nursing.elitecme.com Page 89 Complete Your CE Test Online - Click Here ● ● Increase in pain threshold. ● ● Increase in incidence of physiologic tremor. ● ● Increased reaction time. ● ● Decrease in thermal sensitivity between warm and cool. ● ● Sleep disturbances become more common including insomnia and loss of REM sleep. ● ● Incidence of mood disorders and depression increase. Normal age-related changes may mimic pathological changes. It is important to be able to distinguish between “normal” changes and pathology. Here is information about some common diseases of the nervous system seen in older adults so that nurses can quickly recognize their onset and intervene promptly. Parkinson’s disease Parkinson’s disease is a chronic, progressive disease characterized by progressive muscle rigidity, involuntary tremor, akinesia, and dementia. Complications include aspiration pneumonia, infection, injury from falls, urinary tract infections, and compromised skin integrity. Parkinson’s disease in found in two out of every 1,000 people. It usually develops after the age of 50, but can occur in children and young adults. Parkinson’s disease rates are similar in all ethnic groups, and is found equally in males and females. It is estimated that about 60,000 new cases of Parkinson’s disease are diagnosed every year in the U.S. [9,13]. Nursing consideration: Parkinson’s disease may eventually progress to Parkinson’s disease with dementia. Thus nurses must be prepared to care for older adults who exhibit symptoms of both diseases including memory disorders and movement problems [9]. The cause of Parkinson’s disease is not known, but research suggests that exposure to environmental toxins or a genetic predisposition may play significant parts in its development. Studies of the pathophysiology of the disease show that a dopamine deficiency inhibits the affected brain cells from functioning normally [13]. Parkinson’s requires the presence of two of the following: rest tremor, bradykinesia or rigidity. Other symptoms include: slight shaking or tremor in your finger, thumb, hand, chin or lip; handwriting getting much smaller than previously; loss of smell for certain foods (especially bananas or dill pickles); sudden movements during sleep; stiffness in body, arms or legs; or a serious-looking face, called masking. Usually it is noted that the patient does not blink often or has a blank stare. There are no definitive diagnostic tests. Diagnosis depends on age, history, and presenting signs and symptoms [9,14]. Nursing assessment may be critical to the diagnosis of this and other neurologic diseases that occur in the older adult. There is no cure for Parkinson’s disease. Treatment focuses on symptom relief and maximizing function for as long as possible. Treatment generally includes levodopa (a dopamine replacement), physical therapy, and, in very severe cases, stereotactic neurosurgery or the controversial treatment of fetal cell transplantation [13]. Nursing consideration: Dosages of anti-Parkinson drugs may need to be decreased in older adult patients because of an inability to tolerate higher doses of such medications. Patients and their families must be taught to recognize medication side effects such as orthostatic hypotension, irregular heartbeats, anxiety, and/or confusion [13]. Transient ischemic attack (TIA) or “mini-stroke” Mrs. Stevens is 80 years old and she lives with her husband, who is 81 and dealing with prostate cancer. During an appointment with his oncologist, Mr. Stephens tells the nurse practitioner that he is worried about his wife. He says, “I think there might be something wrong with my wife. Sometimes she acts like she doesn’t know what’s going on. Her speech gets really funny, and she can hardly walk. It only lasts for a few minutes, and then she is OK. But I don’t think this is good.” Mr. Stephens is right to be concerned about his wife. Transient ischemic attack (TIA), often referred to as a “mini-stroke,” is a neurologic deficit caused by a microemboli or a thrombus that temporarily interrupts blood flow (less than 1 hour) in cerebral circulation. This interruption causes symptoms that correlate with the area of the brain affected and may include double vision, slurring speech, trouble walking, falling, and dizziness. The effects last up to an hour and resolve spontaneously. There are not permanent changes from TIAs, but their occurrence is considered to be a warning sign of impending stroke. If neurologic symptoms continue for more than 24 hours, the patient is diagnosed as having had a stroke. Neurologic deficits that resolve before 24 hours are diagnosed as TIA. The incidence of TIA increases significantly after the age of 50 and is greatest among men, African-Americans and Hispanics [9,13]. EBP alert! TIAs have been reported in 50% to 80% of patients who have had a stroke [13]. Thus the occurrence of TIAs indicates a need for meticulous assessment and risk factor management to prevent the occurrence of a stroke. Cerebrovascular accident (CVA) (ischemic stroke) Stroke is an abrupt impairment of cerebral circulation. This impairment interrupts the flow of oxygen to the brain, which can cause serious damage to brain tissue. Depending on the location and extent of damage, the patient can be left with serious disabilities that may affect all aspects of daily living [13]. Risk factors for stroke include [9,13]: ● ● Smoking, this is the number one preventable risk factor. ● ● Hypertension, this is the number one risk factor. ● ● Diabetes mellitus. ● ● Cardiac disease, especially AFib or patent foramen ovale. ● ● Lack of sufficient exercise. ● ● Overweight or obesity. ● ● Elevated cholesterol. ● ● Race. ● ● Family history. There are three major types of stroke [9,13]: ● ● Thrombosis: This is the most common cause in middle-aged and older adults. Thrombosis causes ischemia in brain tissue affected by diminished circulation. ● ● Embolism: Emboli occlude blood vessels due to fragmented clots, tumor, fat, or air. These emboli usually come from a cardiac site, i.e. atrial fibrillation. ● ● Hemorrhage: Hemorrhage is due to a sudden rupture of a cerebral artery (aneurysm) and are usually due to uncontrolled hypertension. Signs and symptoms depend on the location of the stroke and may include: cognitive deficits: weak or flaccid extremities; sensory changes noted on the body; vision disturbances, headaches; and difficulties speaking or understanding [13]. The sooner the patient receives emergency medical intervention, the better the outcome. Emergency administration of medications includes [13]: ● ● Tissue plasminogen activator (tPA) can be used to dissolve clots in non-hemorrhagic stroke. It must be administered within three hours of symptom onset. ● ● The antiplatelet drug ticlopidine may be effective in preventing stroke and in reducing the risk for future strokes in patients who have already suffered one. ● ● Corticosteroids may be administered to reduce cerebral edema and anticonvulsants given to prevent seizures. Patients will need long-term follow-up and rehabilitation. Measures to reduce the risk for stroke include [13]: ● ● Participation in a regular exercise program. ● ● Smoking cessation.