a history of past health concerns and assessment with a look at the person as a whole before then a review of current health issues. Some older focusing on specifics. adults are able to provide information easily, whereas STRUCTURING THE INTERVIEW others may be poor historians. Much will depend on Plan sufficient time for the interview. Older adults the cognitive level of the individual and the complex- typically have a long and complex life story to tell. ity of his or her particular medical history. When the Remember that the speed of recall and verbal responses older adult is unsure of answers, it is often wise to may be slower with age. The individual may feel move on to other topics and attempt to gather the pressured or stressed if the pace of the interview is information from a family member at a later time. In too rapid. addition, you may want to obtain information regard- ing the person’s family and psychosocial status. The Try not to accomplish too much during a single health history data will help the nurse form an overall interview. The effort involved in communication can impression of the older person and help determine be fatiguing to an older individual, particularly one those areas most in need of further exploration and with health problems. It is better to have several brief assessment (Box 8-1). interactions lasting less than 30 minutes each rather than one long interview that leaves the patient PHYSICAL ASSESSMENT OF OLDER ADULTS exhausted. Stay alert for signs of fatigue (e.g., sagging head or shoulders, sighing, altered facial expression, Once the history is obtained, you are ready to proceed and irritability), which indicate the need to end the to the physical assessment. During this assessment, interview. objective information is obtained to accompany the subjective information offered by the older adult. During the interview, a variety of communication Objective information further helps determine the techniques should be used to ensure that the patient person’s abilities and limitations. It may verify the sub- accurately understands the information. Avoid using jective information given by the older adult; it may medical jargon and only use words the older person also reveal problems that were previously unrecog- understands. It is important to speak slowly and nized. When assessing older adults, pay close attention clearly, keeping messages simple without patronizing not only to obvious physiologic changes, but also to older adults. The fact that an older person requires changes in mood or behavior that may signal a change extra time does not mean that the person is mentally in condition. Seemingly small pieces of information impaired. Even if the older adult has been diagnosed can be important to the total assessment. Older adults with a mental impairment, he or she deserves respect- have different physiologic responses than do younger ful and professional responses. Remain calm and persons. For example, a temperature change of just a empathetic. When the patient is speaking, do not inter- few tenths of a degree may indicate the onset of an rupt. Listen to both the verbal and nonverbal messages infection in an older person, rather than rising above being sent. Some older individuals tend to ramble in the 100°F reading, which is expected in younger conversation and may need to be brought back on people. Other changes can be equally meaningful and track. A summary or restatement of the conversation may be missed or ignored if nurses are not especially can help. It is not appropriate to complete sentences careful (Table 8-2). for the older adult. Remain attentive and calm and allow the patient to complete his or her own sentences. Perform the physical assessment in a location that Too often, the nurse’s conclusion is considerably dif- promotes physical comfort of the older adult. Often, ferent from the patient’s. this will be the person’s room or a special examination room. Maintain privacy by keeping doors and curtains The interview should not end abruptly. A statement closed. Be careful not to chill the older adult while such as “We’re almost done for now” prepares the examining the body. Blankets and gowns that provide older person for the end of the interaction. Many lonely adequate warmth should be used to promptly cover persons will try to extend the conversation beyond the parts of the body not being assessed. If the exami- the time the nurse has available. Setting a time for nation is being done during physical care (e.g., during further interaction by saying, “We’ll talk again tomor- the bath), pay particular attention to prevent chilling row morning” or “I’ll set up another appointment so caused by evaporation. we can talk more” can help maintain rapport. It is essential to follow through as promised, or the patient

152 UNIT II  Basic Skills for Gerontologic Nursing • Surgeries (type and date) • Mental health treatment (type and date) Box 8-1  Health History Data • Review of personal health habits such as diet, fluid History should include, but not be limited to, the following intake, exercise practices, sleep patterns, bowel information: and bladder routines, alcohol, caffeine and tobacco use, etc. IDENTIFYING DATA • Name PRESENT MEDICAL HISTORY • Date of birth • Major current problems or concerns (in person’s own • Residence • Ethnicity and cultural preferences words) • Language preferences • Do the problems relate to an accident or fall? • Religion • Symptoms (location, duration, severity, etc.) • Marital/significant other status • Date of onset (sudden or gradual onset) • Previous and/or current occupation • What makes problem worse or better? • Educational background • What was done in response to symptom(s) (home • Advance directives and any other relevant data remedies, MD visit, etc.)? PAST HISTORY • Medications currently taken (look at bottles if possible) • Perception of general health • Compliance with medication regimen • Frequency of medical and dental care, including • Current medical treatments or therapies (oxygen, screenings such as mammography, BP, etc. physical therapy, etc.) • Known or suspected allergies (medicines, food, animals, FAMILY AND PSYCHOSOCIAL HISTORY etc.) • Living family members (spouse, children, siblings, etc.) • Immunizations (type and date) • Exposure to communicable disease such as TB and nature of relationships • Serious childhood illness or injuries (rheumatic fever, • Friends and social activity practices (clubs, church fractures, etc.) activities, community organizations, etc.) • History of serious illnesses (specify illness, date of • Significant deceased family members • Hobbies and interests onset, type of treatment received, resolved vs. ongoing • Pets problem) • Hospitalizations (reason and date) Table 8-2  Atypical Presentation of Illness Collect equipment such as a flashlight, measuring tape, scale, sphygmomanometer, stethoscope, and TYPE OF ILLNESS PRESENTATION thermometer before beginning the assessment to convey a sense of competence and to allow the assess- Infectious Absence of fever ment to progress smoothly. diseases WBC within normal limits Decreased appetite or fluid intake Complete the physical assessment in an orderly Behavioral changes manner so that no important observations are missed. Confusion Begin with an overview of the person, including general appearance, hygiene, grooming, alertness, “Silent” acute Mild abdominal discomfort responsiveness, and general mobility; then proceed abdomen Constipation with more focused assessments. The most common Vague respiratory symptoms method of physical assessment is a head-to-toe approach in which the entire body is assessed system- “Silent” cardiac No complaint of chest pain atically. Other approaches such as body system or problems Vague symptoms of fatigue or nausea functional approaches are also viable. Later chapters Decreased functional status provide guidelines for assessing safety needs, nutri- tion, skin, elimination, activity, sleep, cognitive func- Pulmonary May not exhibit paroxysmal edema, tion, and other areas in more detail. nocturnal dyspnea, or coughing When performing a physical assessment, nurses use Subtle changes in function, appetite a variety of techniques, including inspection, palpation, Confusion auscultation, and percussion. Thyroid disease Hyperthyroidism: fatigue, “slowing INSPECTION down” (opposite of usual Inspection is the most commonly used method of presentation) physical assessment in which the senses of vision, smell, and hearing are used to collect data. Skill at Hypothyroidism: agitation and inspection improves the more often the technique is confusion (opposite of usual done. Inspection requires the nurse to be totally active, presentation) Depression Vague somatic complaints, including GI symptoms, changes in appetite, constipation, sleep problems Modified from Ham R, Sloane D, Warshaw G: Primary care geriatrics: A case-based approach, 2002, St. Louis: Mosby.

Health Assessment of Older Adults  CHAPTER 8 153 alert, and aware of everything he or she sees, hears, or or intermittent. When sounds are intermittent, the smells. It begins the first time we see the older adult. number of times and the interval between occurrences Even during a brief interaction, skilled nurses should should be determined. be inspecting the individual, looking for anything that may indicate a change in his or her condition. Auscultation requires a quiet environment and special skills. Nurses should be skilled in the technique Inspection can be both general and specific. General and knowledgeable regarding the significance of any inspection is used to detect the need for more specific findings. inspection. For example, if the nurse observes that the PERCUSSION older adult is eating poorly, a more specific inspection Percussion is a technique in which the size, position, of the oral cavity may be indicated. If body odor is and density of structures under the skin are assessed detected, a more specific inspection of the skin may be by tapping the area and listening to the resonance of indicated. If the nurse hears noisy breathing, a more the sound. Depending on the amount of vibration specific inspection of the lungs may be necessary. If (sound) heard, the presence of masses, fluid, or air can gait is abnormal, a more complete assessment of the be determined. This technique is used least often by joints, muscles, feet, and nervous system is indicated. nurses. It requires special skill and training. Inspection is used when assessing the overall MEASURING VITAL SIGNS IN OLDER ADULTS level of function, as well as when looking for specific areas of need within any particular area of function. Measurement of vital signs involves all of the tech- When inspecting the older adult, it is important to niques previously discussed. When measuring vital pay close attention to details. Use adequate light signs, nurses should first complete a general inspec- (preferably natural light) when trying to detect subtle tion of the older adult to determine whether there are changes in skin color. Compare size and mobility of any subjective or objective observations that may affect body parts on one side of the body with those on the the procedure or accuracy of the readings. Because opposite side. activity level, medications, eating, stress, disease pro- PALPATION cesses, and the environment can all affect vital signs, Palpation uses the sense of touch in the fingers and the possible contributions of these factors should be hands to obtain data. Palpation is used for evaluation considered. in many parts of a physical assessment, including pulses, temperature and texture of the skin, texture Baseline vital sign readings should be obtained and condition of the hair, the presence and consistency during the initial contact with the older adult. These of tumors or masses under the skin, distention of readings are the basis for comparison with future read- the urinary bladder, and the presence of pain or ings, and they enable nurses to determine whether the tenderness. person’s health status is remaining constant or chang- ing over time. When palpating, use the fingertips, which are the TEMPERATURE most sensitive part of the fingers. Warm hands and The general inspection helps nurses select the most short fingernails promote comfort and reduce the risk appropriate route for temperature assessment. The for trauma to fragile older skin. Light touch should be oral (sublingual) route is used most commonly. Use an used before deeper touch is attempted. When taking electronic thermometer or a glass thermometer that the pulse of an older adult, deep palpation may occlude does not contain mercury to take an oral temperature. blood vessels. Deep pressure may also increase pain. Electronic thermometers are preferred because they Painful areas should be palpated last. can give an accurate temperature in less than 1 minute AUSCULTATION instead of the recommended 3 minutes for a glass ther- Auscultation uses the sense of hearing to detect sounds mometer. However, using the oral route is not always produced within the body. Heart, lung, and bowel possible with older adults. Those who are edentulous sounds are typically assessed using auscultation. (without teeth) or have poor muscle control may be Auscultation involves the use of a stethoscope or other unable to close the mouth tightly enough for an accu- sound amplifier (such as a Doppler) to make the rate reading to be obtained. Older adults who are sounds louder and more easily heard. Sounds are unable to follow directions are also poor candidates for described according to their quality, pitch, intensity, oral temperature checks. and duration. Quality describes the sound being heard through subjective terms such as crackling, whistling, Although acceptable, the rectal route should be or snapping. Pitch describes whether the sounds have used with caution. Use of the rectal route can be psy- a low or high tone. Intensity refers to the loudness chologically traumatic to older adults, particularly if or softness of the tone. Duration refers to the length they are alert but unable to cooperate with an oral of time a sound is heard. Frequency refers to how temperature. The rectal route should not be used in often a sound is heard. A sound can be continuous older persons who have undergone rectal surgery,

154 UNIT II  Basic Skills for Gerontologic Nursing FIGURE 8-2  Assessing vital signs. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, have rectal bleeding, or are having an acute cardiac St. Louis: Mosby.) event such as a myocardial infarction, because per- forming a rectal temperature can stimulate the vagus rate declines in the “oldest old” and is associated with nerve. Rectal readings can be affected by the presence greater longevity. Rates outside this range or signifi- of stool in the rectum. Rectal temperature readings cant changes from an individual’s normal readings reflect changes in core body temperature more slowly indicate the need for further assessment. Older adults, than do oral readings and are usually slightly higher. particularly those with a history of cardiovascular problems and those receiving digitalis, require prompt, Use of the axillary route is not common in older thorough assessment if there is a significant change in adults. This route is time-consuming, and the accuracy the pulse rate. of temperature readings may be affected by environ- mental conditions. In addition, older adults often The arteries of older adults may feel stiff and knotty have decreased axillary tissue, which can lead to “air because of decreased elasticity. In older adults, it is pockets” and a false low temperature reading. common to observe irregularities in rhythm. These may be related to medical conditions or they may have Determination of body temperature using a sensor no identified cause. Promptly report any detection of that measures the temperature of the tympanic mem- an irregular pulse in an older adult whose pulse was brane has received mixed reviews. This method has previously regular for further assessment. A change advantages and disadvantages. Use of the tympanic in pulse volume may indicate the need to assess fluid sensor takes seconds only, is not invasive, and does not balance. Weak, thready pulses are often seen in require patient cooperation; however, the readings individuals with fluid volume deficits or electrolyte obtained using this method are not as accurate as origi- imbalances; full or bounding pulses may indicate nally claimed, particularly when the device is not excessive fluid volume. Weakness of a radial pulse used precisely as directed. Individual agencies need to may make palpation impossible and necessitate use of determine whether this method of assessment is ade- the apical route. quate for their needs. When assessing the apical pulse, help older adults In general, healthy, active older individuals are able assume a comfortable position and drape them to to maintain core body temperature within normal prevent chilling and to provide modesty. The apical limits. The accepted norm for oral temperature is site is located on the left side of the chest. The apical 98.6°F ± 1°F (or 37°C ± 0.6°C). Studies have shown that heartbeat is best heard by placing the stethoscope over older adults, particularly those older than 75 years, the fifth intercostal space even with the middle of the have an average core body temperature of 97.2°F clavicle. Count the apical pulse for a full minute. Each (36°C). This decrease may be a result of inactivity, “lub-dub” sound heard is counted as one heartbeat. decreased subcutaneous fat, an inadequate diet, or Assess the apical pulse for regularity and the presence environmental factors. Environmental temperature of any unusual sounds. appears to play a greater role in older adults because their thermoregulatory control systems are not as effi- When assessing the pulse of an older woman with cient as in younger individuals. sagging breasts, lift the tissue gently and place the PULSE stethoscope at the lower edge of the breast. Apical Before assessing the pulse, position the patient so pulse may be difficult to assess in obese older adults that he or she is comfortable and so that you have or in those who have a change in the shape of the access to the desired site. Position should be consistent chest cavity. (e.g., lying, sitting, or standing) each time the pulse is checked; this will provide meaningful readings for Apical and radial readings, even when taken at the comparison. same time by two nurses, may be different. This is Pulse can be assessed at various sites on the body, including the temporal, carotid, brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis arteries, as well as at the apex of the heart (Figure 8-2). When possible, assess and compare the pulses on both sides of the body. The radial artery is the site most commonly used for routine pulse assessment. The radial pulse is normally palpable at the lateral aspect of the wrist. Palpate this pulse gently in older adults because excessive pressure may occlude the blood vessel. Count the pulse rate, and note the rate, rhythm, and volume. The normal resting pulse rate in older adults ranges from 50 to 90 beats per minute (Stessman et al., 2013). Resting pulse

