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With the continued rapid growth of the older adult population, there remains an increased demand for health-care providers to deliver age-specific care and direct disease management. Advanced Practice Nursing in the Care of Older Adults will serve as a guide for advanced practice nurses who are privileged to provide care to older adults. Designed as a text for students, as well as a reliable source of evidence-based practice for advanced practice nurses, this book contains information on healthy aging, comprehensive geriatric assessment, and common symptoms and illnesses that present in older adults. Given the complexity of prescribing for older adults taking multiple medications, a new chapter on polypharmacy is included. The book concludes with a chapter on care delivery for patients with chronic illnesses who face end-oflife care.
Throughout the book, case studies are included to provide further practice and review. An important feature of this book is the use of the Strength of Recommendation Taxonomy (SORT) [Ebell, M. H., Siwek, J., Weiss, B. D., Woolf, S. H., Susman, J., Ewigman, B., & Bowman, M. (2004). Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in medical literature American Family Physician, 69(3), 548–556], which provides a direct reference to evidence-based practice recommendations for clinicians to consider in the care of older adults.
In Unit I, “The Healthy Older Adult,” the first chapter, “Changes with Aging,” addresses the normal changes of aging, expected laboratory values in older adults, presentation of illness, atypical disease presentation, bimodal conditions, and the impact of chronic illness on functional capacity. In the second chapter, “Health Promotion,” updated information pertaining to health promotion and disease prevention strategies for older adults from Healthy People 2020 and the U.S. Preventive Services Task Force (USPSTF) is provided, including an immunization schedule and information on the Welcome to Medicare Visit. Also covered is an overview of physical activity, sexual behavior, dental health, and substance use, as well as a section pertaining to the older traveler. Recommendations for exercise and safe physical activity are provided in this unit.
Unit II, “Assessment,” opens with a detailed chapter on comprehensive geriatric assessment. Information on physical, functional, and psychological health is delineated, and information on quality of life measures is included. Next is the fifth chapter, “Symptoms and Syndromes,” which provides the clinician with a concise description of more than 20 symptoms prevalent in older adults. A rapid reference detailing common contributing factors and associated symptoms and clinical signs that should be worked up for each presenting condition is included. Recommendations for diagnostic
tests with accompanying results are used to form a differential diagnosis.
Unit III, “Treating Disorders,” provides 11 chapters of concise, updated information pertaining to disease management of illnesses common in older adults, presented by body systems. Each chapter opens with an assessment section that provides the reader with a focused review of systems and the physical examinations needed to obtain pertinent information for diagnosis and treatment of the older adult. Signal symptoms indicating atypical presentation of illness are highlighted at the beginning of each condition. The discussion of each problem and disorder follows a consistent monograph format:
■ Signal symptoms
■ Description
■ Etiology
■ Occurrence
■ Age
■ Ethnicity
■ Gender
■ Contributing factors
■ Signs and symptoms
■ Diagnostic tests
■ Differential diagnosis
■ Treatment
■ Follow-up
■ Sequelae
■ Prevention/prophylaxis
■ Referral
■ Education
Unit IV, “Complex Illness,” addresses complex management of patients requiring chronic illness management, palliative care, and supportive care at end of life, and includes a new chapter on polypharmacy. The text concludes with two appendices—“Physiological Influences of the Aging Process” and “Laboratory Values in the Older Adult”—both of which are ready references for the busy practitioner.
In addition to the content of the book, a Bonus Chapter, Nutritional Support in the Older Adult, selected References, and other online resources to aid the user in practice and review of the key concepts are available at DavisPlus Case studies are provided to support critical thinking and are available for users to complete on their own or for educators to incorporate into their course requirements. To enhance the delivery of competency-based education, the case studies were mapped to the Adult-Gerontology Primary Care Nurse Practitioner Competencies (2016).
For the faculty, there are PowerPoint presentations and a well-developed test bank located on DavisPlus. The
Active Classroom Instructors’ Guide is an online faculty resource that maps the resources available with the text and includes lecture notes and additional case studies. This book is written by and for advanced practice nurses involved in the care of older adults across multiple settings of care. While intended as a guide for the management of care for older adults, clinicians are encouraged to deliver individualized, patient-centered care considering the latest clinical
practice guidelines on prevention and management of conditions common in older adults.
REFERENCE
National Organization of Nurse Practitioner Faculties. (2016). AdultGerontology Acute Care and Primary Care Nurse Practitioner competencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/ resource/resmgr/competencies/NP_Adult_Geri_competencies_4.pdf.
