Final Notes J s

8/19/2019 Final Notes J s

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Moral Development in Younger Adults

• According to Kohlberg, your response to moral dilemmas reversals yourstage of moral development, as well as your level of CD

• Kohlberg proposes a 3-level seuence, subdivided into ! stages"# $reconventional morality %external authority &• $eople who act in this level are doing it to please others or to avoid

punishment# Age varies, and some people might do things for self-interest

• Stage 1: obey rules to avoid punishment

• Stage 2: obey rules to earn rewards"# Conventional level

• Stage 1: good behaviour pleases other people

• Decisions and behaviour bases on concerns about the reactions ofothers %external authority &

• '()ll do something because it will please you or because it is e*pected+

• Capable of empathy

• Stage 2: integrates norm of larger reference groups• beys law because it is the lawrespects authority %external authority &

• .egal / right0 illegal / wrong

• '()ll do it because it is the law and my duty+"# $ostconventional level• Designing own principles for living

• Stage 1: self-chosen principles %inner authority &

• 1ocial contract focusorientation

• 2enerally, adheres to social laws to ensure fairness

• ut laws can be ignored or changed as people)s needs change %e#g#,will change practice based on new evidence& %relativistic view&

• 2oes beyond views about speci4c social order0 designs universalprinciples about 5ustice, euality, and human rights

• '()ll do something because it is morally and legally right, even if it isnot popular with the group#+

• 6pholding the law is important, but will brea7 it when doing so servesthe common good %e#g#, civil disobedience&

• Stage 2:

• Assumes personal responsibility based on fundamental and universalethical principles %inner authority &

• 1till operates in stage ", but incorporates in5ustice, pain, and death asintegral parts of life

• '()ll do something because it is morally, ethically, and spiritually right,even if it is illegal and ( get punished and even if no one elseparticipates+

• $ost-conventional reasoning is relatively rare

Causes and Conseuences of Moral Development

• 8he decline of egocentrism as people move through $iaget)s concreteand formal operational stages is 7ey in moral reasoning


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• 9#g#, greater ability to understand another person)s view is lin7ed tohigher moral reasoning

• Also, the development of moral reasoning reuires support from thesocial environment %e#g#, from parents 9*, giving up seat to someonewho is pregnant or older, holding the door open for someone#Consideration of others0 being a moral agent, less egocentric

• Kohlberg)s 4ndings based on :estern cultures and largely from boys

ronfenbrenner

• ; moral orientations, based on a person)s conte*t %vs stages&

• $erson may move forward and bac7ward, depending on

• Culture

• 9*posure to di# Cognitive %e#g#, identity&3# 9motional %e#g#, self-esteem&?# 1piritual %e#g#, lin7 with higher purpose&0 what is fundamentally

important to you in life


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1ome actors that may (nuence 1C

• 1ocial environment, e#g#,

• egative= poverty, dysfunctional parenting, loss of parent, lac7 ofeducation, parental literacy

• $ositive= stable home, sports, academic success, praise, support

• Eeactions of others that you internalize: there are so many socialfactors telling us what to do, how we should act0 but you are you, beyourself

• 1elf-e*pectations %9llis @ irrational ideas&

• $erceived abilities

• Attitudes

• Fabits

• Knowledge

• ther characteristics

ody (mage %(&

• 8he physical dimension of 1C

• Fow person perceives their physical self

• ( includes the person)s=

• 1urface, internal, and postural picture of body

• Galues, attitudes, emotions, and personality reactions in relation tobody

• (=

• 1hifts %constant revision&

• May not reect actual body structure

• (n adults, is a social creation

actors that may aI;I @ Middle Adulthood Jctober >I, >I"?


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Cohort 9


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• Gerbal ability, increases until around ?I years, and then stays fairlysteady

1trategies that 9*perts 6se to Maintain Figh-$erformance

• 1elective-optimiation %concentrate on particular s7ills to compensate

for losses in others&• Eely on e*perience and intuition

• ften0

• end rules- to advocate for the client %vs# eginners who= use formalprocedures and rules&

• $rocess information automatically, without much thought %8acit,proceduralied&

• Design better solutions and are more e*ible in solving problems

Declarative intelligence= tal7ing through procedures etc#

$rocedural intelligence= going through procedure automatically

Memory

• 3 seuential components"# 1ensory># 1hort-term %or wor7ing&3# .ong-term

• 1ensory and short-term are maintained in middle adulthood

• .ong-term declines for some people, due to less eciency inregistering, storing, and retrieving information

• ut, memory, declines are relatively minor and most can becompensated for

enign orgetfulness= harmless forgetfulness0 9*# 2o into a room and forgetwhy you went in there etc# 1ometimes due to multi-tas7ing

>I;I Jctober >N, >I"?