Health Assessment of Older Adults  CHAPTER 8 155 referred to as a pulse deficit. Inadequate force of the heart or disease of the blood vessels may prevent respiratory rate for older individuals is similar to that transmission of blood from the heart to the peripheral of younger adults. A range of 12 to 20 breaths per vessels. Of the two, the apical pulse rate is considered minute is considered normal. A decrease in the resting more reliable. respiratory rate is significant in the older adult. It may be an indication of impending infection and may Palpate and assess the peripheral pulses of legs and appear before an elevation in temperature is observed. feet to determine whether they are present and to Increased respiratory rate is common with anxiety, determine the quality of the pulse. Peripheral pulse pain, elevated temperatures, and increased activity. rate is not normally counted. Altered peripheral circu- lation may be an early indicator of decreased cardiac The depth of respiration tends to decrease with functioning or vascular changes. Compare pulses on aging. Chest expansion is often decreased because of one side of the body with those on the other side to alterations in the shape of the thoracic cavity, muscle determine whether changes have affected one or both weakness, sedentary lifestyle, or disease processes. sides of the body. Slightly irregular breathing rhythms are not unusual Cardiovascular changes with aging, particularly in the aging population. However, abnormal findings, arteriosclerotic changes, often result in a decrease or such as a highly irregular rhythm, dyspnea, or breath- complete loss of palpable pulses in the lower extremi- lessness with exertion, require further assessment to ties. Start with the pedal pulses. If these are not detect- determine the cause, and should be reported. able, proceed upward toward the trunk and assess the BLOOD PRESSURE popliteal and then the femoral pulses. If pulses cannot Blood pressure readings are an important part of the be palpated, it may be necessary to use a sound ampli- physical assessment. It is essential that these readings fier called a Doppler to evaluate circulation to the be properly obtained. To obtain the most accurate extremities. readings, position the patient so that the upper arm is at the level of the heart. If peripheral pulses are diminished or absent, suspect circulatory impairment and assess the extrem- Equipment should be chosen carefully if meaning- ity for capillary refill time, temperature, color changes, ful results are to be obtained. Cuff selection should be and the absence of hair, all of which may indicate based on the patient’s upper arm size. It is a common serious problems. mistake to use a one-size-fits-all blood pressure cuff. RESPIRATION Many older people, particularly those who are frail, After completing a general assessment of all of the have lost a great deal of upper arm mass. A cuff that factors that influence respiration, place the older adult is too wide for the size of the individual’s arm provides in a comfortable position to maximize ease of breath- falsely low readings. A properly sized cuff is 20% ing. Assess the rate, depth, and ease of breathing wider than the diameter of the arm at its midpoint. (Figure 8-3). Each combination of inspiration and Once the proper cuff has been obtained, apply it expiration is counted as one respiration. The normal gently but snugly to the arm. Pay close attention not to pinch the skin in the cuff, which can easily lead to FIGURE 8-3  Measuring respirations. (From deWit SC: Fundamental bruising. concepts and skills for nursing, ed 2, 2005, Philadelphia: Saunders.) The technique used to obtain the blood pressure measurement should follow the methods approved by the American Heart Association. This includes taking the blood pressure first by palpation, then by ausculta- tion. Do not pump the cuff to excessively high pres- sures, as this can result in inaccurate readings. Blood pressure readings vary widely among older adults. Some older patients have blood pressure read- ings in the low-normal range; others have significantly elevated readings. Hypertension is a common prob­ lem in the older adult population because of renal and cardiovascular changes of aging. Elevated blood pressure can also be related to emotional upset, pain, exertion, eating, or smoking. This type of elevation disappears when the precipitating event is removed. To obtain accurate readings, attempt to reduce or mini- mize these factors before assessing blood pressure, and ensure the older adult has been inactive for 3 to 5 minutes. Persistent elevations in blood pressure (i.e., systolic readings 160 mm Hg or higher; diastolic read- ings 90 mm Hg or higher; or elevations of both systolic

156 UNIT II  Basic Skills for Gerontologic Nursing consciousness. Orthostatic hypotension is commonly and diastolic readings) indicate hypertension. Promptly observed in individuals who are on extended bed rest report an elevation in blood pressure readings, par- or receiving medication for hypertension. ticularly if they are unusual for the individual. To determine the existence and severity of postural Many older adults take medication for hyperten- hypotension, the nurse must obtain several blood pres- sion. Follow through with careful blood pressure mon- sure readings in succession. Performing this assess- itoring when these medications are administered, and ment requires a certain amount of skill. The nurse first rigorously follow all precautions related to the specific takes the blood pressure when the patient is at rest in medication. bed. Then the patient sits at the edge of the bed, and the nurse takes the blood pressure again in 1 to 5 Older adults are susceptible to posture-related minutes. The patient then stands for 1 to 5 minutes, changes in blood pressure. Older adults who have and the nurse takes a third reading. All readings an inactive lifestyle and those who take drugs such are recorded, along with any subjective information as vasodilators, antihypertensives, or tricyclic antide- provided by the patient regarding dizziness, loss pressants are particularly prone to orthostatic or pos- of balance, or other sensations. A drop of more than tural hypotension. Orthostatic hypotension is a sudden 20 mm Hg is always significant and should be reported drop in blood pressure that occurs when a person promptly. A standing systolic blood pressure less than changes from a lying to a sitting or standing position. 100 mm Hg should also be reported. If the individual It may also occur when the person moves from sitting complains of symptoms such as dizziness, safety pre- to standing. Those experiencing postural hypotension cautions should be taken (Table 8-3). complain of lightheadedness or dizziness when chang- ing positions. In severe cases, the person may even lose Table 8-3  Body Systems Approach to Physical Assessment* BODY SYSTEM HISTORY TECHNIQUES ASSESSMENT Skin Injuries, burns, Inspection and • Color (erythema, pallor, cyanosis, jaundice, ecchymosis) infections, palpation • Pigment changes (hypopigmentation hyperpigmentation) allergies, • Elasticity (turgor) anemia, fluid • Temperature intake levels, • Moisture (perspiration, oiliness) when and how • Texture skin change • Lesions occurred, etc. • Primary: Macule, papule, pustule, vesicle, wheal, cyst, tumor • Secondary: Scale, scar, fissure, lichen, ulcer • Vascular: Senile purpura • Hemangioma, spider angioma • Itching/tenderness • Edema • pitting edema SCALE DEGREE RESPONSE Rapid 1+ trace Barely detectable 10–15 sec 1–2 min 2+ mild Less than 14 inch 2–5 min 3+ moderate 14–12 inch 4+ severe Greater than 12 inch Nails Injuries, dietary Inspection and • Shape insufficiency, palpation • Color COPD, etc. • Thickness • Ridges • Angle of nailbed • Surrounding tissues (paronychia) Hair Cosmetic use, Inspection and • Color and texture dietary palpation • Distribution insufficiency, • Quantity (alopecia, hirsutism) hormone • Condition of scalp, presence of nits problems, exposure to parasites

Health Assessment of Older Adults  CHAPTER 8 157 Table 8-3  Body Systems Approach to Physical Assessment—cont’d BODY SYSTEM HISTORY TECHNIQUES ASSESSMENT Skull, Face, Inspection and Congestion, • Size, shape, and symmetry (moon face) and Neck drainage, sore palpation • Smile and frown (look for symmetry or drooping) throat, difficulty • Nose (drainage, symmetry) Eyes swallowing, Inspection • Sinuses (check for tenderness or pressure) dental problems, • Lips (color, moisture, lesions) swelling, • Mouth, including mucous membranes, teeth, and gums exposure to • Throat and tonsils communicable • Shape and movement of neck disease, etc. • Lymph nodes Glaucoma, • Placement of globes (bulging or sunken) cataracts, • Eyelids (crusting, lashes, ptosis, etc.) refractive • Conjunctiva (color, drainage, etc.) problems, dry • Sclera (color) eyes, tearing, • Blinking (15 to 20 times per minute) blurring, double • Pupils (PERRLA) vision, etc. • Dim room (so pupils dilate) Ears Difficulty hearing, Inspection • Check size and shape of pupils (should be equal and Respiratory etc. Inspection, round) COPD, difficulty auscultation • Shine light into one eye (both pupils should constrict) breathing, (palpation and • Have patient look at a distance then focus on a finger 4 shortness of percussion) breath, lack of inches (10 cm) from bridge of nose (both eyes should energy, cough, constrict with accommodation) hemoptysis, • Eye movements (cardinal fields): Have the patient hold tobacco use, head still; then move a finger (12 inches from face) allergies, toward each field, then back to center (may elicit medications, nystagmus) etc. • Light reflex: Shine light 12 inches from face (should be symmetrical reflection on cornea) • Convergence: Watch as you move finger toward nose • Visual acuity: Snellen test (do each eye separately, then together; do first without glasses, then with close reading test—e.g., newspaper) • Placement, shape, drainage • Inspection of external canal (otoscope) • Hearing acuity (whisper test, audiometry) • Shape of thorax (barrel, sunken) • Spinal curvatures (kyphosis, lordosis, scoliosis) • Movement of chest during respiration • Rate, rhythm, and depth of respiration • Listen to lung sounds over fields; compare side to side • Trachea (bronchial sounds) • Assess above clavicle and scapula to assess apex (bronchovesicular sounds) • Stay inside scapula when doing midsection; move out when doing bases (vesicular sounds) • Adventitious lung sounds • Crackles (rales): Fine, short, crackling sounds best heard on inspiration, commonly heard in lung bases • Wheezes: Continuous squeaky, musical sounds; best heard on expiration; may be heard all over lung fields • Gurgles (rhonchi): Continuous low-pitched sounds; coarse with snoring quality; cleared by coughing; heard over trachea and bronchi • Friction rub: Grating sound; similar to the rubbing sound made when sandpaper is used; heard on both inspiration and expiration; heard most often on lower anterior and lateral chest Continued

158 UNIT II  Basic Skills for Gerontologic Nursing Table 8-3  Body Systems Approach to Physical Assessment—cont’d BODY SYSTEM HISTORY TECHNIQUES ASSESSMENT Cardiovascular History of heart Inspection, • Peripheral pulses (carotid, radial, brachial, pedal, popliteal, disease, chest palpation, femoral) for presence, strength, symmetry pain, lack of auscultation energy, fatigue, • Apical pulse high BP, SOB, • Capillary refill time (normal is less than 3 sec) medications, • Presence of varicosities edema, etc. • Signs of thrombophlebitis (tenderness, redness, swelling) Gastrointestinal GI pain, nausea, Inspection, then • Shape and contour of abdomen vomiting, auscultation • Presence of scars constipation, before palpation • Bowel sounds in four quadrants (use diaphragm) every 20 flatulence, (empty bladder, diarrhea, etc. supine with knees seconds slightly bent) Musculoskeletal Weakness, joint or Inspection and • Size and symmetry of muscles muscle pain and palpation • Muscle strength bilaterally tenderness, • Presence of contractures recent injury • Tremors or spasms • Swelling or deformity of joints (tenderness or pain) • Range of motion (smoothness, crepitus) Neurologic Any injury or illness Inspection • Orientation affecting CNS or • Speech PNS, loss of • Movement consciousness, • Grip strength behavioral • Pupillary responses (presence and rate) changes, loss of • Balance or gait balance, • Changes in smell, vision, hearing, sensation, temperature headaches, or sensory changes perception • Reaction to painful stimuli Genitourinary Voiding patterns, Inspection and • Bladder fullness/distention frequency, palpation • Amount, odor, color, and consistency of urine hesitancy, painful voiding, urgency, incontinence, history of STD, discharge or drainage from genitals, open lesions, etc. *This approach is useful for focus assessments. SENSORY ASSESSMENT OF OLDER ADULTS assessment when the older person is wearing the aid but only after checking it for proper functioning. Simple assessments of vision and hearing ability are Special assessment by a vision or audiometric special- based on empiric data (the way the individual responds ist can reveal more precise information regarding to visual or auditory clues). Observe whether the vision and hearing. person is able to read or do close work that requires good central vision or whether he or she participates PSYCHOSOCIAL ASSESSMENT OF OLDER ADULTS in television viewing or other sight-related activities. If the older person uses eyeglasses, assess the ability A psychological assessment is performed to determine to see with and without them. whether the older person is alert and aware of the sur- roundings or suffers from some level of confusion, Talking with older adults can reveal the presence or delirium, or dementia. The differences between these absence of hearing. Indicators of hearing problems conditions are discussed in detail in Chapter 10. include difficulty in gaining attention, the frequent Psychological status is best assessed by direct observa- need to repeat information, or mistakes in understand- tion and by means of standardized assessment tools. ing directions. If applicable, perform the hearing-aid

