NEUROLOGIC DISEASES: COGNITIVE DETERIORATION AND DEMENTIA.

Minor cognitive alteration: intellectual decrease of clinical appearance but there isn’t functional incapacity. If would be this last, it will denominate dementia.

DETERIORATION COGNITIVE EVALUATION

  

• Memory: it loss the work memory, episodic and free memory.
• Language: it loss the denomination and decreased the verbal fluency.
• Decreased the reasoning, capacity to resolve problems and the velocity to process the information.
• It preserves the attention.
• Neurologic evaluation: level of attention, orientation, collaboration, senses, muscle tone, trembling or other moves.
•  Delirium: significant fluctuations in mental status, and changes in the level of attention and level of consciousness.
• Risk factors:

•  Serious disease, depression, alcohol, dehydration, malnutrition.
•  Iatrogenic, physical restriction, use of urinary catheter.

• Depression: adversely affects cognitive functions, and can be confused with dementia. Patients with depression tend to have more subjective complaints of memory loss, often have psychomotor retardation and poor motivation in conducting the test.
• Dementia: is a syndrome that has to be understood as a decline of cognitive function

RATING SACLES:

1. Mini Mental State Examination of Folstein (MMSE)
2. Memory Impairment Screen (MIS)
3. Test seven minutes

ALZHEIMER

It is a progressive brain disorder characterized by degenerative changes of cortical nerve cells and brain nerve endings. This process produces an irreversible impairment of memory and intellectual functions destruction.

The background cause is unknown.

It is characterized by loss of memory, deterioration of intellectual and personality change.

It is classified into three stages:

First state:

• Memory: loss of memory, difficulty to remember nouns or words, loss in family ways…
• Language: decrease of communication, reduction in vocabulary, without facial expression, to say impertinences…
• Behaviour and mood: change of mood, depression, facility to distraction, necessity to look for people or places families…
• Coordination: slowing – down of reaction time, incapacity to drive.

Second state:

• Memory: unknowing about all the recent events.
• Language: repeat the same words and phrases, to speak slowly, decrease demonstration of affection, shaking, hallucination, dream alteration.
• Coordination: loss of coordination and equilibrium, difficulty to walk and write.
• Own care: necessity of help to wash, choose the cloth, fecal and urinary incontinence.

Final state:

• Memory and language: incapacity to learn new concepts, loss of memory of recent and past events, reduction of vocabulary, incapacity to read and comprehension and repeat words or phrases.
• Behaviour and mood: frequently shaking, incapacity to remember the career, difficulty to walk, write, sit down, smile or swallow.
• Own care: necessity to most help to realize the daily activities life.

It is essential that nurses remain clam when confused individuals act out. It is not easy for nurses to deal with repeated irritating or hostile behaviours, but they must remember that anger, arguments, and explanations only confuse the person and make the situation worse. Even if nurses do not say anything negative to the person, body language may communicate a lack of acceptance.

1. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

IMMOBILITY

The immobility can be defined as the decreased of the  ability to perform activities of daily living by deterioration of motor functions.

It is a geriatric problem characterized by a reduction in exercise tolerance, progressive muscle weakness and, in extreme cases, loss of automatisms and postural reflexes which prevent wandering.

• A relative immobility, in which the old man leads a sedentary life but is able to move with more or less independence
• A total immobility involving chronic bed rest, being very limited postural variability.

CAUSES OF THE INMMOBILITY

Physiological:

• Decrease of mass and strength muscular, senile march
• Decrease of sensibility and reflex
• Decrease of cardiac frequency, aerobic capacity
• Decrease of elasticity of thoracic wall

Usual diseases:

• Osteoarthritis, arthritis, fractures…
• Brain damage, Parkinson, dementias…
• Cardiac insuffiency
• Visual deficits
• Depression
• Diabetes mellitus

Environmental causes:

• Obstacles

Social factors:

• Loneliness 

Rehabilitative potential and the monitoring result can be performed by the Barthel index.

GENERAL CARE OF DISABLED PATIENTS

Prevention of skin problems:

• Postural changes
• Hygiene
• Massages
• Padded
• Supply of liquids and foods

AUXILIARY ELEMENTS FOR MOBILIZATION

• Walking stick
• Crutches
• Walker

HOME ADAPTATIONS

• Stairs: reduce height
• Doors, to open easily
• Furniture: space
• Adjust the height of the bed

The best preventive measure is to keep the degree of mobility.

The elder who wears a type of autonomous and active life with regular performance of exercise has statistically decreased risk of mortality.