Ored is added information- from her mouth directlyO

Many Middle Aged adults use memory shortcuts, called schemas, to ease theburden of remembering everything each day

• 1chema @ an organied body of information stored in memory

• $ac7age information together @ you redo your schemas every time youget a new schedule

• M-A people have schemas for

• $articular individuals %e#g#, mother, child&

• Categories of people %e#g#, Es, engineers&

• ehaviours or events %e#g#, eating in a restaurant&

1chemas help people to


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• rganie their behaviour into coherent wholesrepresent how theirworld is organied#

• (nterpret social eventscategorie and interpret new info

• or e*ample, how we are interpreting what happened in ttawa%shooting&, we are trying to ma7e sense of what happened#

•

Convey cultural information

Eesearch about adult cognition

• Most studies cross-sectional %vs# longitudinal&

• 8hus, many factors other than age have a


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• 3 ma5or conseuences of stress"# $hysiological= elevated $, decreased immune function, increased

hormonal activity, psycho physiological># Farmful behaviours= increased use of nicotine, more use of booe,

younger girls are more into the coloured vod7as or the coloured drin7s,drug use, decreased nutrition, decreased sleep

3# (ndirect health-related behaviours= not adhering to health care advice%'o, ( am not going to do that+&, might not see7 health care as uic7lyas they should due to stress,

• 1ympathetic= :hen you)re scared you are counting on your heart,respiratory, blood pressure is going faster, pupils dilate,

• $arasympathetic= body focus) on digestion and normal day-to-daythings

• Gagus nerve= will slow your pulse down, if you give too much digo*inthe pulse will slow way down and it)ll put the heart in failure#

• $ost-traumatic stress= adults who were in the military, people who havelost family members, devastating conseuences, ebola, E)s who

wor7ed on units with children who have serious illness often changetheir 5obs, physician who is called down to e*amine someone who hasbeen in a car accident %only physician in town&0 only to 4nd out it washis son#

Coronary heart disease

• 2enetic disposition, and environment and lifestyle factors @ also se*and age

• Country-to-country variations in incidence

• ehaviour %on a continuum&

• 8ype A %tendency towards frustration and hostility, driven to

accomplish, engage in polyphasic %multi-tas7ing&,easily angered, hasmore stress, and e*cessive arousal& versus 8ype %non-competitive,more patient, lac7 aggression, have less sense of time urgency @ timeisn)t as important to them, rarely hostile&

• $eople are not usually one way or the other, they may be closer to oneend

• 8ype A %versus 8ype & men have >* the rate of coronary heart disease,more fatal heart attac7s, and ;* as many heart problems

• 8he 7ey component that lin7s 8ype A and heart disease is hostility# 8ype A doesn)t cause heart disease, but it is somehow lin7ed to heartdisease

• 8ype A @ wear-and-tear theory= it is hard on people

$ersonality Development

• > perspectives"# ormative-crisis %e#g#, 9ri7 9ri7son& @ 9ri7son says there are stages we

go through %the Q stages of man&

• 1ays that each stage is associated with a crisis"# .ife events= the timing of events shape our personality


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• All theorists agree that MA is a time of continuing and signi4cantpsychological growth

• ther perspectives=

• Gaillant= B 7eeping the meaning) %vs# Eigidity&

• .evinson= Bseasons of your life) midlife transition %a time of

uestioning& and midlife crisis %time of uncertainty, they may haveaccomplished less than they thought&%yet, the evidence of universalityis lac7ing&

1tability versus change in personality=

• 9ri7son and .evinson say there is substantial change

• ther research suggests stability and continuity

• 8he Bbig ;) personality traits"# euroticism= degree to where we are an*ious, moody,># 9*troversion= are we e*traverted or introverted3# penness= how curious are weR