Health Assessment of Older Adults  CHAPTER 8 159 Box 8-2  Mini-Cognitive Assessment Instrument Clinical Situation Step 1: Ask the patient to repeat three unrelated words,   such as “ball,” “dog,” and “television.” Many evidence-based assessment tools are available online Step 2: Ask the patient to draw a simple clock set to 10 from the Hartford Institute of Gerontologic Nursing (http:// minutes after eleven o’clock (11:10). A correct consultgerirn.org/resources). According to the Hartford response is drawing of a circle with all of the numbers Institute, the goal of the Try This: Best Practices in Care for placed in approximately the correct positions, with the Older Adults series of assessment tools is to provide knowl- hands pointing to the 11 and 2. edge that is easily accessible, easily understood, and easily implemented and to encourage the use of these best practices Step 3: Ask the patient to recall the three words from by all direct care nurses. Step 1. One point is given for each item that is recalled correctly. SPECIAL ASSESSMENTS The Minimum Data Set 3.0 NO. OF ITEMS INTERPRETATION INTERPRETATION In an attempt to improve the quality of care provided CORRECTLY OF SCREEN FOR in extended-care facilities, the federal government RECALLED CLOCK DRAWING DEMENTIA instituted major reforms through the Omnibus Budget TEST RESULT Reconciliation Act (OBRA) of 1987. An important 0 Positive focus of this law was the improvement and standard- 0 Normal Positive ization of assessment procedures used in these facili- 1 Abnormal Negative ties. The first reform produced by the U.S. Department 1 Normal Positive of Health and Human Services was the Resident 2 Abnormal Negative Assessment Instrument (RAI), introduced in 1990. 2 Normal Positive This tool specified a comprehensive, standardized 3 Abnormal Negative assessment that was to be completed on admission, 3 Normal Negative with significant change in status, and thereafter on Abnormal a yearly basis. The first version of the database used to conduct this assessment was a printed document From Borson S, Scanlan J, Brush M, Vitallano P, Dokmak A: The mini-cog: called the Minimum Data Set (MDS) 1.0. This tool A cognitive ‘vital signs’ measure for dementia screening in multi-lingual elderly. was designed not only to help assess residents, but Int J Geriatr Psychiatry, 15(11):1021-1027; 2000. also to help caregivers identify problems, develop intervention plans, and monitor outcomes. It was Box 8-3  Examples of Psychological Assessment hoped that the use of this tool would make the assess- Tools on the Internet ment process more consistent and reliable throughout the country and improve the quality of care. MDS • Mini-Mental State Examination (MMSE) 1.0 did help improve assessment and care in many • Cornell Scale for Depression in Dementia cases, but information was often difficult to locate, • Short Test for Dementia and interdepartmental monitoring of problems and • Functional Activities Questionnaire outcomes was difficult because the assessment was • Clinical Dementia Rating Scale paper-based. The MDS 2.0 was an upgraded, comput- • Informant Questionnaire on Cognitive Decline in the erized version of the older document. MDS 3.0 is a new, state of the art, form designed to improve Elderly (IQCODE) patient input into the assessment process by incorpo- • Confusion Assessment Method rating direct resident interviews into the process. (Figure 8-4 shows page one of the forms. The full Many assessment tools are available to assist nurses MDS 3.0 can be found online). It is not merely an in assessing mental status in older adults. One very update or revision of the previo­ us form. Design highly regarded tool is the Mini-Cog™, a sample of improvements in the MDS 3.0 were directed at which is provided in Box 8-2. Performing this assess- increased reliability, enhanced accuracy, and expanded ment can identify cognitive impairments that can be usefulness as a tool to improve clinical assessment. tracked over time. The test can be administered in 3 to This new format went into effect in 2010. All health 4 minutes, making it ideal for both hospital and routine care agencies that receive Medicare and/or Medicaid visits. Other assessment tools may also be used. Several must use the computerized MDS and must be of these are available in computerized form on the capable of transmitting the results to state and federal Internet (Box 8-3). agencies. Data collected from the MDS are used to provide credibility and justify government funding of Assessment of social function is determined by programs. observing the amount, frequency, and type of social interaction in which the older person participates. A variety of levels and degrees of social interaction can be classified as normal as long as the individual is happy or at least content with that level. Chapters 11, 12, and 13 further explore socialization issues.

160 UNIT II  Basic Skills for Gerontologic Nursing FIGURE 8-4  Minimum Data Set (MDS) for nursing home resident assessment and care screening. (From Briggs Corporation, Des Moines, Iowa 50306, Phone 800-307-1744.) The MDS 3.0 is a comprehensive assessment tool Assessment Protocols (RAPs). RAP triggers are now that assesses core areas of function. Unusual findings called Care Area Triggers (CATs). discovered with MDS 3.0 initiate further evaluation using more detailed focus assessments called Care Use of a computer-based system improves the Area Assessments (CAAs). These replace the Resident process of assessment and planning. Use of a computer database helps make the process more comprehensive,

Health Assessment of Older Adults  CHAPTER 8 161 more complete, and easier for the nursing staff and other departments, once the users become familiar ASSESSMENT OF CONDITION CHANGE with the program. Computerization of records in this IN OLDER ADULTS database enhances the flow of information between departments within a facility. For example, the phar- Health status changes in older adults are often subtle macy can verify that psychotropic and antidepressant and different from younger adults. Early recognition medications are administered only when appropri- and treatment of change in status can prevent serious ate medical diagnoses exist, and the physicians and harm for older adults. This is true in at-home care, in nurses can correlate dosage changes with observed extended-care facilities, and in the hospital setting. A behaviors. The dietary department can validate that number of evidence-based instruments have been appropriate diets are ordered based on medical diag- developed to help the nurse perform a systematic and nosis and can detect changes in weight that may indi- comprehensive assessment. cate the need for further intervention. Nurses can identify interventions that will be most beneficial at FULMER SPICES preventing pressure ulcers, constipation, or other SPICES is an acronym for six common “marker con­ common problems. ditions” in older adults that can identify potential health-related problems. This screening tool can be The computerized MDS 3.0 enhances the ability to used routinely during assessments to identify and/or access and correlate data from every long-term care prevent potential problems and to monitor health facility in the United States and provides an unprece- status over time (Fulmer, 2012). Identification of one dented database of information regarding the nursing or more of these problems indicates an increased home population. As the database grows, caregivers risk for functional decline and even death. More will learn more about the population of infirm older in-depth assessments are required when a problem is adults, their most common medical problems, and the identified. (See appropriate chapters for assessment most or least effective treatments and interventions. guidelines.) This assessment is not a total list of signifi- All data from the MDS 3.0 must be transmitted directly cant problems; for example, pain and elimination are to the Center for Medicare Services (CMS) within 14 not included, but the assessment does address the days after the facility completes the minimum data most common and relevant issues. Additional infor- set (MDS) assessment. States may specify additional mation and tools designed to help the nurse perform reporting requirements. effective assessments of older adults are available online. Box 8-4 provides a listing of some of the most The new MDS enables state and federal agencies to helpful sites. evaluate the performance of an individual institution in any number of categories and facilitates a level of Box 8-4  Internet Sites for Assessment comparison between treatment methods that has not of Older Adults previously been available. For example, the frequency, location, and extent of pressure ulcers can be deter- There are many helpful geriatric assessment tools available mined and correlated to age, disease, diet, and other online. These sites contain download or printable forms for factors. It also enables the supervising government use when performing both general and focused geriatric agency to compare various long-term care providers assessments. with one another. Hartford Institute for Geriatric Nursing: http:// The ability to assemble these data on a regional or consultgerirn.org/topics/function/want_to_know_more national basis excites the better health care providers, International Society of Geriatric Oncology: because these correlative data will enable them to identify critical parameters in resident status and www.siog.org/index.php?option=com_content&view develop more effective models for care. Other provid- =article&id=103&Itemid=78http://ge ers, particularly those who may not meet the expected Merck Manual of Geriatrics: www.merckmanuals.com/ standards of care, view this oversight capability less professional/geriatrics.html favorably. National Institute on Aging: www.nia.nih.gov/health Primary Care Geriatrics: www.bmj.com/content/343/ Because the MDS plays such an important role in bmj.d4681?keytype=ref&siteid=bmjjournals&ijkey= determining resident status and planning and evaluat- YKae1pWowPzkI ing care, it must be completed in a timely manner and University of Iowa: www.healthcare.uiowa.edu/igec/ updated regularly. Licensed nursing staff must pay tools/ close attention to the times specified in the statutes and University of Maryland: http://geri-ed.umaryland.edu/ complete all records in a timely manner. As of June 20, assess_tools.html 2013, MDS Frequency Reports are available for all University of Missouri: http://geriatrictoolkit.missouri nursing home residents. The report consolidates all .edu/ historical MDS assessments for each individual, pro- Stall, Robert S. MD—Senior assessment: http:// viding an up-to-date profile of current standard infor- stallseniormedical.com/ mation (cms.gov, 2013).

162 UNIT II  Basic Skills for Gerontologic Nursing these situations, deep, focused assessments are more appropriate and necessary. The following mnemonic Clinical Situation can be used to organize this assessment: F—fluid   A—aeration (oxygenation) N—nutrition The Hartford Institute of Gerontologic Nursing web site includes C—cognition, communication a video demonstration using SPICES: http://consultgerirn.org/ A—activity/abilities resources/media/?vid_id=4200873#player_container. P—pain S—sleep disorders E—elimination P—problems with eating or feeding S—skin/socialization I —incontinence Once the status assessment is completed, the nurse C—confusion must still decide the most appropriate action. A E—evidence of falls summary of nursing responses is presented in S—skin breakdown Table 8-4. FANCAPES When the nurse suspects that an actual emergency or serious problem is present or might be developing, in Table 8-4  Should I Call? Presentation and Action to Take PRESENTATION/CONDITION CHANGE CALL MD OR APRN IMMEDIATELY IF CALL 911 IF Vital signs Systolic BP: >200 or <90 The vital sign changes are associated Diastolic BP: >115 Delirium Resting pulse: >130 or <55 with altered and/or severe Oral temp: >101 symptoms of other kinds of Rectal temp: >102 distress (e.g., airway obstruction or Any sudden onset of change in mental status anaphylaxis) Edema Sudden fluid excess noted in associated Change in mental status shortness of breath (SOB), pink frothy accompanied by suspected or Sleeping difficulties sputum, possibly co-occurring with chest pain possible airway obstruction Bleeding Abrupt onset of edema in one leg only Severe respiratory distress Falls Loss of sensation in swollen leg Clinical signs of shock Chest pain Associated tenderness and/or redness in Medication error Suspicion of a cardiovascular event, affected leg such as syncope, tachycardia, or other symptoms of acute coronary Only if associated with mental status changes syndrome (ACS) Uncontrolled bleeding or repeat episode (e.g., Not applicable prolonged nosebleed) Uncontrolled bleeding Emesis with frank blood Bleeding with symptoms of Bloody stools Vaginal bleeding, profuse impending shock and/or VS changes Obvious deformity of limb or alignment of same Trauma with or without evidence of Joint or hip pain with reduced range of motion overt injury Inability to bear weight Laceration with uncontrolled bleeding Major trauma event, such as a fall of a significant distance with New-onset or recurrent pain not relieved associated loss of consciousness in 20 min with previously ordered or VS changes nitroglycerine ×3 Complaints of chest pain associated Chest pain accompanied by VS changes, with or followed by LOC changes dyspnea, diaphoresis, nausea/vomiting or obvious arrhythmia with pulse check such as severe bradycardia Resident is symptomatic because of the error (<40) or tachycardia (>150) Resident is symptomatic and there are VS and/or LOC changes

Health Assessment of Older Adults  CHAPTER 8 163 Table 8-4  Should I Call? Presentation and Action to Take—cont’d PRESENTATION/CONDITION CHANGE CALL MD OR APRN IMMEDIATELY IF CALL 911 IF Constipation/diarrhea/emesis Only when associated with other Severe abdominal pain Rigid abdomen or extreme tenderness on symptoms such as mental status changes or in conjunction with palpation other cardiovascular symptoms Bowel sounds absent that would necessitate transfer Guarding (tensing of abdominal wall to protect Severe, uncontrolled pain inflamed underlying organs) VS abnormalities Pain Associated with a fall/trauma LOC change Noticeable and new inability to perform ROM Suspected sepsis such as narrowed Headache with altered vision and/or LOC pulse pressures, tachycardia, fever, Dehydration More than 1 episode of vomiting in 24 hours mental status changes. and decreased fluid intake Not applicable Less than 50% of normal fluid intake over Expressed suicidal ideation with a 24 hours plan and inability to monitor resident in the assisted living Pressure ulcers/skin rash Stage II, III, or IV receiving no treatment and no residence Depression/suicidal ideation protocol to cover the condition Seizures New onset or status epilepticus Signs of wound infection: purulent discharge, associated with: possible airway erythema, odor compromise, severe respiratory distress, signs of shock Fever Suspected stroke Expression of suicidal ideation that contains a plan for carrying it out in the assisted living Evidence of inadequate oxygenation residence (e.g., “I have a lot of medications (cyanosis, increased respiratory hidden away to use when I think my time has rate, paradoxical chest movement, come.”) diaphragmatic breathing, use of accessory muscles) despite New onset interventions, such as oxygen via Status epilepticus nasal cannula (0.25 to 4 L/min) or through simple mask (5 to Visual changes Associated stroke symptoms (e.g., hemiparesis, 12 L/min) Shortness of breath slurred speech, headache, facial drooping) Complaints of seeing “halos” (a person will look at a light and see a halo or rainbow-colored circle around the light) Any abrupt onset Suspected trauma with severe pain VS changes or suspected cardiovascular involvement Labored breathing Ashen appearance Cyanosis LOC, Level of consciousness; VS, vital sign. From Montgomery J, Mitty E, 2008. (Adapted with permission from B. Jordan, MS, ARNP, BCPCN, and J. Sandberg-Cook, MS, ARNP, BCPCN, Dartmouth- Hitchcock Medical Center, Hanover, NH.)