Sue A. Anderson, PhD, RN, FNP-BC
Associate Professor, Family Nurse Practitioner
Program Coordinator
Saint Mary’s College Notre Dame, Indiana Epistaxis; Rhinitis; Asthma
Louann Bailey, CRNP
Nurse Practitioner
Inpatient Medical Services Akron, Ohio
Chest Pain
Tracy Ballard, MSN, GNP-BC
Nurse Practitioner
Optum
Greensboro, North Carolina
Gastroenteritis
Judith A. Berg, PhD, RN, WHNP-BC, FAANP, FNAP, FAAN
Clinical Professor
The University of Arizona College of Nursing San Diego, California
Atrophic Vaginitis; Breast Cancer
Sharon Biby, MSN, APRN, ANVP-BC, AGPCNP-BC
Nurse Practitioner, Advanced-Practice Stroke Nurse
Cone Health
Greensboro, North Carolina Stroke
Anna Wentz Boone, PhD, ANP-BC
Adult Nurse Practitioner
Rockingham Gastroenterology, Cone Health Medical Group
Reidsville, North Carolina
C. Difficile; Cholecystitis; Peptic Ulcer Disease; Gastritis
Angela Brown, DNP, FNP-BC, ANP-BC, CDE
Clinical Assistant Professor, Family Nurse Practitioner
University of Arizona Tucson, Arizona
Cellulitis; Hearing Loss
Contributors
Lisa Byrd, PhD, FNP, GNP, FAANP
Practice Administrator
Florida Health Care Plans
Nurse Practitioner, Assistant Professor University of South Alabama Lake Mary, Florida
Bowel Incontinence; Diarrhea; Fatigue; Urinary Incontinence; Wandering
Carol Calianno, RN, MSN, CWOCN, CRNP
Nurse Practitioner – Dermatology and Wound Ostomy Continence Specialist
Philadelphia VA Medical Center Philadelphia, Pennsylvania
Skin Cancer
Christina Coletta-Hansen, MSN, ANP-BC, ACHPN
Palliative Care Nurse Practitioner
Einstein Medical Center Montgomery Norristown, Pennsylvania
Palliative and End of Life Care
Kristin R. Curcio, DNP, AGPCNP-BC, AOCNP Nurse Practitioner
Cone Health Cancer Center at Wesley Long Greensboro, North Carolina
Lung Cancer; Bladder Cancer; Liver Cancer; Brain Tumor; Pancreatic Cancer
Nancy Dirubbo, DNP, FNP-BC, FAANP, Certificate in Travel Health
Director
Travel Health of New Hamsphire, PLLC Laconia, New Hampshire
Travel and Leisure
Brenda L. Douglass, DNP, APRN, FNP-BC, CDE, CTTS
DNP Program Director, Assistant Clinical Professor, Family Nurse Practitioner
Drexel University Philadelphia, Pennsylvania
Chronic Obstructive Pulmonary Disease
Contributors
Janet DuBois, DNP, APRN, FNP-BC, FAANP, FNAP
Associate Professor
Loyola University New Orleans
New Orleans, Louisiana
Pneumonia; Upper Respiratory Tract Infection
Kristen Tomblin Duffy, CRNP
Nurse Practitioner
Lehigh Valley Health Network
Allentown, Pennsylvania
Dysphagia; Hematuria
Renee E. Edkins, DNP, ANP-C, Fellow, American
Society of Lasers in Medicine & Surgery
Director Laser Surgery Program, UNC Division of Plastic & Reconstructive Surgery, Medical Laser Safety Officer
University of North Carolina, Department of Surgery
Chapel Hill, North Carolina
Burns
Vaunette P. Fay, PhD, RNC, FNP, GNP
Director, Continuing Education; Lead Nurse Planner; Professor of Nursing
The University of Texas Health Science Center at Houston, Cizik School of Nursing
Houston, Texas
Dehydration; Pruritus
Carrie Fernald, DNP, AGPCNP-BC
Nurse Practitioner
PACE of Triad
Greensboro, North Carolina
Joint Pain; Osteoarthritis
Diana Filipek-Oberg, RN, BSN, MSN, AGACNP-BC
Surgery APN
Cooper University Hospital
Camden, New Jersey
Clinical Adjunct Faculty
Drexel University
Philadelphia, Pennsylvania
Chapter 7 Case Study; Assessment of the Respiratory System; Chapter 8 Case Study
Nancy A. Fisher, RN, MSN, GNP-BC
Nurse Practitioner, Rheumatology
Cleveland Department of Veterans Affairs
Cleveland, Ohio
Gout; Rheumatoid Arthritis
Debra A. Friedrich, DNP, FNP-BC, CLS, BC-ADM, FNLA, FAANP
Diplomate, Accreditation Council for Clinical Lipidology
Assistant Professor University of South Florida College of Nursing
Tampa, Florida
Hyperlipidemia
Cynthia Gerstenlauer, ANP-BC, GCNS-BC, CDE, CCD
Nurse Practitioner
Troy Internal Medicine
Troy, Michigan Osteoporosis
Larry Ryan Gibson, MSN, AGNP-C
Nurse Practitioner
Alliance Urology Specialists
Greensboro, North Carolina Cystitis
Eric Gill, DNP, AGNP-C
Nurse Practitioner
Rockingham Gastroenterology Cone Health Medical Group
Reidsville, North Carolina
Cirrohsis; Esophagitis; Gastroesophageal Reflux Disease; Irritable Bowel Syndrome; Acute Pancreatitis; Chronic Pancreatitis
Mary Jane Griffith, RN, MSN, GNP-BC, ACHPN
Nurse Practitioner
LTC Health Solutions
Columbia, South Carolina Palliative and End of Life Care
Mary Guhwe, DNP, FNP-BC, SCRN
Nurse Practitioner
Duke University Hospital
Durham, North Carolina Dizziness
Candace Currie Harrington, PhD, DNP, APRN, AGPCNP-BC, CDP
Clinical Professor
East Carolina University
Greenville, North Carolina Heart Failure
Melodee Harris, PhD, APRN, GNP-BC, AGPCNP-BC
Assistant Professor
University of Arkansas for Medical Sciences College of Nursing
Little Rock, Arkansas
Delirium; Dementia
Theresa C. Hollander, CRNP
Nurse Practitioner
Jefferson Health
Abington, Pennsylvania
Ischemic Heart Disease
Shelly Jesberger, MSN
Nurse Practitioner
Veterans Health Administration Cleveland, Ohio
Hemoptysis
