NR601/ NR 601 Final Exam Review Solution Guide (A+ solution guide 2021)

Glucose metabolism disorders Types of DM 1. Type 1- insulin deficiency. Subjective findings- polyuria, polydipsia, and polyphagia. Objective- dehydration. 2. Type 2- Type 2 DM is characterized by the abnormal secretion of insulin, resistance to the action of insulin in the target tissues, and/or an inadequate response at the level of the insulin receptor. A patient may, however, present with pruritus, fatigue, neuropathic complaints such as numbness and tingling, or blurred vision. • Diagnostic criteria- AIC of 6.5 or higher, symptoms of diabetes plus random glucose of 200 mg/dL or higher, fasting glucose of 126 or higher, and 2 hour plasma glucose level of 200 mg/dL. A1C, fasting, and plasma should be repeated. Diagnosis of type 2 diabetes mellitus: two fasting blood glucoses ≥126 mg/dL or two random blood glucoses ≥200 mg/dL. • Initial Treatment- The initial goal of treatment for type 1 DM is to normalize the elevated blood glucose level. This is best accomplished by intensive insulin regimens to achieve the following goals: plasma glucose levels of 80 to 130 mg/dL before meals, peak postprandial (1–2 hours after the beginning of a meal) glucose levels of less than 180 mg/dL, and an A1C below 7% for adults with type 1 DM. Type 2-Pharmacological therapy for type 2 DM is required when lifestyle management does not result in adequate blood glucose control. Drug therapy should always be considered an adjunctive therapy to lifestyle management, as the latter is typically initiated first. The ADA and AACE recommend metformin if there are no contraindications, such as renal disease or abnormal creatinine clearance, acute myocardial infarction, or septicemia. The AACE recommends adding a second agent to lifestyle treatment and metformin if the A1C is more than 7.5% at the time of diagnosis or after 3 months of monotherapy without achievement of the patient’s blood glucose goals. Metformin can be used as a monotherapy unless the patient has contraindications or intolerance. Although metformin is the first-line medication recommended by the ADA and the AACE for DM type 2, it should be used only in patients with adequate renal function and should not be used in patients with an eGFR below 45 mL/min/1.73 m2. Metformin also has a boxed warning in its FDA-approved prescribing information for lactic acidosis, although this side effect is very rare. Metformin should be discontinued 24 to 48 hours before diagnostic and surgical procedures due to the risk of decreased kidney function, and its administration should not be resumed for at least 6 hours after these procedures or until the patient is adequately hydrated. Initial dosing is 500 mg once a day with breakfast or dinner for 1 week, then twice daily with breakfast and dinner. Several weeks of therapy may be needed to achieve maximum effects of the given dose. Common adverse reactions include diarrhea, nausea, anorexia, and abdominal discomfort, which usually resolve with a gradual increase of dosage. Metformin has been shown to cause decreased vitamin B12 absorption, and patients on long-term metformin therapy should undergo periodic testing for B12 deficiency, especially if the patient complains of peripheral neuropathy. At the maximum dose, the monthly cost of metformin in the United States is approximately $4 on many generic formularies. Metformin is currently found in 20 combination formulations with other medications. • Immediately upon diagnosis of type 2 DM, begin lifestyle therapy with medically assisted obesity treatment. • If glycemic goals are still not met 3 months later, begin single-agent or dual therapy with oral antidiabetic agents, depending on whether A1C is less than or greater than 7.5%. • If glycemic goals are not met in 3 months, initiate triple therapy. • If after 3 additional months (or at the time of diagnosis) A1C is 9.0% or higher and the patient is symptomatic, add insulin therapy. • Treatment goals for older adults (Kennedy table 14-2). Healthy (few chronic illnesses) A1C 7.5, Fasting glucose 90-130, Bedtime 90-150, BP 140/90, statins Complex (multiple chronic illnesses, ADL impairment, cognitive impairment) A1C 8.0%, fasting 90- 150, bedtime 100-180, BP same as above Very complex (LTC or end stage illnesses) A1C 8.5%, fasting 100-180, bedtime 110-200, BP 150/90 Risk factors- Diabetes Mellitus Type 2 Family history (first-degree relative) Body mass index 25 kg/m2 (lower for Asian Americans) Age 45 years Impaired fasting glucose or A1C 5.7% History of gestational diabetes Hypertension ( 140/90 mm Hg or on antihypertensive therapy) Hyperlipidemia (high-density lipoprotein 35 mg/dL, triglycerides 250 mg/dL) Women with polycystic ovarian syndrome Race/Ethnicity • African American • Latino • Native American • Asian American • Pacific Islander Complications: DKA, recurring fasting hyperglycemia of greater than 300 mg/dL, Hb A1c of greater than 13%, or severe hypoglycemia with changes in sensorium, altered behavior, seizures, or coma. Complications