164 UNIT II  Basic Skills for Gerontologic Nursing 3. When taking a radial pulse of an older adult, the nurse finds it difficult to count a weak and thready pulse. Get Ready for the NCLEX® Examination! What should the nurse do? 1. Gently apply more pressure with three fingers to Key Points obtain a stronger pulse. 2. Take the person’s blood pressure to get the heart • Although the initial health assessment of an older adult rate reading from the machine. is important, it is only a starting point. Assessment is a 3. Take an apical pulse instead. continuous and ongoing process. 4. Record, “Weak, thread pulse, rate N/A.” • As each older adult’s condition changes, objective and 4. When performing an assessment of the gastrointestinal subjective data will also change. system of an older adult, the nurse would proceed in what order? Place the parts of a gastrointestinal system • MDS 3.0 helps caregivers identify problems, develop assessment in sequence from first to last. intervention plans, and monitor outcomes, and is 1. Palpate abdomen. required to be used by all facilities that receive 2. Observe abdomen for scars. Medicare and/or Medicaid. 3. Obtain a health history. 4. Inspect the oral cavity. • Because nurses spend the greatest amount of time 5. Auscultate bowel sounds. with older adults, they have the greatest opportunity to assess and recognize significant changes. 5. When performing an interview with an older adult, the nurse should consider physical environment factors by: • Nurses are responsible for assessing continually (Select all that apply.) and instituting changes in care, based on those 1. Explaining what will take place during the observations. assessment 2. Ensuring privacy and minimum noise levels Additional Learning Resources 3. Selecting a room with a comfortable temperature 4. Ensuring bright lighting to enable the older adult to   Go to your Evolve website at http://evolve.elsevier see clearly .com/Williams/geriatric for the additional online resources. 5. Having the interview done by a nurse of the same gender to build rapport Review Questions for the NCLEX® Examination 6. Seeking a location in close proximity to a restroom 1. Which assessment tool is most highly regarded, and often used to determine the mental status of the older adult? 1. SPICES Assessment Tool 2. The Mini-Cog™ 3. Short Test for dementia 4. MDS 3.0 2. When assessing the respiratory system of an older adult, the nurse hears continuous, coarse, low-pitched sounds. How would these be reported? 1. Rales (crackles) 2. Wheezes 3. Friction rub 4. Rhonchi (gurgles)

Meeting Safety Needs of Older Adults chapter 9  Objectives http://evolve.elsevier.com/Williams/geriatric 1. Explore the types and extent of safety problems 5. Discuss factors that place older adults at risk for experienced by the aging population. imbalanced thermoregulation. 2. Describe internal and external factors that increase safety 6. Describe those older adults who are most at risk risks for older adults. for developing problems related to imbalanced thermoregulation. 3. Discuss interventions that promote safety for older adults. 7. Identify interventions that assist older adults in maintaining normal body temperature. 4. Examine fall prevention strategies for older adults. hypothermia  (hī-pō-THĔR-mē-ă, p. 172) Key Terms thermoregulation  (thĕr-mō-RĔG-ū-lā-shŭn, p. 172) heatstroke  (HĒT-strōk, p. 174) hyperthermia  (hī-pĕr-THĔR-mē-ă, p. 173) Safety is a major concern when working with or pro- the position and speed of motor vehicles. Night vision viding care to older adults. The Centers for Disease diminishes. In dim light or glare, older adults may be Control and Prevention (CDC) (2014b) reports that unable to see that a curb, step, or other hazard is over 41,000 older adults died from unintentional injury present. They may be unable to see or read stationary in 2010. The largest number of accidental deaths in the road signs that provide directions or warnings. Falls older adult population, by a wide margin, is from falls, or motor vehicle accidents often result from altered the risk of which peaks sharply in the ninth decade of vision. life. Motor vehicle accidents and choking also claim many lives of older adults prematurely. Changes in visual acuity make it more difficult to read labels with small print. This can make it difficult Falls, choking, poisoning, burns, and automobile for older adults to read the directions on prescriptions. accidents are the most common safety problems among Many older adults have taken incorrect medications or older adults. Exposure to temperature extremes also wrong doses or have even consumed poisonous sub- places older adults at risk for injury or death. Older stances, because they could not see adequately to read adults are more susceptible to accidents and injuries the labels. than are younger adults because of internal and exter- nal factors. Internal factors are specific to the person Decreased auditory acuity reduces an older per- and include normal physiologic changes with aging, son’s ability to detect and respond appropriately to incidence of chronic disease, use of medications, and warning calls, whistles, or alarms. For example, older cognitive or emotional changes. External factors are adults may not hear a warning call of impending specific to the environment and include factors that danger, may not hear a motor vehicle or siren in time present hazards to older adults, such as poor lighting to avoid an accident, or may not respond to a fire alarm or a slippery floor. in time to leave a building safely. INTERNAL RISK FACTORS The senses of smell and taste also help protect us from consuming substances that might be harmful to Vision and hearing are protective senses. When the the body. Decreased sensitivity of these senses increases acuteness of the senses diminishes, the risk for injury the risk for accidental food or chemical poisoning increases. Vision and hearing changes are common in the older adult population. with aging. Diminished range of peripheral vision and changes in depth perception are common and can Older adults often experience one or more physio- interfere with the ability of older adults to judge the logic changes that increase their risk for falls and distance and height of stairs and curbs or to determine other accidental injuries. Any of these changes alone or in combination can reduce the older person’s ability to respond quickly enough to prevent an accidental injury. When these problems are combined with 165

166 UNIT II  Basic Skills for Gerontologic Nursing beverages, particularly in combination with prescrip- tion drugs, increase the risk for falls and other injuries. chronic diseases or health problems, the risk increases More information regarding safe use of medications is dramatically. Common physiologic changes that affect included in Chapter 7. safety include the following: • Decreased mobility Cognitive changes or emotional disturbance and • Decreased flexibility depression may be overlooked as risk factors for falls • Decreased muscle strength or injury. These disturbances reduce the older person’s • Slowed reaction time ability to recognize and process information. Distracted • Gait changes or preoccupied older adults are less likely to pay full • Difficulty lifting the feet attention to what is happening or what they are doing. • Altered sense of balance This lack of attention and caution increases the risk for • Postural changes accidents and injury. Conditions affecting the cardiovascular, nervous, and musculoskeletal systems are most likely to contribute FALLS to safety problems. Any cardiovascular condition that Falls are the most common safety problems in older results in decreased cardiac output and decreased adults. Consider the following statistics: oxygen supply to the brain can cause older adults to 1. Falls are the leading cause of both fatal and nonfatal experience vertigo (dizziness) or syncope (fainting). Common disorders with this result include anemia, injuries among older adults. cardiac arrhythmias, and orthostatic hypotension. 2. Approximately 30% of people older than age 65 Studies have shown that approximately 52% of long- term nursing home residents older than age 60 experi- who live in the community fall each year. ence four or more episodes of orthostatic hypotension 3. Any fall is the best predictor of future falls. Two- every day. thirds of those who have experienced one fall will Older adults with neurologic disorders, such as fall again within six months. Fear contributes to this Parkinson disease or stroke, experience weakness risk, as the person who has fallen may reduce their and alterations in gait and balance that increase the physical activity and physical fitness out of fear of risk for falls. Neurologic and circulatory changes can falling. also decrease the ability to sense painful stimuli or 4. The older a person becomes, the more likely he or temperature changes, increasing the risk for tissue she is to suffer serious consequences, such as a hip injuries, burns, and frostbite. A study has shown that fracture or traumatic brain injury, from a fall. nursing home residents with diabetes are more than 5. Falls are a leading death caused by injury in people twice as likely to suffer from falls as those who do not older than age 65 and number one for men over 80 have diabetes. and women over 75. 6. Approximately one-fourth of older adults who Musculoskeletal conditions, such as arthritis, further experience falls will die within a year and another reduce joint mobility and flexibility, decreasing the 50% will never return to their previous level of inde- ability of the older person to move and respond to pendence or mobility. hazards and intensifying the likelihood of accidents or 7. The incidence of falls is higher among those resid- injury. Box 9-1 lists injury risks for older adults. ing in long-term care facilities than among those who live independently in the community. Medications often contribute to falls, and, because 8. Ninety-five percent of hip fractures are caused by older adults commonly take one or more medications, falls. their risk for untoward effects is increased. Any 9. The direct cost of falls reached $30 billion medication that alters sensation or perception, slows in 2010. reaction time, or causes orthostatic hypotension is Many independent older adults are reluctant to report potentially dangerous for older adults. Common types a fall because of the implication that they are frail and of hazardous medications include sedatives, hypnot- dependent. In addition to causing bodily harm, falls ics, tranquilizers, diuretics, antihypertensives, and take a psychological toll on the older adult, causing antihistamines. Alcohol, although not a prescription them to lose confidence and decrease mobility. This is medication, acts as a drug in the body. Alcoholic unfortunate because early recognition and interven- tions can reduce the risk for further falls. Older adults Box 9-1  Injury Risks for Older Adults living independently in the community often do not recognize hazards in their home environment that • Impaired physical mobility place them at risk for falls because they are too • Sensory deficits accustomed to their surroundings to view them as • Lack of knowledge of health practices or safety potential hazards. Older adults and their family members need to be aware of things they can do to precautions reduce the risk for falls. Some helpful approaches are • Hazardous environment summarized in Box 9-2. • History of accidents or injuries

Meeting Safety Needs of Older Adults  CHAPTER 9 167 Box 9-2  Reducing the Risk for Falls research, promote public education, and provide ser- vices proven to reduce or prevent falls in older adults. • Prepare safe surroundings. Ensure there is adequate In 2009 and 2010, additional legislation designed to lighting, particularly in stairwells. Keep frequently reduce the number of falls among older adults was needed items such as the telephone, tissues, etc., on passed. Legislation requiring training on fall preven- a table near the chair or bedside. Consider a low-rise tion for long-term care workers also has been imple- bed (14 inches from the floor). Personal alarms and mented. The Joint Commission has also identified fall pressure sensor alarms alert nursing staff of patient prevention as a priority: National Patient Safety Goal movement. 09.02.01 requires organizations to implement and eval- uate a falls reduction program (The Joint Commission, • Reduce environmental hazards and risky practices. 2015), including risk assessment upon admission, Ensure there are no throw rugs, uneven floors, electric after a change in patient condition, after any fall, and wires, oxygen tubing, or other items that could cause upon transfer. Overall, evidence is emerging that fall tripping. Mop up spills in the kitchen or bathroom prevention programs are effective across all settings immediately. Avoid placing items on the floor. (Gray-Miceli & Quigley, 2012). Encourage the older adult to not climb on anything other than an approved step stool to reach high places. Assessment begins with identifying and docu­ menting intrinsic risk factors that place an individual • Allow adequate time to complete an activity or task. at high risk for falls. These include (Gray-Miceli & Haste increases the risk for falls or other injuries. If the Quigley, 2012): older adult feels dizzy or lightheaded, encourage • Age 75 or older sitting for a while before standing. • Recent history of falling • Dementia, hip fracture, diabetes type 2, Parkinson • Encourage proper-fitting footwear. Shoes with nonslip soles and low heels are recommended, because disease, arthritis, depression high-heeled shoes contribute to balance problems. • Use of assistive devices Shoes should have closures that are easy to • Cognitive impairment manipulate. If shoes have laces, check that they do • Gait, balance, or visual impairment not come loose and cause tripping. Loose-fitting • Use of high-risk medications slippers or shoes can drop off the foot and lead • Urge urinary incontinence to a fall. • Physical restraint use • Bare feet or inappropriate shoe wear • Encourage assistive devices when needed. If the patient is found to be at risk for falls, more Prescription eyeglasses enable the older adult to frequent assessments must be performed and clearly see their environment. A cane or walker documented. provides security with ambulation by enlarging the base of support. Keep these assistive devices close at TOOLS TO ASSESS FOR FALLS hand to avoid leaning or reaching. The tips of the Many tools have been developed to help assess one’s cane or walker should have solid rubber grips to fall risk. Some of these tools require no special equip- prevent slipping and may need to be modified on icy ment at all and can easily be used in a home or com- surfaces to promote gripping. munity setting in one to two minutes. A summary of some common, validated tests and tools can be found • Encourage the older adult to ask for help when in Table 9-1. necessary. Failure to seek help can lead to serious injury. Encourage older adults to recognize that good SPECIFIC STRATEGIES TO PREVENT FALLS judgment is a sign of healthy aging, not a sign of It is very important to communicate fall risk to the weakness. patient, family, and staff. Fall risk should be commu- nicated via the medical record, handoff report, signs • Provide toileting assistance at regular intervals. on the door or wall, and patient wristband. Once fall Assisting the older adult every two hours can help risk factors have been identified and documented, an reduce fall risk. individualized strategy can be developed and imple- mented to reduce risk for falling. For example, studies FALL PREVENTION have shown that falls are reduced when an individual engages in exercise focusing on two or more of the Fall prevention is everyone’s responsibility. Outreach following elements: balance, strength, endurance, and sessions about fall prevention designed to meet the flexibility. Exercising in a supervised group, practicing needs of older adults, their families, and anyone who Tai Chi, and performing individual exercise have all has contact with older adults could be offered at senior proven to be effective in this manner. centers, libraries, businesses, and community colleges. Health care settings need to maintain current and com- Environmental modifications have been shown to plete policies and procedures for fall prevention, new be effective in reducing falls in those at high risk, such employee training regarding fall prevention, a method for prompt reporting and investigation of all falls, and scheduled multidisciplinary meetings to identify prob- lems and plan interventions. The federal government enacted the Elder Fall Prevention Act of 2003 to develop a national initiative intended to reduce falls. This act was designed to fund

