GERIATRIC NURSING.pptx Neurological Disorder of Elderly People

Neurological Disorder of Elderly People

1. Presentation on: Neurological Disorder of elderly PREPARED BY: SABITA MAHARA ROLL NO. : 9 SUBJECT: GERIATRIC NURSING BNS 2 ND YEAR (CRITICAL CARE NURSING) CIVIL SERVICE HOSPITAL NURSING CAMPUS

2. Alzheimeir's disease Dementia Multiple sclerosis Parkinson's disease CVA (cerebrovascular accident)/ stroke Herpes zoster ( shigeles ) NEUROLOGICAL DISORDER

3. At the end of this teaching session, all the student will be able to explain neurological disorder of elderly. General objectives

4. At the end of this teaching session, all the student will be able to; Describe parkinson’s disease. Elaborate cerebrovascular accident/ stroke. Elucidate herpes zoster. Specific objective

5. Parkinson's disease is a degenerative disorder of the central nervous system . The disease is named after English physician James Parkinson; PARKINSON'S DISEASE

6. The motor symptoms of Parkinson's disease result from the death of dopamine-generating cells in the substantia nigra , a region of the midbrain;

7. The exact cause of Parkinson s disease is unknown. Scientists think that Parkinson’s is probably due to a combination of genetic and environmental factors. Environmental factors pesticides and herbicides A higher incidence of parkinsonism has long been noted in people who live in rural areas . Etiology

8. Head trauma, encephalitis, cerebral ischemia Cerebral anoxia Drug induced ( phennothiazines , reserpine, salbutamol)

9. Age : The average age of onset of Parkinson's disease is 55 . Gender: more common in men than in women. Family History Race and Ethnicity: African- and Asian- Americans appear to have a lower risk than Caucasians . Risk factor

10. Smoking and nicotine replacement Coffee consumption

11. It is the second most common neurodegenerative disorder after Alzheimer's disease. Prevalence rises from 1% in those over 60 years of age to 4% of the population over 80 years. Incidence

12. Destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Depletion of dopamine stores Degeneration of the dopaminergic nigrostriatal pathway Imbalance of excitatory (acetylcholine) and inhibiting (dopamine) neurotransmitters in the corpus striatum Pathophysiology

13. Impairment of extrapyramidal tracts controlling complex body movements: Tremors , Rigidity, Bradykinesia , Postural Changes

14. The following classification of PD is helpful in evaluating a patient's degree of disability and charting progression of the disease. Stage 1: unilateral involvement only Stage II: bilateral involvement only Stage III: impaired posture mild to moderate disability Stage IV: fully developed, severe disease, marked disability Stage V: confinement to bed or wheelchair. Classification

15. PD has a gradual onset, a slow progression of the symptoms, and a chronic, prolonged course. The cardinal symptoms are (mnemonic "TRAP" ) Tremor ( arms, legs, jaw and face) Rigidity Bradykinesia / akinesia Postural instability (impaired balance and coordination ) Clinical Features

16. a ) Motor symptoms include Speech and swallowing disturbances. - Hypophonia (soft voice) - Monotonic speech - Drooling - Dysphagia

17. Fatigue (up to 50% of cases) Gait disturbance, shuffling gait, festinate ( accelerate) with walking Masked faces: reduced degree of facial expression Difficulty rolling in bed or rising from a seated position Forward posture Freezing (difficulty in gait initiation) Micrographia (small, cramped handwriting) b ) Other motor symptoms

18. Anosmia: the loss of the sense of smell, either total or partial Sensory disturbance Mood disorder (e.g. depression) Autonomic disturbances such as orthostatic hypotension, gastrointestinal disturbances, genito -urinary disturbances, sexual dysfunctions. Cognitive disturbances: Dementia, Short term memory loss Sleep disturbance c) Non-motor manifestations

19. There are currently no blood or laboratory tests that have been proven to help in diagnosing PD. Medical history Neurological Exam Parkinson's may be suspected in patients who have at least two of the following four symptoms, especially if they are more obvious on one side of the body: - Tremor (shaking) when the limb is at rest Diagnosis