Carol G. Kelley, PhD, AGPCNP-BC
Associate Professor
Frances Payne Bolton School of Nursing, Case Western Reserve University Cleveland, Ohio
Falls
Nanette LaVoie-Vaughan, ANP-C, DNP
Nurse Practitioner
Geriatric Neuropsychiatry Services
Raleigh, North Carolina
Agitation; Constipation; Failure to Thrive
Sheree L. Loftus, PhD, MSN, APRN-BC
Nurse Scientist
Mount Sinai Union Square
New York, New York Investigator
CHEAR Center
Bronx, New York
Parkinson’s Disease; Restless Legs Syndrome
William J. Lorman, JD, PhD, MSN, PMHNP-BC, CARN-AP
Vice President & Chief Clinical Officer
Livengrin Foundation
Bensalem, Pennsylvania
Alcohol Abuse; Prescription Drug Abuse
Denise Lucas, PhD, FNP-BC, CRNP, FAANP
Chair, Advance Practice Programs
Duquesne University
Pittsburgh, Pennsylvania
Benign Prostatic Hyperplasia; Drug-Induced Impotence; Prostate Cancer; Prostatitis
Rhonda W. Lucas, MSN, AGNPC
House Calls Provider
Optum
United Healthcare
Reidsville, North Carolina
Herpes Zoster
Donna Behler McArthur, PhD, FNP-BC, FAANP, FNAP
Adjunct Clinical Professor
Vanderbilt University School of Nursing
University of Arizona College of Nursing & Department of Neurology, College of Medicine
Tuscon, Arizona
Headache; Seizure Disorders
Sincere McMillan, ANP-BC
Nurse Practitioner
Memorial Sloan Kettering Cancer Center
New York, New York
Colorectal Cancer
Laurie Lovejoy McNichol, MSN, RN, CNS, GNP, CWOCN, CWON-AP, FAAN
Clinical Nurse Specialist, WOC Nurse
Cone Health
Greensboro, North Carolina
Pressure Injuries
Jennifer Mondillo, MSN, MBA, CRNP
Clinical Instructor
Villanova University
Villanova, Pennsylvania
Assessment of the Cardiovascular System
LaTroy Navaroli, DNP, FNP-BC, CWS
Nurse Practitioner Would Specialist
Navaroli Medical
Warren, Pennsylvania
Oral Nutritional Supplementation
D. Che Navey, A-GNP, MSN, RN
Neurohospitalist, Advanced Practice Clinician
Novant Health Presbyterian Medical Center
Charlotte, North Carolina
Tremor
Olivia Faith Ogburn, AGPCNP
Nurse Practitioner
Gastroenterology Oncology Clinic
Wake Forest Baptist Medical Center
Winston Salem, North Carolina
Gastric Cancer
Loretta Phillips, RN, NP-C, APRN, BC
Nurse Practitioner
Capital Nephrology Associates
Raleigh, North Carolina
Acute Kidney Injury; Chronic Kidney Disease
Sabrina Pickens, PhD, RN, ANP-BC, GNP-BC
Assistant Professor – Tenure Track, Faculty
University of Texas Health Science Center at Houston
Cizik School of Nursing Houston, Texas Elder Abuse
Allen V. Prettyman, PhD, FNP-BC, FAANP
Associate Professor – College of Nursing University of Arizona Tucson, Arizona Pulmonary Tuberculosis
Catherine R. Ratliff, PhD, GNP-BC, CWOCN, CFN Nurse Practitioner/Clinical Associate Professor, School of Nursing
University of Virginia Health System Charlottesville, Virgina Peripheral Vascular Disorders
Barbara Reall, MBA, MSN, CRNP
Senior Clinical Services Manager Optum Horsham, Pennsylvania Hypertension
Luann Richardson, PhD, DNP
Associate Professor
Robert Morris University Moon Township, Pennsylvania Anxiety; Bipolar Disorder
Lauren Robbins, DNP, APRN, GNP-BC Nurse Practitioner
Atlanta VA Healthcare System Decatur, Georgia Bowel Obstruction
Mary Ellen E. Roberts, DNP, APN-c, FNAP, FAANP, FAAN
Director – Doctor of Nursing Practice Program
Seton Hall University South Orange, New Jersey
Cardiac Arrhythmias; Myocardial Infarction
Barbara Rogers, CRNP, MN, AOCN, ANP-BC Nurse Practitioner Fox Chase Cancer Center Philadelphia, Pennsylvania Leukemias
Susan D. Ruppert, PhD, RN, FNP-C, ANP-BC, FNAP, FCCM, FAANP, FAAN
Professor, Associate Dean of Graduate Studies
Cizik School of Nursing at The University of Texas Health Science Center at Houston
Houston, Texas
Anemia of Chronic Disease; Anemia; Iron Deficiency
Valerie K. Sabol, PhD, ACNP-BC, GNP-BC, ANEF, FAANP
Professor and Division Chair, Healthcare in Adult Populations
Duke University School of Nursing
Adult Acute Care & Gerontology Nurse Practitioner
Department of Medicine, Division of Endocrinology, Metabolism and Nutrition
Duke University Medical Center
Durham, North Carolina
Obesity
Susan Kate Sandstrom, MSN, APRN-BC, ADCN Nurse Practitioner
University Hospitals, Seidman Cancer Center
Cleveland, Ohio
Oral Cancer
Jennifer Serafin, RN, BSN, MS, GNP-BC Nurse Practitioner
Kaiser Permanente
South San Francisco, California
Endometrial Cancer; Ovarian Cancer
Terri Setzer, NP-C
Nurse Practitioner
Reidsville Clinic for GI Diseases, Cone Health Medical Group
Reidsville, North Carolina
Nonalcoholic Fatty Liver Disease
Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAAN, FAANP
Clinical Associate Professor, Retired PMHNP Specialty Coordinator
University of Arizona, College of Nursing
Tucson, Arizona
Depression
Tracey Sherrod, MSN, ANP-C, GNP BC
Adult and Gerontological Nurse Practitioner
Vidant Healthplex
Wilson, North Carolina
Nephrolithiasis
Carroll M. Spinks, GNP-BC
Nurse Practitioner
Triad HealthCare Network
Greensboro, North Carolina
Corns and Calluses
David V. Strider, DNP, MSB, APRN, CCRN, ACNP-BC
Nurse Practitioner, Clinical Assistant Professor of Nursing