168 UNIT II  Basic Skills for Gerontologic Nursing Table 9-1  Examples of Validated Tests and Tools Available for Screening and Assessment of Fall Risk TEST AND CRITERIA PRACTICAL ASPECTS Screening in the Community: Timed Up and Go Test Description This test measures the time taken for a person to rise from a chair, walk 3 meters at normal pace with their usual assistive device, turn, return to the chair, and sit down Criterion A time of ≥12 seconds indicates increased risk of falling Time to undertake test 1 to 2 minutes Equipment Chair and stopwatch or minute hand on watch Assessment in the Community: QuickScreen Description QuickScreen is a risk assessment tool designed for use by practice and rural nurses, allied health workers, and general practitioners. It allows the clinician to estimate the level of increased fall risk and determine which sensorimotor systems are impaired. The test measures previous falls, drug use, vision, peripheral sensation, lower limb strength, balance, and coordination Criterion A score of 4 or more indicates an increased risk of falling Time to undertake test 10 minutes Equipment A low contrast eye chart, a filament for measuring touch sensation, and a small step Screening in the Emergency Department: Prevention of Falls in the Elderly Trial Description Used in people presenting to the emergency department after a fall. Three simple questions identify people at increased risk of further falls: (1) Have you had any other falls over the past 12 months? (2) Have you fallen indoors? (3) Have you been unable to get up after a fall? Criterion If the patient answers yes to any of the questions, further assessment and intervention are needed Time to undertake test 1 to 2 minutes Equipment None Screening in Hospital: Modified STRATIFY Description Six-item weighted questionnaire with questions relating to falls, cognition, transfer and mobility skills, vision, and toileting practice Criterion A score of ≥9 identifies high-risk fallers Time to undertake test 1 to 2 minutes Equipment None Screening in Nursing and Residential Care: Residential Aged Care Falls Screen Description Clinical algorithm based on the person’s ability to stand unaided, previous falls, drug use, and continence status Criterion Depending on risk factors identified, outcome will be either high- or low-risk of falls Time to undertake test 1 to 2 minutes Equipment Medium density 15 cm thick foam mat STRATIFY = St. Thomas’ risk assessment tool. From Close JCT, Lord SR. Fall assessment in older people. Br Med J 343: d5153, 2011. as people with severe visual deficits. Such modifica- Cataract surgery will reduce the fall risk for someone tions and safety strategies can be found in Box 9-2. The with cataracts. Vitamin-D supplements may reduce community-based older adult at risk for falls should the fall risk for someone who is deficient. Other pre- have some sort of device to call for help in the event vention strategies can be found in Box 9-3. of a fall, such as Life Alert®.  Coordinated Care As noted above, medications can increase the fall risk for an older person. Gradual withdrawal of some Collaboration sleep medications, antianxiety agents, and antidepres- sants from the regimen of older adults has been shown FALL PREVENTION to reduce falls (Gillespie et al, 2010), so these medica- Nursing assistants are important members of the team and tions should be reviewed regularly to ensure they are often have good insights into the reasons for a fall. Ask the truly needed. certified nursing assistant (CNA) for suggestions for actions that might help prevent a future fall based on their observations Other individual risk factors can be medically or of the patient. Include these ideas in the plan of care. When surgically corrected to lower the risk of falls. For the entire team is involved in developing the plan, compliance example, pacemaker placement reduces the risk of is improved. Ensure the nursing staff and all other departments falls in someone with carotid sinus hypersensitivity. take fall prevention seriously. Report the presence of any

Meeting Safety Needs of Older Adults  CHAPTER 9 169 Box 9-3  Preventing Falls and Injuries in the Home • Provide grip assistance wherever appropriate. Install handrails in all stairwells to provide support for stair • Ensure that all rugs are firmly fixed to the floor. Tack climbing. Grab bars alongside the toilet and in the down loose edges, ensure that rubber skid-proofing is bathtub and shower also help provide support. secure, and remove decorative scatter rugs. Lightweight cooking utensils with large handles and enlarged stove knobs make cooking easier and safer for • Maintain electric safety. Check regularly to ensure that older adults. there are no broken or frayed electric cords or plugs. Have defective electric plugs or cords repaired by an • Place frequently used items at shoulder height or lower approved repair person. Discard all electric appliances where they can be reached easily. Keeping frequently that cannot be repaired. Install ground fault interrupt used items available decreases the need to use (GFI) electric sockets near water sources to prevent climbing devices. Use only approved devices such as accidental shocks with appliances use. step stools when reaching for items that cannot be reached easily. Ladders are not recommended for use • Decrease clutter and other hazards. Discard by older adults, but if they are used, ensure that they unnecessary items such as old newspapers. Keep are fully open and locked. Excessive reaching should be shoes, wastebaskets, and electric or telephone cords avoided, and another person should stand by to steady out of traffic areas. Never place or store anything on the ladder, reducing the risk for tipping. stairs. Clear ice promptly from sidewalks and outside staircases. Cat litter can be used to provide traction on • Take measures to prevent burns. Avoid smoking or the icy surfaces. use of open flames whenever possible. Do not wear loose, long sleeves when cooking on a gas stove. • Provide adequate lighting. This is particularly important Check that the hot water tank setting does not exceed in stairwells. Switches should be located at both the top 120° F. Use a mixer valve to prevent sudden bursts of and bottom of stairs. Use nightlights in the bedroom, hot water. Have a plan for leaving the residence in case bathroom, and hallways. Ensure adequate lighting in of fire. food preparation areas of the kitchen to facilitate label reading and to reduce the risk for injury when sharp objects are used. unsafe conditions, no matter how minor they seem. Notify hazard. Environmental hazards are everywhere: in the housekeeping, maintenance, or security promptly and then home, on the street, in public buildings, and in health verify that the problem has been corrected. Another strategy care settings. Box 9-3 lists tips on preventing falls and is “Catch me doing something right.” Too often we are quick injuries in the home. Although injuries can and do to blame someone when a fall occurs. It is a far better practice occur often in the home, a change in environment, to praise the staff when you see call lights being answered such as hospitalization, travel, or any other move from promptly, spills being mopped up, and proper footwear or a familiar environment, increases the likelihood of assistive devices being used. Some literature even suggests injury for older adults. identification of a “Falls Champion”—a staff member who has additional training regarding fall prevention and who can then FIRE HAZARDS provide training to others, act as a mentor to new staff, and Older adults are among the highest risk groups for keep a high awareness of the need for fall prevention. injury or death caused by fire. Hospitals and long-term care facilities are well aware of the danger of fire. Cultural Considerations Building codes for these institutions require safety doors, fire extinguishers, exit windows, oxygen pre-   cautions, and other safety measures. Each institution must have a fire safety plan designed to reduce the risk Home Fall Risk Among Chinese Older Adults for fire, a quick notification system to the local fire department, protocols for fire containment, and an A study designed to identify risk factors for falls in the homes evacuation plan. Fortunately, these measures have of older adults residing in China revealed data that are very made institutional fires an uncommon occurrence. similar to those found in the United States. In China, falls are Fires in the community are another story. Studies show the second leading cause of accidental death. Many older that over 1000 Americans over age 65 die each year as adults do not recognize safety hazards because they have lived a result of fires. Residential fires injure an average of with them for a long time. Risk areas and hazards in China and 3000 older adults each year. Most fire injuries are a the United States are almost identical. Tai chi chuan, an exer- result of cooking accidents, whereas the majority of fire cise designed to maintain balance, is a common daily practice deaths are smoking-related. Many of these deaths among older adults in China. The benefits of this exercise for could be prevented by instituting these basic fire safety fall reduction are being researched in the United States. precautions in the home: • Make sure smoke detectors are installed. Check that EXTERNAL RISK FACTORS the batteries are working monthly and replace the Environmental hazards include everything that sur- batteries twice a year. Do not disable the device if rounds older adults. Potential hazards are presented by the people and the variety of objects a person comes into contact with on a daily basis. Even the climate in which a person lives can present an environmental

170 UNIT II  Basic Skills for Gerontologic Nursing Box 9-4  Home Security Guidelines cooking fumes or steam causes it to sound. Instead, • Think and plan ahead to reduce risks to personal move the device or try a different type of detector. safety. Unfortunately, we live in a society that is less • Use caution with cigarettes or open flames. Do not safe than the one in which older adults grew up. leave them unattended or on an unstable surface Precautions that may not have been necessary in where they could fall onto flammable floors or fur- the past should now be part of each person’s daily niture. Empty all smoking materials into a metal planning. container so no smoldering materials can combust. NEVER smoke in bed. • Identify ways an intruder could enter the home. • Make sure there are no open flames from cigarettes, Defective locks on windows or doors should be matches, candles, etc., if oxygen is in use. Oxygen replaced. Locks should be secured and checked each does not burn, but it supports the combustion of time the person enters and leaves. Lost or stolen keys other flammable items. may necessitate lock changes. • Check extension cords for fraying or loose plugs. Do not pull cords out by tugging on the wire. Be careful • Maintain regular contact with friends and family. Daily not to overload an outlet. Avoid using extension phone calls or some sort of signaling system should cords; get an electrical block with a circuit breaker be used to indicate that everything is all right. instead. • Be sure to turn off the stove or oven if you are • Use the telephone safely. Keep a phone at the leaving the area. Keep baking soda and a pot lid bedside and near the favorite sitting area. This available to smother a fire if it occurs. Do not use eliminates the need to hurry to another room. If water, particularly if grease is involved. possible, obtain a phone with large numbers, which • Never cook while wearing long, loose sleeves that enables accurate dialing in a stressful situation. An could catch fire, causing serious burns. Secure your autodial function with emergency numbers is also hair if it is long. helpful. An answering machine is useful in screening • If you live in a rental unit, report any fire safety unwanted or late-night calls. Women living alone hazards such as blocked exits, cluttered hallways, should never broadcast this fact to strangers. Using or other problems to the owner or management a male voice on the answering machine is a wise promptly. If these problems are not resolved, notify precaution. the fire department. • Have an escape plan. Plan more than one escape • Answer the door safely. Ensure that doors are secure route if possible. Practice how you would get out, with a peephole at eye level for viewing visitors before particularly if you use a wheelchair or other mobil- opening the door. Make sure that outside lighting is ity aids. Keep a flashlight, eyeglasses, and a whistle available and working so that nighttime visitors can be (to warn others or to help them find you) at the observed. Ask for proper identification before opening bedside. If the fire is in your residence, get out to the door for a stranger. Do not open the door if there safety before calling the fire department. Close the is any doubt about who is there; authentic sales door behind you to prevent the spread of the fire. agents or service employees will wait and not be DO NOT try to fight the fire yourself. offended by having their identification checked with • DO NOT use elevators when there is a fire. their company. HOME SECURITY People, particularly strangers, present a risk to older • Bank safely. Withdraw cash in small-denomination adults. Older adults are more vulnerable than younger bills. Do not carry or display large amounts of cash. persons to attack and injury from those who prey on Secure money immediately in a wallet, money belt, or weaker or more defenseless people, such as the infirm handbag. It is wise not to put large sums of money in or older adults. Older adults need to be aware of the a shoulder or strap handbag that can be pulled away risks presented by strangers and learn to institute mea- easily. It is better to keep wallets in an internal pocket sures to reduce the likelihood of injury (Box 9-4). or body pouch. Keep large amounts of cash and VEHICULAR ACCIDENTS valuables in a bank or other financial institution. Vary Probably the most dangerous hazards, because of their the day and time that banking is done. When using an size and speed, are motor vehicles. Motor vehicle acci- automated teller machine, avoid nighttime visits and dents are more likely to occur with aging, whether the whenever possible, have another person along for older person is a pedestrian or a driver. safety. Studies reveal facts that demonstrate the magnitude of the problem. Crossing roads is a significant problem • Prepare for emergencies. Have emergency numbers for older pedestrians. One study revealed that only 1% posted in large, clear lettering near each telephone. If of independent persons older than 72 years were able entry door locks have dead bolts, they should be left unlocked with the key in place while the older person is inside. This reduces the risk of the older person being trapped in the building in case of fire and enables emergency care providers to enter the housing unit if services are needed.