20. - Slowness of movement ( bradykinesia ) - Rigidity , stiffness, or increased resistance to movement in the limbs or torso - Poor balance (postural instability) Drug Challenge Test An 18F PET (Positron Emission Tomography) scan

21. a) Medical management No drugs can stop the degeneration of the basal ganglia. Levodopa : It is precursor of dopamine , Carbidopa ( dopa -decarboxylase inhibitor) is almost always prescribed in combination with levodopa, in either immediate-release or extended-release formulations. Management

22. Other agents include: - Anticholinergic drugs ( trihexyphenidyl ) - Dopamine receptor agonists ( bromocriptine ), - COMT (Catechol-O-Methyl Transferase ) inhibitors ( entacapone ). - Monoamine Oxidase Inhibitors ( Selegiline , Rasagiline ). - Anti-depressant (Amitriptyline, Duloxetine )

23. Physiotherapy and speech therapy: Physiotherapy helps reduce rigidity and corrects abnormal posture. Speech therapy may help correct dysarthria and dysphonia.

24. Stereotactic Surgery: destroy small areas of abnormal brain tissue (e.g., thalamotomy or pallidotomy ) - Thalamotomy : thalamus , a tiny area of the brain, is destroyed. - Pallidotomy : the globus pallidus (one of the basal nuclei of the brain), which is then heated to 80 °C (176 °F) for 60 seconds, to destroy a small area of brain cells Stem Cell Implantation: b ) Surgical M anagement

25. Encourage patient for physical activity and exercise such as stretching and range-of- motion exercises, gardening, walking, swimming (especially in warm water), or using a stationary bike or exercise bands. Often, a person with Parkinson's disease experiences being "stuck", so, gentle yet firm commands (such as "Long steps," "March," and "Step up"), using music or metronome may help to initiate movement . c) Nursing Management

26. Visual targets, such as strips of white tape placed horizontally across high-traffic paths at home, also help the patient take longer steps and minimize scuffing. An alternative is to attach a flashlight to the front of a walker so that the beam shines approximately one foot ahead of the walker . If s/he can no longer safely perform these activities, or if have difficulty with daily tasks, such as bathing or dressing, occupational or physical therapy may benefit them

27. Modify home environment like smoothing floor surface (such as wood is preferable to carpet, low-cut carpet is preferable to one with high nap), removing throw rugs and clearing away other obstacles (such as small end tables, magazine racks and footstools), creating a wide path for the approach to a commonly used chair or bed which may decrease the likelihood of a person with Parkinson's getting "stuck" in his movement.

28. Encourage patient to concentrate on walking erect, to watch the horizon, and to use a wide-based gait Give warm baths and massage to reducing muscle freezing. Encourage patient to swing the arms and raise the feet while walking and to use a heel-toe, heel-toe gait in fairly long strides. Teach deep breathing and coughing exercises .

29. Provide frequent rest periods to decrease fatigue . Encourage, teach, and support the patient during Activities of daily livings ( ADL ) Encourage to use adaptive or assistive devices to perform ADLs . Encourage to follow a regular bowel routine. Encourage to increase fluid intake and eat foods with moderate fiber content. Encourage to use a raised toilet seat to facilitate toilet activities

30. Monitor weight on a weekly basis. Provide supplementary or nasogastric tube feeding as necessary. Encourage patient to sit in an upright position during mealtime. Provide a semisolid diet with thick liquids but avoid thin liquids. - Teach to place the food on the tongue, close the lips and teeth, lift the tongue up and back, and swallow. Encourage the patient to chew first on one side of the mouth and then on the other

31. Encourage to use an electric warming tray to keep food warm as eating may take longer time. Encourage the use a plate that is stabilized, a non-spill cup, and eating utensils with built-up handles To improve communication, remind the patient to face the listener, exaggerate the pronunciation of words, speak in short sentences, and take a few deep breaths before speaking.

32. Encourage the patient and point out that activities are being maintained through active participation Use combination of physiotherapy, psychotherapy, medication therapy and support group participation.

