Module 3

Module 3: Congestive Heart Failure, Dizziness, Sleep Disorders & Pressure Ulcers
East Texas Geriatric Education Center (ETGEC) Module Series in Basic Geriatrics & Gerontology
Module 3 Geriatric Syndromes: Congestive Heart Failure, Dizziness, Sleep Disorders, and Pressure Ulcers
Bronx VA GRECC Interdisciplinary Curriculum: Geriatrics, Palliative Care and Interprofessional Teamwork East Texas Geriatric Education Center: Interdisciplinary Patient Care for Older Adults
Module 3: Congestive Heart Failure, Dizziness, Sleep Disorders & Pressure Ulcers Table of Contents Page Learning Objectives ....................................................................................................... 3 Congestive Heart Failure ............................................................................................... 4 Epidemiology............................................................................................................. 4 Stages of Heart Failure ............................................................................................ 5 Systolic and Diastolic Heart Failure........................................................................... 8 Classic and Atypical CHF........................................................................................ 10 Therapy and Management of CHF.......................................................................... 13 Dizziness ..................................................................................................................... 16 Case Study............................................................................................................. 16 Terms, History and Physical Exam ........................................................................ 18 Dix-Hallpike Maneuver ........................................................................................... 19 Vertigo.................................................................................................................... 21 Sleep Disorders............................................................................................................ 22 Demographics ........................................................................................................ 22 Normal Age-related Changes................................................................................. 22 Types, Causes, Assessment.................................................................................. 23 Treatment............................................................................................................... 26 Pressure Ulcers......................................................................................................... 25 Epidemiology.......................................................................................................... 25 Risk Assessment.................................................................................................... 25 Pathophysiology..................................................................................................... 26 Prevention .............................................................................................................. 26 Stages and Treatment............................................................................................ 28 Braden Scale......................................................................................................... 30 Sources Cited............................................................................................................... 31 Case Study................................................................................................................... 32 Discussion Questions................................................................................................... 34 Module evaluation ........................................................................................................ 35
Learning Objectives 1. Describe the prevalence and risk factors associated with CHF, dizziness, sleep disorders and pressure ulcers in the elderly. 2. Identify the components of evaluation for the above conditions: history and physical examination. 3. Discuss interventions for CHF, dizziness, sleep disorders and pressure ulcers in the elderly in the elderly.
Congestive Heart Failure in the Elderly Epidemiology 5 million Americans have HF today Incidence approaching 10 per 1000 population among persons older than 65 Over the past decade, rate of hospitalization has increased by 159% In 1997, about $5,501 spent for every hospital discharge Another $1,742 per month required. HF primarily disease of the elderly The prevalence and incidence of CHF increase with age. 6 to 10 percent of people older than 65 years have CHF CHF developed in 27 percent of older population (mean age=81 years) Multiple clinical trials show a substantial reduction in mortality for patients with systolic heart failure during the past 15 years. Symptomatic heart failure confers a worse prognosis than the majority of cancers in the USA. One year mortality approximately 45 percent.
Definition Defined as impairment in heart function leading to low cardiac output symptoms CHF represents a more advanced stage CHF should not be considered a specific disease rather a syndrome.
Stages of Heart Failure

Stage Description These patients are at high risk of developing HF due to the presence of other conditions that are strongly associated with the development of HF. These patients have no identified functional or structural abnormalities of cardiac valves, myocardium or pericardium. They also have no previous signs or symptoms of HF These patients have developed structural heart disease that is strongly associated with the development of HF but also were previously asymptomatic. These patients are those who have current or prior symptoms of HF which are associated with an underlying structural heart disease. Patients with advanced structural heart disease and marked symptoms of HF at rest despite maximal medical therapy and who require specialized interventions. Examples Coronary artery disease, systemic hypertension, diabetes mellitus, history of cardiotoxic drug therapy or alcohol abuse, personal history of rheumatic fever or family of cardiomyopathy.
Left ventricular hypertrophy or fibrosis, left ventricular dilation or hypocontractility, previous myocardial infarction, asymptomatic valvular heart disease. Dyspnea or fatigue due to left ventricular systolic dysfunction, asymptomatic patients who are undergoing treatment for prior HF symptoms. Patients who are frequently hospitalized for HF and cannot be safely discharged from the hospital; patients in the hospital awaiting heart transplants; patients at home receiving continuous intravenous support with a mechanical circulatory assist device; patients in hospice setting for the management of HF.
Ventricular Remodelling after MI and in Diastolic and Systolic Heart Failure
Source: Jessup M & Brozena S. (2003). Heart Failure. N Engl J Med 348; 20:2007-2018.
Copyright 2003 Massachusetts Medical Society. All rights reserved.
Heart Failure Disease Process