Meeting Safety Needs of Older Adults  CHAPTER 9 171 to cross a street before the traffic signal changed. The no mandatory reporting laws for mental impairment. CDC reports that 20% of pedestrian deaths in 2012 Some states encourage but do not require physician were over age 65 (CDC, 2014a). Some communities reporting. Only eight states (California, Delaware, with high numbers of older adults have adopted modi- Georgia, Idaho, Maine, Nevada, New Jersey, Oregon, fications that make street crossing safer. These include and Pennsylvania) require physician reporting. Some pedestrian-controlled timers, safety islands, and state requirements are vague (“conditions hazardous restrictions on vehicle turns at intersections. Active to driving”), unspecified, or address only seizure lobbying by seniors in other communities can help disorder/lapse on consciousness (American Medical initiate some of these safety innovations. Association, 2013). Older adults are often unwilling to stop driving in The National Motorists Association takes the posi- spite of the serious risks to themselves and others. tion that changes in understanding, judgment, and Independence is the main reason voiced by older memory pose a greater threat on the roads than do adults for continued driving. A driver’s license is a physical changes. Yet advocates for people with ticket to freedom. From adolescence on, Americans’ Alzheimer disease often recommend limiting rather preferred method of transportation is the car. In some than terminating driving privileges. parts of the country, however, driving seems to be more a necessity than a luxury. Rural and suburban Community Considerations areas may not have viable alternatives other than reli- ance on another person to provide transportation.   Currently, there are few legal measures in place to determine when an older adult’s driving privileges Baby Boomers are a large segment of the automobile market. should be terminated, but many proposals are being As this group ages, automakers are adapting their vehicles to discussed in states all across the country. This is a dif- be more friendly to older adults while still marketing a stylish ficult issue, often pitting younger family members image to entice Baby Boomers to buy their cars. Modifications against aging parents. Some states have begun requir- include larger numbers on the instrument panel, easier-to-grip ing a vision test for license renewal after a certain age. handles, adjustable pedal height, back-up sensors or cameras, Other states offer “limited licenses,” which allow older higher and wider bucket seats, and many other features. drivers to only drive specific routes they travel regu- Senior citizens are encouraged to ask auto dealers about larly (Copeland, 2009). Health care providers are often which “senior-friendly” features or options are available. caught in the middle of this dilemma. Although people are usually aware of the need to Driving by older adults is a major concern in com- modify activity levels as they age, older adults may munities in which large numbers of senior citizens not be equally aware of the need to make adjustments reside. In 2008, 5500 people age 65 and older died in in driving. Initiating safe driving modifications can motor vehicle crashes, and nearly 200,000 were injured enable older adults to enjoy the freedom of movement (CDC, 2013). Drivers over age 65 have the highest provided by automobiles while protecting themselves crash rate per mile driven. In 2009 there were 33 million and others (Box 9-5). Sometimes these adjustments are drivers over age 65. This number is expected to increase not enough, and the difficult decision to stop driving dramatically as the Baby Boom generation ages. Although it has not been shown that older drivers pose Box 9-5  Safe Driving Practices for Older Adults a greater risk for injury or death to others, they them- selves are more likely to die from injuries because of DO increased susceptibility to injury and medical compli- • Plan ahead to know where you are going cations. The fatality rate for drivers over age 85 is the • Add extra time so that you do not feel rushed highest for any age group. • Limit your driving to places close to home, familiar, Several factors contribute to these statistics. Age- and easy to get to related vision changes result in altered depth percep- • Avoid distractions such as talking, playing the radio, tion, changes in night vision, and diminished ability to recover from glare. Hearing changes can interfere with or using a cell phone the ability to recognize sirens or other auditory warn- • Wear your seat belt at all times ings. Decreased muscle strength, reduced flexibility, • Wear appropriate eyeglasses and hearing aids and slower reflexes reduce the ability to respond to • Pace trips to allow for frequent rest breaks hazards while controlling a motor vehicle. Other • Use extra caution when approaching intersections medical conditions or medications may also have • Drive at a safe distance behind other cars effects on driving ability. One of the growing risk factors is related to changes in cognitive functioning, AVOID DRIVING particularly due to Alzheimer disease. Estimates indi- • If taking medications that affect driving skills cate that between 30% and 45% of people with early • During rush hour Alzheimer disease continue to drive. Most states have • At night, when lighting is limited, or during inclement weather • On busy streets and in congested traffic areas • On limited-access roads with high speed limits and complex intersections such as freeways

172 UNIT II  Basic Skills for Gerontologic Nursing exposed to even minor climate changes. Even active, healthy older adults are at increased risk when must be made. Warning signs that indicate a person exposed to extremely hot or cold temperatures. should stop driving include, but are not limited to, the following: Home Health Considerations • Nervousness or lack of comfort behind the wheel • Difficulty staying in one lane   • More “near misses” • More dents or scrapes on the car (or hitting or scrap- Hypothermia and Hyperthermia ing the garage, mailbox, etc.) As the cost of heating the home increases, older adults may • Other drivers “honking” at you more often try to save money by lowering their thermostat setting. This • Friends or family not wanting to ride with you can be dangerous because a drop in environmental tempera- • Confusing the brake and gas pedals ture below 65° F can result in hypothermia for older adults in • Difficulty turning to look over your shoulder when their eighties and nineties. Likewise, air-conditioning costs are considerable, and many people may be reluctant to use it even making lane changes or reversing when available. The National Institute on Aging offers free “Age • Medical conditions or medications that affect your Pages” that provide information on how to avoid hypothermia and hyperthermia (National Institute on Aging, 2014). This ability to maneuver the car information can be obtained online (www.nia.nih.gov) or by • Being easily distracted or having difficulty concen- telephone (800-222-2225). The National Energy Assistance Referral (NEAR) Project can help seniors pay their heating bills. trating while driving NEAR phone operators (866-674-6327) will give callers the • Getting lost number to reach their state Low-Income Home Energy • Receiving more warnings or traffic tickets Assistance Program (LIHEAP) office, as well as referrals to When older adults stop driving, they need alternative local agencies that offer assistance with paying energy means of getting around. Family and friends are often bills. This information can also be obtained by emailing willing to provide transportation. Volunteers from [email protected]. churches or civic agencies may also provide rides for senior citizens. Some communities provide low-cost Thermoregulation, the ability to maintain body tem- bus or taxi services. The local Agency on Aging (can perature in a safe range, is controlled by the hypothala- be found on the national website: www.n4a.org) can mus. The normal core body temperature is maintained provide information regarding services that are avail- between 97° F and 99° F. Body temperature can be able in the area. Older adults may complain that alter- affected by numerous internal and external factors. native transportation is too costly. This can be countered Internal factors include muscle activity, peripheral cir- by statistics that estimate the yearly cost of owning and culation, amount of subcutaneous fat, metabolic rate, operating a car at about $6000 per year. That amount amount and type of foods and fluids ingested, medica- will pay for quite a bit of alternative transportation. tions, and disease processes. External factors include humidity, environmental temperature, air movement, THERMAL HAZARDS and amount and type of clothing or covering. Another external factor that presents risks to older adults is extremes in environmental climate. Older Heat is produced by metabolic processes and by persons in extreme conditions (temperatures below muscular activity such as shivering and conserved by 60° F or above 90° F) are at increased risk for develop- vasoconstriction. Heat is lost through vasodilation and ing problems related to thermoregulation. Older perspiration. Anything that changes the balance of persons who are sick, frail, inactive, or take medica- heat lost and heat retained can cause problems. tions that prevent the body from regulating tempera- ture normally (Box 9-6) are at serious risk when Hypothermia is defined as a core body temperature of 95° F or lower. Older adults are highly susceptible Box 9-6  Thermoregulation Risks for Older Adults to hypothermia for several reasons. Normal changes that occur with aging affect the body’s ability to regu- • Exposure to excessively cold or hot environments late temperature. Changes in the skin reduce the older • Limited financial resources to pay for heat or clothing person’s ability to perceive dangerously hot or cold environments. Decreased muscle tissue, decreased appropriate for environmental temperature muscle activity, diminished peripheral circulation, • Neurologic, endocrine, or cardiovascular disease reduced subcutaneous fat, and decreased metabolic • Hypometabolic or hypermetabolic disorders (diabetes, rate affect the amount of heat produced and retained by the body. As a person ages, metabolism slows, cancer, hypothyroidism, hyperthyroidism, malnutrition, activity decreases, and shivering diminishes. When obesity) exposed to low environmental temperatures, body • Infection or other febrile illness temperature drops further. These changes further • Dehydration or electrolyte imbalances decrease activity and heat production, allowing body • Inactivity or excessive activity temperature to decrease even further. If this cycle is • Temperature-altering medications (alcohol, not stopped, death may occur. The National Institute antidepressants, barbiturates, reserpine, on Aging estimates that more than 2.5 million older benzodiazepines, phenothiazines, anticholinergics)

Meeting Safety Needs of Older Adults  CHAPTER 9 173 Box 9-7  Signs of Hypothermia complications and to rewarm the person. This should be done even when the person appears to be dead • Mental confusion because a pulse may not be palpable as a result of • Decreased pulse and respiratory rate severe vasoconstriction. If the person is conscious, • Decreased body temperature move the older adult into a warmer environment. • Cool/cold skin Remove cold and/or wet clothing and wrap the person • Pallor or cyanosis with blankets or other insulating coverings. Warm • Swollen or puffy face blankets may be used, but avoid heating pads, electric • Muscle stiffness blankets, or immersion in a hot bath because these may • Fine tremors cause cardiovascular problems and cause damage to • Altered coordination fragile skin. Warm, not hot, beverages are appropriate • Changes in gait and balance and beneficial if the person is conscious and able • Lethargy, apathy, irritability, hostility, or aggression to drink. adults are at risk for hypothermia, and the CDC reports Hyperthermia, a higher than normal body tempera- that approximately 700 deaths per year were attrib- ture, occurs when the body is unable to get rid of uted to exposure to excessive cold. excess heat. Deaths directly or indirectly caused by hyperthermia average about 700 per year in the United Disease processes such as hypothyroidism, hypo- States. Men die from hyperthermia about twice as glycemia, and malnutrition can also cause a decrease often as women (CDC, 2012). Most hyperthermia in heat production. Medications that decrease environ- deaths occur in adults over age 50. Hyperthermia mental awareness, such as barbiturates, tranquilizers, can be caused by excessively high environmental tem- and antidepressants, can increase the risk for hypo- peratures, an inability to dissipate heat, or increased thermia. Alcohol ingestion is highly dangerous because heat production caused by exercise, infection, or it decreases environmental awareness and, at the same hyperthyroidism. time, increases vasodilation with resulting heat loss. Many parts of the country experience extremely Although decreased body temperature is the major high temperature during summer months. When this symptom of hypothermia, an older person may mani- heat is combined with high humidity, the normal fest other signs or symptoms (Box 9-7). One of the first cooling mechanisms of the body are ineffective. Even signs of hypothermia in older adults is growing mental under moderate conditions, it takes longer for older confusion that can progress from simple memory loss adults to begin sweating, and, because of diminished or changes in logical thinking to total disorientation. thirst and decreased body water, they produce less Pulse and respiratory rate slow with hypothermia and perspiration. These factors render older adults more may be difficult to detect in severe cases. The skin likely to develop heat exhaustion and heatstroke. becomes cool or cold to the touch, and pallor or cya- nosis is often present (particularly on the extremities). Hyperthermia can place a significant strain on The face may appear swollen or puffy. Muscles appear the heart and blood vessels of older adults. Cardio­ to be stiff, and fine tremors may occur. Changes in vascular problems and heat are a deadly combination. coordination, including poor balance or gait changes, Endocrine problems such as diabetes and psychiatric are common. Behavior changes such as lethargy or disorders also increase the risk for hyperthermia. apathy may occur, but irritability, hostility, and aggres- Medications commonly used by older adults can com- sion are also possible responses. Shivering, an indica- promise the body’s normal adaptation to heat. Diuretics tion that the body is having difficulty maintaining prevent the body from storing fluids and can diminish adequate body temperature, may or may not be evident superficial vasodilation. Anticholinergic medication in older adults, because this response often diminishes used to treat Parkinson disease (e.g., benztropine with aging. Because many of the signs and symptoms and trihexyphenidyl) can interfere with perspiration, of hypothermia are similar to those of other disorders as does a wide range of psychotropic medications. in older adults, they can easily be missed or mistaken Consumption of alcohol should be avoided because it for something else. The National Institutes of Health can decrease awareness of symptoms and contribute suggests an assessment of the “umbles”—mumbles, to fluid loss. stumbles, fumbles, and grumbles—to look for possible indications of hypothermia. Symptoms of hyperthermia are progressive. Mild, early signs of heat stress include feeling hot, listless, With proper precautions, hypothermia is prevent- or uncomfortable. Cramps in the legs, arms, and able. Approaches to prevention are identified in the abdomen are early indicators of elevated body tem- nursing interventions section later in the chapter. perature. Indications of a serious heat-related problem When hypothermia is suspected, immediate interven- may include hot, dry skin without perspiration; tachy- tion is necessary to prevent serious complications or cardia; chest pain; breathing problems; throbbing death. If the person is unconscious, call 911; special headache; dizziness; profound weakness; mental or care will be required to prevent cardiovascular perceptual changes; vomiting; abdominal cramps; nausea; and diarrhea.

174 UNIT II  Basic Skills for Gerontologic Nursing • Where are chemicals and cleaning supplies stored? • Are there safety hazards in the home? Scatter rugs? Heat exhaustion occurs gradually and is caused by water or sodium depletion. Both active and inactive Electric wires? Others? older adults can develop heat exhaustion if they do not consume adequate fluids and electrolytes when NURSING DIAGNOSES exposed to hot environments. If heat exhaustion is not recognized and treated, it can progress to a more severe   condition called heatstroke. Risk for Falls, Risk for Injury, Risk for Trauma, Risk for Heatstroke, a condition in which the body tempera- Poisoning ture can climb as high as 104° F, is a life-threatening emergency. Heatstroke is a very real concern for NURSING GOALS/OUTCOMES active older persons, particularly those living in hot climates. Strategies that can prevent or reduce the inci-   dence of hyperthermia are listed under Nursing Interventions in each of the Nursing Process sections IDENTIFICATION that follow. The nursing goals for an older person at risk for injury, trauma, or poisoning are to experience a decrease in SUMMARY the frequency and severity of injuries and to identify and correct unsafe conditions and behaviors. Psychological trauma caused by falls, assaults, motor vehicle accidents, fires, thermal events, or other inju- NURSING INTERVENTIONS/IMPLEMENTATION ries can be more serious than the physical trauma itself. Fear of injury often confines older adults to their   homes and can cause them to lose confidence in their ability to perform even simple actions. They may The following nursing interventions for those at risk restrict their activity, thereby contributing to further for injury, trauma, or poisoning should take place in loss of strength, decreased mobility, social isolation, hospitals or extended-care facilities: and increased dependence. If too much function is lost, 1. Evaluate the person for the risk for falls. Older institutionalization may be necessary. adults who experience dizziness or fainting with NURSING PROCESS FOR RISK position changes are at increased risk for falls. These symptoms are often caused by a sudden drop in   blood pressure (orthostatic hypotension). Instruct these individuals to move slowly and to remain FOR INJURY seated until the dizziness passes. Episodes of ortho- static hypotension are more likely to occur early ASSESSMENT/DATA COLLECTION in the morning, particularly before breakfast, and may be aggravated by dehydration or medications.   Promptly report any episode of dizziness to the primary care provider so that the cause can be • Does the person have a history of falls or other determined. Evaluate laboratory values for the injuries? presence of anemia, which can increase the risk for falls. Notify the primary care provider of any • If yes, how often has the person fallen? When and abnormal values so that appropriate interventions where did the fall occur? What types of injuries can be initiated. Assess all new admissions for have occurred? problems with balance and gait so that appropri- ate safety strategies can be initiated. Encourage • How often does the person suffer injuries? older adults to move at a comfortable pace and • What is the person’s level of vision? Hearing? not to hurry. Hurrying increases the risk for falling. Encourage older adults to wear comfort- Temperature perception? able, supportive footwear. Assistive devices that • Is there any impairment in gait or balance? improve stability by providing a wider base of • Does the person use any assistive devices such as a support (e.g., canes and walkers) may be needed (Figure 9-1). cane or a walker? Check high-risk individuals frequently. Ensure the • What kind of footwear is usually worn? • Does the person suffer from cognitive impairment? call signal is readily available whether the person is in bed or in a chair. Lounges and bathrooms Forgetfulness? should be equipped with call signals. Answer • Does the person smoke? Light candles in the home? calls from older adults promptly. If older adults have to wait too long for assistance, they may Use a gas stove? attempt to stand or walk even if they know it is • Does the home have a smoke detector? Is it working? unsafe. • Does the person live alone? Provide adequate assistance based on the patient’s • What medications does the person take? abilities and limitations. Use lifts and other • Does the person suffer from dizziness or fainting? transfer devices when appropriate. Take care • What are the hemoglobin and hematocrit levels? to prevent injury to both the patient and • Is the person able to follow directions? the caregiver. • Does the person drive? Does he or she wear a seat- belt when riding in a car? • If living at home, where are medications stored?