University of Virginia School of Nursing Charlottesville, Virginia
Peripheral Vascular Disorders
Ladsine Taylor, MSN, GNP-BC
Gerontology Nurse Practitioner Bill Hefner VA Medical Center Community Living Center
Salisbury, North Carolina
Peripheral Neuropathy
Barbara A. Todd, DNP, CRNP, FAANP, FAAN
Director, Graduate Nurse Education Demonstration
Hospital University of Pennsylvania Philadelphia, Pennsylvania
Valvular Heart Disease
Renee Walters, PhD, RN, CCRN, FNP-BC
Clinical Operations Manager, Clinical Associate Professor Boise State University Boise, Idaho
Restrictive Lung Disease; Immune Thrombocytopenic Purpura
Jennifer L. Warren, MSN, NP-C
Nurse Practitioner
Anticoagulation Clinic
Wake Forest Baptist Health
High Point, North Carolina
Pulmonary Embolism
Tomika Williams, PhD, AGPCNP-C
Assistant Professor of Nursing East Carolina University Greenville, North Carolina
Malnutrition
Colleen Wojciechowski, MSN, GNP-BC Nurse Practitioner, Retired Veteran Administration Durham Health Care System Cary, North Carolina
Cough
M. Catherine Wollman, DNP, GNP-BC, CRNP Consultant
Ponte Vedra, Florida
Chronic Illness and the APRN
Wendy Biddle, CFNP
Program Director MSN-FP program South University Savannah, Georgia
Joan Blum, MSN, APRN
Assistant Professor Clarkson College Omaha, Nebraska
Sharon Chalmers, PhD, CNE, APRN, FNP-BC
Professor of Nursing University of North Georgia Dahlonega, Georgia
Claudia M. Chaperon, PhD, RN, APRN, BC
Associate Professor College of Nursing University of Nebraska Medical Center Omaha, Nebraska
Reviewers
Valerie Flattes, APRN, MS, ANP-BC
Assistant Professor University of Utah Salt Lake City, Utah
Stacy Harris, DNP, APRN
Graduate Program Coordinator, Assistant Professor University of Central Arkansas Conway, Arkansas
Ann McDonald, DNP, MSN
Assistant Professor
Western Carolina University Cullowhee, North Carolina
Clarice Wasmuth, MSN, NP Professor
Georgia State University Atlanta, Georgia
The second edition of this book would not be a reality if not for the kind assistance and guidance of some wonderful people whom we would like to thank. To Susan R. Rhyner, our Senior Acquisitions Editor, who believed in the timeliness of updating this edition given the impact that the APRN consensus model for advanced practice registered nurses has on nursing education and practice with the required inclusion of gerontology and geriatrics for all advanced practice nurses taking care of older adults. To Christine M. Abshire, our Senior Content Project Manager, who kept us on track and provided us order. To Teresa Wilson for your quick turnaround editing and to Sharon Y. Lee, Daniel Domzalski, and
crew for carrying us over the finish line, without which we would not have completed the charge. To Ashleigh Lucas, Amy Daniels, and Tyesha Harvey who assisted in information retrieval, thanks for your timely research. We are most appreciative to our dedicated contributors who believe in the importance of creating a reference specific to the care of older adults written by advanced practice registered nurses. We also would like to acknowledge those who have contributed to our previous books. We especially want to thank Kathleen Ryan Fletcher for being a part of the journey over the past 20 years; your expertise and dedication to advanced practice gerontological nursing will not be forgotten.
Unit I
The Healthy Older Adult 1
CHAPTER 1 Changes With Aging 2
Fundamental Considerations 2
Physiological Changes With Aging 2
Laboratory Values in Older Adults 3
Presenting Features of Illness/Disease in the Older Adult 3
Chronic Illness and Functional Capacity 5
Summary 5
CHAPTER 2 Health Promotion 6
Primary, Secondary, and Tertiary Prevention 7
Healthy Lifestyle Counseling 7
Screening and Prevention 9
Immunizations 12
Travel and Leisure 12
Summary 17
Case Study 17
CHAPTER 3 Exercise in Older Adults 19
Available Resources 19
Barriers and Facilitators to Exercise for Older Adults 20
Plan for Incorporating Exercise into Patient Encounter 20
Key Guidelines for Safe Physical Activity (Physical Activity Guidelines Advisory Committee, 2008) 21
Summary 22
Case Study 23
Unit II
Assessment 25
CHAPTER 4 Comprehensive Geriatric Assessment 26
Physical Health 26
Functional Health 30
Psychological Health 31
Socioenvironmental Supports 32
Quality of Life Measures 32
Summary 32
CHAPTER 5 Symptoms and Syndromes 34
Assessment 34
Bowel Incontinence 34
Chest Pain 38
Constipation 41
Cough 43
Dehydration 46
Diarrhea 47
Dizziness 51
Dysphagia 53 Falls 55
Fatigue 57
Headache 59
Hematuria 63
Hemoptysis 65
Involuntary Weight Loss 67
Joint Pain 72
Peripheral Edema 74
Pruritus 77
Syncope 78
Tremor 81
Urinary Incontinence 83
Wandering 88 Case Study 90
Unit III
Treating Disorders 95
CHAPTER 6 Skin and Lymphatic Disorders 96 Assessment 96 Burns 97
Cellulitis 103
Corns and Calluses 104
Herpes Zoster 106
Pressure Injuries 109
Psoriasis 113
Skin Cancer 117
Superficial Fungal Infections 120
Case Study 125
CHAPTER 7 Head, Neck, and Face Disorders 127