33. Cerebrovascular accident is the sudden death or destruction (infarction) of some brain cells. It is caused by the interruption of the blood supply to the brain by a blood vessel burst or blocked by a clot. CEREBROVASCULAR ACCIDENT ( CVA ) / STROKE / BRAIN ATTACK

34. This obstruction cuts off the supply of oxygen and nutrients, causing damage to the brain tissue. Older people are most at risk of having strokes ( NHS Choices, 2013). Nearly three-quarters of all strokes occur in people over the age of 65 . The risk of having a stroke more than doubles each decade after the age of 55. According to the World Health Organization, 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled ("Stroke Statistics", n.d. ).

35. With age, blood vessels become stiffer and less elastic . Even if the heart tries to pump more blood, the arteries cannot expand as well as they use to. This restricts blood flow and increases the pressure against the artery walls (hypertension).

36. Modifiable Risk Factors High blood pressure (hypertension) High blood cholesterol Atrial fibrillation Being overweight Risk factors Physical inactivity Smoking Alcoholism Stress Diabetes

37. b) Non Modifiable Risk Factors Age: increased risk in 5 th and 6 th decades of life. Gender: more common in women Family History Ethnicity History of stroke or TIA

38. Arterial occlusion: Occlusion by thrombi or emboli: Venous occlusion Non-occlusive causes: - Compression due to herniation - Hypoxic-ischemic encephalopathy - Hypertension Etiology

39. Types of stroke according to American Heart Association

40. 1. Transient attack In this type of stroke, the focal deficit recovers within 24 hours.

41. Ischaemic stroke is the most common type of stroke and is caused by a blockage of the blood vessels supplying the brain. This may be due to 'hardening' and narrowing of the arteries (atherosclerosis) or by a blood clot blocking a blood vessel. 2. Ischemic stroke (87%)

42. Cause of ischemic stroke

43. The most severe type of stroke is a haemorrhagic stroke. Hemorrhagic strokes are caused by the sudden and violent breaking or bursts of a blood vessel in the brain, called a hemorrhage. 3. Hemorrhagic stroke

44. High blood pressure and aneurysms (weak spots on blood vessel walls) are among some of the known causes of this type of stroke .

45. Subarachnoid haemorrhage : which occurs in the space around the brain Intracerebral haemorrhage : the more common type , which involves bleeding within the brain parenchyma or the leptomeninges . There are 2 types:

46. Pathophysiology a) Ischemic stroke

47. b) Haemorrhagic stroke

48. The immediate symptoms are as follows: Confusion , including trouble with speaking and understanding Headache, may occur, especially if the stroke is caused by bleeding in the brain. A headache Starts suddenly and may be severe Occurs when person is lying flat or wakes up from sleep It gets worse when person change positions or bend, strain, or cough Clinical features

49. Numbness of the face, arm or leg, particularly on one side of the body Trouble with seeing, in one or both eyes Trouble with walking, including dizziness and lack of co-ordination. Nausea, vomiting Seizure

50. Strokes can lead to long-term problems. Bladder or bowel control problems Depression Pain in the hands and feet that gets worse with movement and temperature changes Paralysis or weakness on one or both sides of the body

51. Other deficits: Motor deficits: Hemiparesis, Hemiplegia, Dysarthria, Ataxia, Dysphagia Sensory deficits: Paresthesia (Numbness, tingling, difficulty in proprioception) Verbal deficits: Expressive aphasia, receptive, global Visual field defects: Hemianopsia , Photophobia, Diplopia

52. Self-care deficits Cognitive deficits: Memory loss, Decreased attention span, Impaired Poor abstract reasoning, Altered judgment concentration

53. History taking Physical examination Investigation: Angiogram of the head Carotid duplex (ultrasound) Diagnosis Echocardiogram CT scan MRI scan Electrocardiogram ( ECG )

54. Other tests include Bleeding time Blood cholesterol and sugar Blood clotting tests ( prothrombin time or partial thromboplastin time ) Complete blood count (WBC)

55. FAST acronyms help people recognize the most common symptoms of stroke because rapid diagnosis and treatment of acute ischemic strokes is essential to reduce death and disability from stroke. F - Face: Face look uneven? A- Arms: One arm hanging down? S-Speech: Slurred or confusing speech?