Scientific evidence increasingly indicates that regular physical activity can extend years of active independent life, reduce disability, and improve the quality of life for older persons.

In my opinion we must promotion the activity in the elderly to maintain the independence. We must explain to de elder the importance of realise exercise.

Nurses should educate older person about the importance of exercise and emphasize the benefits such as weight loss, prevent obesity, prevent or reduce depression, retain mobility, maintain or improve musculoskeletal function, improve appetite, encourage sleep…

We must motivate to the patients and show them different ways to do exercise. 

1. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

PRESURE ULCERS 

Pressure ulcers  can be defined as any damage to the area of skin and underlying tissue caused by the prolonged pressure on a hard plane, not necessarily intense, and independent of position.
Prevention is a priority mainly based on methods that quantify risk factors that help predict tissue involvement because 95% of ulcers are preventable.


RISK FACTORS

Pathophysiological

• Skin lesions
• Oxygen transport disorders
• Nutritional deficits
• Immunological disorders
• Disturbances of consciousness
• Motor deficit
• Sensory deficit
• Removal altercations

Derivatives of treatment:

• Immobility imposed by treatment
• Immunosuppressive treatment: radiotherapy, chemotherapy
• Drilling for diagnostic or treatment

Situational

• Poor hygiene
• Wrinkling
• Rubbing objects
• Immobility by pain, fatigue

Environment

• Lack or misuse prevention material
• Professional motivation due to lack of training and / or specific information
• Work overload
• Lack of uniform criteria in planning cures
• Lack of health education for caregivers and patients
• Deterioration of the image of the disease.

Neuropathic Ulcers:

• Presence of distal pulses.
• Small injuries.
• Cellulites, abscess.
• Rapid progression, painless.
• Location: digital support areas
• Joints metatarsicafalángicas 
• Plantar area

Venous Ulcers:

• Hyperpigmentation
• Appear from the distal malleolus to the distal third of calf
• Can develop rapidly
• Shallow, irregular edges and bleeding, oozing plentiful
• Pigmented dermatitis around.
• Lipodermatosclerosis
• Distal pulses +

Arterial ulcers

• Develop much in the fingers
• Shallow
• Related to diabetes
• Weak distal pulses
• They tend to hurt more
• Deep, neurotic little granulation, exuding no sharp edges.

I think that the best for the pressure ulcer is the prevention. We must to explain to the patient how prevent it. The skin must be clean and there are very important the postural changes. a good nutrition is necessary too.

The job of the nurses is very important in these patients because we must do a lot of palliative treatment.

We must explain the risk factors to the patient for prevent if it is possible.

I think that our job is necessary to prevent the infection, pain, the loss of function, and even death.

1. Martínez Cuervo F., Pareras Galofré E.. La efectividad de los ácidos grasos hiperoxigenados en el cuidado de la piel perilesional, la prevención de las úlceras por presión, vasculares y de pie diabético. Gerokomos  [revista en la Internet]. 2009  Mar [citado  2013  Abr  28] ;  20(1): 41-46. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1134-928X2009000100006&lng=es.  http://dx.doi.org/10.4321/S1134-928X2009000100006.
2. Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012
3. Medeiros Adriana Bessa Fernandes, Lopes Consuelo Helena Aires de Freitas, Jorge Maria Salete Bessa. Análise da prevenção e tratamento das úlceras por pressão propostos por enfermeiros. Rev. esc. enferm. USP  [serial on the Internet]. 2009  Mar [cited  2013  Apr  28] ;  43(1): 223-228. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0080-62342009000100029&lng=en.  http://dx.doi.org/10.1590/S0080-62342009000100029.

GERIATRIC SINDROMES

INTRODUCTION

Clearly there are a few diseases that affect only persons recognized as elders, even many of them appear in preceding ages 65. What is certain is that there is a higher incidence of these processes at certain ages and especially the consequences that any of them can be in this group.

GENERAL ASPECT OF DISEASES IN THE ELDERLY

In geriatric disease processes, symptoms does not appear clearly as we have seen. However there are a number of recurring symptoms in various diseases, although not known for being itself and / or specifies the population.

PAIN 

Pain is a manifestation linked to different situations. Chronicity is common and that is why many people have adapted to their way of life by minimizing its valuation.

Pain is a subjective perception. It is what the person tells you it is. Everyone experiences pain in a unique way.

We must believe to the patient and no underestimate him because we must take away the pain.

Nurses can neither see pain nor measure pain with a meter, but the ca detectc its presence by careful listening and observation.