resulting from prolonged hyperglycemia include renal failure, blindness, coronary artery disease, stroke, peripheral vascular disease, slow- healing wounds, autonomic neuropathies, hypertension, sexual problems, and genitourinary system disorders. Macrovascular complications from diabetes substantially increase the risk of morbidity and death from coronary artery disease, stroke, and peripheral vascular disease. Complications may result from either type 1 or type 2 diabetes. Evidence indicates that the degree of severity with respect to microvascular, neuropathic, and possibly macrovascular complications seems to be related to the number of years a patient has had hyperglycemia and the magnitude of the glucose elevation. Treatment for complications: evaluate response, tolerability to therapy, goal reassessment, and management of acute and chronic complications. Response to treatment is judged based on home glucose monitoring results and Hb A1c. The Hb A1c reflects the average control over the past 3 months and is not useful for judging the response to recent treatment adjustments. Older patients and patients on insulin therapy may need to be seen every 3 months. When there is a sudden change in health status or treatment regimen, follow-up of 1 month or less may be indicated. For stable patients who can maintain treatment goals, follow-up may be every 3 to 6 months. The following evaluations are recommended at follow-up visits: BP, BS logs, review meds, check feet, ask about annual eye exam including dilation, routine UA for albuminuria , albumin to creatinine ratio, serum creatinine levels and eGFR, annual electrocardiogram and fasting lipid profile, Hb A1c q 3 to 6 months, evaluation for neurovascular complications, self-management education, immunization update including influenza and pneumococcal vaccines, and a biannual oral examination. A special nutritional benefit is available for diabetics from Medicare and should be taken advantage of yearly. Medicare also covers the yearly ophthalmological examination for diabetics. • A patient with Type 2 diabetes comes to the clinic after reading a magazine article about metformin and has some concerns about taking metformin. Which condition listed below would be a contraindication to taking metformin? Which of the following laboratory results meets criteria for diagnosis of diabetes? The nurse practitioner student is reviewing the lab results from an annual an annual exam. The CMP fasting glucose was 128 mg/dL. What is the nurse practitioner student's next action? Which diagnosis below refers to hyperglycemic state that does not meet criteria for a Type 2 diabetes diagnosis? Question 5 What are some of the signs and symptoms of hypoglycemia? Symptoms of hypoglycemia, which can present when blood glucose is 60 mg/dl. Brain function is impaired when glucose levels 50 mg/dl . Symptoms can vary but include sweating, tremulousness, dizziness, confusion, anxiety and palpitations. Headaches, fatigue, weakness, drowsiness, syncope, diplopia, blurred vision and personality changes are due to neurological changes. Seizure and coma can occur with severe cases. Dunphy p.935 Obesity • Comorbidities related to obesity- Obesity is defined as a BMI 30 with morbid obesity as a BMI 40. Overweight is defined as a BMI of 25 to 29. The obese patient is more likely to develop coronary artery disease, hypertension, and hyperlipidemia. There is an increased risk of developing type 2 diabetes mellitus, cerebrovascular disease, and CKD. The obese patient is more likely to develop obstructive sleep apnea, gallbladder disease, fatty liver disease, and osteoarthritis. BMI DEFINITION 18.5 Underweight 18.5–24.9 Normal 25.0–29.9 Overweight 30.0–34.9 Class I obesity 35.0–39.9 Class II obesity 40.0 Class III extreme obesity Urology and aging UTI risk factors, differences based on gender- A lower UTI occurs when the normally sterile environment of the urinary tract system is invaded by pathogenic bacteria. Women may present with urethritis and cystitis simultaneously. The most frequently reported symptoms in both men and women are dysuria, urinary frequency or urgency, nocturia, hematuria, low back or suprapubic pain, UI, and cloudy, foul-smelling urine. Infections of the lower urinary tract can occur in the urethra, bladder, and, in men, the prostate. Infection of the urethra (urethritis) and infection of the urinary bladder (cystitis) usually occur together. Women may be diagnosed with chronic inflammation of the bladder wall (interstitial cystitis [IC]. Infections can be acute, chronic, recurrent, complicated, or uncomplicated. Acute infections are characterized by the onset of UTI in a previously symptom-free individual. Infections can become chronic when unresolved after standard treatment is rendered. UTIs become chronic because of obstructions, antibiotic-resistant bacteria, or the presence of multiple strains of bacteria that are not susceptible to the antibiotic therapy prescribed. A UTI is considered recurrent when it occurs again within 2 weeks of the original