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Advancement of age is associated with many chronic health issues that affect the quality of life. Elderly patients form a unique subset of the patient population that many advanced practice nurse practitioners (APNP) will interact with in their practice for evaluation and treatment. Some of the chronic conditions associated with advancing age include dementia, osteoporosis, and other forms of cognitive impairment.
It is the mandate of the health care providers to ensure that elderly patients have a full functional ability to care for themselves fully. To elicit problems facing elderly patients, comprehensive history taking, physical examination, and mental state examination are necessary. Several assessment tools for their health conditions and functioning are available; hence, APNPs should appropriately use those that can be of help in evaluating the patients they meet.
In this case, Mr. W is a 92-year-old retired college professor living at home with his wife in an upscale suburban neighborhood that offers little public transport. Her wife prefers him to drive despite her ability to operate a motor vehicle. Mr. W’s medical history includes obstructive sleep apnea (OSA), hypertension managed with lifestyle modification, chronic anemia, osteoporosis, edema, history of prostate cancer, and edema. However, he can carry out his activities of daily living appropriately.
He reports presenting to his geriatrician 8 years ago and reported forgetfulness when he lost his way while driving to a family museum. He has a history of difficulty in recalling his personal art collection and has experienced falls. In 2009, he reported troublesome memory loss that made his driving more difficult, although there were no reported unsafe practices. His geriatrician diagnosed him with mild cognitive impairment (MCI) secondary to early onset Alzheimer’s disease with recommendations of assessment at a driving evaluation clinic.
In developing an evaluation plan for the patient, it is important to note that the history of falls and confusion indicating underlying immobility, cognitive dysfunction, and sensory deprivation may require adequate attention. From the history, only hypertension is being managed and his only medication is vitamin B12. There is a need for the patient to be on iron supplements to manage the anemia as well as restless leg syndrome (Trotti & Becker, 2019), as well as bisphosphonates, which will manage his osteoporosis and reduce the risk of falls (Reid & Billington, 2022). The edema would be suggesting a cardiac issue such as heart failure and being that he is hypertensive, it is crucial to evaluate the cardiovascular system comprehensively.
There are many assessment tools for the patient. As stated by Arevalo-Rodriguez et al. (2021), the mini-mental state examination (MMSE) is a brief neuropsychological test that is used in evaluating for cognitive function in the setting of individuals with symptoms of cognitive dysfunction. Patients who have mild cognitive impairment, like Mr. W, should be evaluated and monitored as they have a high risk of progressing into dementia.
As outlined in the history, the patient underwent two MMSE evaluations, for which, in the first presentation, he scored 30/30 and in the second assessment, 29/30. The MMSE is a 30-question assessment of cognitive function that is based on attention, orientation, memory, registration, recall, calculation, language, and the ability to draw a complex polygon. The MMSE is appropriate for this patient, with no ethical issues being involved. Since he is still driving, there are assessment tools that can be used to measure his driving competency.
According to Toups et al. (2022), driving is a complex work that requires learned skills and coordination of complex cognitive and physical tasks. On-road evaluations such as performance-based road tests and driving simulation studies can be used to identify and remediate poor driving behaviors to prevent adverse outcomes (Toups et al., 2022). Again, the MMSE can be a psychometric evaluation test that can be used to evaluate driving competency as it evaluates cognitive functioning, which is applied in driving.
The comprehensive geriatric assessment (CGA) is a multidisciplinary instrument that can be used in elderly patients with a risk of falling (Appeadu & Bordoni, 2023). The instrument uses scales such as the Berg Balance Scale to evaluate static and dynamic balance, the Falls Efficacy Scale to assess the fear of falling, and the Timed Up and Go Test to assess a patient’s mobility. Other assessment tools for fall risk among elderly patients include the Tinetti Gait and Balance Assessment Tool and the one-legged and tandem stance assessments (Appeadu & Bordoni, 2023).
A number of geriatric patients have problems with memory, concentrating, learning, or making decisions that impact their daily lives because of their age (Khanna & Metgud, 2020). When evaluating such patients, there should be more effort during evaluation to obtain adequate information, especially during history taking because of their cognitive impairment that may disturb their memory. Their level of education may impact their assessment as well as the language being used. Therefore, as an advanced nurse practitioner, there should be a demonstration of cultural competency when evaluating adults, as most tend to incline their thoughts and symptoms to culture.
