NURS 404_Thru Final

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1

For disaster preparedness, seniors should keep what types of items ready?

Extra wheelchair batteries

O2 & meds (including back-up refrigeration in emergency)

Catheters

Food for service animals

List of type & model # of medical devices required

2

In the event landlines & cell lines are overwhelmed during a disaster, this may be an alternative means of communication

Text message

3

Emergency preparedness includes the following steps:

Making a plan

Preparing an emergency kit (meds, extra essentials, copies of important documents & financial forms)

4

A STANDARD EMERGENCY KIT INCLUDES FOOD WATER AND MEDICINE TO SUSTAIN ALL MEMBERS OF YOUR HOUSEHOLD FOR HOW LONG?

At least 3 days

5

If unable to obtain an emergency supply of meds, a way to prevent running out of them is to do what?

Always fill Rx on first day you're able to

*Don't wait until you run out!

6

In addition to keeping important documents, such as birth certificates, in your emergency kit, you should also do what as an additional measure?

Back-up copies on a portable flash drive

7

Seniors who depend on mail for their SS benefits should do what to protect themselves?

Switch to electronic payments

8

In addition to the normal emergency kit, a kit for an Alzheimer's patient may also include:

Incontinence garments, wipes, lotion

Pillow, toy, or something to hold on to

Physician's name, address, #

Recent photos of the individual

9

Relocating an Alzheimer's patient during a disaster should involve these measures:

Make sure patient wears ID bracelet

Take Alzheimer's emergency kit

Pack familiar, comforting items - take household pet if possible

Try to find the quietest place possible

10

To minimize the hazard of being separated from an Alzheimer's patient, these measures can be taken:

Enroll person in MedicAlert + Alzheimer's Association Safe Return Program (ID program for people who may get lost)

Place labels on garments to aid in ID & keep article of person's clothing in bag to help dogs find him/her

ID neighbors that can help in crisis - include them in plan

Give trusted person house key & list of emergency #'s

Provide local police & services photos of person & copies of medical documents

11

Process of gradual, ongoing, yet highly variable changes in cognitive functions that occur as people get older

Lifelong

Not a disease or quantifiable level of function

Cognitive aging

12

In the context of aging, this is exemplified by an individual who maintains his or her optimal cognitive function with age

Cognitive health

13

T/F:

Cognitive aging is not a disease or a quantifiable level of function

T

14

T/F:

Cognitive aging does not inevitably lead to dementia or Alzheimer's disease

T

15

Actions one can take to maintain cognitive health & reduce effects of cognitive aging

Be active

Reduce & manage CV disease risk factors (e.g. HTN, DM, smoking)

Discuss & review health conditions & meds that may influence cognition with provider

16

A significant chronic loss in mental functions

A progressive neurodegenerative condition

Dementia

17

T/F: Dementia is...

-Lifelong

-Abrupt or acute

-Normal aging

F

*Dementia is significant, also

18

T/F: Dementia isn't necessarily...

-A problem with memory

-Alzheimer's

-Disturbed behavior

-Age-related

-Fatal

T

19

Most common d/o of dementia

Alzheimer's

20

Progressive neurodegenerative disorder that gradually erodes cognitive function and eventually causes death

Alzheimer's (dementia)

21

Forms of dementia other than Alzheimer's include:

–Vascular dementia (VD)

–Lewy Body disease

–Mixed types (e.g., AD and VD, AD and Lewy Body)

–Fronto-temporal dementia

–Resulting from head trauma or anoxia

–Normal pressure hydrocephalus

22

Cardinal S/S of dementia include:

–Memory impairment (amnesia), followed by one or more of the following:

  • aphasia (impaired language)
  • apraxia (inability to perform complex motor activities)
  • agnosia (failure to recognize or use familiar objects or utensils)
  • abulia (disturbances in executive functions, e.g., planning, organizing, sequencing, abstracting, problem-solving)
23

Condition in which a person has problems with memory, language or another essential cognitive function

–Severe enough to be noticeable to others and show up on tests

–Not severe enough to interfere with daily life.

–Some people go on to develop dementia.

–For others, the symptoms do not progress to dementia

Mild Cognitive Impairment

24

Memory impairment + one of the following:

-Aphasia (speech problem)

-Apraxia (motor activity problem)

-Agnosia (recognition problem)

-Executive dysfunction

Alzheimer's

25

T/F:

Alzheimer's is functional impairment 2/2 cognition, not another cause

T

26

Alzheimer's characteristics include:

–High concentration of beta-amyloid plaques

–Neurofibrillary tangles (tauopathies) seen on postmortem examination

–Reduced neurotrophic factors

–Synaptic loss

27

Theories on Causes of AD include:

–Genetic mutations

–Environmental exposures

–Abnormalities in brain proteins or neurotransmitters

28

Genetics of AD:

__1__ age of onset (<__ years), linking strongly to genetics

Most are __2__-associated & considered __3__

Presence of __4__ increases risk, especially if it's __5__

1. Early, <60

2. Age-associated

3. Sporadic

4. Apolipoprotein 4

5. Homozygous

29

T/F:

Alzheimer's is probably a consequence of multiple brain changes that accumulate

T

30

Alzheimer's diagnostic criteria:

1. This, plus...

2. One of the following conditions Memory impairment + one of the following:

1. Memory impairment

2. Aphasia, apraxia, agnosia, executive dysfunction

31

These types of dementia don't happen commonly, & don't go a long time without being identified

Examples include normal pressure hydrocephalus, alcohol-related, B12/folate deficiency, electrolytes, etc.