Assessment 127
Cataract 128
Epistaxis 130
Glaucoma, Acute and Chronic 132
Glaucoma, Acute (Primary Angle-Closure) 132
Glaucoma, Chronic (Primary Open-Angle) 133
Hearing Loss 136
Hordeolum and Chalazion 138
Age-Related Macular Degeneration 139
Oral Cancer 141
Retinopathy 144
Rhinitis 146
Case Study 150
CHAPTER 8 Chest Disorders 152
Assessment of the Cardiovascular System 152
Assessment of Risk Factors for Coronary Artery Disease 152
Clinical Examination Features 153
Assessment of the Respiratory System 154
Asthma 155
Cardiac Arrhythmias 160
Chronic Obstructive Pulmonary Disease 164
Heart Failure 170
Hypertension 175
Ischemic Heart Disease 179
Lung Cancer 185
Myocardial Infarction 187
Pneumonia 191
Pulmonary Embolism 196
Pulmonary Tuberculosis 199
Restrictive Lung Disease 203
Upper Respiratory Tract Infection 205
Valvular Heart Disease 207
Case Study 211
CHAPTER 9 Peripheral Vascular Disorders 215
Assessment 215
Abdominal Aortic Aneurysm 216
Chronic Lymphedema 218
Peripheral Vascular Disease 219
Venous Disease (Chronic Venous Insufficiency) 221
Case Study 223
CHAPTER 10 Abdominal Disorders 225
Assessment 225
Acute Kidney Injury 226
Bladder Cancer 230
Bowel Obstruction 231
Cholecystitis 233
Chronic Kidney Disease 235
Cirrhosis of the Liver 239
Clostridium difficile 242
Colorectal Cancer 245
Diverticulitis 249
Esophagitis 251
Gastric Cancer 253
Gastritis 256
Gastroenteritis 258
Gastroesophageal Reflux Disease 260
Hernia 263
Irritable Bowel Syndrome 265
Liver Cancer 268
Nephrolithiasis 270
Nonalcoholic Fatty Liver Disease 272
Peptic Ulcer Disease 274
Case Study 276
CHAPTER 11 Urological and Gynecological Disorders 280
Assessment 280
Atrophic Vaginitis 282
Breast Cancer 284
Cystitis 289
Endometrial Cancer 292
Ovarian Cancer 293
Benign Prostatic Hyperplasia (Benign Prostatic Hypertrophy) 295
Drug-Induced Erectile Dysfunction 297
Prostate Cancer 299
Prostatitis 301
Case Study 303
CHAPTER 12 Musculoskeletal Disorders 305
Assessment 305
Bursitis, Tendinitis, Soft Tissue Syndromes 307
Fractures 310
Gout 312
Osteoarthritis 315
Polymyalgia Rheumatica 319
Rheumatoid Arthritis 322
Case Study 325
CHAPTER 13 Central and Peripheral Nervous System Disorders 328
Assessment 328
Brain Tumor 331
Parkinson’s Disease 333
Peripheral Neuropathy 336
Restless Legs Syndrome 344
Seizure Disorders 346
Stroke 352
Case Study 359
CHAPTER 14 Endocrine, Metabolic, and Nutritional Disorders 361
Assessment 361
Acute Pancreatitis 362
Chronic Pancreatitis 366
Diabetes Mellitus, Types 1 and 2 369
Failure to Thrive 377
Hyperlipidemia 379
Hyperthyroidism 384
Hypothyroidism 387
Malnutrition 389
Obesity 392
Osteoporosis 396
Pancreatic Cancer 402
Case Study 404
CHAPTER 15 Hematological and Immune System Disorders 407
Assessment 407
Anemia of Chronic Disease 408
Anemia, Iron Deficiency 410
Immune Thrombocytopenic Purpura (Idiopathic Thrombocytopenic Purpura) 413
Leukemias 414
Acute Lymphoblastic Leukemia 414
Acute Myeloid Leukemia 416
Chronic Lymphocytic Leukemia 419
Chronic Myeloid Leukemia 423
Case Study 426
CHAPTER 16 Psychosocial Disorders 428
Assessment 428
Agitation 429
Alcohol Misuse (Hazardous or Risky Drinkers) 431
Anxiety 434
Bipolar Disorder 436
Delirium 439
Dementia 443
Depression 451
Elder Abuse 456
Grief and Bereavement 459
Insomnia 461
Prescription Drug Misuse (Hazardous or Risky Users) 463
Case Study 466
Unit IV Complex Illness 469
CHAPTER 17 Polypharmacy 470
Pharmacokinetic/Pharmacodynamic Changes 470
Tools to Assist Providers to Avoid PIMs and Polypharmacy 472
Preventing Polypharmacy, Addressing Polypharmacy 472
CHAPTER 18 Chronic Illness and the APRN 474
Definitions of Chronic Disease and Chronic Illness 474
Demographics of Chronic Illness 474
Multiple Chronic Conditions 475
Economic Burden of Chronic Disease 477
Minorities and Chronic Disease 478
Function and Frailty 478
Evidence-Based Practice and Chronic Disease 479
Chronic Care Model of Quality Improvement 479
Legislation and Chronic Disease 480
Transitions of Care 480
Provider Reimbursement for Chronic Illness Care 482
The Role of APRNs in Chronic Disease 482
Case Study 483
CHAPTER 19 Palliative Care and End-of-Life Care 485
Overview of Palliative Care 485
Symptom Management 486
Delirium 486
Dyspnea 488
Pain 490
The Dying Patient 493
Grief and Bereavement 496
Case Study 497
Changes With Aging
LaurieKennedy-Malone
FUNDAMENTAL CONSIDERATIONS
The aged population continues to be incredibly diverse; it includes some individuals who are nearly twice as old as others and is reflective of growing cultural diversity as well. Knowing what is expected in aging, what diseases are prevalent in aging, and what constitutes successful aging is an immense challenge even for the most skillful advanced clinician. When assessing the aged individual, the advanced practice nurse should be familiar with the range of normal and expected changes associated with aging so that older persons falling outside this range may be identified and interventions taken appropriately and expeditiously.
