NURS 6540: Advanced Practice Care of Frail Elders | Week 2

As patients age, they are more likely to develop health issues. While some of these health issues are normal changes due to aging, some of them are abnormal and require further evaluation. Consider a 92-year-old patient who has been diagnosed with several disorders, including obstructive sleep apnea, hypertension, mild chronic anemia, restless leg syndrome, and osteoporosis. Despite these disorders, he can independently perform all basic activities of daily living, walk a quarter mile without difficulty, and pass functional and cognitive assessments. However, he did report that he fell a few times and had lost his way while driving to a familiar location (Carr & Ott, 2010). As an advanced practice nurse caring for geriatric patients, you will likely encounter patients like this. While he can pass the basic assessments, the report of falls and confusion might indicate underlying issues of immobility, sensory deprivation, and/or cognitive dysfunction that require further attention. To identify these potential underlying issues and distinguish between normal and abnormal changes due to aging, health care providers use a variety of assessments. These assessments are key tools in the care of geriatric patients. NURS 6540: Week 2: Assessing Geriatric Patients

This week, you examine assessment tools and evaluation plans used to assess geriatric patients presenting with potential issues of immobility, sensory deprivation, and cognitive dysfunction. Then, you explore implications of normal and abnormal age-related changes and consider how functional assessments are used to distinguish between these changes.

Learning Objectives – NURS 6540: Week 2: Assessing Geriatric Patients 

By the end of this week, students will:

• Evaluate assessment tools used to assess geriatric patients
• Design an evaluation plan for patient with immobility, sensory deprivation, or cognitive dysfunction
• Analyze implications of age-related changes in geriatric patients*
• Analyze the use of functional assessments to distinguish between normal and abnormal implications of aging*

*These Learning Objectives support assignments that are assigned this week, but due in Week 4.

Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings

Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.

• • Chapter 5, “Assessment” (pp. 36-41)

This chapter reviews essential components of the comprehensive geriatric assessment, including physical, cognitive, psychologic, and social assessment. It also emphasizes other areas of importance, such as assessing quality of life and driving concerns.

Holroyd-Leduc, J., & Reddy, M. (Eds.). (2012). Evidence-based geriatric medicine: A practical clinical guide. Hoboken, NJ: Blackwell Publishing.

• • Chapter 1, “Function and Frailty: The Cornerstones of Geriatric Assessment” (pp. 1–12)

This chapter describes frailty and provides guidelines for assessing frailty in older adults. It also examines functional impairment in older adults and identifies functional assessment tools for treating and preventing functional decline in frail older adults.

Rosen, S., & Reuben, D. (2011). Geriatric assessment tools. The Mount Sinai Journal of Medicine, New York, 78(4), 489–497.

This article identifies common conditions that impact elderly patients. It also presents assessment tools that screen for geriatric syndromes, such as hearing impairment, vision impairment, functional decline, falls, urinary incontinence, cognitive impairment, depression, and malnutrition.

Optional Resources – NURS 6540: Week 2: Assessing Geriatric Patients 

Note: The following resource is highly recommended for addition to your professional library. You are encouraged to utilize this “pocket” text during your on-site practicum experiences.

Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2012). Geriatrics at your fingertips (14th ed.). New York, NY: American Geriatrics Society.

Discussion: Assessment Tools

As geriatric patients age, their health and functional stability may decline resulting in the inability to perform basic activities of daily living. In your role as the advanced practice nurse, you must assess whether the needs of these aging patients are being met. Comprehensive geriatric assessments are used to determine whether these patients have developed or are at risk of developing age-related changes that interfere with their functional status. Since the health status and living situation of geriatric patients often differ, there are a variety of assessment tools that can be used to evaluate wellness and functional ability.

For this Discussion, consider which assessment tools would be appropriate for the patients in the following three case studies:

Case Study 1

Mr. Smith, age 77, reports for an annual physical examination. He says he is doing well. His only known problem is osteoarthritis. He also requests a flu shot. He takes no medications other than Tylenol for arthritis pain. When he walks into the exam room, you notice that he is using a straight cane in his right hand. When you ask about the cane, he says he began using the cane because the pain in his right hip had increased significantly over the past 6 months.