"Reversible" Dementias

32

Clinical hallmarks of Alzheimer's:

1) _____ & _____ decline over years

2) Often a _____ presentation for medical care

3) Death usually occurs 2/2 medical causes in about __-__ years

1. Slow & steady

2. Late

3. 8-10 years

33

3 appropriate situations which warrant the use of indwelling catheters

Severe acute illness

Retention not controlled by meds & intermittent cath

UI management for patients with Stage III-IV trunk ulcers

34

Meds used for cognitive S/S (e.g. dementia) include:

ACE Inhibitors (e.g. Aricept)

NMDA receptor antagonists (e.g. Memantine - Namenda)

35

Medication therapy for behavioral S/S should follow these guidelines

Short-term use at lowest dose

Avoid TCAs for depression (r/t anticholinergic effects)

Traditional antipsychotics (e.g. Haldol) reserved for psychotic or behaviors that endager self or others

36

Common meds prescribed for Behavioral and Psychological Symptoms of Alzheimer’s (BPSD) include:

SSRIs (fluoxetine, sertraline)

SNRIs (venlafexine)

Other antidepressants (e.g. trazadone)

Mood stabilizers (benzos * Beer's)

37

Which of the following are common causes of confusion in older adults?

  • Delirium
  • Dementia
  • An adverse reaction to medication
  • Normal aging process
  • Delirium
  • Dementia
  • An adverse reaction to medication

*The normal aging process does not cause confusion

38

Delirium vs. Dementia: The difference in...

-Attention

Delirium: Impaired

Dementia: Normal (except when terminal)

39

Delirium vs. Dementia: The difference in...

-Consciousness

Delirium: Fluctuates (usually reduced)

Dementia: Clear (except when terminal)

40

Delirium vs. Dementia: The difference in...

-Sleep/Wake cycle

Delirium: Worse @ night & awakening - INSOMNIA

Dementia: Worse in evening; "sundowning"; reversed sleep

41

Delirium vs. Dementia: The difference in...

-Speech

Delirium: Incoherent, disorganized

Dementia: Ordered (may have aphasic errors)

42

Delirium vs. Dementia: The difference in...

-Judgement

Delirium: Impaired - difficulty separating facts & hallucinations

Dementia: Impaired - bad decisions, denies problems

43

Delirium vs. Dementia: The difference in...

-Recent memory

Delirium: Impaired, but remote memory intact

Dementia: Short-term memory deficit early, progressing to long-term deficits

44

A serious medical emergency

A sign that a patient is really sick and at increased risk of death/disability

Delirium

*Acute brain failure, post-op psychosis, ICU psychosis, toxic-metabolic encephalopathy, etc.

45

Complications of ICU delirium include increases in:

Mortality

LOS/cost

Time on vent

Re-intubation

Long-term cognitive impairment

D/C to long-term care facility

46

CAM-ICU is a tool to ID delirium in the ICU; has 4 features

In order for a diagnosis of delirium to be made, the patient must have:

1. These 2 S/S, plus...

2. Either of these 2

1. Acute LOC change or fluctuating course AND inattention

2. Disorganized thinking OR altered LOC

47

The most common predisposing risk factors for delirium include:

Dementia

Male gender

Older age (65+)

Medical illness

48

Precipitating factors which can contribute to a patient developing delirium during the hospital stay include:

Polypharmacy

Restraints

Indwelling catheter

Iatrogenic event

Untreated pain

F&E imbalance

Relocation (esp. to ICU)

Sleep deprivation

49

Commonly ordered meds which may contribute to delirium include:

Analgesics (Demerol, opiates)

Antiemetics (Phenergan)

Antihistamines (Benadryl)

Antihypertensives (clonidine)

Anxiolytics (benzos)

Antispasmodics (oxybutynin)

H2 antagonist

Muscle relaxants (Flexeril)

TCAs

50

Challenges surrounding geriatric pharmacotherapy include:

New drugs available each year (fewer trials on older adults)

FDA approved & off-label uses expanding

Cost & changing formularies

Popularity of herbals or "nutriceuticals"

Effects of aging physiology on drug therapy & multiple co-morbid states

Polypharmacy

Adherence

51

This can lead to:

-Adverse drug effects (ADEs)

-Drug interactions

-Non-adherence

Polypharmacy

52

Polypharmacy risk factors include:

Poor communication among providers

Multiple co-morbidities

53

What is the "Prescribing Cascade"?