In the past, wellness was considered the mere absence of disease, but with more information from longitudinal studies of aging, we are learning a great deal about the characteristics of successful physiological and psychosocial agers (O’Brien et al., 2009). A profile of what constitutes successful aging is beginning to emerge, and the illness–health continuum continues to expand to include adults living into old age. This chapter focuses on familiarizing the advanced practice nurse with fundamental underpinnings that serve to guide the approach to assessment and management of the older adult. In addition to appreciating the physiological changes that come with aging, the advanced practice nurse needs to understand how aging changes influence reference laboratory values. Recognizing that presenting features of disease/illness may be different and having a greater awareness of the impact of chronic illness on functional capacity and quality of life provide the advanced practice nurse with a perspective in approaching the older adult that is different from that of younger adults.
PHYSIOLOGICAL CHANGES WITH AGING
The physiological changes associated with the usual aging process have been detailed by system, and the impact of these changes has been described. (These can be found in Appendix
A.) Although Appendix A uses a single-system approach, the clinician must be aware that all the systems interact and, in doing so, can increase the older person’s vulnerability to illness/disease. For example, the risk of respiratory infection in the geriatric population is considerable, and the physiological influences may include limited chest wall expansion, cilia atrophy, and alterations in the immune system. During the clinical decision-making process, the clinician knowledgeable about physiological changes with aging will be less likely to undertreat a treatable condition. For example, the astute clinician will use the diagnostic process to differentiate the more benign seborrheic keratosis from the more serious melanoma in the aged individual. While educating the older patient, the informed professional will be less likely to attribute a finding to the aging process alone. When clinicians associate findings to aging alone, the older person may conclude that there is no point in changing behavior because the process is inevitable. Additionally, the clinician may take a fatalistic approach and undertreat common conditions such as heart failure and diabetes.
The major impact of these physiological changes can be highlighted with four primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there are the changes in the sympathetic response, which contribute to orthostasis and falls, as well as lack of hypoglycemic response. Fourth, there is impaired immunological function: infection risk is greater and autoimmune diseases are more prevalent. The clinician is advised not to be complacent in that some processes previously considered normal, age-related changes are now being refuted. Historically, normal aging studies were conducted using a cross-sectional study method. Today, results are becoming increasingly available from longitudinal studies of aged populations, some of which began in the 1930s (Besdine, 2016; O’Brien et al., 2009).
This more reliable methodology provides some challenges to previously held conclusions. The clinician is encouraged to stay informed regarding the research in expected and successful aging so that this information may be carefully
considered, interpreted, and translated quickly into the clinical setting.
LABORATORY VALUES IN OLDER ADULTS
Healthy individuals of all ages often have asymmetrical distribution of test results. Normality in a statistical sense may be extrapolated incorrectly to normality in terms of health. In addition, the standards previously available to the healthcare worker with which to compare normal laboratory values have been based on randomly collected samples of younger healthy adults. Many factors can influence laboratory value interpretation in the older adult, including the physiological changes with aging, the prevalence of chronic disease, changes in nutritional and fluid intake, lifestyle (including activity), and the medications taken (Dharmarajan & Pitchumoni, 2012).
Clinicians may find that reference ranges, therefore, may be preferable. Reference ranges or intervals, such as age, sex, or race, can be defined demographically. For example, the reference range for older adults might be the intervals within which 95% of persons over age 70 fall. These may be further defined physiologically (e.g., fasting or activity status) or pharmacologically (e.g., medication, tobacco or alcohol use). Even this more precise method does not ensure a healthy sampled population as the standard, and using the reference range method may not differentiate normal aging from disease. The reference values presented for the older adult cohort (see Appendix B) are not necessarily desirable ones. Longitudinal chemical studies support the concept of biochemical individuality; that is, each individual’s variation is often much smaller than that of the larger group. Biochemical individuality is of particular importance in detecting asymptomatic abnormalities in older adults. Significant homeostatic disturbances in the same individual may be detected through serial laboratory tests, even though all individual test results may lie within normal limits of the reference interval for the entire group.
The clinician must determine whether a value obtained reflects a normal aging change, a disease, or the potential for disease. Although abnormal laboratory findings are often attributed to old age, rarely are they true aging changes. Misinterpretation of an abnormal laboratory value as an aging change can lead to underdiagnoses and undertreatment in some situations (e.g., anemia or urinary tract infection) and overdiagnosis and overtreatment in others (e.g., hyperglycemia or asymptomatic bacteriuria). At times, the result of a laboratory value may be within the appropriate reference range, yet indicate pathology for the older adult (Dharmarajan & Pitchumoni, 2012). The serum creatinine level may be within the normal range, yet indicate renal impairment in a patient with inadequate protein stores, and different measures might need to be considered. One value of significance to the practitioner with prescriptive privileges is the calculation of creatinine clearance in the estimation of renal function, for instance when dosing enoxaparin (Shaikh & Regal, 2017).
Reduced renal function, particularly the glomerular filtration rate (GFR), affects the clearance of many drugs, and
creatinine clearance provides an index of renal function for use in choosing doses of renally eliminated or nephrotoxic drugs (such as digoxin, H2 blockers, lithium, and watersoluble antibiotics). The Modification of Diet in Renal Disease (MDRD) and Cockcroft-Gault equations both provide useful estimates of the GFR (Boparai & Korc-Grodzicki, 2011). The performance of these two formulas was compared in an older adult population, and the Cockcroft-Gault formula was found to be inferior to the MDRD equation; however, the MDRD equation is not as practical and is more complex to use (Fliser, 2008). The use of serum drug concentration measurements (where these are available) or timed urine specimens is recommended until more acceptable methods of calculating renal function in this population become available.