Meeting Safety Needs of Older Adults  CHAPTER 9 175 FIGURE 9-1  Assistive devices promote support and safety. A, Quad cane. B, Walker. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, St. Louis, Mosby.) AB FIGURE 9-2  Handrails provide support when walking. (From opposite the caregiver should be up to reduce the Kostelnick C: Mosby’s textbook for long-term care nursing chance of falls. Electronic sensors or alarm systems assistants, ed 7, 2015, St. Louis, Mosby.) designed to signal when an at-risk person attempts to stand up from a chair or get out of bed unassisted 2. Modify the environment to reduce risks. To prevent may be helpful, particularly in cases of cognitive falls resulting from visual changes, stairwells should impairment where the older adult is unaware of the be well illuminated both day and night. Mark the risk for falling. Lock and store medication carts edges of stairs, shower lips, and any other eleva- when not in use. Never leave medications at the tions using a dark or contrasting color stripe to help bedside unless permitted by the primary care pro- the aging individual recognize the edge. Hallways vider and facility policy. Medications intended for should have strong grip rails to provide support one individual can easily be taken by a confused during ambulation (Figure 9-2). Remove all clutter person who wanders into the room. Lock cleaning such as newspapers, wastebaskets, shoes, and other carts and supplies in a cabinet or closet when not items from the floor. Provide nonskid footwear. Be in use. sure to lock all devices with wheels such as beds and wheelchairs. Use low beds or keep beds in low Safety Alert position unless the caregiver is at the bedside. If the caregiver has to leave the person, even briefly, lower   the bed. Whenever the bed is elevated, the side rail All poisonous agents, including cleaning solutions, must be stored in locked cabinets or closets where they are out of the reach of residents. Cleaning carts should be kept within sight of staff. Restraints can represent a violation of basic patient rights and may lead to injury or even death. They should only be used as a last resort. If restraints are ever used, they must be used with caution and only when there is a documented reason for them, and only after the person or his or her guardian agrees to their use. This includes use of foot pedals, vest and waist restraints, and even chair tables and safety belts. Omnibus Budget Reconciliation Act (OBRA) regula- tions are very specific about when and what types of restraints are permitted. A primary care provider’s order is needed to use restraints; a standing order or “prn” order cannot be used. In acute and critical care settings, restraint orders should be renewed every four hours, and the patient should be examined by the pre- scribing practitioner every 24 hours while the device is in use (Bradas, 2012). Restraints must meet the following four criteria to be in compliance with

176 UNIT II  Basic Skills for Gerontologic Nursing • How many of these actions have you seen used in care settings? regulations: (1) “be necessary to treat a medical symptom; (2) not be used to discipline a resident or for • Have you tried any yourself? How effective was the staff convenience in the absence of a medical symptom; alternative intervention? (3) not be used because of family request in the absence of a medical symptom; and (4) be the least restrictive Complementary and Alternative Therapies device possible, in use for the least amount of time per day possible; and the facility must have an active plan   in place to decrease usage or for eventual removal of the restraint” (Centers for Medicare and Medicaid Music Therapy Services, 2013). Research has found that older patients who listen to music  Coordinated Care they enjoy exhibit significantly more positive behaviors while out of restraint than do older patients who are not exposed to Collaboration music. No single type of music is right for everyone. Family members may be helpful in identifying favorite music, or the USE OF RESTRAINTS staff may try different types of music and observe the patient’s All staff, including nursing assistants, should be thoroughly response. Some may prefer classical; others like jazz; still trained regarding the use of each type of restraining device. others love gospel music. Considering the demographics, Close attention should be paid to when, what, how, and why the music of the Baby Boomers (e.g., Elvis, James Taylor, The restraints are used. Beatles) may soon be what is found to be effective. • When: Only when other less restrictive methods have been The following interventions should take place in tried first and found to be ineffective. Never use restraints the home: as a form of punishment. Primary care provider’s orders are 1. Assess the environment for hazards and modify necessary for both physical and chemical restraints. Obtain informed consent from the patient or legal guardian before it to reduce the likelihood of injury. The home using restraints. environment can be dangerous for older adults. To • What: The least restrictive device that allows the highest reduce the likelihood of poisoning, store all clean- level of function but still provides protection. For example, ing supplies well away from food or medications. a waist bar or lap board in a wheel chair would be preferable If the older person has impaired judgment, it may to a full-vest restraint. be necessary to keep all poisonous substances in a • How: Read all manufacturers’ directions and agency poli- locked cabinet or closet. Clearly label all medica- cies before applying a restraint. Use the correct-size device. tions in large letters so that individuals can distin- Identify the front and back of the device before applying. guish their names and directions. Check refrigerator When the restraint has tie straps, attach them to a part of for spoiled or outdated food. Teach individuals the bed or chair that moves with the patient so that they with circulatory changes the importance of check- do not become overly constricting. Use only quick-release ing the temperature of bath water with a thermom- hitch knots that are affixed in locations where the nurse, but eter. They should not add hot water when sitting in not the patient, can easily reach them. Check the patient a tub or adjust the temperature of the water while frequently. Release restraints at least every 2 hours, and in the shower. Use only nonskid shower mats. Mop inspect tissues beneath the restraint for signs of altered up spills promptly to reduce the risk of slipping. circulation or tissue damage. Discourage older adults from climbing because • Why: Inappropriate use of restraints is dangerous for the patient. The potential for lawsuits charging abuse or neglect falls from higher places are more likely to cause increases when restraints are in use. To reduce the risk serious injury. In general, chairs, footstools, and for legal liability, document carefully, including: (1) baseline other pieces of furniture are unsafe. If the person assessment of physical condition, including vital signs, needs to reach a high area, a good step stool with infections, pain, fluid and nutritional status, elimination a broad base of support should be used. Select status, medications, vision, hearing, mental status, and furniture that is steady and easy to get out of typical behavior patterns; (2) specific behaviors that without assistance. necessitated the need for restraints, including persons or Keep stairs free of clutter. Handrails in stairwells events that may have triggered the behavior; (3) the type should be sturdy and in good repair. Install grip and time the devices were used; (4) the patient’s response rails in showers, tubs, and around toilets, making to restraint; and (5) interventions identified as part of the sure they are tightly attached to the structure plan of care designed to prevent recurrences of the need (studs) of the wall, not just the plaster. for restraint. Make sure there is adequate lighting without glare, particularly in stairwells and bathrooms. Keep a Critical Thinking flashlight at the bedside for emergencies or when a light cannot be easily reached. Check the floor   for hazards such as clutter, scatter rugs, or loose carpet edges that, when rolled up, may trip a Restraints person. Remove or repair all hazardous items to reduce the risk for falls. Identify as many alternatives to using restraints as you can. • Why do you think that these alternative actions will decrease the need for restraints?

Meeting Safety Needs of Older Adults  CHAPTER 9 177 Make sure smoke detectors are installed and that NURSING DIAGNOSES they are working correctly. Change batteries twice a year in the spring and fall when clocks   are changed for daylight savings time. Hypothermia, Hyperthermia, Risk for Imbalanced Encourage use of a medical alert, “panic button,” Body Temperature, Ineffective Thermoregulation emergency call device that is worn as a necklace or bracelet. This can be activated to summon help NURSING GOALS/OUTCOMES IDENTIFICATION if a fall occurs. In addition, assess the person for a depressed mood. Studies have shown that the   incidence of falls is three times higher among depressed individuals living at home. The nursing goals for an older person with hypother- mia, hyperthermia, imbalanced body temperature, or 2. Recruit the assistance of a family member or ineffective thermoregulation are to maintain core body friend to check on the older person at regular temperature within the normal range and to state the intervals. Regular visits to the home permit a quick appropriate modifications in dress, activity, and envi- check of the most obvious hazards. Correct any ronment needed to maintain body temperature within unsafe conditions before an injury occurs. Review the normal limits. the most common concerns with the visitors so that they are more alert and aware. Although frequent NURSING INTERVENTIONS/IMPLEMENTATION checks will not always prevent injury, they can reduce the chance of an injured older person lying   helpless for extended periods. Some older persons invest in special call signal devices that can be worn The following nursing interventions should take place on their bodies. These call signals can be activated in hospitals or extended-care facilities: in case of emergency to summon help. They should 1. Monitor the environmental temperature, humid- be purchased only after the reputation of the company who sells and services the device has been ity, and air movement. Maintain room temperature carefully checked with an agency such as the Better at a comfortable level between 70° F and 75° F. Business Bureau. Many of these so-called safety Relative humidity between 40% and 60% is com- systems are worthless and provide a false sense of fortable for most people. Ventilation should provide security to older adults. an exchange of air without drafts that may cause chilling. Limit the time an older adult is exposed to 3. Use any appropriate interventions that are used in extreme temperatures, either hot or cold. the institutional setting. 2. Monitor body temperature at regular intervals. Regularly monitor the temperature of any person NURSING PROCESS FOR at risk for hyperthermia or hypothermia. In many cases, a thermometer that registers tempera-   tures below 95° F is needed for accurate measure- ment. Electronic thermometers or thermal ear HYPOTHERMIA/HYPERTHERMIA sensors provide accurate temperatures when used correctly. ASSESSMENT/DATA COLLECTION 3. Provide clothing and bed covers that are suitable for the environment. Extra clothing and blankets   may be necessary for inactive persons. Knit under- garments, layered clothing, bed socks, nightcaps, • What is the person’s body temperature? and flannel sheets or blankets are particularly effec- • How does it change throughout the day? tive at retaining body heat. Make sure to use ade- • Is the person inactive or excessively active? quate covers or an adequately warmed room when • Does the person show any signs of infection, includ- bathing a frail older adult. In the summer, clothing should be lightweight, loose, and nonconstricting to ing behavioral changes? allow adequate movement of air over the body. • Does the person complain of feeling hot or cold? 4. Promote adequate fluid and food intake. In cold • Does the person have any disease conditions that weather, a diet rich in protein and additional snacks can help maintain subcutaneous fat needed for increase the risk for ineffective thermoregulation? insulation and promote adequate muscle mass • Does the person suffer from electrolyte imbalance? needed to sustain heat production. In hot weather, • Does the person consume alcohol or other older adults should have fresh fluids at the bedside at all times. Provide pitchers of a cool sugar-free temperature-altering medications? beverage in day rooms, activity centers, and lounges. • Does the person suffer from dementia, depression, Because older adults may have a diminished sense of thirst, frequent reminders to drink may be or other conditions that decrease awareness? necessary. • Does the individual have adequate financial 5. Monitor activity level in accordance with environ- mental temperature. Increased physical activity resources to pay for housing that has adequate heat helps older adults keep warm in cool weather. and ventilation? Excessive activity should be avoided during hot • Does the individual have clothing suitable for the environmental conditions? See Box 9-6 for a list of thermoregulation risks for older adults.