Drug 1 prescribed

Subsequent S/E interpreted as new medical condition

Drug 2 prescribed for S/E

Subsequent S/E interpreted as new medical condition

Drug 3 prescribed for S/E

*Polypharmacy

54

Described as the bioavailability of a given drug

Fraction of a drug dose reaching the systemic circulation

Absorption

*Pharmacokinetics (PK)

55

What are the 4 components of pharmacokinetics (PK)?

Absorption

Distribution

Metabolism

Elimination

56

Locations in the body a that drug penetrates, expressed as volume per weight (e.g. L/kg)

Distribution

*Pharmacokinetics (PK)

57

Drug conversion to alternate compounds that may be pharmacologically active or inactive

Metabolism

*Pharmacokinetics (PK)

58

Drug’s final route(s) of exit from body expressed in
terms of half-life or clearance

Elimination

*Pharmacokinetics (PK)

59

What age-related changes in an older adult affect distribution of medications?

Less body water (less distro for hydrophilic drugs)

Less body mass (less distro for muscle-binding drugs - anticholinergics)

Less plasma protein (albumin) (more unbound & active drug)

More fat (more distro for lipophilic drugs)

60

Due to a decrease in body water as we age, what happens to the concentration of water-soluble drugs (e.g. aminoglycosides, digoxin) in the body?

Serum levels may increase

Risk of toxicity

61

Drug metabolism:

A decrease in hepatic blood flow can decrease this component of drug metabolism

First-pass effect

*Increases serum concentrations

62

What age-related changes in the liver effect the metabolism of drugs?

Decreased hepatic blood flow - reduces first-pass effect

Decreased phase I metabolism (redox, hydrolysis, etc.)

63

The older adult:

Hepatic congestion 2/2 heart failure may cause a reduction in the metabolism of this drug, requiring an increase in the dose

Warfarin

64

Time course and intensity of pharmacologic effect of a drug

Pharmacodynamics

65

Pharmacodynamics: Some drug/substance effects are increased, whilst others are decreased

What drugs and/or substances have diminished potency in older adults?

Beta blockers (diminished HR response)

Dopamine, Lasix

*Delayed toxicity possible

66

Adverse Drug Effects:

1) Older adults are _____x more at risk for 'em

2) Risk is proportional to what?

3) Any new S/S should be considered what?

1. 2-3x more at risk

2. # of drugs being taken

3. An ADE until proven otherwise

67

Common ADEs in older adults include:

Cognition changes, depression

Hypotension

UI

Constipation

Vision/hearing impairment

Sleep/sexual dysfunction

Mobility problems - FALLS!!!

68

Most common drugs associated with ADEs in older adults include:

Opiates

NSAIDs

Benzos

Anticholinergics

*1/3 of ED visits for ADEs due to insulin, warfarin, digoxin

69

Nonadherence, whether intentional or not, may be due to these circumstances

Clinician’s failure to consider patient’s financial, cognitive, functional status

Patient’s beliefs/understanding of drugs & diseases

Medicare Part D “donut hole”

70

For behavioral issues, we should use meds as a last resort

The acronym TA-DA! covers this approach, and stands for...

Tolerate

Anticipate

Don't Agitate

71

How can we enhance adherence to meds?

Avoid newer, more expensive meds that aren't superior to less expensive ones

Simplify regimen

Utilize organizers or calendars

Educate patient & family

72

What's the mantra regarding the initiation of drug therapy in an older adult?

Start low, go slow

Avoid starting 2 drugs at same time

Avoid prescribing cascade (polypharmacy)

Look for potentially inappropriate medications (Beer's)

Brown bag review

73

Gender which reports severely painful joints more often

Women

*Probably due to menopause & loss of estrogen - loss of bone benefits & osteoporosis?

74

Explained by ongoing tissue injury (from mechanical, thermal, chemical noxious stimuli)

Nociceptive pain

*Somatic & visceral

75

Pain believed to be sustained by psychological factors

Psychogenic pain

76

In regards to the older adult & pain, we should consider the idea of Total Pain

The 4 components of total pain include:

Physical pain

Emotional

Social

Spiritual

*...and their interactions with one another

77

Pain from arthritis or bone metastases would be classified as this

Somatic pain (nociceptive)

78

Pain from renal colic or constipation would be classified as this

Visceral pain (nociceptive)

79

Pain from diabetic neuropathy, post-stroke syndrome, or intervertebral disc herniation would be classified as this

Neuropathic pain

80

Myths about pain in the older adult include:

Chronic pain is inevitable in aging

Acknowledging pain is weakness - will lead to intrusive & possibly painful tests as well as loss of independence

Pain is punishment for the past

Chronic pain means death is coming for ya!

Chronic pain means something serious is going on!