Finally, when considering which laboratory tests to order, it is worth remembering the doctrine primum non nocere, to do no harm. Excessive blood sampling may lower the hematocrit; repeated fasting tests may provoke nutritional compromise; and extensive use of tests often requires drugs that may cause adverse reactions. Any risks involved in laboratory testing must be considered with respect to the patient’s clinical condition and weighed against the test’s expected benefits. The clinician should plan in advance the use for each test result value obtained, especially for less specific or less sensitive tests such as sedimentation rate and serum alkaline phosphatase levels. “Ordering a test requires assessing the likelihood that a patient has specific conditions prior to the order, along with the accuracy of test and as to how it will change management” (Dharmarajan & Pitchumoni, 2012, p. 267). Once laboratory tests are available for review, test results should be discussed with the patients, with abnormal test results interpreted for the aging individual and addressed with the patient and/or caregivers. In addition to understanding the fundamental changes that accompany aging and their influence on interpreting laboratory values and medication management, the advanced practice nurse needs to understand the presenting features of illness/disease in older adults (Dharmarajan & Pitchumoni, 2012).
PRESENTING FEATURES OF ILLNESS/DISEASE IN THE OLDER ADULT
The manifestations of illness and disease in the older adult can be very different, even if the underlying pathological process is the same as in younger individuals. The advanced practice nurse should be aware of what can influence the presentation. Underreporting of symptoms by older adults may occur if they attribute the new sign or symptom to age itself (Amella, 2004). By erroneously associating aging with disease, disuse, and disability, older adults perceive this change as inevitable and either fail to present to the health-care provider or, if they do, fail to challenge the assumption that this represents normal aging. At times an acute symptom such as pain or dyspnea is superimposed on a chronic symptom, and the older adult may not recognize that it represents a new or exacerbated pathology (Bell et al., 2016). The advanced practice nurse is well advised to never attribute something to normal aging without doing a careful and methodical search for a treatable condition.
Certain diseases are more common in the older adult and an understanding of the epidemiology is critical in the interpretation. Certain neoplasms and malignancies such as basal cell carcinoma, chronic lymphocytic leukemia, and prostate cancer have a high prevalence beginning in older adulthood. Neurological conditions such as Parkinson’s disease, dementias, stroke, and complex partial seizures are more common to have initial onset in older age. Polymyalgia rheumatica along with giant cell arteritis almost exclusively begins in patients over the age of 50 (Besdine, 2016).
Complicating the care of older adults is when patients develop geriatric syndromes that often involve multiple body systems and have more than one underlying cause (Bell et al., 2016). For patients presenting with one or more of new geriatric giants: frailty, anorexia of aging, sarcopenia, and cognitive impairment, the risk escalates for falls, delirium, injuries, and depression, subsequently placing these patients at dangers for iatrogenic events that could lead to hospitalization, institutionalization, and subsequently, death (Morley, 2017).
Altered Presentation of Illness
Advanced practice nurses managing the care of older adults are challenged to recognize altered, atypical, vague, or even nonspecific signs and symptoms of common conditions in older adults (Auerhahn & Kennedy-Malone, 2010). It is well documented that disease progress may be different for the older adult, especially the frail older adult (Bell et al., 2016). The failure to develop an elevated temperature or fever with an underlying infectious process differs greatly from presentation of illness in a younger patient. The patient with depression may not present with a dysphoric mood but rather agitation and psychotic features. The older adult may present with cardiac manifestations of undiagnosed thyroid disease (Amella, 2004). Additional illustrative examples include jaundice, which is suggestive of viral hepatitis in younger individuals but may represent gallbladder disease or a malignancy in the older adult, and delusions or hallucinations, which are suggestive of bipolar disorder in younger individuals but may represent dementia or medication side effects in the older adult (Williams, 2008).
Because the symptoms or signs of illness or disease may be vague and nonspecific, even a modest change in functional level or behavior should alert the clinician to carefully explore the potential for a treatable condition. Family members or caregivers may report that a patient may no longer be cooperating or participating in individual care. Unusual changes such as these become red flags to the beginning of an atypical presentation of illness. In many cases the progression of the condition is insidious, often presenting as a change in cognition or an alteration in functional status. Other significant changes in patients with altered presentation of illness often include new onset of falls, weakness, fatigue, anorexia, and unexplained tachypnea (Auerhahn & Kennedy-Malone, 2010). Table 1-1 depicts common conditions that often have altered presentation of illness in older adults.