178 UNIT II  Basic Skills for Gerontologic Nursing 3. Teach good health habits. 4. Use any appropriate interventions that are used in weather, particularly during daytime hours when heat is greatest. the institutional setting. The following interventions should take place in the home: TO PREVENT HYPERTHERMIA 1. Verify that the residence has adequate heat in cold weather and adequate ventilation in hot weather.   Many older adults, particularly those who live alone and those with limited financial resources, (1) Decrease physical activity during the daytime. live in marginal or substandard housing. There is (2) Do heavy chores such as laundry early in the often inadequate heat to provide warmth in winter morning or in the evening. (3) Perform outdoor activi- or inadequate ventilation to keep cool in the ties after sunset. (4) Dress in light-colored, loose-fitting summer. If the home is poorly heated, encourage cotton clothing. (5) Keep out of direct sunlight—use the person to stay active and dress warmly. If the hats, umbrellas, awnings, or other types of sunscreens house is too hot or is poorly ventilated, encourage to reduce sun exposure. (6) In excessive heat, take the person to reduce activity and dress in cool cloth- cool baths or showers several times a day, or apply ing. If air-conditioned public buildings, such as cool, wet towels or ice packs to the axillae and groin. shopping plazas, libraries, or senior citizen centers, (7) Drink a minimum of 8 to 10 glasses of water or cool are accessible, encourage older adults to spend the beverages each day regardless of thirst. When there are hottest times of day in such facilities. medical restrictions on fluid intake, the primary care 2. Identify community resources that can help older provider should be consulted regarding the recom- adults maintain a safe environment. Many public mended amount of intake. (8) Avoid drinking hot bev- utility companies have special programs designed erages and alcohol. (9) Eat several small meals instead to ensure that older adults have adequate heat in of a few large ones. winter. Some also provide fans or air conditioners TO PREVENT HYPOTHERMIA in the summer. Often these are available to older adults at reduced prices. Special payment plans that   spread the cost of heating or air conditioning over the year are also available in most areas of the (1) Keep the heat within the safe temperature range of country. Such plans can enable older adults to 70° F to 75° F. (2) Stay active. (3) Wear several layers of budget their limited resources while maintaining a clothing rather than one heavy layer. Wool, knits, and safe thermal environment. flannel are particularly warm. (4) Drink 8 to 10 glasses of fluid daily, including warm beverages. (5) Avoid consuming alcohol. (6) Eat several small, warm meals throughout the day. Get Ready for the NCLEX® Examination!   Online Resources: Key Points • Speak Up: Reduce Your Risk of Falling brochure available in English and Spanish from the Joint • The normal physiologic changes of aging, increased Commission: www.jointcommission.org/Speak_Up incidence of chronic illness, increased use of __Reduce_Your_Risk_of_Falling/ medications, and sensory or cognitive changes place the aging population at increased risk for injury. Review Questions for the NCLEX® Examination • Risk for injury increases dramatically when older adults 1. A factor that contributes to the development of are exposed to multiple environmental hazards. hypothermia in older adults is decreased: 1. Activity level • The most common injuries experienced by older adults 2. Sensory perception of cold include falls, burns, poisoning, and automobile 3. Percentage of body fat accidents. 4. Nutritional and fluid intake • Falls are the leading cause of both fatal and nonfatal 2. Which manifestation(s) indicate(s) serious heat-related injuries among older adults. problems? (Select all that apply.) 1. Cramps in the legs • Nurses can play an important role by helping older 2. Vomiting adults recognize their risk factors, by planning coping 3. Heavy perspiration strategies to promote safety, and by modifying their 4. Profound weakness environment to minimize the likelihood of injury. 5. Mental changes 6. Throbbing headache Additional Learning Resources   Go to your Evolve website at http://evolve.elsevier .com/Williams/geriatric for the additional online resources.

Meeting Safety Needs of Older Adults  CHAPTER 9 179 3. The nurse should instruct the nursing assistant who is 5. Your team is developing a fall reduction program on caring for a client who is receiving antihypertensive your unit. Which of the following would be important to medication to: 1. Have at least two people assist with ambulation remember when developing such a program? (Select all 2. Allow them to stand up slowly from sitting or lying position that apply.) 3. Take the blood pressure if they complain of diplopia 1. Patient assessment for fall risk factors upon 4. Provide additional salt with their meals admission and any change in patient condition 4. The nurse is aware that the best predictor of an older 2. Identification and removal of environmental hazards adult falling is: 3. Avoid placing signage identifying patient at risk for 1. A history of previous falls 2. Use of multiple medications falls to protect privacy 3. Sensory deficits 4. Encourage patient participation in supervised group 4. Alterations in balance exercise program 5. Perform regular medication reviews 6. Use restraints on patients at high risk for falling

Unit III Psychosocial Care of Older Adults chapter 10  Cognition and Perception http://evolve.elsevier.com/Williams/geriatric 6. Identify current nursing diagnoses related to cognitive and perceptual problems. Objectives 7. Select nursing interventions that are appropriate for older 1. Describe normal sensory and cognitive functions. individuals experiencing problems related to perception or 2. Describe how sensory perception and cognition change cognition. with aging. 8. Discuss pain assessment and management as they relate 3. Examine the effects of disease processes on perception to older individuals. and cognition. hemianopsia  (hĕm-ē-ŭn-ŌP-sē-ă, p. 184) 4. Describe methods of assessing changes in perception intelligence  (ĭn-tĕl-ĭ-jĕns, p. 180) memory  (mĕm-ŏ-rē, p. 180) and cognition. otosclerosis  (ō-tō-sklĕ-RŌ-sĭs, p. 181) 5. Identify older adults who are most at risk for experiencing perception  (pĕr-sĕp-shŭn, p. 180) presbyopia  (prĕz-bē-Ō-pē-ă, p. 181) perceptual or cognitive problems. stimuli  (STĬM-ū-lĭ, p. 180) sundowning  (SŬN-doun-ĭng, p. 188) Key Terms aphasia  (ă-FĀ-zē-ă, p. 193) catastrophic reactions  (p. 188) cognition  (KŎG-nĭ-shŭn, p. 180) confusion  (kŭn-FĔW-shŭn, p. 185) crystallized intelligence  (p. 181) delirium  (dĕ-LĬR-ē-ŭm, p. 186) dementia  (dĕ-MĔN-shē-ă, p. 187) dysarthria  (dĭs-ĂR-thrē-ă, p. 192) dysphasia  (dĭs-FĀ-jē-ă, p. 193) The cognitive-perceptual health pattern deals with centers in the brain results in disturbed perception and the ways people gain information from the environ­ cognition. ment and the way they interpret and use this informa­ tion. Perception includes the collection, interpretation, If the senses do not function appropriately, stimuli and recognition of stimuli, including pain. Cognition do not enter the brain and there is not enough infor­ includes intelligence, memory, language, and decision mation for accurate interpretation. Individuals with making. Cognition and perception are intimately con­ sensory deficits in one area often attempt to compen­ nected to the functioning of the central nervous system sate for these deficits by gathering more information and the special senses of vision, hearing, touch, smell, from those senses that function normally. People with and taste. hearing deficits often lip read or otherwise rely on visual cues. People with visual deficits rely more NORMAL COGNITIVE-PERCEPTUAL FUNCTIONING heavily on the senses of hearing and touch. People with multiple sensory deficits have great difficulty The environment excites or stimulates the senses. The collecting information and often experience serious senses, in turn, pass these stimuli on to the cerebral cognitive and perceptual problems. Adult hearing cortex, where recognition (perception) and interpreta­ impairment has been associated with social isolation tion (cognition) occur. Specific regions of the cerebral and depression. People with sensory deficits have a cortex are responsible for detecting and processing normal ability to think and learn, but for them, the the stimuli acquired by the various senses. Malfunc­ process is more difficult tion of the sensory organs or of the interpretation 180 As discussed in Chapter 3, numerous sensory changes occur with aging. Common visual changes include farsightedness, caused by a loss of elasticity of

Cognition and Perception  CHAPTER 10 181 FIGURE 10-1  Cataract of the left eye. (From Swartz M: Textbook a lifetime. Because young people have less knowledge of physical diagnosis, ed 5, 2006, Philadelphia, Saunders.) and experience, they must rely more on fluid intelli­ the lens and resulting decrease in the power of accom­ gence. With advanced age comes an abundance of modation (presbyopia); decreased ability to respond to skills and knowledge that has been acquired over time, changes in light, resulting in night blindness; and cata­ and crystallized intelligence is used more often. racts (Figure 10-1), which cloud the lens and result in blurred vision and sensitivity to glare. Common audi­ Intelligence is often measured by means of tests. tory changes include loss of hearing acuity, particu­ Although intelligence tests are commonly used, they larly of higher-pitched sounds (presbycusis); loss of have distinct limitations. Most written tests measure hearing resulting from decreased sound transmission verbal and mathematic ability. Thus, a person who (otosclerosis); and ringing in the ears (tinnitus), which has had little formal education can have a high level can be caused by Ménière disease, age-related changes, of cognition and yet score poorly on standardized or medications. Older adults are increasingly suscep­ intelligence tests. Cognition is not the same as educa­ tible to misperception and therefore misinterpretation tion. Cognition is the ability to think and reason. when one or more of these changes are present. Many people have good cognitive skills but limited education. Cognition, or thought, takes place in the cerebral cortex of the brain. Cognitive development starts at Intelligence tests are normally timed. Because all the time of birth and perhaps even earlier. When the individuals do not process information at the same human brain is repeatedly exposed to stimuli, connec­ speed, two individuals with a similar pool of knowl­ tions develop between nerve fibers of the cerebral edge and skills may be judged very differently, simply cortex. Each time stimuli are introduced to the brain, because they respond at different speeds. Those with they are associated (at an unconscious level) with the a rapid rate of information processing are typically pool of facts, memories, and experiences that are stored judged as more intelligent than those who take longer there. Once these connections are firmly established, to process information, even if the end result is the information is said to be learned. Once learning has same. This is probably reflective of our culture, which taken place, information or skills can be retrieved as values speed. needed. Memory enables people to retain and recall COGNITION AND LANGUAGE previously experienced sensations, ideas, concepts, Language is a product of cognitive function. In both impressions, and all information that has been previ­ spoken and written forms, language allows humans to ously learned. The human mind is extraordinary in its communicate ideas and thoughts. Language develops ability to learn and process extensive amounts of infor­ early in life. By age 2, the average child has a vocabu­ mation. It is able to retrieve information on demand, lary of several hundred words. Very specific areas of correlate random pieces of information, make judg­ the brain are dedicated to language, and they change ments, solve problems, and create ideas. significantly as language skills improve. COGNITIVE AND INTELLIGENCE We all have different levels of cognitive ability. People Sensory and cognitive problems can result in poor often speak of intelligence quotients (IQs) when they language development or loss of language skills. try to describe cognitive ability. However, IQ can be Damage to the language centers of the brain can result deceptive because there are different types of intelli­ in aphasia, a condition in which people are unable to gence, and standardized testing procedures do not understand or express themselves through language. measure all types of intelligence. Aging people commonly experience sensory Fluid intelligence is the ability to perform tasks or changes that interfere with the collection of informa­ make judgments based on unfamiliar stimuli. This is tion. Visual and hearing changes, changes in taste and sometimes referred to as the ability to “think on your smell, and changes in touch and sensation all interfere feet.” Crystallized intelligence (often called wisdom) is with the ability to collect accurate information from the ability to perform tasks and make judgments based the environment (Figure 10-2). on the knowledge and experience acquired throughout Many older people who are considered confused actually perceive their environment inaccurately. An older person who does not hear well (Box 10-1) or see well may walk into traffic or make mistakes about directions; these mistakes are not made because of con­ fusion, but rather because the person does not have enough sensory information to make an appropriate decision. Multiple competing stimuli can also cause problems if older adults are unable to focus on the important stimuli and disregard nonessential stimuli. Intelligence does not automatically decrease with aging, nor does the ability to learn. Some people seem less intelligent as they age because of their tendency to

182 UNIT III  Psychosocial Care of Older Adults problem. Careful assessment is needed to distinguish mild memory loss from an early indication of a more FIGURE 10-2  One type of vision disturbance that is common in older serious cognitive disorder. adults: restricted peripheral visual field. (From Kostelnick C: Mosby’s textbook for long-term care nursing assistants, ed 7, 2015, There is no known reason why memory loss St. Louis, Mosby.) happens, but nearly 13% of those over age 60 surveyed reported memory loss (Centers for Disease Control Box 10-1  Possible Indicators of Hearing Loss and Prevention [CDC], 2013). The more memories a person has developed throughout life, the more he or • Difficulty understanding high-pitched voices she will retain, so well-educated older adults tend to • Trouble following a conversation when more than one retain a higher level of function than do less well- educated older adults. Even without formal education, person is talking many older people are able to compensate for memory • Difficulty hearing over the phone gaps by relying more on the large pool of experience • Difficulty hearing when there is background noise gathered over a lifetime. • Complaints that other people are mumbling • Increased volume of radio or television Critical Thinking • Straining to hear conversation at a normal volume   be slower and more cautious in their responses. Rather than be embarrassed, older adults often take more time Use It or Lose It to be certain of the answer before they respond. This Memories that are not called up from the brain and used infre- hesitancy or uncertainty may be mistaken for a lack of quently are more likely to be forgotten over time. Transience, intelligence, which it is not. the tendency to forget things over time, is actually the brain’s way of improving efficiency by clearing unused information and Lack of formal schooling may make older adults making room for new memories. Unless this becomes extreme appear less intelligent. They may lack polish in their or persistent, it is considered normal, healthy brain functioning speech and have a more limited vocabulary than (Harvard, 2012). better-educated people. Many older adults who grew up in difficult times ended their formal educations at NURSING PROCESS FOR DISTURBANCE a young age because they had to work to help support the family. When today’s older adults entered the   workforce, advanced education was not needed to earn a decent living. Many continued to read and learn IN SENSORY PERCEPTION and often exceeded what school would have provided. Still, these older adults may be intimidated by young, An older person can experience disturbances in any of well-educated caregivers. the senses. The extent of disturbances can range from very small changes to total loss of sensory function. The speed of information processing and recall by The more serious the disturbance, the greater the risks the brain changes with age. It is common for older are. Different nursing approaches are necessary for dif­ adults to take longer to recall a specific piece of infor­ ferent types of sensory disturbances. mation. Short-term memory is more likely to be affected than is long-term memory. An older person ASSESSMENT/DATA COLLECTION who cannot remember what he or she had for break­ fast may be able to describe in great detail an event   that occurred 50 years ago. • Has the person mentioned any changes in the taste Some degree of forgetfulness or memory loss is or smell of food? common with aging. This problem can be disturbing to the alert older adult. Many begin to fear that they • Can the person detect whether something is cold or are “losing their minds” or developing a serious warm? Smooth or rough? • Does the person have known vision problems (e.g., glaucoma, macular degeneration, cataracts, refrac­ tive errors)? • Does the person see small details or shadows? • Does the person frequently walk into or trip over objects? • Can the person read? If not, why not? If yes, can he or she read newsprint or only large-print headlines? • How close does the person sit to the television? • Does the person wear eyeglasses? If yes, are they single lens, bifocal, or trifocal? • When was the last vision examination? • Does the person respond when people speak to him or her at normal volumes? • Can the person hear a whisper from someone behind or to the side of him or her who cannot be seen?