?# Agreeableness= how easy going and helpful are weR;# Conscientiousness= how organied and responsible are weR• Although there are some variations in speci4c traits %"-3 decline0 ?L;

increase&, the basic pattern is stability in these traits

9motional development in MA

• 1elf-assess and greater introspection

• Appraise achievements against goals and values

• Eealies

• Fow past choices limited present choices

• 8hat time is 4nite

Development crisis %9ri7son&= generativity vs# 1elf-absorption and stagnation

• Characteristics of generativity

• 9ual concern for others and self

• 1ense of parenthood and creativity

• 2uiding %e#g#, the ne*t generation, the arts, a profession&

• eels important to the welfare of human7ind

• 1elf seems less important

• 1ervice, love, and compassion gain new meaning and drive actions

• Comfort in lifestyle

•

2rati4cation from 5ob well done• Accepts self and body

• 1incere, mature 5udgement0 empathy

• 1table values that spur reection and caution

G9E161

• Characteristics of stagnationself-absorption

• Eegressed behaviour


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• Fates aging body

• eels insecure, in-adept in handling self

• (mpairedless socially organied intellectually s7ills and values

• (ntellectual s7ills fused by emotions

• 1ee7s private self-absorption and vicarious immersion in problems of

others• 8hese methods of coping maynot wor7

Moral Development in MA

• (ncreases whenever we e*perience sustained responsibility for others

• MA, if lived generativity, provides this e*perience

• Consistent commitment to ethical application of higher principles

• .evel of cognitive development sets upper limits for moraldevelopment, for e*ample,

• (f stays in concrete operations of cognitive development, will unli7elymove beyond conventional level of moral development %law and order

reasoning&, because post-conventional reuires in-depth understandingof events, along with critical reasoning ability

actors that May (nuence ody (mage in MA

• $hysical change

• :or7

• (llness or death of others

• Concern about health

• ear of aging

• eliefs %e#g#, youth is best&

•

9


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• Corporate leaders= incorporating new s7ills and ventures# 9*#, Esgoing into wor7ing with architects to build 1enior homes

• 8he time spent in full-time wor7 has increased over the past >I years,leading to a decrease in leisure and in private life

• Fow we are connected to wor7

•

MA women wor7ing outside the home and thus 'in the middle+%sandwiched& in terms of demands on their time and energy

Marriage

• More singles today

• Coping mechanisms for successful marriages=

• Eealistic e*pectations of each other

• ocus on the positive about the partner

• Compromise %versus win-lose&

• $artners discuss what is bother them

• :hy marriages unravel

• (ndividualistic western culture• Divorce more socially acceptable

• ewer legal impediments

• :ife less dependent on husband

• 9roding love and e*citement, more boredom

• 1tress

• (n4delity

• ewer women %especially older women& than men remarry after divorce

• Eeason for the age di


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• (nvolved= actively engaged with the grandchildren

• Companionate= more detached, give support, li7e buddies to thegrandchildren, might visit and call freuently, might ta7e grandchildrenon vacation or invite them to visit

• Eemote= more detacheddistant, show little interest in grandchildren,

might criticie the grandchildren)s behavioursamily violence and domestic abuse %physical, psychological&

• o segment of society is immune

• Cycle of violence= economic concern, people who grew up in a familythat is violent have a better chance of being violent

• 8ension-building= batterer becomes upset and shows dissatisfaction @verbal abuse, may be physical behaviour li7e shoving, or grabbing

• Acute bettering= shoved, 7ic7ed, stepped on, burned, forced to engagein physical activity,

• .oving contrition %remorse has no bearing on the possibility of future

violence&= abuser see7s forgiveness, apologies, person who wasabused may feel responsible for what had happened

Cultural Eoots of Giolence

• 8raditions in which violence is viewed as acceptable

• 9*amine legal, political, educational, and economic roles of men andwomen

:or7 and Careers

• Younger adults @ interested in abstract and future @ orientatedconcerns

• MA interested in here-and-now ualities of wor7

• :or7-related challenges=

• urnout

• 6nemployment

• 1witching and starting careers

OE9M9M9E 8F9 ACEYM ‘OCEAN’O penness, Conscientiousness,9*traversion, Agreeableness, euroticism

N2050 November 03,

2014

Perimenopause

• Normal transition

• Begins with first change in menstrual cycles

• n!s after cessation of menses" after the perio!s stop

#enopause


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• $essation of menses associate! with !eclining ovarian function

• %fter one year of amenorrhea

• &tarts gra!ually

• 'sually associate! with changes in menstruation (e)g), flows increase!, !ecrease!,

irregular, or a combination*

•%ccompanie! by"

• +ecline in secon!ary seual characteristics

• +ecreases in"

• Breast tissue

• Bo!y hair

• &-in elasticity

• &ubcutaneous fat

• &i.e of ovaries an! uterus

• $ervi an! vagina become pale an! friable

• /asomotor instability" not as reliable

• ongterm conseuences" changes in estragon increase! ris- of osteoporosis, increase!

ris- of heart !isease because estragon seems to give a protection for heart !isease so aftermenopause that barrier is gone)

Postmenopause

• ime after menopause

• hen menopause happens"

• 6anges from 44 to 55 years, average is 51 years

• $auses of earlier menopause inclu!es"