56. T-Time: note the time notice any of these signs, time is critical. It's time to call emergency/ambulance and get to the hospital. Stroke- there is treatment if act FAST . Do not ignore any of these signs even if they last only a short time

57. 1. Ischemic stroke 180 minute window of time Time is tissue The longer the brain is without oxygen and glucose the more brain cells die . Goal is to restore blood flow as soon as possible Treatment is a system beginning with early recognition and continuing through rehabilitation MANAGEMENT Medical Management

58. Immediate treatment of ischemic stroke aims at dissolving the blood clot. In acute ischemic stroke usually given aspirin to help thin the blood. If patients arrive at the hospital within 3 - 4 hours of stroke onset (when symptoms first appear), they may be candidates for thrombolytic drug therapy. The standard thrombolytic drugs are tissue plasminogen activators (t- PAs ). They include alteplase and reteplase .

59. The following steps are critical before injecting a clot-buster drug: Before the thrombolytic is given, a CT scan must first confirm that the stroke is not hemorrhagic. If the stroke is ischemic, a CT scan can also suggest if injuries are very extensive, which might affect the use of thrombolytics . Thrombolytics must generally be administered within 3-4 hours of a stroke to have any effect. Best results are achieved if patients are treated with 90 minutes of a stroke.

60. Medications : Various types of drugs are given depending on the cause of the bleeding. If high blood pressure is the cause, antihypertensive medications are administered If anticoagulant medications, such as warfarin (Coumadin, generic) or heparin, are the cause, they are immediately discontinued And other drugs may be given to increase blood coagulation. 2. Hemorrhagic stroke

61. Other drugs, such as the calcium channel blocker nimodipine , can help reduce the risk of ischemic stroke following hemorrhagic stroke.

62. 1. Ischemic stroke Evacuation of intracerebral clot or hematoma Angioplasty and stenting Superior temporal artery-anastomosis Endarterectomy Surgical Management

63. 2. Hemorrhagic Stroke Surgery may be performed for aneurysms or arteriovenous malformations that are bleeding. Craniotomy If the aneurysm has ruptured, a clip may be placed on it to prevent further leaking of blood into the brain. (Clipping for cerebral)

64. Less invasive techniques can be done by threading a catheter. Thin metal wires are put into the aneurysm. They then coil up into a mesh ball. (coil procedure)

65. In acute stage: Monitor vital signs and neuro checks and observe for signs of increased ICP shock hyperthermia, and seizures - Vital signs, signs of increased ICP (e.g. increased BP, decreased pulse and HR , nausea & vomiting decreased LOC ). - Airway (secretion, swallowing difficulty to find out risk of aspiration) - Assess cranial nerve e.g. pupil, facial gaze, gag reflex, swallowing Nursing management

66. Assess bladder and bowel function (incontinence or retention ) Maintain patent airway and adequate ventilation Provide complete bed rest as prescribed Maintain fluid and electrolyte balance and ensure adequate nutrition : - IV therapy for the first few days - NG tube feeding if the patient is unable to swallow - Fluid restriction as ordered to decrease cerebral edema

67. Maintain proper positioning and body alignment - Head of the bed may be elevated 30 degrees to 45 degrees to lower the ICP . - Turn and reposition every 2 hours (only 20 minutes on the affected side) - Passive ROM exercise every 4 hours

68. Promote optimum skin integrity; change positions and apply lotion every 2 hours Maintain adequate elimination; - Offer bedpan or urinal every 2 hours, catheterize only if absolutely necessary - Administer stool softener and suppositories as prescribed

69. Monitor neglect syndrome (unilateral neglect) and - Continuously remind the patient to make conscious effort to use and touch affected side of the body they are neglecting - Encourage for consciously scan the environment to prevent injury to the affected part

70. Establish a means of communication with the patient Administer medication as prescribed

71. Hemiplegia: - Change position every 2 hours and maintain normal body alignment to prevent deformities - Support the paralyzed arm on the pillow or use sling while out of bed to prevent - Elevated extremities to prevent dependent edema - Provide active and passive ROM exercise every 4 hours Rehabilitation stage:

72. Sensory/perceptual deficit: Apraxia: - Loss of ability to perform purposeful, skilled act - Guide the patient through intended movement and keep repeating the movement take wash clothes and guide the patient throughout the washing.