infection. A complicated UTI is either an acute or chronic infection that is accompanied by factors that predispose a patient to the infection or make treatment more difficult, such as instrumentation (e.g., indwelling, suprapubic, or intermittent catheterization), underlying chronic disease, systemic symptoms, or pregnancy. An uncomplicated UTI is one that can be resolved without addressing such factors and is localized to the lower urinary tract. Empirical treatment of UTI in men (by definition, a complicated UTI) should be extended to at least 7 days. Nitrofurantoin and beta-lactams should be avoided. Treatment of UTI during pregnancy is especially important because an established link exists between premature delivery and UTI (especially pyelonephritis). Empirical therapy may include ampicillin 500 mg by mouth four times daily, nitrofurantoin (Macrobid, Macrodantin) 100 mg orally two times daily, cephalexin (Keflex) 500 mg orally two times daily, or sulfisoxazole (Sulfafurazole )1 g orally four times daily. Broader-spectrum regimens may include amoxicillin-clavulanate (Augmentin) 500 mg/125 mg orally two times daily or cefpodoxime (Vantin) 100 mg orally two times daily. Most clinicians will choose to treat UTI during pregnancy for 1 full week. Fluoroquinolones should be avoided, given concern for their effects on bone and cartilage formation in the developing fetus, and TMP-SMX should be avoided in the first and third trimesters of pregnancy. • UTI diagnostic criteria and when to treat- Diagnosis of lower UTI is made based on the subjective complaints of the patient and a clean-catch midstream urine sample showing the presence of bacteria, especially if more than 100,000 organisms/mL of the same morphology are present in a sample from a female patient. Traditionally, a bacterial concentration of at least 100,000 colony- forming units (CFUs)/mL on urine culture has been used to define UTI, but UTI may result from far lower bacterial loads. UTI is currently defined as a urine sample with greater than 100 organisms/mL in the presence of characteristic clinical symptoms. UTIs may be treated with empiric antibiotic therapy based on knowledge of the most common bacterial etiologies. However, urine culture and antibiotic sensitivity testing will aid in definitively identifying the infecting microorganism and the appropriate antibiotic therapy. Although the diagnosis of UTI is made both clinically and by urinalysis, generally urine culture and antibiotic sensitivities are indicated if complicated infection is suspected, atypical symptoms are present, or symptoms persist or recur within 1 month of the patient receiving a prior empirical course of antibiotic therapy or a new treatment regimen is desired. Treatment- UTI. Uncomplicated lower UTI may often be treated effectively with a short (3-days) course of trimethoprim-sulfamethoxazole (TMP-SMX) or a longer 10-day course of ampicillin. However, epidemiological surveillance has revealed increasing rates of resistance in E. coli isolates to ampicillin and sulfonamides, whereas only a small percentage of these isolates were resistant to nitrofurantoin (Macrodantin, Macrobid), which is known to concentrate in the urine. Thus, a 7-day course of nitrofurantoin should be used as an alternative in patients with documented sulfa drug allergy or in patients with previous antibiotic use within the past 3 months. Uncomplicated UTI- Bactrim DS BID x 3 days Nitrofurantoin 100 mg BID x 5-7 days (50-100 mg QID for active infection or once daily at bedtime to prevent infection. Sexuality and aging • STis • Age related changes GSM • Signs and symptoms • When to treat, common treatments Menopause It is defined as the final menstrual period (FMP) and is reached when there have been 12 consecutive months of amenorrhea. A diagnosis of menopause can be made based on a history of amenorrhea and the presence of menopause-associated symptoms in age-appropriate women. Several tests are appropriate for women presenting with amenorrhea. Initially, a quantitative beta–hCG test should be done. An elevated level could reflect intrauterine pregnancy, molar pregnancy, ectopic pregnancy, or even certain germ cell tumors. Serum FSH and LH levels may be checked and will be elevated in menopause. FSH levels between 10 to 25 IU/mL suggest relative ovarian resistance consistent with menopausal transition. FSH levels of greater than 40 IU/mL are consistent with complete cessation of ovarian function. LH levels are a less sensitive indicator of hormonal and ovarian function. While they do rise during the menopausal transition, they may also be elevated during the midcycle surge and in cases of chronic anovulation. Women younger than 40 years presenting with amenorrhea and menopausal symptoms may be given a progesterone challenge test, in which medroxyprogesterone acetate 10 mg is given daily for 5 days and the induction of uterine bleeding is monitored in the week after treatment. If no bleeding occurs, a measurement of a serum estradiol may be helpful. Normal estradiol levels