• 7llness

• 6emoval of uterus or both ovaries

• %!verse effects of ra!iation therapy or chemo

• +rugs

• %ge at which menopause occurs is not affecte! by (myths*

• %ge at menarche" meaning when you first start to get your perio!s

• Physical characteristics

• Number of pregnancies

• +ate of last pregnancy

• 'se of oral contraceptive

• arlier menopause is associate! with

• 8enetic factors

• %utoimmune con!itions" means the bo!y for some reason is attac-ing itself) 7t thin-s

itself is a foreign thing an! it attac-s itself)• $igarette smo-ing

• 6acial or ethnic factors

vents that result in menopause are starte! by changes in ovary

• 6egression of follicles in each ovary start with puberty an! accelerates after age 35

• ith increasing age, fewer an! fewer follicles respon! to 9&: (follicle stimulating

hormone in the ovary*


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• 9&: stimulates !ominant follicle to secrete estrogen

• hen follicles no longer respon! to 9&:, ovarian pro!uction of estrogen an!

progesterone !eclines

• Perimenopausal ( peri aroun!" aroun! menopause* women can get pregnant until

menopause has occurre!

•

+ecrease! ovarian function lea!s to !ecrease! levels of estrogen an! a gra!ual increasein 9&: an! : (a negative fee!bac- process*

• By menopause, a 10to20fol! increase in 9&:

• he increase! 9&: may ta-e several years to return to premenopause level

• 6e!uce! estrogen causes a !ecrease in freuency of ovulation an! results in changes in

repro!uctive organs an! tissues (e)g), atrophy of vaginal tissue*

$linical manifestations of perimenopause

• 7rregular menses (irregular vaginal blee!ing ; coul! in!icate cancer *

•


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• 8reater ris- for coronary artery !isease an! osteoporosis

• oint pain

• 6e!uce! s-in elasticity• $hanges in hair (amount, !istribution*

• %trophy of eternal genitalia an! breast tissue

:allmar-s of perimenopause inclu!e

• /asomotor instability (hot flashes* an! irregular menses

• :ot flash"

• armth in upper chest, nec- an! face, then

• Profuse perspiration

• asts several secon!s to 5 minutes

•


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$linical manifestations of Postmenopause (after menopause*

• $essation of menses (menstruation stops*

• /asomotor instability (hot flashes, night sweats*

• %trophy of 8' tissue (e)g), vaginal epithelium*

• &tress an! urge incontinence

• Breast ten!erness

+iagnosis of Perimenopause

• #a-e only after other causes of women@s symptoms have been rule! out

•


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• 9lui! retention

• :ea!ache

• Breast enlargement

• &ome a!verse effects of progesterone"

• 8reater appetite

• eight gain• 7rritability

• +epression

• &potting

• Breast ten!erness

% commonly use! estrogen preparation

• 0)A25 mg of con>ugate! estrogen (Premarin* !aily

• #ay nee! higher !ose for symptom relief

o receive the protective benefit of progesterone

• 5 to 10 mg of me!royprogesterone (Provera* is in!icate! for 12 !ays of each month on a

cyclical regimen, or

• 2)5 mg if on a continuous regimen

7f estrogen is to be increase! for symptom relief, the progesterone shoul! also be increase!


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• 6aloifene competes with estrogen for estrogen receptor sites

• 7t !ecrease! bone loss an! cholesterol but has minimal effects on breast an! uterine tissue

• e are sociali.e! to over prescribing ; C 7 have a health problem, give me a !rug for itD

Biphohonates (e)g), al!enronate, rise!ronate*

• 'se! to !ecrease ris- of osteoporosis in P# women

%lternative herapies for #enopausal &ymptoms

• 9or hot flashes"

• #easures to !ecrease heat pro!uction an! increase heat loss

• )g), cool environment, limit caffeine an! alcohol, behaviour changes (e)g), relaation*,

increase! air circulation at night, avoi! be!!ing that traps heat, loosefitting clothes, cool

cloths, vitamin

• 9or aniety an! !epression"

• 8oo! nutrition, eercise, sleep

• 9or sleep ; avoi! alcohol, stress re!uction

• 9or bone loss an! weight gain"

• 6egular eercise, which also mo!ifies the ris- for coronary artery !isease ; in the

myocar!ium of the heart (e)g), stress, obesity, inactivity, an! hypertension*

Nutrition

• o !ecrease car!iovascular !isease, osteoporosis, an! vasomotor symptoms

• +aily inta-e of about 30 -cal=-g of bo!y weight

• %!euate inta-e of calcium an! vitamin + to maintain bones

• P# women not ta-ing supplemental estrogen nee! at least 1500 mg of calcium !aily

• hose ta-ing estrogen nee! at least 1000 mg=!ay

• $alcium supplements are best absorber with meals• ither !ietary calcium or calcium supplements may be use!