Bimodality of Age of Onset of Clinical Conditions
Understanding of the epidemiology of clinical conditions includes having the knowledge of etiology of the disease,
Presentation of Illness in Older Adults
ILLNESSATYPICAL PRESENTATIONS
Acute abdomenAbsence of symptoms or vague symptoms
Acute confusion
Mild discomfort and constipation
Some tachypnea and possibly vague respiratory symptoms
Appendicitis pain may begin in right lower quadrant and become diffuse
DepressionAnorexia, vague abdominal complaints, new onset of constipation, insomnia, hyperactivity, lack of sadness
HyperthyroidismHyperthyroidism presenting as “apathetic thyrotoxicosis,” i.e., fatigue and weakness; weight loss may result instead of weight gain; patients report palpitations, tachycardia, new onset of atrial fibrillation, and heart failure may occur with undiagnosed hyperthyroidism
HypothyroidismHypothyroidism often presents with confusion and agitation; new onset of anorexia, weight loss, and arthralgias may occur
Malignancy
Myocardial infarction (MI)
Overall infectious diseases process
New or worsening back pain secondary to metastases from slow growing breast masses
Silent masses of the bowel
Absence of chest pain
Vague symptoms of fatigue, nausea, and a decrease in functional and cognitive status; classic presentations: dyspnea, epigastric discomfort, weakness, vomiting; history of previous cardiac failure
Higher prevalence in females versus males
Non-Q-wave MI
Absence of fever or low-grade fever
Malaise
Sepsis without usual leukocytosis and fever
Falls, anorexia, new onset of confusion and/or alteration in change in mental status, decrease in usual functional status
Peptic ulcer disease
Absence of abdominal pain, dyspepsia, early satiety
Painless, bloodless
New onset of confusion, unexplained tachycardia, and/or hypotension
PneumoniaAbsence of fever; mild coughing without copious sputum, especially in dehydrated patients; tachycardia and tachypnea; anorexia and malaise are common; alteration in cognition.
Pulmonary edemaLack of paroxysmal nocturnal dyspnea or coughing; insidious onset with changes in function, food or fluid intake, or confusion
Tuberculosis (TB)Atypical signs of TB in older adults include hepatosplenomegaly, abnormalities in liver function tests, and anemia
Urinary tract infection
Absence of fever, worsening mental or functional status, dizziness, anorexia, fatigue, weakness
Source: Amella, E. J. (2004); Bell et al., 2016; Besdine (2016); Chmura & Chan (2006); Peters (2010); Rehman & Qazi (2013); Rowe & Juthani-Mehta, M. (2014); Van Duin (2011); Wester, Dunlop, Melby, Dahle, & Wyller (2013); Williams (2008).
TABLE 1-1
Dermatological
Psoriasis
Gastrointestinal
Select Bimodal Presentations of Illness in Younger Adults versus Older Adults
Inflammatory bowel disease
Ulcerative colitis (UC)
Crohn’s disease (CD)
Malignancies
Hodgkin’s lymphoma
Neurodegenerative
Myasthenia gravis (MG)
Late teens to 20s
Irregular course which tends to generalize
Hereditary factors
20–40 years old
Right lower UC
Insidious onset
20–30 years old
Possible infectious etiology
Women 20–40 years old
More thymus abnormalities
50s—males
60s—females
Sporadic onset
>60–75 years old a second peak occurs
More often older women
Proctitis
Left-sided UC
Higher rates of anemia
May present as chronic diarrhea
Fistula development
Increased cases of associated malnutrition
Extraintestinal manifestations including: arthritis spondylitis, uveitis, and erythema nodosum
More comorbid conditions
May be confused with other forms of colitis
>50 years old
Increased mortality
Men—50–70 years old
Women—70 years old
Dysphonia
More frequent ocular form MG
Increased rate of AChR seropositivity
Source: Alkhawajah & Oger (2015); del Val (2011); Henseler & Christophers (1985); Louis & Dogu (2007); Montero-Odasso (2006); Shenoy, Maggioncalda, Malik, & Flowers (2011); Smith (2013); Smith, Kassab, Payne, & Beer (1993); Wester, Dunlop, Melby, Dahle, & Wyller (2013); Woon & Lim (2003); Živković, Clemens, & Lacomis (2012).
prevalence and incidence rates, risk factors, age of onset, and gender distribution. There are a number of conditions that are known or suggested to have a bimodal age of onset. In some conditions the difference is not only the decade(s) in life that the disease more likely presents but the dominance of the gender that the condition presents. Myasthenia gravis is one condition that tends to present initially in younger females, with a preponderance in older males (Alkhawajah & Oger, 2015).
Often the presentation of the same illness is different for older adults as compared to their younger counterparts. The onset of the condition may be acute versus progressive, with different symptomatology and clinical signs. For instance, in patients with late onset rheumatoid arthritis the joint involvement is more often in the larger joints such as the shoulder and they experience constitutional symptoms such as fever, malaise, weight loss, and depression (Evcik, 2013).
Knowledge of the bimodality of age onset of certain disease conditions will aid the advanced practice nurse in avoiding misdiagnosis or delay in diagnosis due to lack of recognition. Table 1-2 describes medical conditions that present differently in younger versus older adults.
CHRONIC ILLNESS AND FUNCTIONAL CAPACITY
Approximately 80% of those 65 or older have one chronic disease, and 50% have two or more. The most common of these are related to heart disease, arthritis, respiratory problems, cancer, diabetes, and stroke (U.S. Department of Health
and Human Services [USDHHS], Centers for Disease Control and Prevention [CDC], 2010). Treating patients with multimorbidities can be very complex and can result in polypharmacy. Patients with multimorbidities are known to have a treatment burden in terms of understanding and self-care management of their conditions. This burden entails not only patients managing the conditions but attending multiple appointments and comprehending and affording complex drug regimens (Wallace et al., 2015).
These conditions often impair functional capacity and limit the person’s ability to perform activities of daily living (ADLs) such as bathing and dressing, and instrumental activities of daily living (IADLs) such as managing medications and traveling. More than 25% of community-dwelling Medicare beneficiaries report difficulties performing ADLs, and 14% report difficulties performing IADLs (USDHHS, Administration on Aging [AOA], 2010).
SUMMARY
■ Assessment and management of older adults is different from that of younger adults, and it is of critical importance that the advanced practice nurse working with the older adult has the knowledge, skill, and ability to recognize these differences and take them into consideration. This chapter highlighted how the approach of the clinician might be different based on an understanding of the physiological changes of aging and the impact of these changes on medication management and laboratory interpretation; how the presenting features of disease and illness may be different in the older adult; and how the older adult are disproportionately affected with chronic disease and functional impairments.