At a personal level, life course vaccination programs substantially contribute to lowering the burden of infectious disease, decreasing mortality, and mitigating infection-related mortality (Michel & Frangos, 2022). Similarly, with the implementation of more vaccination programs in countries like the United States, United Kingdom, Canada, and Australia, the incidence of morbidity and mortality of infectious diseases has drastically decreased by over 90%. Vaccines are of the essence in the elderly population. It has been documented that tetanus, polio, and flu vaccines may play a role in preventing the onset of Alzheimer’s disease (AD) (Michel & Frangos, 2022). It will be important to ensure the patient receives his annual flu vaccine to ensure he does not contract influenza or pneumococcal pneumonia. According to Michel and Frangos (2022), patients aged above 65 years should receive tetanus, polio, and flu vaccines.
Appeadu, M., & Bordoni, B. (2023, June 4). Falls and Fall Prevention in the Elderly. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560761/
Arevalo-Rodriguez, I., Smailagic, N., Roqué-Figuls, M., Ciapponi, A., Sanchez-Perez, E., Giannakou, A., Pedraza, O. L., Bonfill Cosp, X., & Cullum, S. (2021). Mini-Mental State Examination (MMSE) for the Early Detection of Dementia in People with Mild Cognitive Impairment (MCI). Cochrane Database of Systematic Reviews, 2021(7). https://doi.org/10.1002/14651858.cd010783.pub3
Khanna, A., & Metgud, C. (2020). Prevalence of cognitive impairment in elderly population residing in an urban area of Belagavi. Journal of Family Medicine and Primary Care, 9(6), 2699. https://doi.org/10.4103/jfmpc.jfmpc_240_20
Michel, J.-P., & Frangos, E. (2022). The Implications of Vaccines in Older Populations. Vaccines, 10(3), 431. https://doi.org/10.3390/vaccines10030431
Reid, I. R., & Billington, E. O. (2022). Drug therapy for osteoporosis in older adults. The Lancet, 399(10329), 1080–1092. https://doi.org/10.1016/s0140-6736(21)02646-5
Toups, R., Chirles, T. J., Ehsani, J. P., Michael, J. P., Bernstein, J. P. K., Calamia, M., Parsons, T. D., Carr, D. B., & Keller, J. N. (2022). Driving Performance in Older Adults: Current Measures, Findings, and Implications for Roadway Safety. Innovation in Aging, 6(1), igab051. https://doi.org/10.1093/geroni/igab051
Trotti, L. M., & Becker, L. A. (2019). Iron for the treatment of restless legs syndrome. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd007834.pub3
As patients age, they are more likely to develop health issues. While some of these health issues are normal changes due to aging, some of them are abnormal and require further evaluation. Consider a 92-year-old patient who has been diagnosed with several disorders, including obstructive sleep apnea, hypertension, mild chronic anemia, restless leg syndrome, and osteoporosis. Despite these disorders, he can independently perform all basic activities of daily living, walk a quarter mile without difficulty, and pass functional and cognitive assessments. However, he did report that he fell a few times and had lost his way while driving to a familiar location (Carr & Ott, 2010).
As an advanced practice nurse caring for geriatric patients, you will likely encounter patients like this. While he can pass the basic assessments, the report of falls and confusion might indicate underlying issues of immobility, sensory deprivation, and/or cognitive dysfunction that require further attention. To identify these potential underlying issues and distinguish between normal and abnormal changes due to aging, healthcare providers use a variety of assessments. These assessments are a key tool in the care of geriatric patients.
This week, you examine assessment tools and evaluation plans used to assess geriatric patients presenting with potential issues of immobility, sensory deprivation, and cognitive dysfunction.
Reference:
Carr, D. B., & Ott, B. R. (2010). The older adult driver with cognitive impairment: “It’s a very frustrating life.” Journal of the American Medical Association, 303(16), 1632–1641. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2915446/
Students will:
Also Read: NRNP 6540 Week 9 Assignment
Required Readings (click to expand/reduce)
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Changes with aging. In Advanced practice nursing in the care of older adults (2nd ed., pp. 2–5). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Health promotion. In Advanced practice nursing in the care of older adults (2nd ed., pp. 6–18). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Exercise in older adults. In Advanced practice nursing in the care of older adults (2nd ed., pp. 19–24). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Comprehensive geriatric assessment. In Advanced practice nursing in the care of older adults (2nd ed., pp. 26–33). F. A. Davis.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Symptoms and syndromes. In Advanced practice nursing in the care of older adults (2nd ed., pp. 34–94). F. A. Davis.