+iet high in

• $omple carbohy!rates

• /itamin B comple (especially BA*

Phytoestrogens (e)g), soy, tofu, chic-peas, sunflower see!s* may re!uce menopausal symptoms

• ith soy, consult :$P if have history of breast, ovarian, or uterine cancer or

en!ometriosis

•&oy may interact with warfarin

• :erbs (e)g), blac- cohosh*

• Please remember that many herbs cause serious a!verse effects

$ulturally $ompetent $are

• #enopause is a universal phase in a woman@s life

• :owever


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• he perception of this change varies by culture

• )g),

• :in!u women may loo- forwar! to it

• hen el!ers are revere!, menopause is a transition to being a Ewise woman@

• N% culture ; negative about aging an! high value on youth ; therefore, menopausal

symptoms viewe! as troublesome an! nee! to be treate! (me!icali.ation*• hus, menopause is a milestone embe!!e! in each woman@s personality an! culture


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• &trengthening inner resources

• 6esearch" inci!ence of acute #7 greater within 24 hours of !eath of a significant other

an! grief over the !eath was associate! with an acutely increase! ris- of #7 in the

subseuent !ays (heart attac- greater ris-*

%pocalyptic +emography

• e shoul! neither un!eremphasi.e nor overemphasi.e the social importance of

population aging

• Fet, some people try to overemphasi.e it via a !iscourse=i!eology calle! %pocalyptic (or

voo!oo* !emography

• +efine!" it is use! to characteri.e the oversimplifie! notion that a !emographic tren!

population aging ;will be catastrophic for our society

5 interrelate! themes of apocalyptic !iscourse"

• %ging is a social problem that nee!s fiing

• :omogeni.es


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• 6everence for youth in many mo!ern western societies (e)g), me!ia ; !ying hair,

plastic surgery, Boto, etc)*

• #eanwhile, in colonial '&%, an! to!ay in %sia an! in Native societies,


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• hat report was !e!icate! to


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• $ounter ageism

• 7ntegrate care (continuum for aging in place*

• $omparable access to services across the country

• %gefrien!ly cities an! communities

• liminate poverty

•

&upport the voluntary sector • :ealth an! social care wor-force O

• 7ncorporate research an! new technology

• 9e!eral population groups ; lea!ing by eample (e)g), veterans, 9irst Nations an!

7nuit*

6ecommen!ations in +iing +onger, liing well - %eniors %trategy for Ontario, &inha

(2013*

• Promote health an! wellness

• &trengthen=enhance

• Primary care for


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• #any


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• 7mmune !eficiency" cause ; normal aging changes, un!erlying viruses, protein

!eficiency

• 7mpotence" cause ; un!erlying con!itions, !iabetes, !rugs, athrosclerosis

• %ssessment of physiologic illness becomes even more !ifficult when


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ea!ing causes of !eath for


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• ey features (an! eamples* of %$unit strategies to prevent !elirium"

• Physical environment

• %!mission processes" try to i!entify early ; screening on a!mission,

• %ssessment incorporating $8%

• %voi! unnecessary stress

•

+ischarge (seamless care*• 9rail u!gement, calculation, an! visuospatial s-ills) %ttention must be pai! to the possibility of !elirium, !epression, !ementia, an! mil! cognitive impairment)

• 9unctional mobility" a person@s ability to stan!, wal-, an! transfer from be! to a

chair) Be! rest inhibits a person@s capability to perform these functions as it

contributes to muscle atrophy an! re!uce! en!urance

• #e!ication management" reviewing each person@s me!ication list, !osages (!ose

an! !ose interval*, potential me!ication interactions an! balancing the benefits

versus the ris-s of me!ications)


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• Nutrition an! hy!ration" ensuring a!euate amount an! type(s* of foo! an! liui!

consume!, assessing for any swallowing !ifficulties an!=or foo! allergies, an!

supplementing inta-e, where necessary)• Pain" refers to the use of me!ications an! other interventions (such as massage,

eercise, or physiotherapy* to prevent, re!uce, or stop acute or chronic pain

7n $ana!a, over 50H acutecare be!s occupie! by


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• &yn!rome of !ysfunction (Palmer*

$osts of functional !ecline

• 8reater

• 6is- of illness an! !eath

• +epen!ence• +iminishe!