Mechanical Dysfunction Pressure Overload Hypertension Pulmonary hypertension Aortic/pulmonic Valve stenosis Volume overload Aortic, mitral, tricuspid valve insufficiency Impaired Heart Filling Ventricular hypertrophy Pericardial disease Mycardial restriction Mitral/tricuspid stenosis Direct Cell Injury Cardiomyopathy Myocarditis Myocardial infarction Drug/toxin induced Systemic disease
Disease Process
CHF may result from either systolic or diastolic ventricular dysfunction

Systolic Heart Failure Systolic dysfunction occurs in 50 to 60 percent of cases. In the remainders, Systolic LVFx is normal. Diastolic Heart Failure 20 to 50 percent of patients with heart failure have preserved systolic fx or normal LVEF. Relaxation abnormality common feature in diastolic heart failure. Patients frequently have DM, HTN Female Obesity Mortality among these patients may be as high as that among patients with systolic heart failure. Diagnosis can be made clinically and by the finding of normal systolic function Diagnosis of CHF in elderly may be difficult because the history is often atypical or unobtainable or symptoms minimized by patients or attributed to age. Most common atypical presentation is Delirium.
Characteristics of Systolic Heart Failure (SHF) as Compared to Diastolic Heart Failure (DHF)*
Characteristic Clinical features: Symptoms (eg dyspnea) Congestive state (e.g. edema) Neurohormonal activation Left ventricular structure & function: Ejection fraction Relative wall thickness** Left ventricular mass End diastolic volume End diastolic pressure Left atrial size Exercise: Exercise capacity Cardiac output augmentation End diastolic pressure DHF Yes Yes Yes Normal Increased Increased Normal Increased Increased Decreased Decreased Increased SHF Yes Yes Yes Decreased Decreased Increased Increased Increased Increased Decreased Decreased Increased
*The clinical features of DHF are similar to those of systolic heart failure, but left ventricular
function and structure are distinctly different. **The descriptor of left ventricular geometry is relative wall thickness, defined as the ratio of left ventricular wall thickness to the radius of the left ventricular cavity. Source: Aurigemma, GP et al. (2004) N Engl J Med 351 :1097-1105.
Classic and Atypical manifestation of CHF in the Elderly CLASSIC Dyspnea Orthopnea PND Peripheral edema Unexplained weigh gain Weakness Poor exercise tolerance Abdominal Pain Fatigue ATYPICAL (Non-cerebral) Chronic cough Insomnia Weigh loss Nausea Nocturia Syncope ATYPICAL (Cerebral) No history Falls Anorexia Behavioral Disturbances Decreased fx Status
Factors That Precipitate Congestive Heart failure
Anemia Arrhythmias COPD Digoxin withdrawal Drugs: Cardiac depressants Hypoxia Hyperthyroidism Intravenous fluid overload Infection
Myocardial infarction Ischemia Dietary or medication noncompliance Pulmonary embolism Renal Insufficiency Sepsis
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Primary Targets of Treatment in Heart Failure
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Stages of Heart Failure and Treatment Options for Systolic Heart Failure
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Management Principles for Patients with Diastolic Heart Failure

Goal Reduce congestive state Treatment* Reduce salt intake Diuretics ACE inhibitors Angiotension II-receptor blockers Maintain atrial contraction and prevent tachycardia Cardioversion of atrial fibrillation Sequential atrioventricular pacing Beta-blockers Calcium-channel blockers Radiofrequency ablation modification of atrioventricular node and pacing Nitrates Beta blockers Calcium-channel blockers Coronary-artery bypass surgery, precutaneous coronary intervention Antihypertensive agents Daily medication dose <2g of sodium/day Furosemide 10-120mg Hydochlorothiazide 12.5-25 mg Enalapril 2.5-40 mg Lisinopril 10-40 mg Candesartan 4-32 mg Losartan 25-100 mg Atenolol 12.5-100 mg Metoprolol 25-100 mg Diltiazem, 120-540 mg Verapamil, 120-360 mg Isosorbide dinitrate, 30-180 mg Isosorbide mononitrate, 30-90 mg Atenolol 12.5-100 mg Metoprolol 25-100 mg Diltiazem, 120-540 mg Verapamil, 120-360 mg
Treat and prevent myocardial ischemia
Control hypertension
Chlorthalidone 12.5-25 mg Hydochlorothiazide 12.5-50 mg Atenolol 12.5-100 mg Metoprolol 25-100 mg Amlodipine 2.5-10 mg Felodipine 2.5-20 mg Enalapril 2.5-40 mg Lisinopril 10-40 mg Candesartan 4-32 mg Losartan 50-100 mg Measures with Theoretical Benefit in Diastolic Heart Failure Promote regression of ACE inhibitors Enalapril 2.5-40 mg hypertrophy and prevent Lisinopril 10-40 mg myocardial fibrosis Ramipril 5-20 mg Captopriil 25-150 mg Angiotensin-receptor blockers Candesartan 4-32 mg Losartan 25-100 mg Spironolactone 25-75 mg
* Treatment listed for the first four goals are those generally used in clinical practice. ACE inhibitors, angiotensin-receptor blockers, and spironolactone inhibit the rennin-angiotensin-aldosterone system and thus have a theoretical benefit, but more data are required to show that they reduce the risk of heart failure. This list of medications is not comprehensive, but rather includes examples that are in common clinical use or have been included in studies of pathiphysiological mechanism in diastolic dysfunction or heart failure or were included in larger trials that were not designed to assess outcomes in diastolic heart failure.
Source: Aurigemma GP et al. (2004). N Engl J Med 351:1097-1105.