Centers for Disease Control and Prevention. (2020). Recommended adult immunization schedule for ages 19 years or older. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf
Coll, P. P., Costello, V. W., Kuchel, G. A., Bartley, J., & McElhaney, J. E. (2019). The prevention of infections in older adults: Vaccination. Journal of the American Geriatrics Society, 68(1), 207–214. https://doi.org/10.1111/jgs.16205
Hartford Institute for Geriatric Nursing. (2020). General assessment series. In Try This: Series. Author. https://consultgeri.org/try-this/general-assessment
U.S. Preventive Services Task Force. (n.d.). Information for health professionals. Retrieved June 8, 2020 from https://www.uspreventiveservicestaskforce.org/uspstf/information-health-professionals
U.S. Preventive Services Task Force. (2019). Appendix III. USPSTF LitWatch process. https://www.uspreventiveservicestaskforce.org/uspstf/procedure-manual-appendix-iii-uspstf-litwatch-process
Recommended Reading (click to expand/reduce)
Goldberg, C. (2019). Role of physical exam, general observation, skin screening and vital signs. https://meded.ucsd.edu/clinicalmed/assets/docs/Vital%20Signs%20and%20Introduction%20to%20the%20Exam.pdf
Recommended Media (click to expand/reduce)
Engage-IL (Producer). (2017m). Geriatric health promotion and disease prevention [Video]. https://engageil.com/modules/geriatric-health-promotion-and-disease-prevention/
Note: View the Geriatric Health Promotion and Disease Prevention video module available in this free course. If you choose to view the Engage-IL media, you will need to create a free account at the Engage-IL website.
Engage-IL (Producer). (2017w). The process of aging [Video]. https://engageil.com/modules/the-process-of-aging/
Note: View the Process of Aging video module available in this free course.
As geriatric patients age, their health and functional stability may decline resulting in the inability to perform basic activities of daily living. In your role as a nurse practitioner, you must assess whether the needs of these aging patients are being met. Comprehensive geriatric assessments are used to determine whether these patients have developed or are at risk of developing age-related changes that interfere with their functional status. Since the health status and living situation of older adult patients often differ, there are a variety of assessment tools that can be used to evaluate wellness and functional ability. For this Discussion, you will consider which assessment tools would be appropriate for a patient in a case scenario.
Photo Credit: LIGHTFIELD STUDIOS / Adobe Stock
To prepare:
By Day 3
Post an explanation of your evaluation plan for the patient in the case study provided, and explain which type of assessment tool you might use for the patient. Explain whether the assessment tool was validated for use with this patient’s specific patient population and whether this poses issues. Include additional factors that might present issues when performing assessments, such as language, education, prosthetics, etc. Also explain the immunization requirements related to health promotion and disease prevention for the patient.
Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues on two different days in one or more of the following ways:
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Post to Discussion Question link, and then select Create Thread to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Select Grid View or List View to change the rubric’s layout.
Name: NRNP_6540_Week1_Discussion_Rubric
Grid View
List View
Excellent
Point range: 90–100 Good
Point range: 80–89 Fair
Point range: 70–79 Poor
Point range: 0–69
Main Posting:
Response to the discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
40 (40%) – 44 (44%)
Thoroughly responds to the discussion question(s).
Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
No less than 75% of post has exceptional depth and breadth.
Supported by at least 3 current credible sources.
35 (35%) – 39 (39%)
Responds to most of the discussion question(s).
Is somewhat reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module.
50% of the post has exceptional depth and breadth.
Supported by at least 3 credible references.
31 (31%) – 34 (34%)
Responds to some of the discussion question(s).
One to two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with fewer than 2 credible references.
0 (0%) – 30 (30%)
Does not respond to the discussion question(s).
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only 1 or no credible references.
Main Posting:
Writing
6 (6%) – 6 (6%)
Written clearly and concisely.
Contains no grammatical or spelling errors.
Further adheres to current APA manual writing rules and style.
5 (5%) – 5 (5%)
Written concisely.