Response to pain differs from person to person.

Assessment of pain: 

• Onset of pain
• Pain perception
• Pain response
• Pain threshold
• Stimulus onset
• Pain Tolerance
• Amount and duration of pain.
• Location
• Intensity
• Duration
• Quality
• History
• Facial expression
• Body mobilization

I think that the nurses must provide comfort to the patients, avoid actions that increase pain, administer medication as ordered…

URINARY AND DIGESTIVE PROBLEMS

To function properly, the body must be able to rid itself of waste products effectively, the two major systems involved in waste elimination are the urinary system and the gastrointestinal system.

We must assess patterns of elimination and causative factors.

FATIGUE OR WEAKENESS

TREMOR

SENIL PRURITUS

MENTAL DISORDERS

PRINCIPAL RISK FACTORS:

Organic's origin:

• Hypertension
• Malnutrition
• Sensory difficulties
• Incontinence

Environmental's origin:

• Architectural barriers
• Poor economic
• Inactivity
• Polypharmacy
• Alcoholism
• Changes in the environment

Relational risk:

• Loneliness / isolation
• Insomnia
• Disorientation

We must control this risk to help the elders. We must to do information about this risk and teach them how prevente it.

In nursing consultation we must hep with the organic risk. We must control the hypertension for example.

Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

GERIATRIC NURSING CARE

VALUATION

We can set the value directly or indirectly.

• Direct: patient, family, friends, community
• Indirect: Clinical history, archives, bibliography

This will make it through:

• Interview
• Observation
• Physical exam

To develop nursing history which allows us to identify the needs and problems.

“I think that is very important to observe and listen to the patient carefully. All the information is necessary to make a good care plan with easy objectives. If you set impossible objectives the patient could be discourage”.

PLANNING

The care plan contains objectives, expected changes of the patient and nurse activities and collaboration of the health team.

Use the assessment data and diagnostic statements to develop a care plan.

IMPLEMENTATION

They put in place the strategies listed in the plan of care to achieve the objectives.

EVALUATION

Needs in geriatric patients. Virginia Henderson:

GLOBAL GERIATRIC ASSESSMENT

Health assessment of older adults can be done on several levels, ranging from simple screenings to complex, in-depth evaluations. To perform assessments accurately, nurses and other health care providers who gather information regarding older adults must possess the necessary knowledge and skill to perform the assessment correctly.

PHYSICAL ASSESSMENT

Before starting a physical assessment, the nurse will use interviewing techniques to obtain a health history.

Obtain the health history:

In the elderly, there are factors that hinder the clinical interview and make it more difficult

The nurse must be aware of these limitations:

• Communication
• Vague description of symptoms
• Multiple complaints

Identifying data:

• Name
• Date of birth
• Residence
• Marital/significant other status
• Previous and/ or current occupation

Past history:

• Perfection of general health
• Frequency of medical and dental care, including screenings
• Immunizations
• History of serious illnesses
• Hospitalizations
• Surgeries

Present medical history:

• Major current problems or concerns
• Symptoms
• Date of onset
• Medications currently taken

Family and psychosocial history:

• Living family members and nature relationships
• Friends and social activity practices
• Hobbies and interests

Mini Nutricional Assessment

Inspection: is the most commonly used method of physical assessment in with the senses of vision, smell and hearing are used to collect data.

Palpation uses the sense of touch in the fingers and hands to obtain data. Is used for evaluation pulses, temperature and texture of the skin…

Auscultation

Percusision

Assessing vital signs: temperature, pulse, respiration, blood pressure..

Body systems approach to physical assessment:

• Skin: colour, pigment, temperature, lesions, edema
• Nails: shape, color, thickness
• Hair: color and texture, distribution
• Skull, face and neck
• Eyes: check size of pupils
• Ears
• Respiration: shape of torax, spinal curvatures, rate and ryth, of respiration
• Cardiovascular
• Gastrointestinal
• Musculoskeletal
• Neurologyc
• Genitourinary

VALUATION OF FUNCTIONAL AREA

When progresses the degree of functional impairment increases:

• The number of hospital admissions and length of stay
• Medical visits
• The consumption of drugs
• The risk of institutionalization
• Social resource requirements

Scales used to assess AVDB:

• Index of Activities of Daily Living (Katz):
• Barthel Index
• Physical Disability Scale of Red Cross
• Plutchik Scale

Scales used to assess AVDI:

• Lawton and Brody index

When exploring the cognitive sphere, we must question about:

• School-level, profession
• Presence of cardiovascular risk factors (hypertension, diabetes, atrial fibrillation)
• Family history of dementia
• Psychiatric background
• Consumption of drugs and toxic
• Complaint, a start and progression of symptoms
• Guidance
• Complaints of memory impairment
• Problems in recognition of family and friends.
• Language
• Capacity for abstraction / trial
• Conduct disorders

SHORT PORTABLE MENTAL STATUS DE PFEIFFER (SPMSQ)

MINI-MENTAL STATE EXAMINATIO DE FOLSTEIN (MMSE)

The anxiety and depression, major affective symptoms in old age and is an emotional state of uneasiness and apprehension disproportionate to the stimulus that triggers it. It has an impact on life quality, performance on cognitive functions, exacerbates depressive and physical discomfort.

To assess the affective sphere, we have:

• Scale of Yesavage Geriatric Depression
• Hamilton Depression Inventory
• Beck Depression Inventory
• Scale of Zung
• Cornell Scale of Depression in Dementia
• Anxiety and Depression Scale of Goldberg

I think we should pay attention to the patient since the moment he coming in.

Communication with the patient must be clear and we must speak loud for he listen us well.

A good global assessment is important to detect problems quickly.

Gloria Hoffmann Wold. Basic Geriatric Nursing. 5^th ed. Milwaukee, Wisconsin:Elsevier; 2012

THEORIES OF AGING

There is no single universally accepted definition of aging. Aging is series of changes that occur over time, contribute to loss of function and ultimately result in the death of a living organism.

BIOLOGIC THEORIES

Biologic theories of aging attempt to explain why the physical changes of aging occur. Researcher try to identify which biologic factors have the greatest influence or longevity.

1. The programmed theory: in this theory each individual has a genetic program specifying an unknown but predetermined number of cells divisions.
2. The rut-out-program theory: proposes that every person has a limited amount of genetic material that will run out over a time.
3. The living theory: this proposes that individuals have a finite numbers of breaths or hearts beats that are used up over a time.
4. The gen theory: proposes that the existence of one or more harmful genes that activate over the time resulting in the typical changes seen with aging and limiting the life span of the individual.
5. The molecular theories: propose that aging is controlled by genetic materials that are encoded to predetermine growth and decline.
6. The error theory: proposes that error in ribonucleic acid, protein synthesis cause errors to occur in cells in the body, resulting in a progressive decline in biologic function.
7. The somatic mutations theory: is similar bus proposes that aging result from deoxyribonucleic acid (DNA) damage causes by exposure to chemical or radiation and that this damage causes chromosomal abnormalities that lead to disease or loss function later in life.
8. The free radical theory: excessive accumulation of free radicals in the body is purported to cause or contribute to the physiologic changes of aging and a variety of diseases.
9. The cross line: also called connective tissue theory: is one variation of the free radical theory.
10. The clinker theory: combines somatic mutation, free radicals, and crosslink theories to suggest that chemicals produced by metabolism accumulate in normal cells and cause damage to body organs such as the muscles, heart, nerves and brain.
11. The neuroendrocrine theory: focuses on the complicated of chemical interactions set off by the hypothalamus in the brain.
12. The immunologic theory: the neurologic theory proposes that aging is a function of changes in the immune system. According to this theory, the immune system weakens over the time making an aging persona more susceptible to disease.

PSYCHOSOCIAL THEORIES

Psychosocial theories of aging do not explain why the physical changes of aging.

1. The disengagement theory: This theory proposed that older people are systematically separated, excluded or disengaged from society because that are not perceived to be benefit to the society as a whole. This theory further proposes that older adults desire to withdraw from society as the age, so the disengagement is mutually beneficial.
2. The activity theory: that activity theory proposes that activity is necessary to successful aging.
3. Life course theories: are perhaps the theories best known to nursing. These trace personality and personal adjustment throughout a person’s life..

• Erikson’s theory identifies 8 stages of developmental tasks than an individual must confront throughout the life span: 1. Trust versus mistrusts. 2. Autonomy versus shame and doubt. 3. Initiative versus guilt. 4. Industry versus inferiority. 5. Identify versus identity confusion. 6. Intimacy versus isolation. 7. Generativity versus stagnation. 8. Integrity versus despair.
• Havighurt’s Theory: details the process of aging and defines specific tasks for late life, including:
• Adjusting to decreased physical strength and health.
• Adjusting to retirement and decreased income.
• Adjusting to the loss of a spouse.
• Establishing relationship with one’s age group.
• Adapting to social roles in a flexible way.
• Establishing satisfactory living arrangements.
• Jung’s theory: proposes that development continues trhougt life by a process of searching, questioning and setting goals that are consistent with the individuals personality.