Older adults are likely to become addicted to pain meds

81

T/F:

Older adults, especially those with cognitive impairment, have a higher pain tolerance, so assessment of their pain cannot be done accurately

F (to both elements)

82

Under-treating pain can lead to an increased risk for _____

Falls

*...and subsequent injuries

83

Age-related changes in pain include:

Reduction in # & function of peripheral nociceptive neurons

Slowed conduction

Sensory threshold for thermal/vibratory stimuli increases

Receptors decreased in certain areas

Diminished endogenous analgesic response (endorphins)

84

During the pain assessment of an older adult, screening for this should also be conducted

Depression, anxiety

85

When asking about an older adult's pain, what's an important consideration to elicit an accurate response?

Preferred pain terminology (e.g. pain, ache, hurt, discomfort)

*People think of pain differently

86

T/F:

A person with moderate cognitive impairment (e.g. MMSE = 12) cannot respond accurately to a verbal assessment of pain, so asking them isn't a prudent nursing action

F

*Even persons with moderate impairment (e.g. MMSE=12) can still reliably report pain with good test-retest reliability, so ASK!!!

87

Cognitive impairment may do what to the perceived analgesic effectiveness in an older adult?

May decrease effectiveness

*May actually require higher dose

88

Pain assessment in dementia:

1) Is self report still reliable?

2) What other resources are available?

3) What is an appropriate scale to use with dementia patient?

4) What should you not ask the patient to do?

1. Yes

2. Family/caregivers

3. Facial scale - situation dependent

4. Don't ask to recall information from past

89

When using opiates in the older adult r/t moderate-to-severe acute pain, we should begin with opioids that have what characteristic?

Short half-life

90

–Not recommended as first-line if opiate-naïve

–100x more potent than morphine

–Absorption altered by temperature

–Deposit of drug in excess adipose tissue

Fentanyl patch

91

This opiate should be avoided in the older adult because it's less potent & has more S/E

Codeine

92

What term should we use instead of "opioid"?

Narcotic

93

The chronic pain cycle consists of these 6 elements

1. Pain

2. Fear of injury

3. Fear of movement

4. Less movement

5. Deconditioning/disuse syndrome

6. Physical & mental deconditioning

94

T/F:

Incontinence isn't a typical accompaniment of aging

T

95

This muscle contracts the bladder

Detrusor

96

In older adults, urine production _____ at night

Increases

*Increased risk for UI

97

Economic implication for older adults with UI

Costs not covered by insurance

98

Risk factors for UI in the older adult:

1. Low _____ _____

2. The conditions

3. This GI emergency

4. Intake of these substances

5. These meds

1. Fluid intake

2. Co-morbid conditions

3. Fecal impaction

4. Caffeine, ETOH

5. Ca++ blockers, diuretics, ACE-Is

99

Appropriate indications for indwelling catheter use include:

Severe acute/critical illness

Urinary retention uncontrollable by medication and intermittent catheterization

UI management for patients with Stage III-IV pressure ulcers of the trunk

100

This type of catheterization may result in a lower incidence of UTI & may be a viable alternative to placement of an indwelling urinary catheter

Sterile intermittent cath

101

Type of UI characterized by the sudden onset of potentially reversible symptoms

–Usually has a duration of less than 6 months

–Almost always preventable, or at least reversible, once underlying causes of UI are identified and treated

Transient UI

*Other type is Established UI

102

Types of Established UI include:

Stress

Urge

Overflow

Reflex

Functional

103

Involuntary loss of urine associated w/activities that increase intra-abdominal pressure

  • Individuals present with complaints of small amounts of daytime urine loss that occurs during physical activity or with increased intra-abdominal pressure (e.g., coughing, sneezing)

Stress UI

*Established UI

104

Stress UI is more common in women, but men may experience it following this procedure

Prostatectomy

105

Stress UI management includes:

PFMEs (Kegels): 15x TID - contract x10 sec, relax x10 sec

Urine stream interruption test (UST) - simple measure of pelvic floor muscle strength

106

Involuntary urine loss associated with a preceding strong desire to void

Urge UI

107

S/S of Urge UI include:

Frequency

Nocturia

Enuresis

Moderate-to-large amounts of incontinent urine

108

A person may confuse the urgency caused by this as having Urge UI

Overactive bladder (OAB)

*Treated with Oxybutynin

109

Treating Urge UI involves:

Behavioral therapy

Distraction & relaxation techniques

Kegel's

Anticholinergics to reduce detrusor spasm

110

May be caused by an under-active detrusor muscle or bladder outlet obstruction leading to over distention and urine overflow

Overflow UI

111

Individuals with overflow UI often state they have urine __1__, along with a feeling of being unable to __2__

Furthermore, they note urine loss without a _____ 3 _____, as well as an uncomfortable sensation of 4)_____/_____ in the abdomen

1. Dribbling

2. Empty their bladder

3. Recognizable urge

4. Fullness/pressure

112

Overflow UI management includes:

Crede's maneuver

Timed/double voiding

Intermittent cath

BS for PVR

113

Related to birth defects, spine or nerve damage, developmental disability, senility, pelvic traum

No warning prior to incontinent episode

Large amount urine lost

Episodic or continual incontinence

Treatment - determine cause; may need intermittent catheterization or timed voiding program

Reflex UI

114

Functional UI is defined as...