range between 40 and 300 pg/mL. A level greater than 30 pg/mL may indicate some degree of residual ovarian function. Levels less than 30 pg/mL indicate cessation of ovarian function. All women experiencing menopause earlier than 40 years will require additional testing to assess cause. Menopausal HT has been approved by the U.S. Food and Drug Administration (FDA) for the prevention of osteoporosis, relief of vasomotor symptoms, and the treatment of vulvovaginal atrophy associated with menopause. The NAMS position statement on HT recognizes HT as the most effective treatment for vasomotor symptoms and genitourinary symptoms of menopause. HT can also aid in the prevention of bone loss. For healthy menopausal women younger than 60 years and who are within 10 years of menopause, HT is a reasonable option for menopause symptom management. In healthy, young postmenopausal women taking combination HT for 5 years, the risk of adverse effects is low. Women without a uterus do not need to take progestin, and the risk of adverse effects remains low for 10 years. Which of the following symptoms is the most common subjective complaint of a woman presenting with an uncomplicated urinary tract infection? Question 2 How does the female anatomy make women more susceptible to UTIs? Question 3 Which of the following is a non-hormonal option for vasomotor symptoms? SSRI Women with moderate symptoms can receive benefit from SSRIs and SNRIS. SSRIS are also the only nonhormal option provided. Dunphy 719 Question 4 Menopause management is based on which of the following? symptom management Treatment of menopause symptoms is focused on symptom management. Treatments will vary based on presenting symptoms. Dunphy p. 719 The nurse practitioner considers which of the following when discussing causes of erectile dysfunction (ED) with a 70-year-old male? Erectile Dysfunction- Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is sufficient for satisfactory sexual performance. ED can also manifest as a lack of sexual desire or an inability to ejaculate. ED can result from many causes, including physiological, psychological, endocrinological, vascular, and neurologic etiologies. Neurologic Diseases • Anterior temporal lobe lesions • Disease of the spinal cord • Loss of sensory input (secondary to diabetes mellitus, polyneuropathies), tabes dorsales (disease of dorsal root ganglia) • Disease of nervi erigentes (secondary to complete prostatectomy, retrosigmoid operations, aortic bypass) Vascular Disease • Leriche syndrome Endocrine Disorders • Testicular failure (primary or secondary) • Hyperprolactinemia Penile Disorders • Failure of detumescence • Priapism • Penile trauma • Peyronie’s disease Medications • Phenothiazines • Thioridazine • Imipramine • Methyldopa • Guanethidine • Reserpine • Spironolactone • Alcohol • Heroin • Methadone • Estrogen • Beta blockers • Thiazide diuretics • Antihypertensives Diagnosis- A physical examination, including a thorough genital examination to rule out any abnormalities of the penis itself, is critical. The testes should be palpated for size or abnormal masses. If their length is less than 4 cm, hypogonadism should be considered. Evidence of feminization such as gynecomastia and abnormal body hair distribution should be assessed. All pulses should be palpated, including the penile pulse, which can be felt by pressing both corpora between the thumb and forefinger and palpating to either side of the midline. If there is an indication of a vascular etiology from either the patient’s history or physical examination, an aortogram may be indicated. A neurologic examination to evaluate the erectile reflex, including anal sphincter tone, perineal sensation, and the bulbospongiosus reflex, should be part of the physical examination. The reflex can be evaluated by squeezing the glans penis and noting the degree of anal sphincter constriction. An examination for signs of peripheral neuropathy, including distal muscle weakness and loss of tendon reflexes in the legs, is important, along with tests that will reveal any impairment of vibratory, position, tactile, or pain sensation. nitially, laboratory tests that rule out the various causes of ED should be done. These tests include a fasting blood sugar to rule out diabetes mellitus, a lipid profile to rule out dyslipidemia, thyroid-stimulating hormone (TSH), and a testosterone level. If the testosterone level is below 300 ng/dL, a serum prolactin level is warranted. Laboratory tests for patients with established ED should include a complete blood count, a blood chemistry profile (including fasting glucose or glycosylated hemoglobin levels), a TSH level, and prostate-specific antigen (PSA) in men as young as 40 years if they have a family history of prostate cancer. Most men older than 55 years will have some abnormal laboratory findings or risk factors, but these may not necessarily be the cause of the ED. • • Treatment- Testosterone (Do not use in pt’s with liver, kidney, cardiac disease, prostate or breast cancer). Vasoactive therapy- Viagra