• Muality of life (en! up !ying or going into longterm care*

• %utonomy

• 7nstitutionali.ation

• onger stays

• 6ea!mission=reci!ivism

hus, 6Ns must loo- for ris-s an! intervene

$omple contributors to functional !ecline

• %ging an! the hospital

• Both illness an! hospital environment, e)g),

• nvironment !esigne! for caregivers (vs) Patients*

• #yopic mo!els for care"


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6esources"

• Bolt. et al) (2012*) vi!encebase! geriatric nursing protocols for best practice

(4th e!)*

• John % :artfor! 9oun!ation 7nstitute for 8eriatric Nursing) Best Nursing

Practices in $are for


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• hought content

• #oo! an! affect

• 9ocus on each component systematically

• 6ecor! observations to evaluate changes over time

• &everal tests can help to !iagnose an! to monitor

•

But many factors may influence performance an! interpretation of mental statustests, e)g),

• !ucation

• 9irst language

• &ensory challenges

• Poor baseline intellect

• 7mplications of health challenges

• &tress from being eamine!

• hus, scores on tests shoul! not replace a comprehensive eamination

+ifferential +iagnosis of $onfusion

here may be several causes, inclu!ing

• +isor!ers of the brain

• &ystemic illness presenting atypically

• &ensory impairment (e)g), re!uce! hearing*

• %!verse effects of !rugs or alcohol

i-e many other !isor!ers in


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• Prevalence" might be 15H on a!mission might be coming in with !elirium, in

hospital 1=3 might be !elirious 22H community living people with !ementia

15K0H in $ resi!ents L0H or more in 7$'• Pre!isposing factors"

• 7mpaire! sense

•

&ensory !eprivation• &leep !eprivation

• 7mmobili.ation

• ransfer to unfamiliar environment

• Number of me!s

• +ementia

• 9unctional !epen!ency

• ey features of !elirium

• +isturbances of consciousness

• $hanges in cognition not better accounte! for by !ementia

• %cute onset (hours to !ays*

• 9luctuating cognitive status (signs an! symptoms*• vi!ence that is cause! by physiological conseuences of a me!ical con!ition

• he ma>or features that !istinguish !elirium from other causes of impaire!

cognitive function

• $haracteristics of !elirium

• +ifficulty sustaining attention

• &ensory misperceptions (e)g), illusions*

• 9ragmente! or !isor!ere! thin-ing

• +isturbe! psychomotor activity (hyper or hypo*

• motional !isturbances

• Neurological signs are uncommon

• #a>or features that !istinguish !elirium from other causes of impaire! functionare "

o !isturbances of consciousness

o acute onset

o fluctuating cog) status

• 9actors associate! with !evelopment of !elirium in hospital"

•


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• 7s a poor prognostic sign for a!verse outcomes (e)g), nursing home placement,

!eath*

• herefore, i!entify an! treat all causes uic-ly)

$onfusion %ssessment #etho! ($%#*

• % vali!ate! tool to i!entify !elirium• 6euires the presence of

• %cute onset an! fluctuating course and

• 7nattention and

• +isorgani.e! thin-ing or

• %ltere! consciousness

• 9%#$%# (reports from family an! informal caregivers*

• &hort Portable #ental &tatus Muestionnaire

• #inimental &tatus

• #inicog

• #ontreal $ognitive %ssessment

• Tung &elfrating +epression &cale

+ifferentiating !elirium from !ementia is crucial because

• +ementia is not imme!iately lifethreatening

• rongly labelling a !elirious patient as !emente! may !elay !iagnosis of serious

an! treatable un!erlying con!itions

• he !iagnosis of !ementia must await the treatment of all potentially reversible

causes of !elirium

(People can have !epression from one or more causes, !elirium from one or morecauses, an! !ementia from one or more causes, all at the same time*

• 6emember, ol!er age !oes not impair cog) enough to cause !ysfunction

$ommon causes of !elirium in


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• 7ntoication (alcohol, other*

• :ypo or hyperthermia

• %cute psychoses

People can have"

• !ep from one or more causes• !el from one or more causes

• !em from one or more causes

• all at the same time $


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+epression an! !ementia may coeist

Non reversible !ementiasV"4 categories

1) +egenerative !iseases of $N&

1) %+2) +em with ewy bo!ies (+B*

3) Par-inson !isease4) Pic- !isease (a type of frontotemporal !ementia*

5) :untington !isease

A) Progressive nuclear palsy

b) /ascular !ementias1) #ultiinfarct !ementia (#7+*

2) Binswanger !isease

3) $erebral embolism4) %rteritis

5) %noia secon!ary to car!iac arrest, car!iac failure of carbon monoi!eintoication

b) raumatic +ementia

1) craniocerebral in>ury

2) !ementia pugilistica b) 7nfections

1) :7/

2)