...the inability to get to bathroom facilities due to functional reasons, e.g. immobility, obesity, environmental clutter

  • May be associated with urge incontinence (mixed incontinence)
  • Treatment - modify environment and lifestyle
115

Behavioral technique used to treat urge UI and OAB

Requires baseline bladder diary to determine the timing of voids and UI episodes

Bladder training

*If frequency present, instruct patient to lengthen the time between voids in an effort to retrain the bladder

116

Bladder training:

When strong urge to void occurs, and if person is not in a position to empty the bladder in a socially appropriate manner, what are they taught to do?

Quickly squeeze and relax pelvic floor muscles several times to suppress the urge to void

*Knack Maneuver - Janice Miller

117

Bladder training involves these key components

Bladder diary

Incremental voiding schedule

Relaxation/distraction

Kegel's or Knack Maneuver

118

Healthy Bladder Behavior Skills:

A weight reduction program should be considered with this BMI level

>27

119

Healthy Bladder Behavior Skills:

Education should focus on the adverse consequence of _____ _____ _____

Inadequate fluid intake

*Concentrated urine increases bladder contractions & urgency

120

Lifestyle changes r/t urinary incontinence include:

Reduce caffeine (increases detrusor pressure)

Fluid management w/24 hr I&O diary

Weight reduction

121

Regarding fluid intake and urinary incontinence, excess intake should be reduced to how much?

6 glasses (8 oz.) per day

122

These facts should be considered when looking at treating urinary incontinence with medications

Less effective than behavioral therapy

Adverse S/E - including cognition

*Use lowest dose available - time for events, such as outings

123

Block acetylcholine-induced stimulation of postganglionic muscarinic receptors on detrusor smooth muscle > bladder contraction

Consider CrCl & reduced renal function

Antimuscarinics (anticholinergics)

*Oxybutynin

124

Systemic administration of this may worsen incontinence symptoms

Vaginal administration may improve frequency, nocturia, urgency, incontinence episodes and bladder capacity

Estrogen

125

Other therapies for older adults suffering from UI include:

Pessaries for women

Percutaneous Tibial Nerve Stimulation

Botulinum toxin (BOTOX) into detrusor muscle

SX

126

For older adults w/mild cognitive impairment & UI, this management approach should be considered

Simplified behavioral therapy

Reduce caffeine

*Timed voiding

*Requires caregiver involvement

**Anticholinergics should be used w/caution r/t worsening cognition

127

Shared planning, decision-making, responsibility, and accountability

–Increases likelihood that issues will be addressed

–Increases coordination of care

–More efficient care delivery

Collaboration of care

128

Community Models of Care include:

Patient-Centered Health (Medical) Home

GRACE

Guided Care

Integrated Chronic Care Management

PACE

Village Model

129

Thanks to advancing technology, this service can increase access to care & improve management

Issues stem from cross-state practice & varying scope/standards

Telehealth

130

Nursing Home Models:

  • Program champion
  • Communication tools (e.g. SBAR, "Stop & Watch" for CNAs)
  • Advanced Directive Care Planning

INTERACT II

131

Nursing Home Models:

  • Person-directed nursing home culture
  • Most everything revolves around the older adult's preferences & habits

Pioneer

132

Nursing Home Models:

  • Nursing home alternative
  • Small intentional communities
  • Clusters of residents (gen. 8-10)

–Private rooms/baths

–Open kitchen

  • Receive care/support without it becoming the primary focus

Architecture changes: warm, smart

Green House Concept

133

Hospital Models:

  • Usually accept patients as transfer from other units who meet certain criteria or are experiencing geriatric syndromes such as falls, delirium
  • Multidisciplinary, geriatrician led approach
  • Primarily used in VA settings

Geriatric Evaluation & Management (GEM) units

134

Specific unit designed to care for older patients

Safe, functional environment designed to foster functional independence for older adults

Assessment focused on maintaining pre-hospital function and preventing iatrogenic complications

Acute Care of the Elderly (ACE) Units

135
  • Interdisciplinary team rounds and discharge planning
  • Patient-centered interdisciplinary care guided by nurse-driven protocols
  • Research shows modest benefit on costs and outcomes of care for community-dwelling elders
  • Delirium room in unit

ACE Unit

136

Responsibilities of the Geriatric Resource Nurse (GRN) include:

  • Initial and ongoing geroeducation
  • Competency evaluation
  • Operational policies
  • Patient selection & consultation to other staff (other RNs, LPNs, CNAs etc)
  • Mentoring from an Advanced Practice Nurse
  • Participates in CQI activities
137
  • Begins with institutional assessment (GIAP)
  • Uses both GRN* and the ACE Models of Care
  • Protocols to manage geriatric syndromes
  • Resources for staff development

Promotes changes in the nurse practice environment (as per Aiken et al. 1997)

–Nurse autonomy

–RN/MD relations

–Control of resources

NICHE

138

Why is there a need for transitional care in the elderly?