73. Susceptibility to hazards: - Keep side rails up at all times - Institute safety measures - Inspect the body parts frequently for signs of injury

74. Dysphagia: - Check gag reflex before feeding the patient - Select food which should be thicken liquid, mechanical soft easy to swallow food - Maintain a calm, unhurried approach - Place the patient in upright position

75. - Place the food in the unaffected side of the mouth and offer soft food Assess the pouching food in the affected side that increase the risk of aspiration - Advice patient tuck the chin to chest while swallowing that helps food down difficulty swallowing is present - Give mouth care before and after meals

76. Homonymous hemianopsia : loss of half of each visual field - Approach the patient on unaffected side - Gradually teach and encourage the patient always turn head to see side to side see all vision field to prevent injury

77. Aphasia: a. Receptive aphasia: unable to comprehend - Give simple slow direction, use short phrase, simple details - Give one command at a time; gradually shift topic - Use nonverbal technique - Remove any distraction because of short attention. - Be patient and repeat several times or repeat again and again

78. - Listen and watch very carefully when the patient attempts to speak. - Be patient, allow sufficient time, let them speak, don't rush or try out to out what he/she want to say - Ask question one at a time, the question should be direct with simple option or responses - Use communication board, paper, pencil etc - Anticipate the patient's needs to decrease frustration and feeling of helplessness

79. b. Expressive aphasia: comprehend but trouble responding back Listen and watch very carefully when the patient attempts to speak. Be patient, allow sufficient time, let them speak, don't rush or try out to out what he/she want to say Ask question one at a time, the question should be direct with simple option or responses

80. Use communication board, paper, pencil etc Anticipate the patient's needs to decrease frustration and feeling of helplessness

81. Sensory/perceptual deficit: Assist with self-care Provide safety measures Initially arrange objects on the affected side then gradually teach the patient take care of the side and to turn frequently and look at the side

82. Apraxia: Loss of ability to perform purposeful, skilled act Guide the patient through intended movement and keep repeating the movement take wash clothes and guide the patient throughout the washing.

83. HERPES ZOSTER ( SHInGLES )

84. The viruses causing chickenpox and herpes zoster are indistinguishable, hence the name varicella-zoster virus. It is assumed that herpes zoster represents a reactivation of latent varicella virus infection And reflects lowered immunity such as lymphoma, leukemia, and possible HIV infection .

85. It is a significant ailment of older adults, ranging from 690 to 1600 cases/100,000 person - years in those 60 years and older. The varicella zoster virus remains latent in the dorsal root ganglia of the nervous system after its initial infection usually resolves in childhood .

86. Etiology of Herpes Zoster

87. Increasing age (particularly after 50 yrs ) Immunosuppression ( eg , by HIV/AIDS)   Immunosuppressive therapy (transplantation) Primary VZV infection in utero or in early infancy, when the normal immune response is decreased Anti-tumor necrosis factor ( TNF ) Auto immune condition Risk factors

88. Gender (female) Immune reconstitution inflammatory syndrome (IRIS) Acute lymphocytic  leukemia  and other malignancies Physical trauma Acute or chronic disease processes (particularly malignancies and infections) Emotional stress

89. pathophysiology

90. dermatome

91. Pain : The eruption is usually accompanied or preceded by pain, which may radiate over the entire region supplied by the affected nerves. The pain may be burning, lancinating (i.e., tearing or sharply cutting), stabbing, or aching. If an ophthalmic nerve is involved, the patient may have eye pain. Itching and tenderness: Some patients have no pain, but itching and tenderness may occur over the area. Clinical Manifestations

92. Burning, and weakness of muscles associated with the involved nerve may be noted Sometimes, malaise and gastrointestinal disturbances precede the eruption. The patches of grouped vesicles appear on the red and swollen skin. The early vesicles, which contain serum, later may become purulent, rupture, and form crusts.