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o rouble learning, retainingW (%re they repeating themselves %re they

freuently misplacing things %re they >ust stresse! out*

o rouble completing comple tas-sW (%re they having trouble balancing a

cheue boo- $oo-ing a meal*

o rouble reasoning=problem solvingW (+o they -now what to !o in an

emergency situation %re they behaving in unusual ways*o rouble with spatial ability, orientationW) (%re they having trouble

fin!ing their way in familiar places*

o anguageW) (%re they having trouble following conversation eaving

sentences unfinishe!*

o BehaviourW (7s there a change in their personality*

7f suspecte! of having !em"

a) :istory 2hysical illnesses, complaints 3rugs (prescription an! non prescription, inclu!ing alcohol* /ature and seerity of sym$toms and signs

(!eficits, onset, rate of progress, irregular stepwise vs) gra!ual loss, neuro signs or

not, !ementia an! then su!!enly worse* Associated $sychological sym$toms(!epression, aniety, agitation, paranoi!, psychotic* :elpful in !ifferentiating

!em, !ep, or mie! %s- about common problems (wan!ering, !riving,

behaviour, !elusions or hallucinations, insomnia, poor hygiene, malnutrition,incontinence*

b) &ocial &ituation iving arrangements, supports, relatives an! caregivers

(inclu!ing their employment, health* functional status

c) Physical eam 9ocus particularly on $/ (e hypertension* an! neuro (eunilateral wea-ness or sensory !eficit* assessment (may inclu!e #7+* 7mpaire!

stereognosis or graphesthesia 8ait !isor!er %bnormalities on cerebellar

testing Par-insonian signs (e tremor, bra!y-inesia, muscle rigi!ity* may mean

!em associate! with ewy bo!ies or fran- Par-) !isease!) $omprehensive #ental &tatus am an! &tan!ar!i.e! #ental &tatus est e

#ini$o! for screening #ini#ental &tate am an! ime an! $hange est toget ob>ective score re cog) function Neuropsychological testing (e to !iffer !ep

an! !em*

+iagnostic &tu!ies to rule out reversible !ementias"

• Bloo!

o $B$, glucose, urea nitrogen, lytes, calcium, phosphorous, liver function,

thyroi!, vitamin B12 an! folate, syphilis, :7/

•

6a!iographic stu!ieso $ or #67 of hea!

• $onsi!er !rugs that may be causes

• Neuropsychological testing

reatment of +ementia"

• $omplete cure is not available for most !ementias but optimal management can

improve function an! well being of patients, families, caregivers


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• reat all causes of reversible or potentially reversible !em (e prevent more

stro-es by controlling BP*)

+rug treatment of +ementia"

hree %pproaches"

1) nhance cognition an! function

2) reat coeisting !epression3) reat complications (Paranoia, !elusions, agitation*

+rugs for !epression may benefit

Primary !rug approach to %+ is cholinesterase inhibitors

ffectiveness is controversial carefully weigh potential benefits vs ris-s an! costs*

•


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2) +istribution

3) #etabolism (biotransformation*

4) cretion

Pharmaco!ynamics

hat !rug !oes to the bo!y (how !rug affects bo!y*

%bsorption 9actors that affect rate"

• %!ministration route

• 9oo!, flui!s given with !rug

• +osage formulation

• &tatus of absorptive surface

• 6ate of bloo! flow to small intestine

• %ci!ity of stomach

• &tatus of 87 motility

9irst Pass 6outes (goes through the liver*"

•


38/48

iui!s, eliirs, syrups 9astest

&uspension solutions

Pow!ers

$apsules

ablets

$oate! tablets

ntericcoate! tablets &lowest

+osage forms that eist"

• nteral (87 e tablets, capsules, pills sublingual, buccal, eliirs, suspensions,

emulsions*

• Parenteral (most commonly means in>ection e solutions, suspensions,

emulsions, pow!ers for reconstitution, may inclu!e 7/, subcutaneous,intramuscular, intrathecally, intraarticular*

• opical (e aerosols, ointments, creams, paste, pow!er, solutions, foams, gels,

trans!ermal patches, inhalers*

he specific characteristics of the !osages forms affect an! how an! to what etent !rug

is absorbe!