High re-admittance

Most D/C w/out communication b/w hospital & PCP

Only 1/2 of those readmitted had visit from PCP

139

What important characteristics of care-giving are caregivers not in-tune with or mentored in grooming?

NOT...

-trained how to deliver complicated care

-treated as partners in patient care

-encouraged to maintain own health

140

What are some negative emotional consequences of caregiving?

  • Increased burden*
  • Depression*
  • Anxiety
  • Fear
  • Psychosomatic symptoms
  • Marital/relational strain
141

Eligibility for Medicare benefits (Aged) entails meeting these requirements

> 65 years old

US citizen OR

  • legal resident for at least 5 years

Paid “Medicare tax” for at least 10 years OR

  • spouse paid for at least 10 years
142

Eligibility for Medicare benefits (Disabled) entails meeting these requirements

Receiving Social Security Disability Insurance (SSDI) benefits

  • ALS: immediately
  • ESRD: immediately – 4 months depending on treatment
  • Other disabilities: 24 months
143

Federal-state health insurance program

  • For people with limited income/resources
  • Certain people with disabilities
  • Covers most health care costs*

Run by states, governed jointly

  • Eligibility determined by state

Medicaid

* If you have both Medicare and Medicaid

144

The 4 parts of Medicare include:

Part A: Hospital Insurance

Part B: Medical Insurance

Part C: Medicare Advantage Plans (HMOs, PPOs); includes Part A & B & sometimes Part D

Part D: Medicare Prescription Drug Coverage

145

Parts of Medicare:

–Inpatient hospital care

–Up to 100 days of skilled nursing facility care

–Hospice care

–Limited home health services post-hospital

–Funded by payroll tax (Hospital Insurance Trust Fund)

Part A

146

Parts of Medicare:

–Physician services

–Outpatient hospital care

–Preventive services (e.g., mammography)

–Mental health services

–Home health

–X-rays and other diagnostic procedures

–Durable medical equipment

–Financed by premiums and general revenues

Part B

147

Parts of Medicare:

  • Alternative to original Medicare;
    beneficiaries can enroll in private
    plan to receive Medicare-covered
    benefits, and (often) extra benefits
  • Includes HMOs, PPOs, private-
    fee-for-service (PFFS) plans
  • Government pays private
    insurers fixed amount/enrollee

Part C

148

Parts of Medicare:

–Helps pay for outpatient prescription drugs

–Benefits provided by private plans that contract w/Medicare

–Two types of plan: stand-alone prescription drug plans and Medicare Advantage plans

–Funded by premiums, general revenues and state payments

Part D

149

What are the contrasting cost benefits of Medigap insurance vs. Medicare Advantage?

Medigap: Generally higher premiums and no copayment. Plan F has high deductible option with lower premiums

Medicare:

Generally lower premiums

PPO has deductibles

Annual out-of-pocket limit

Enrollee pays copayments with use

150

Largest benefit expansion in Medicare history

Medicare Prescription Drug Improvement & Modernization Act of 2003 – Part D

151

What's the "Donut Hole" highlighted within the Medicare program?

Under Medicare Part D, when person’s prescription drug costs reach a certain amount:

  • Medicare stops paying for any prescription drug costs
  • They have to pay for 100% of their drugs out-of-pocket, until they reach the maximum out-of-pocket amount
  • Once they reach this maximum ($4,550.00), they are
    out of the donut hole - Catastrophic Coverage begins,
    and Medicare starts to help cover the costs again
152

Primary payer for primary care services & in-hospital care: Physicians and Nurse Practitioners / Clinical Nurse Specialists

  • Fee-for-service (FFS) option
  • Covers office visits, ambulance services, ER care, visits in the home, hospital, nursing home

Medicare

153

__1__ is the primary payer for short-term skilled (≤ 3 mo) nursing care in the home (if homebound), whereas __2__ pays for long-term home health care for eligible persons

1. Medicare (short-term)

2. Medicaid (long-term)

154

In order for hospice benefits to be granted under Medicare, these stipulations must be met

  • Medicare Part A beneficiary
  • 2 physicians certify terminal illness with expected lifespan of 6 months or less if the illness runs its usual course (neither NP or PA may certify)
  • Patient elects hospice care instead of other Medicare benefits for treatment of the terminal illness
  • Patient chooses a Medicare-certified hospice
155

Specialty hospitals that specialize in patients that need prolonged acute care.