Céspedes Miranda Ela, Rodríguez Capote Karina, Llópiz Janer Niurka, Cruz Martí Niurys. Un acercamiento a la teoría de los radicales libres y el estrés oxidativo en el envejecimiento. Rev Cubana Invest Bioméd  [revista en la Internet]. 2000  Dic [citado  2013  Abr  08] ;  19(3): 186-190. Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-03002000000300007&lng=es.

PHYSIOLOGIC CHANGES. THE AGEING.

Health: state of complete physical mental and social well-being and not merely the absence of disease, or infirmity.

The ageing process represents the universal biological changes that occur with age and care unaffected by disease and environmental influences. Not all of these age- related changes have adverse clinical impacts.

The process of ageing is strongly influenced by the effects of environmental, lifestyle and disease states that in turn, are related to or change with ageing but are not due to ageing itself. Often what was once thought to be a consequence of normal ageing is now more appropriated.

1. It’s a normal process.
2. It occurs in all human beings.
3. It starts as soon as we are born.
4. It becomes more noticeable in our final years.
5. It restricts our adaptability and reaction time.
6. It’s not a standardized process.
7. It’s different from one species to another. Each species has its own time limit.
8. It’s different from one man to another.
9. Not all organs of a human being get old at the same time.

There are some biologic changes. The goal is identify anatomical and physiological changes, which are attributed to the normal aging process. There are changes in:

• The integumentary system: the epidermis becomes more fragile
• The musculosketal system
• The respiratory system
• The cardiovascular system
• The hematopoietic and lymphatic systems
• The gastrointestinal system
• The urinary system
• The nervous system

Psychic changes:

• Changes in intellectual capacity: The capacity to resolve problems becomes slower and there is a lack of spontaneity in one’s thought processes.
• Character and personality: personality does not usually change unless there are pathological alterations. The ability to adapt usually becomes harder due to the fear of unknown situations.

Social changes:

• Change of rol and personality
• Change of rol in the community
• Change of rol at work

“If you want to make of aging a positive experience, longer life must be accompanied by continuing opportunities for autonomy and health, productivity and protection”.¹

1. Llanes Betancourt Caridad. Evaluación funcional y anciano frágil. Rev Cubana Enfermer  [revista en la Internet]. 2008  Jun [citado  2013  Abr  04] ;  24(2): Disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0864-03192008000200005&lng=es.

2. Hidalgo González J.G. El Envejecimiento: Aspectos Sociales. 1ª ed. Costa Rica. Ed de la Universidad de Costa Rica. 2001.

INTRODUCTION

Gerontology: is the science that studies the aging process in general as well as biological, psychological and social changes that occur in the elderly.

Geriatrics: is the branch of medicine that studies the acute and chronic diseases in older patients in both its clinical, therapeutic, preventive and social.

Principles of Geriatrics:

• Take care, not cure. Provide comfort and independence
• Essence: comprehensive geriatric assessment
• Know when to treat or cure. Make effective palliative treatment
• No over treated for mild conditions or sub-contract serious condition
• Rehabilitate.
• The family is crucial to good geriatric care
• The old man can be educated
• Search for undiagnosed illnesses
• Be alert for atypical presentations of disease
• Depression: the great masked geriatrics
• Never underestimate the morbid impact of vision and hearing loss
• Always try and prevent more disability 

“Caring involves a conscious and intentional responsibility for the nurse. It is a moral ideal that requires sensitivity and a high ethical and moral commitment”.¹

Geriatrics Goals:

- Prevent the elderly becomes a social burden or chronically ill (independence)

- Improve the quality of life rather than prolong

“Adding years to life and health to life, life to years”

Different situations of old age:

-         Healthy elderly person

-         Elderly person sick

-         Frail elderly

-         Patient Geriatric Presents 3 or more of the following criteria:

o       Over 75 years old.

o       Significant comorbidity.

o       Principal disabling disease.

o       Mental pathology.

o       Social problems regarding his health.

I think that thanks to geriatric nursing elders have higher level of wellness and get an increase in life expectancy.

1. Abades Porcel Mercedes. Los cuidados enfermeros en los centros geriátricos según el modelo de Watson. Gerokomos  [revista en la Internet]. 2007  Dic [citado  2013  Abr  04];  18(4): 18-22. Disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1134-928X2007000400003&lng=es.  http://dx.doi.org/10.4321/S1134-928X2007000400003.