Elder abuse- Tell-tale signs indicative of abuse may include bruises, broken bones, poor personal hygiene, abrupt changes in finances, sudden withdrawal in normal activities, unexplained weight loss, and excessive power or control by a close family member or friend. Department of Health and Human Services Administration on Aging states that the term elder abuse describes any knowing, intentional, or negligent act performed by a caregiver or another person that may cause harm or risk of harm to an older adult who is vulnerable. Types of abuse- Physical abuse: causing physical pain or injuring a vulnerable elder ■ Sexual abuse: sexual contact with a vulnerable elder without his or her consent ■ Neglect: failing to provide food, shelter, health care, or protection for a vulnerable elder ■ Exploitation: the taking of funds, property, or any assets of a vulnerable elder without legal consent and not for the benefit of the elder ■ Emotional abuse: using verbal or nonverbal means to cause mental pain, anguish, or distress in an elder ■ Abandonment: deserting the vulnerable elder once someone has assumed responsibility for that individual ■ Self-neglect: the elder fails to perform the needed activities to protect his or her own health and safety (lacks food/utilities, refuses medications, hoards, lives in unsafe conditions, neglects his or her grooming/appearance, is unable to handle finances, is isolated, is disoriented, develops a dependence on drugs and/or alcohol) • Provider responsibilities in suspected abuse- If elder abuse is suspected, it is the health-care professional’s responsibility—and in most cases his or her legal obligation—to report this to either 911 or the state elder abuse hotline (National Council on Child Abuse and Family Violence, 2015). Carefully collect information regarding the patient, using physical findings, patient’s functional abilities, testing results, and verbal information from the patient and his or her caregivers. Use the interdisciplinary team and speak with social workers, nursing staff, and others who may have interacted with the patient and caregiver. Document all findings, because they may be required to be presented in court later. Alzheimers- Alzheimer’s disease (AD) is a progressive, neurodegenerative condition and the most common form of dementia. Progressive cognitive decline; and an array of emotional and behavioral problems that result from cognitive decline. Impaired ability to learn new information or recall previously learned information and one or more additional cognitive disturbances in language (aphasia), function (apraxia), perception (agnosia), or executive function. Distinguishing features- The patient usually presents initially with complaints of memory problems. The clinician should take a focused history documenting signs and symptoms related to the dementia, chronology of the problem (including onset, duration, and stepwise vs. continuous progression), and family history. Other causes of cognitive impairment, such as medication side effects, thyroid disease, low levels of B12, depression, anxiety, and sleep issues, should be evaluated for and addressed. Advanced Assessment: Alzheimer’s Disease LEARNING AND MEMORY The patient becomes repetitive; has trouble remembering recent conversations, events, appointments; or frequently misplaces objects. These problems disrupt daily life. HANDLING COMPLEX TASKS The patient has trouble following a complex set of tasks that require many steps, such as organizing bills or following a recipe. REASONING ABILITY The patient is unable to respond with a reasonable plan to challenges at work or home, such as knowing what to do if the kitchen sink is plugged; shows poor judgment. SPATIAL RELATIONSHIPS The patient has trouble remembering directions or driving to what once was a familiar place, organizing objects around the house, unfamiliarity with familiar objects and places. SPEECH The patient has increasing difficulty with finding the words to express him or herself and following along with conversations. CHANGES IN BEHAVIOR The patient appears less social and responsive; is more irritable, depressed, anxious, and suspicious than usual. Diagnostics- Laboratory tests (complete blood count, electrolytes, blood glucose, serum calcium, thyroid- stimulating hormone level, and vitamin B12) may be used to rule out other conditions that impair brain function. Structural imaging should be used in the diagnostic evaluation of every patient suspected of dementia. Noncontrast computed tomography can be used to identify surgically treatable lesions and vascular disease. For increased sensitivity, magnetic resonance imaging (MRI) should be used. Management- Treatment with cholinesterase inhibitors should be considered at the time of diagnosis. Cholinesterase Inhibitors- Donepezil (Aricept) Galantamine (Reminyl) Rivastigmine (Exelon) (oral as well as patch) Galantamine (Razadyne). For mild to moderate AD Side effects include nausea, diarrhea, anorexia, and weight loss. Use with caution in patients with mild