Case Study 2

Mr. Jones, a 68-year-old man, was referred to your office for a hearing evaluation. He continues to work in a printing company, although he works only part-time. He has worked at the printing company for the past 35 years. He complains that he cannot hear much of the dialogue on the television. He is accompanied by his wife, who states that her husband cannot hear her at home. He has no history of dizziness, tinnitus, or vertigo. He has had cerumen impactions removed from both ears in the past. Overall, his medical history is quite benign. His only medications are aspirin 81 mg daily, a multivitamin daily, and occasional ibuprofen for back pain.

Case Study 3

Mrs. Roberts, an 83-year-old widow, is brought to the office by her daughter. The daughter claims that her mother seems to be depressed. There is a history of depression approximately five years ago, shortly after Mrs. Roberts’ husband died. At that time, she was successfully treated with antidepressants. Currently, the daughter states that her mother’s memory for appointments and events has declined severely, and she can no longer drive because she does not remember the route to the store or other familiar places. The daughter also noted that her mother’s house seemed very disorganized and dirty, there was a limited amount of food in the kitchen, and the checkbook had not been balanced for several months. Mrs. Roberts appears slightly disheveled, she has a flat affect, and she does not maintain eye contact during your interview.

To prepare:

• Review the Rosen and Reuben article in this week’s Learning Resources. Consider how assessment tools are used to evaluate patients.
• Select one of the three case studies. Based on the provided information, think about a possible patient evaluation plan. As part of your evaluation planning, consider where the evaluation would take place, whether any other professionals or family members should be present, appropriate assessment tools and guidelines, and any other relevant information you may wish to address.
• Consider whether the assessment tool you identified was validated for use with this specific patient population and if this poses issues. Think about additional factors that might present issues when performing assessments, such as language, education, prosthetics, missing limbs, etc.

By Day 3

Post an explanation of your evaluation plan for the patient in the case study you selected and explain which type of assessment tool you might use for the patient. Explain whether the assessment tool was validated for use with this patient’s specific patient population and whether this poses issues. Include additional factors that might present issues when performing assessments, such as language, education, prosthetics, missing limbs, etc.

Read a selection of your colleagues’ responses.

By Day 6

Respond to at least two of your colleagues on two different days in one or more of the ways listed below. Respond to colleagues who selected different case studies than you did.

• Suggest alternative assessment tools and explain why these tools might be appropriate for your colleagues’ patients.
• Recommend strategies for mitigating issues related to use of the assessment tools your colleagues discussed.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit! NURS 6540: Week 2: Assessing Geriatric Patients 

 

 

 

ADDITIONAL INFO 

Assessing Geriatric Patients

Introduction

If you’re an older person, your doctor may need to assess you for fall risk—and it’s important that you be prepared. The good news: there are some simple tools at your disposal that can help your doctor see where you might be at risk of falling. Here’s how to do an older person fall risk assessment and what information your doctor needs to know about your current health and lifestyle.

Review the patient’s medical history and current medications

The first step in assessing the patient is to review their medical history and current medications. This will help you see if there are any interactions between these drugs, or if they might cause problems. If a medication is no longer necessary, consider stopping it before continuing with your assessment of geriatric patients.

The second step is to ask questions about the patient’s lifestyle and activity level, as well as any other concerns that may be affecting their health status or quality of life (QOL). Some examples include:

• How frequently do they exercise? Is it more than once per week? Less than once per week? Do they have trouble walking up stairs without using an elevator? Is there anything else which limits physical activity levels such as arthritis pain or poor vision/cognitive abilities?

Practice an older person fall risk assessment.

In addition to the physical assessment, you should also conduct an older person fall risk assessment. This will help identify any medical conditions that may make them more likely to fall and ensure that medications are being used appropriately.

You can use this checklist:

• Does your patient have any problems with balance or gait?

• What medications is he taking?

• How long has he been taking it?

Obtain a family history

Obtain a family history of dementia, heart disease, cancer and osteoporosis.