May contain one to two grammatical or spelling errors.
Adheres to current APA manual writing rules and style.
4 (4%) – 4 (4%)
Written somewhat concisely.
May contain more than two spelling or grammatical errors.
Contains some APA formatting errors.
0 (0%) – 3 (3%)
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style.
Main Posting:
Timely and full participation
9 (9%) – 10 (10%)
Meets requirements for timely, full, and active participation.
Posts main discussion by due date.
8 (8%) – 8 (8%)
Posts main discussion by due date.
Meets requirements for full participation.
7 (7%) – 7 (7%)
Posts main discussion by due date.
0 (0%) – 6 (6%)
Does not meet requirements for full participation.
Does not post main discussion by due date.
First Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
First Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
First Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Second Response:
Post to colleague’s main post that is reflective and justified with credible sources.
9 (9%) – 9 (9%)
Response exhibits critical thinking and application to practice settings.
Responds to questions posed by faculty.
The use of scholarly sources to support ideas demonstrates synthesis and understanding of learning objectives.
8 (8%) – 8 (8%)
Response has some depth and may exhibit critical thinking or application to practice setting.
7 (7%) – 7 (7%)
Response is on topic, may have some depth.
0 (0%) – 6 (6%)
Response may not be on topic, lacks depth.
Second Response:
Writing
6 (6%) – 6 (6%)
Communication is professional and respectful to colleagues.
Response to faculty questions are fully answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in Standard, Edited English.
5 (5%) – 5 (5%)
Communication is mostly professional and respectful to colleagues.
Response to faculty questions are mostly answered, if posed.
Provides opinions and ideas that are supported by few credible sources.
Response is written in Standard, Edited English.
4 (4%) – 4 (4%)
Response posed in the discussion may lack effective professional communication.
Response to faculty questions are somewhat answered, if posed.
Few or no credible sources are cited.
0 (0%) – 3 (3%)
Responses posted in the discussion lack effective communication.
Response to faculty questions are missing.
No credible sources are cited.
Second Response:
Timely and full participation
5 (5%) – 5 (5%)
Meets requirements for timely, full, and active participation.
Posts by due date.
4 (4%) – 4 (4%)
Meets requirements for full participation.
Posts by due date.
3 (3%) – 3 (3%)
Posts by due date.
0 (0%) – 2 (2%)
Does not meet requirements for full participation.
Does not post by due date.
Total Points: 100
Name: NRNP_6540_Week1_Discussion_Rubric
Mr. Y is a 78-year-old man who was born in Korea and moved to the U.S with his wife 50 years ago. Together, the couple opened a floral shop and ran the business for 40 years. Mrs. Y enjoyed watching her husband’s talent and love of nature come out in his flower arrangements.
When Mr. Y was in his late 60’s, he starting having difficulty making his favorite flower arrangements. Their son also noticed Mr. Y misplacing tools, losing paper orders, and forgetting important pick-up times. At home, Mrs. Y noticed her husband having problems remembering recent events, and waking up at odd hours in the night thinking it was time to open the shop. Mr. Y was becoming irritable at home and at the shop.
When Mr. Y was 70 years old, the family decided to sell the business. Their health-care providers confirmed that Mr. Y was presenting with early stage Alzheimer’s disease. The family then decided that Mrs. Y would be appointed as her husband’s Power of Attorney for personal care and property. She continued to care for her husband at home.
When Mr. Y turned 75 years old, he was having increased difficulty remembering where things were in the house. He often woke his wife at odd hours of the night thinking it was time to get up and ready. When Mrs. Y reoriented her husband that it was still night-time, he would get confused and easily upset. Mr. Y was also becoming more physically weak, but did not perceive his limitations. He was having frequent falls at home. A few times, Mr. Y had become lost outside of their home, forgetting where he had to go and which house was his.
Their son recognized that his mother was not as happy as she used to be. She was constantly worrying about her husband’s increasing care needs, and could not enjoy activities she used to do. She was stressed and was not sleeping properly. With support from their health-care providers, the family decided that a long-term care setting would benefit Mr. Y and Mrs. Y’s well-being.