to moderate hepatic impairment. The failure to institute timely pharmacologic management in patients with AD may result in a more rapid need for institutionalization, an increase in aggression, further difficulty with ADLs, and further cognitive decline. Referral to a memory disorder center is usually warranted. Delirium -Delirium is a neurocognitive disorder that presents as a disturbance “in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). The onset of the disturbance is rapid (hours to days) and typically fluctuates over the course of the day. Cognitive changes (poor memory, disorientation, speech disturbance) and/or perceptual disturbances are distinct from a pre-existing, established, or evolving neurocognitive disorder (DSM-5 Criterion C and D). Delirium frequently represents a sudden and significant decline from a previous level of functioning, and there is usually evidence from the history, physical examination, or laboratory tests of a direct physiological etiology of a general medical condition, substance intoxication or withdrawal, use of a medication, toxin exposure, or a combination of these factors. The DSM-5 differentiates delirium into the following categories: 1. Substance intoxication delirium 2. Substance withdrawal delirium 3. Medication-induced delirium 4. Delirium due to another medical condition 5. Delirium due to multiple etiologies Delirium should also be specified as acute or persistent, as well as hyperactive, hypoactive, or mixed level activity. Etiology: Causes of delirium are numerous, and in older adult hospitalized patients there are often multiple etiologies: ■ Metabolic: renal failure, hepatic failure, anemia, hypoxia, hypoglycemia, thiamine deficiency, electrolyte abnormalities ■ Infection: meningitis, encephalitis, sepsis, urinary tract infection (UTI), respiratory infection ■ Cardiac: myocardial infarction, congestive heart failure, arrhythmia ■ Neurological: stroke, intracranial hemorrhage, head trauma, seizures, undiagnosed pain ■ Pulmonary: respiratory failure, COPD causing hypoxia ■ Sensory impairment: visual and/or hearing deficits ■ Medications: benzodiazepines, sedative-hypnotics, opioids, anticholinergics, antihypertensives, corticosteroids, lithium ■ Toxins: alcohol, amphetamines, cocaine, substance intoxication or withdrawal Distinguishing features- Signal Symptoms: Change in mental status, confusion, disorientation (time, place, and person), agitation. The clinical presentation may include confusion; difficulty sustaining and shifting attention; extreme distractibility; disorganized thinking; rambling, irrelevant, pressured, and incoherent speech; impaired reasoning ability and goal-directed behavior; disorientation to time and place; impairment of recent memory; misperceptions about the environment, including illusions and hallucinations; emotional instability; and psychomotor activity that fluctuates between agitation, purposeless movements, and a vegetative state. Disorientation to other persons occurs commonly. Dysarthria is a frequent speech and language disturbance, and dysnomia (impaired ability to name objects), dysgraphia (impaired ability to write), or aphasia may be observed. Commonly associated features of delirium include disturbances in the sleep–wake cycle, such as daytime sleepiness, nighttime agitation, and disturbances in sleep continuity. Diagnostic Tests: Laboratory work will assist in identifying potential causative factors, as will rating scales that measure cognition and establish diagnostic data such as the Confusion Assessment Method (CAM), the Delirium Rating Scale – Revised, or the Delirium Observation Screening Scale. Treatment: Appropriate treatment for delirium involves discovering the causes, many of which are reversible, and preventing complications through prompt treatment of specific, identified disorders. Nonpharmacological Interventions: A therapeutic environment would include frequent reassurance and reality orientation; clear communication; caregiver consistency; decreased stimuli (noise reduction, adequate lighting, sufficient time to perform tasks); decreased stress and anxiety through frequent reassurance and provision of a daily routine; comfort maintenance (eyeglasses, hearing aids, personal belongings); reestablishment of a sleep–wake cycle by controlling nighttime noise and unnecessary disruptions; guarantee of adequate daily fluid intake; assurance that elimination needs are met; provision of space and programs for physical activity, ambulation, and range of motion; and avoidance of chemical or physical restraint. Medication should be used as a last resort. Pharmacotherapy: Data support the use of first-generation (e.g., haloperidol) and second-generation (e.g., olanzapine, risperidone, ziprasidone, and quetiapine) antipsychotic medications to control behavioral symptoms of delirium and prevent injury to self or others. Antipsychotic medications have significant side effects, especially for older persons with dementia, and should be prescribed at the lowest effective dose and only 1 to 