•


39/48

less of both !rugs boun! or

less of one of the !rugs boun!

hat results in

more free, unboun! !rug an!

possibility of !rug!rug interaction (one !rug causes a greater or lesser responseof the other !rug*

• +rug is !istribute! first to areas most etensively supplie! with bloo! (e heart,

liver, -i!neys, brain*

• %reas of slower !istribution" muscle, s-in, fat

• 'sually, highly watersoluble !rugs have small volume of !istribution an! high

bloo! concentrations

• 9atsoluble !rugs have large volume of !istribution an! low bloo! concentrations

• +rugs that are water soluble an! highly protein boun! are less li-ely to be

absorbe! into tissues thus, their !istribution an! onset of action can be slow

• +rugs that are highly fat soluble an! poorly boun! to protein are easily ta-en into

tissues

• 7n some sites" may be !ifficult to !istribute !rug !ue either to poor bloo! supply

(e bone* or barriers (e bloo!brain barrier*

#etabolism

ransform !rug into"

• 7nactive metabolite

• #ore soluble compoun!

• #ore potent metabolite

iver is most responsible


40/48

• :y!rolysis

$on>ugation

6esult"

• 8reater polarity of chemical, an! thus more water soluble an! more easilysecrete!

•


41/48

re!uce! serum creatinine !oes not reflect renal function (896* as accurately in


42/48

• New to mar-et

• $N& effects

• :ighly protein boun!

• liminate! by -i!neys

• :igh first pass effect

•

ow therapeutictotoicity ratio

Prescription +rug 'se an!


43/48

1) &ocio!emog characteristics of users" more prescribing for


44/48

BP (lying, sitting, stan!ing*, emp, Pulses, 6espirations, limination (bowel an!

bla!!er* patterns

3) +rug assessment=appropriateness of regimen" reason=!iagnosis for each !rug,non!rug metho!s consi!ere!, effectiveness of each !rug, !rugs use! to treat si!e

effects of other !rugs, !oses a!>uste! to age=weight=N%$s, potential=actual

troublesome si!e effects, !rug interactions, !rugs with !efine! therapeuticwin!ows monitore! (by serum !rug concentrations*, regimen can be simplifie!,

!rugs not generally recommen!e! for


45/48

• sleep apnea

• stress

• lower e!ucation, socioeconomic status

• !iet (higher fats, so!ium, alcohol lower potassium*

:ealthy


46/48

• 6enal" e 6enal parenchymal !isease, renal artery stenosis, reninpro!ucing

tumors

• n!ocrine" e acromegaly, hypothyroi!ism, hyperthyroi!ism, a!renal !isor!ers

• Neurologic" e increase! intracranial pressure, sleep apnea, autonomic !ysrefleia

• +rugs" e some herbal, illegal, oral contraceptives

Pathologic con!itions affecting $/ wellness in


47/48

• 6is-s for it"

o Pathologic processes &ystolic :N, +iabetes mellitus, par-inson

!isease, multisystem atrophy

o +rugs !iuretics, antihypertensive !rugs ingeste! before meals

• Physiologic cause" 7mpaire! autonomic function

•

$ontributing factors" 87 vasoactive pepti!es, impaire! glucose metabolism• %ssess in


48/48

Physical eam" vital signs an! weight, loo- at fun!us on eye for retinal hypertension

!amage (any signs of hemorrhage, eu!ate, papille!ema etc)*, eamine nec- vessels for

bruits, loo- for >ugular vein !istension, loo- for enlarge! thyroi!, auscultate the heart,chec- for increase! heart rate, abnormal rhythms, enlargement etc, chec- for precor!ial

impulses, listen for murmurs, listen for &3 an! &4 heart soun!s amine ab!omen to

ab!ominal aortic artery for any bruits, eamine ab!omen for enlarge! -i!neys, assess alletremities for symmetry

7n or!er to ta-e an accurate bloo! pressure, 7 woul! begin by gathering my euipmentan! selecting an appropriate cuff si.e for my patient) 7 woul! position the patient so that

his=her arm is level to their heart an! put the cuff on so that the artery mar-er is pointing

towar!s the brachial artery) 7 woul! palpate at the antecubical fossa for the strongest

pulse an! auscultate with my stethoscope) 7 woul! then pump up the cuff 3040 mm:ghigher than their normal BP (or 1A01L0 mm:g if a normal rea!ing is not available* an!

listen for the first rhythmic soun! which is the systolic BP, an! the last rhythmic soun!

which is the !iastolic BP)

ab ests for investigation"

• $omplete bloo! cell count

• 'rinalysis

• lectrolyte levels

• 9asting bloo! glucose

• Bloo! urea nitrogen (B'N*

• $8

• $hest Uray

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