  • Medically complex, multi-trauma, multiple complications
  • Intensive medical mgmt, vent weaning, dialysis, IV abx, wound care, basic rehabilitation
  • Physician visits 3x/wk minimum
  • Up to 1 hour of PT/OT per day

Long Term Acute Care Hospital

*Medicare or private insurance only

156

Primary source of social services for older adults

Services include:

  • Congregate meals
  • Meals-on-Wheels
  • Transportation
  • Ombudsman services

Families

157

Primary source of publicly-funded social services for older adults

Older Americans Act (OAA)

158

Intended to assist state in offering coordinated systems serving older adults via grants

Include services for access, in-home care, legal, & supportive

Older Americans Act (OAA)

*Title III

159

Have become part of Medicare System of care as part of ACA in 2012

Goal is to get different types of providers and care organizations to work together to deliver care; high quality care gets rewarded

Aim to:

–Improve care

–Improve health

–Lower costs

Accountable Care Organizations (ACOs)

160

The Affordable Care Act (ACA) introduces what changes to Medicare?

Benefit improvements:

  • Boost payments for primary care
  • Gradually close "donut hole"
  • All recipients will eventually pay 25% of Rx drugs

Medicare savings:

  • Reduce payments to Medicare Advantage plans
  • Reduce payments for hospitals, other non-MD providers
161

The ACA introduced expanded coverage for this type of patient care service

Preventive health

*e.g. annual wellness, risk assessments, vaccinations, etc.

162

Under the ACA, these 3 vaccinations will be covered at no cost to the individual

Flu

Pneumococcal

Hep B

163

With the exception of Medicaid and Medicare-reimbursed home care and nursing home care, there are no specific eligibility or access requirements in any alternative living arrangements (e.g. assisted living, adult home) other than one’s ability to do what?

Pay for it

*Need more affordable care

164

PRIMARY Preventive Screening Activities for older adults

Annual basis

HT/WT

BP

Diabetes screening

165

Some SECONDARY Preventive Screening Activities for older adults include:

Vision/hearing annually

Depression screening

Smoker/ETOH use?

Sexually active - at risk for STIs?

*Males: Last colorectal & prostate screening?

166

This popular OTC herbal supplement interacts with many other medications

Should be discussed during brown bag

Gingko biloba

*Interacts w/ASA, Ibu, Celexa, among others

167

Dietary intake of this can interact with Synthroid

Ca++

168

This OTC herbal supplement interacts with drugs metabolized by the P450 system

St. John's wort

169

Common drug-drug interactions:

ACEi + diuretic

Hypotension

Hyperkalemia

170

Common drug-drug interactions:

ACEi + potassium

Hyperkalemia

171

Common drug-drug interactions:

Antiarrhythmic + diuretic

Electrolyte imbalance

Arrythmias

172

Common drug-drug interactions:

Benzo + antidepressant/antipsychotic/other benzo

Confusion

Sedation

Falls

173

Common drug-drug interactions:

Calcium blocker + diuretic/nitrate

Hypotension

174

Common drug-drug interactions:

Digitalis + diuretic

Arrhythmias

175

This has been developed to assist healthcare providers in improving medication safety in older adult

The purpose is toimake clinical decision-making concerning the prescribing of medications for older adults in order to improve safety and quality of care

Identify Potentially Inappropriate Medications (PIMs)

Beers Criteria (list)

176

CONFFUSED is a mnemonic used to describe the many potential underlying causes of delirium, and stands for:

CNS insults

Organ insufficiency/ischemia

Nutritional deficiencies

F&E imbalance

Fever & infection

Urinary d/o

Sensory difficulties

Endocrine

Drugs

177

The 4 ranges of scores for the MMSE, as well as the meaning of each

Questionably significant: 25-30

Mild dementia: 20-25 pts

Mod dementia: 10-20 pts

Sev dementia: 0-10

178

Persons with the following type of dementia are particularly sensitive to neuroleptics/antipsychotics

Alzheimer's disease

Lewy body dementia

Vascular dementia

Frontotemporal dementia

Lewy body dementia

179

Persons with the following type of dementia may show changes in personality, affect, and behavior even prior to changes in memory:

Alzheimer's disease

Lewy body dementia

Vascular dementia

Frontotemporal dementia

Frontotemporal dementia

180

The triad of symptoms seen in patients with normal-pressure hydrocephalus is:

Memory impairment

Gait disturbance

Incontinence

181

The nurse is caring for a 70-year old patient, Mr. Barnes, with osteoarthritis. Mr. Barnes complains of pain in his hands and takes naproxen sodium in the morning with good relief. This type of pain would be best classified as:

Neuropathic

Nociceptive

Acute

Nociceptive

182

A patient taking Naproxen or another NSAID-type medication every morning to relieve arthritic pain should be assessed for this complication

GI bleeding

183

Patients who experience unrelieved pain are at risk of all of the following EXCEPT:

Delirium

Post-op complications

Anticipatory pain

Impaired immunity

Anticipatory pain

184

T/F:

Older adults with cognitive impairment due to dementia do not experience pain like older adults who are cognitively intact.