2 days or the shortest interval possible depending upon the setting, such as surgery or intensive care. Dementia- Dementia is defined as a clinical syndrome with global cognitive decline from a previous level of baseline function that interferes with activities of daily living (ADLs). Signal Symptoms: Cognitive changes including confusion, disorientation (as to time, place, person), and impaired short-term memory. Personality changes, psychiatric symptoms, problem behaviors, and changes in daily functioning. AD has a gradual onset, and the course of illness and progression is typically slow. STAGE ASSOCIATED SYMPTOMS Preclinical Impaired memory, excused or covered Insidious instrumental ADLs losses (money handling, bills) 2-4 years or longer Preserved basic ADLs Poor judgment and decisions Subtle personality changes Decreased spontaneity, sense of initiative Increased anxiety, socially normal Mild-moderate Obvious memory impairment Overt instrumental ADL impairment Basic ADLs failing Prominent behavioral difficulties Shortened attention span Language difficulty Variable social skills Supervision required 2-10 years Severe Memory fragments only No recognition of familiar people Assistance with basic ADLs required Fewer troublesome behaviors Reduced mobility Weight loss, infections Seizures, dysphagia Incontinence Groaning, moaning, grunting 1-2 years or longer Diagnostic and Screening Tests: Evidence-based studies support the following routine laboratory studies: CBC, electrolytes, glucose, blood urea nitrogen (BUN), creatinine, LFTs, TSH, serum B12, folate, syphilis serology, and urinalysis. A noncontrast CT scan will detect vascular insults (infarcts, stroke), and based on history and physical findings and clinical suspicion, an MRI may assist in ruling out medical/neurological processes and assist in differential diagnosis. Tests for early diagnosis of AD are in investigative stages and include a positron emission tomography (PET) scan and biological markers. Mental Status Examination and Cognitive Testing: A full mental status examination may uncover mood and neurovegetative symptoms that indicate treatable comorbid psychiatric conditions (e.g., depression, anxiety) that may contribute to cognitive difficulties. The Montreal Cognitive Assessment (MoCA) and the St. Louis University Mental Status Exam (SLUMS) are well-validated instruments that may be used in the assessment of dementia. The Clock Drawing Test (CDT) can be administered alone or within other cognitive screening instruments (e.g., SLUMS) and screens for AD and other types of dementia. Diagnosis: Definitive diagnosis of AD is only possible on autopsy and upon finding disease- specific pathology in the brain. As such, the diagnosis of AD is presumptive and based upon the following diagnostic criteria: Major or Mild Neurocognitive Disorder Due to AD DIAGNOSTIC CRITERIA A. The criteria are met for major or mild neurocognitive disorder. B. There is insidious onset and gradual progression of impairment in one or more cognitive domains (for major neurocognitive disorder, at least two domains must be impaired). C. Criteria are met for either probable or possible AD disease as follows: Pharmacotherapy: Cholinesterase inhibitors (ChEIs) are the cornerstone of pharmacological therapy, with the aim to enhance or preserve cognitive and behavioral status. The three commonly prescribed ChEIs are donepezil, rivastigmine, and galantamine. Common side effects of ChEIs are nausea, vomiting, dyspepsia, anorexia, diarrhea, insomnia, vivid dreams, fatigue, increased urination, and cramps. Uncommon side effects of ChEIs are syncope, bradycardia, confusion, depression, and agitation. Use cautiously in patients with liver or gastric disease, COPD, bradycardia, and inadequate supervision. Distinguishing features Question 1 According to the Alzheimer's disease reasoning algorithm, what is the next step for patients without impairment of multiple cognitive functions? Question 2 Which type of dementia has the highest incidence? Question 3 An elderly patient arrives with her daughter for an appointment. The mother reports the daughter will not provide assistance with her activities of daily living. As a result the mother has poor hygiene, has lost weight, and is not taking medications as prescribed. The nurse practitioner diagnoses the patient with which of the following? Question 4 Which neurological change presents with an acute change in mental status? Question 5 Which of the following presents with an insidious onset over months to years? Ethical issues and end of life care Older adults should be asked about their end-of-life (EOL) preparations at annual office visits, when entering the hospital, or when undergoing an outpatient procedure. • Living Will—A directive to health-care providers that communicates wishes for EOL medical care in case a person becomes unable to communicate them. Without documentation expressing those wishes, family members and healthcare providers are left to guess what the patient would prefer, which can often lead to