Admission to long-term care
At the admission conference, the long-term care home’s social worker and charge nurse met Mr. Y and his family, and learned more about his history and preferences. His medical diagnosis includes moderate Alzheimer’s disease and osteoarthritis, with a history of urinary tract infections. Mr. Y hears well, uses reading glasses, and wears upper and lower dentures. Mr. Y also requires reminders to use his walker properly. Mrs. Y always prompted her husband for toileting, as well as when to eat and take medications. Mr. Y requires limited assistance from his wife during activities of daily living, such as dressing or transfers. As for his preferences, Mr. Y loves homemade Korean food, pastries, and warm drinks. He had always enjoyed baths in the evenings.
At the end of the second week in LTC, Mr. Y was no longer pacing the halls. He was often found napping in his room during the days. One afternoon, a nurse went into Mr. Y’s room and found him sleeping. She tried to gently wake Mr. Y, but he was not easy to arouse. She tried a second time and asked very loudly, “Mr. Y, it’s lunch time, are you ready to go?” Mr. Y slowly opened his eyes. The nurse repeated her question, and Mr. Y replied slowly, “Oh, I ate last week.” The nurse then asked, “I know you had breakfast this morning, now it’s lunch time.
Are you hungry?” Mr. Y paused and closed his eyes. The nurse gently woke him again by rubbing his arm and repeated her question. Mr. Y slowly replied, “Yes, my wife is cooking, I will eat”. Together, they walked slowly to the dining room.
In the dining room, Mr. Y stared out the window and did not answer the CNAs when they asked him for his lunch preference. When approached a third time, Mr. Y rambled slowly in English and in Korean to the CNAs. He continued to speak Korean to the CNAs as they tried to assist him with his lunch, but he was unfocused and inattentive. He was unable to finish his meal because of his behavior. The staff were worried that he was not eating or drinking enough since admission.
When there were group activities, the therapists found it harder to encourage Mr. Y to attend and participate like he had been doing before. It took a lot of encouragement and assistance to have him attend. During the activity, he did not participate or sometimes fell asleep in the middle of the exercise or social program.
A few nights in a row, he was found wandering outside his bedroom without his walker. One time, he told the nurse, “Someone is looking for me.” The nurse reassured him that he is safe, and tried to direct him back to his room. But Mr. Y walked past the nurse and said, “I have to go to the bus stop.” After a few attempts, the nurse was able to direct Mr. Y to his room to sleep, and reoriented him to the use of the call bell. This behavior continued with increasing disorientation. The sleep disturbances resulted in Mr. Y being too drowsy in the mornings, and not able to eat any breakfast.
Although Mrs. Y was kept informed of her husband’s condition since admission to long-term care, it was not until her first visit during Mr. Y’s third week in long-term care when she realized how much her husband had changed. She was alarmed and asked the staff, “What is happening? What will be done for him? How can I help?”
Dela Cruz, Dedic, Famador, Finefrock, Fritcher, Gallik, Gelegdorj, Go, Joseph, Kabir, Lopez
Ms. Washington is a 67-year-old African American female who is brought to your office by her daughter with concerns about “forgetfulness.” She has lived with her daughter for 4 years now, and her daughter reports noticing she asks the same questions even after they have been answered. She even reports her mom getting lost in Walmart recently. Ms. Washington has lived with her daughter since losing her husband of 57 years about 4 years ago. Her daughter states her mother is a retired teacher and usually very astute but notices more forgetfulness.
According to Ms. Washington’s daughter, Angela, her mom has been demonstrating increased forgetfulness of more recent things but can easily recall historical moments and events. She also reports that sometimes her mom has difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation. She also said her mother will “laugh off” things when she forgets important appointments and/or becomes upset or critical of others who try to point these things out.
Note: Be sure to review the Mini-Mental State Exam (MMSE) and how to interpret the results. Use the MMSE in the attached document to determine the patient’s MMSE score in the video. Make sure you document the patient’s score in your SOAP note document: Mental State Assessment Tests.
Ms. Washington is a 67-year-old female who is alert and cooperative with today’s clinical interview. Her eye contact is fair. Speech is clear and coherent but tangential at times. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She is alert and oriented to person, partially oriented to place, but is disoriented to time and place. (She reported that she thought was headed to work but “wound up here,” referring to your office, at which point she begins to laugh it off.) She denies any falls or pain.
All other Review of System and Physical Exam findings are negative other than stated.
PMH: Hypertension, Hyperlipidemia, O
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