F

185

The nurse is caring for a 75-year old patient day 0 status-post coronary artery bypass graft (CABG) surgery. The patient is ordered IM Demerol (meperidine) q3-4h prn. The nurse's best response is to:

Give the medication on an around-the-clock schedule, rather than prn

Administer as ordered

Discuss the use of an alternative medication delivery method with the prescribing provider

Discuss the use of an alternative medication delivery method with the prescribing provider

*Sorry, while ATC is better for older adults, this is a medication on the Beers list, and IM is not recommended in older adults

186

T/F:

Some urinary incontinence is normal in older women, but rare in older men

F

187

ID the model of comprehensive primary care for older adults:

Community-based health center

Low-income

Monthly contact

Services not covered by Medicare/Medicaid

Team members besides PCP: Many

GRACE

188

Pharmacodynamics: Some drug/substance effects are increased, whilst others are decreased

What drugs and/or substances have greater potency in older adults?

ETOH

Benzos

Opiates

Digoxin

ACE-Is

189

ID the model of comprehensive primary care for older adults:

Day health center

Eligibility: Certified as requiring long-term care

Contact 1-5 days/week

Services covered by Medicare & Medicaid

Team members besides PCP: Many

PACE

190

T/F:

One of the major benefits of interdisciplinary team care for older adults is the ability to better address complex conditions and problems

T

191

T/F:

Compared to a traditional medical-surgical unit, patients on ACE units are more likely to experience delirium

F

192

T/F:

Naylor's Transitional Care Model features a "transition coach" who is frequently an RN

F

193

T/F:

As the hospice nurse working with a terminally ill older adult patient with metastatic lung cancer and his family the most important and useful thing you can do to support caregiving by the family is to provide them with information regarding end of life trajectory

F

194

The model of comprehensive primary care provided in a medical home in which the care coordination is handled primarily by a Registered Nurse who manages a panel of 55-60 complex older adults is:

Guided Care

195

The model of comprehensive care provided in the community for persons who would otherwise be eligible in a long-term care facility is:

PACE

196

Common objectives of Geriatric Acute Care Models include all of the following EXCEPT:

Promotion of intradisciplinary communication

Incorporating patient and family goals into the plan of care

Addressing discharge, posthospital care, and care transitions proactively

Facilitation of geriatric education for health providers

Promotion of intradisciplinary communication

*Focus on interdisciplinary

197

A way for nurses to create a positive culture change in long-term care settings is to do what?

Work to create a sense of home within the setting for residents

198

While caregiving may be a positive experience, it may also have negative consequences for the informal caregiver. The two most common problems reported are:

Depression and feeling increased burden

199

Does Medicare cover the following services?

1. Acupuncture

2. Flu shot

3. Mammogram

4. Smoking cessation

1. No

2. Yes - 1x per year (fall or winter)

3. Yes - annually

4. Yes - x8 face-to-face visits annually

200

Changes occurring with the “Patient Protection and Affordable Care Act of 2010” include which of the following?

  1. Increased access to primary care providers
  2. Lower prescription drug costs
  3. Free wellness visit and preventive screenings
  4. Goal of coordinated, appropriate and effective care

2,3,4

201

T/F:

Among those enrolled in Medicare fee-for-service, more than half of the costs are incurred by only 10% of users

T

202

Alzheimer’s:

Speech problem

Aphasia

203

Alzheimer’s:

Motor activity problem

Apraxia

204

Alzheimer’s:

Recognition problem

Agnosia

205

Alzheimer’s:

Disturbances in executive functions (e.g. planning, organizing, sequencing, abstracting, problem-solving)

Abulia

206

This community-based, low-income health center isn’t covered by Medicare/Medicaid

GRACE

207

Levels of prevention based on disease presence - not just one type of prevention or another:

This level of prevention includes activities that prevent disease from occurring, such as exercise, nutrition, smoking cessation, taking vitamins/minerals, immunizations, condoms, & hand washing in HEALTHY indiividuals

Primary prevention

208

Levels of prevention based on disease presence - not just one type of prevention or another:

This level of prevention includes activities that are aimed at catching a disease early (before it's symptomatic/clinically diagnosed) to limit later health effects - to include early detection/screening (for cancer, diabetes, heart disease, STDs, depression, glaucoma screening)

Secondary prevention

209

Levels of prevention based on disease presence - not just one type of prevention or another:

This level of prevention includes activities that are aimed at limiting impact/complications of disease in people whose disease is already diagnosed … includes things like reduction of risk factors in people who already have diagnosed disease, rehabilitation and monitoring after diagnosis/treatment (e.g., cardiac rehabilitation, reducing cholesterol after myocardial infarction, reducing salt for diagnosed hypertension or heart failure, eating more “greens” after cancer diagnosis, screening for recurrence)

Tertiary prevention