family disputes. Each state has regulations and laws regarding living wills; health-care providers should know what the requirements are in the state they practice in. Barriers to end of life care- Hospice and palliative care services are poorly understood. Delayed access to hospice and palliative care services happens because people often don't understand the purpose and benefits. Primary care providers can be confused on when it's appropriate to consult palliative care. Because of this delay patients and families often do not reap the full benefits of a hospice and palliative care team. Denial of death often prevents many from accessing palliative care. Differences between palliative care and hospice- Hospice care provides care to patients at the end of life. Palliative care provides comfort care and a support system to both the family and patient, integrating the psychological and spiritual aspects of patient care, throughout the trajectory of illness, from the time of diagnosis until death, and encompasses end-of-life care. Both palliative care and hospice care provide supportive medical, social, emotional, and spiritual services to patients and their caregivers. Both services rely on the combined knowledge and skill of interdisciplinary teams of professionals. Advanced directives/Advanced care planning (ACP) Barriers to ACP- More than 25% of all adults have given no thought to their end-of-life wishes. The lack of preparation for end-of-life care and decision-making places a burden, not only on the family of the patient, but increases healthcare costs. Some of those barriers to end the life decision making include that patients don't want to think about or talk about the subject and that providers fear increasing patient or family anxiety. Durable power of attorney for healthcare- Durable Power of Attorney—this document enables older adults to appoint an agent, such as a trusted friend or relative, to handle health decision making. If the patient is no longer able to make decisions for themselves, such as in advanced Alzheimer’s disease or stroke or when a patient is comatose, the person listed as having durable power of attorney is someone who knows and understands the patients’ health and EOL wishes and is authorized to speak for the patient. POLST (physician orders for life-sustaining treatment)- This document is developed for patients with less than a year life expectancy. This document is not a living will or an advanced directive. This document outlines appropriate care for the patient, it is a set of orders that is to be followed by emergency workers. This document is important because emergency workers are not bound to follow a living well, but they are bound to follow orders outlined a POLST. Palliative Care: provides physical, psychosocial, and spiritual care through thorough assessment and the development of a comprehensive treatment plan. “Palliative” is defined as relieving pain without dealing with the cause of the condition. Palliative care focuses primarily on anticipating, preventing, diagnosing, and treating symptoms experienced by patients with a serious or life-threatening illness and helping patients and their families make medically important decisions. The goal of palliative care is “to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Eligibility criteria- Medicare reimbursement requires that a hospice patient has a life expectancy of 6 months or less. Many states now have an “open access” model that allows for patients seeking curative care to still receive hospice services. Services offered- This includes managing physical symptoms, psychological, social, and existential distress. Secondary, or specialty palliative care, provides the extra layer of support that's initiated in specific patient situations. These services include specialty care and management of complex patients. Patients can receive palliative care at any stage of their disease and often includes chronic conditions such as heart failure, chronic lung disease, and stage kidney disease and Alzheimer's disease. Length of eligibility- Palliative care can be involved at any stage of illness. Symptom management (Kennedy table 19-4) Hospice: care provides care to patients at the end of life. Palliative care provides comfort care and a support system to both the family and patient, integrating the psychological and spiritual aspects of patient care, throughout the trajectory of illness, from the time of diagnosis until death, and encompasses end-of-life care. Both palliative care and hospice care provide supportive medical, social, emotional, and spiritual services to patients and their caregivers. Both services rely on the combined knowledge and skill of interdisciplinary teams of professionals. Eligibility criteria- Services offered Length of eligibility- Hospice is a program of care designed for the last 6 months of a person’s life. Pain management options in palliative and hospice care Indications-most appropriate medications for each type of pain (Table 78.1) Onset of action Side effects