Ask about any previous medical conditions that might increase the risk of dementia or other health problems.

Ask about high blood pressure (hypertension). If you have diabetes or stroke in your family history, these may also be reasons to monitor your patient for signs of cognitive decline.

Measure blood pressure in both arms and document which arm reads higher.

• Measure both arms and document which arm reads higher.

• If the systolic blood pressure is greater than 140 mmHg, refer to a doctor.

• If the diastolic blood pressure is greater than 90 mmHg, refer to a doctor.

Perform an eye exam, including vision, eyeglass prescription, cataract check, and intraocular pressure check.

Eye exams are performed to assess the general health of the eye, including vision, eyeglass prescription and cataract check.

• Look for signs of eye disease:

• Glaucoma is an optic nerve disease that can cause decreased vision or blindness. It may be present as early as middle age but usually develops later in life. Loss of peripheral vision is a common symptom and you should be aware if this patient has had any loss due to glaucoma at any time since they last visited you or went to the doctor’s office. If so, this would suggest treatment before it progresses further down his or her visual pathway.* Cataracts occur when there are changes in the lens of your eye (the clear part). This causes blurred vision even though you see well enough with no glasses on; however, once these changes occur they cannot be reversed without surgery.* Diabetes mellitus affects blood sugar levels over time leading up towards diabetic complications such as nerve damage among other things like kidney failure.* Macular degeneration occurs when there is loss of central vision caused by damage either directly through injury or indirectly when patients develop other conditions such as glaucoma which damages their peripheral retinaes first before affecting central vision later down line(s).

Assess for a hearing loss

To assess for hearing loss, you will need to do a hearing test. The patient should be asked to listen to one of the following sounds:

• Train horn (D+1)

• Trolley train (D+2)

• Siren (D+3)

The patient may also have their sound turned off for the duration of this test and then be asked if they can hear it again. If the person cannot hear any noise at all after being told what it is, they may have some degree of hearing loss.

Check sensation in the toes

The most common complaint of patients over the age of 60 is numbness in the toes. If you suspect numbness, check for circulation problems and diabetes. In addition to feeling a patient’s toes for sensation, you can also check their gait (walking) pattern; if they have trouble walking because of pain or weakness in one foot, this may be an indication that there is a nerve problem involved with their feet.

If you suspect that your patient has a vitamin deficiency—either due to diet or lack of sunlight exposure—you should ask them about taking supplements such as B12 or fish oil capsules before prescribing any medications that could interfere with absorption (such as antibiotics).

Check gait and balance

• Check for a wide base of support. A patient with Parkinson’s disease may have difficulty maintaining balance and stability, so you’ll want to look at how their feet land on the ground while they walk. Does the heel rise higher than the toes? Do they move in an exaggerated manner as they walk?

• Check for symmetry in gait. Patients with Parkinson’s disease often have an asymmetrical gait—that is, one foot takes longer than another to reach forward or back when walking—and this can cause them to fall more easily during daily activities such as getting dressed and taking a shower, according to National Institute on Aging research scientist Audrey Foutz-Haroian (1). When assessing balance with patients who have Parkinson’s disease, look for any abnormalities in their gait pattern and make sure that both feet are even before moving onto other tests (2).

How do you assess older people? Our expert has some suggestions for you.

It is important to assess older people, as they have different needs than younger people. Older adults may be at risk of falls and it’s important to check their balance.

If you are assessing an older patient, it is important that you take into account their physical condition and mental health status before conducting your assessment. The following checklist can help you determine whether or not an older person might need any additional support:

• Do they have poor eyesight? If so, what type of glasses do they need?

• Are they having difficulty walking up stairs or getting around inside their home due to joint pain/discomfort (arthritis)? Is there any loss in mobility due low stamina/energy levels caused by chronic illness such as diabetes mellitus (DMT)?

Conclusion

With a little preparation, you’ll be able to assess geriatric patients well in advance. You can also use this checklist for your next checkup at the doctor’s office. In the meantime, if you have any questions about assessing elderly people or other topics related to living with old age, please let us know!