93. The inflammation is usually unilateral, involving the thoracic, cervical, or cranial nerves in a band like configuration. The blisters are usually confined to a narrow region of the face or trunk . More than 20 vesicles outside of the primary dermatome suggest disseminated zoster, as may be seen in immunocompromised patients or patients with granulocytic lesions .

94. post herpetic neuralgia

95. Phase of herpes zoster

96. History taking Physical examination Direct fluorescent antibody ( DFA ) testing of vesicular fluid or a corneal lesion PCR for detection of viral DNA (vesicular fluid or blood ) Diagnosis

97. Tzanck smear : a sample scraped from the base of an intact vesicle. The appearance of multinucleated giant cells may indicate a herpetic infection . (lower sensitivity and specificity than DFA or PCR )

98. A) Medical Management The goals of herpes zoster management are to relieve the pain and to reduce or avoid complications, which include infection, scarring, and post herpetic neuralgia and eye complications . Herpes zoster in healthy adults is usually localized and benign. Uncomplicated zoster does not require inpatient care . Management

99. Episodes of herpes zoster (shingles) are generally self-limited and resolve without intervention. The healing time varies from 7 to 26 days. Therapeutic management generally depend on the host’s immune state and on the presentation of zoster. The clinical course varies from 1 to 3 weeks.

100. Hospital admission should be considered for patients with any of the following: Severe symptoms Immunosuppression Atypical presentations ( eg , myelitis) Involvement of more than 2 dermatomes

101. Significant facial bacterial superinfection Disseminated herpes zoster Ophthalmic involvement Meningoencephalopathic involvement

102. Use of analgesic: NSAIDs ; Pain is controlled with analgesics, Systemic corticosteroids may be prescribed for patients older than age 50 years to reduce the incidence and duration of post herpetic neuralgia. Use of Triamcinolone anti-inflammatory drugs: injected subcutaneously under painful areas is effective as an anti- inflammatory agent .

103. Antiviral drugs: such as acyclovir or famciclovir are administered within 24 hours of the initial eruption. Intravenous acyclovir, if started early, is effective in significantly reducing the pain and halting the progression of the disease . In older patients, the pain from herpes zoster may persist as post herpetic neuralgia for months after the skin lesions disappear (Hall, 2000 ).

104. Acyclovir is a safe but variably efficacious agent, although famciclovir is also used. It was found that famciclovir was well tolerated and had a more favorable adverse event profile than acyclovir . Herpes zoster opthalmicus occurs when an eye is involved. This is considered an ophthalmic emergency, and the patient should be referred to an ophthalmologist immediately to prevent the possible sequel of keratitis, Uveitis, ulceration, and blindness .

105. Patients with disseminated disease or severe immunosuppression or who are unresponsive to therapy should be transferred to a higher level of care. According to the multicenter Shingles Prevention Study, vaccine administration reduces the incidence, burden, and post herpetic neuralgia ( PHN )

106. Oral antibiotics covering staphylococci and streptococci are used to control secondary infection . Treatment is more challenging for PHN and requires the concomitant use of pain medication, such as topical capsaicin .

107. Surgical care is not generally indicated, though it may be required to treat certain complications ( eg , necrotizing fasciitis). Rhizotomy (surgical separation of pain fibers) may be considered in cases of extreme, intractable pain.

108. The nurse assesses the patient's discomfort and response to medication and collaborates with the physician to make necessary adjustments to the treatment regimen . Wet dressings with 5% aluminum acetate ( Burow solution) , applied for 30-60 minutes 4-6 times daily; and lotions (such as calamine ). The patient is taught how to apply wet dressings or medication to the lesions and to follow proper hand hygiene techniques to avoid spreading the virus. b ) Nursing management

109. Diversionary activities and relaxation techniques are encouraged to ensure restful sleep and to alleviate discomfort. A caregiver may be required to assist with dressings, particularly if the patient is elderly and unable to apply them. Relatives, neighbors, or a home care nurse may need to help with dressing changes and Food preparation for patients who cannot care for themselves or prepare nourishing meals.

110. Complications

111. Prevention

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