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Common Clinical Problems in patients with HF and Recommended Solutions

Clinical Problem
The patient has classic symptoms of heart failure with a normal left ventricular ejection fraction The patient has hypotension: when is the systolic pressure too low?
Recommended Solution*
Consider diastolic heart failure, valvular heart disease, hypertensive heart disease and ischemia. Asymptomatic patients with dilated cardiomyopathy often tolerate a systolic blood pressure of 90 mm Hg. If the patient has no lightheadedness or undue fatigue, peripheral perfusion is adequate, and blood urea nitrogen and creatinine are unchanged, continue the same dose of medications. If symptomatic, decrease the dose of diuretic. If symptoms persist, adjustment of the timing of concomitant medications may be helpful. Decreasing the dose of the ACE inhibitor, betablocker, ARB or vasodilator is indicated.
The patient has hyperkalemia.
Ensure that the patient is taking no exogenous potassium supplement or potassium-containing salt-substitute. Avoid hypovolemia. Consider decreasing the dose of a potassiumsparing diuretic. Concomitant use of an ACE inhibitor or ARB and spironolactone may increase the risk of hyperkalemia. Avoid high doses of ACE inhibitors and ARBs in patients receiving spironolactone. Avoid use of spironolactone in patients with renal failure, and use low doses of ACE inhibitors and ARBs. Decrease dose of diuretic. Consider renal-artery stenosis if azotemia persists. Rule out worsening congestive heart failure. Change to ARB if severe cough persists. Start beta-blocker therapy if there are no contraindications.
The patient has increasing azotemia while taking ACE inhibitors. Patient has a cough while taking ACE inhibitors. Should the dose of the ACE inhibitor be increased or should the beta-blocker therapy by initiated in a symptomatic patient? Should an ARB be added to ACE-inhibitor therapy or should a beta-blocker be added in a symptomatic patient? The patient has worsening symptoms of congestive heart failure after starting beta-blocker therapy. The patient has worsening bronchospasm after starting beta-blocker therapy. The patient requires repeated hospitalizations.
Start beta-blocker therapy if there are no contraindications.
Increase dose of diuretic and slow the titration of the betablocker. Decrease the does of the beta-blocker. Consider a betaselective agent. Discontinue treatment with the drug if the problem persists.
A multidisciplinary approach should be initiated, with a visiting nurse in the home. Referral for heart failure is indicated. * ACE refers to angiotensin-coverting enzyme and ARB refers to angiotensin-receptor blocker. Source: Jessup M & Brozena S. (2003). Heart Failure. N Engl J Med 348; 20:2007-2018.
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Suggested Reading: Jessup M & Brozena S. (2003). Heart Failure. N Engl J Med 348; 20:2007-2018. Aurigemma GP et al. (2004). N Engl J Med 351:1097-1105.
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Dizziness
Case: A patient with Dizziness Evaluation and treatment of Dizziness Dizziness: A possible Geriatric Syndrome HPI: Patient is 87 years old white woman came to the clinic with chief complaint of dizziness. Pt. States, she is having this problem off and on for last 2 years, but is really troublesome for last two month. Her dizziness is associated with imbalance, light headedness and nausea. Her dizziness increases with turning head and bending down. She denies room spinning or vomiting. She also complaints of lower extremity numbness and discomfort, especially on standing and walking. Past Medical History OA X 45 Years HTN X 2-3 months Hypercholesterolemia B/L Cataract H/O Fluid Ear *** Immunization Up-to-date Current Medications Vasotec 5 mg PO QD Lipitor 10 mg PO QD HCTZ 25 mg PO QD ASA 81 mg PO QD Folate 1mg PO QD Tylenol 650mg PRN Family History Widow x 27 years 11 Children 4 Daughters and one Son with DM Mother had DM
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Social History Lives alone, does all her activities, work and money management by herself, family support for transportation and assist IADLs Ex-smoker (x50 yrs), quit 20 yrs ago. No ETOH/ IV Drugs ROS: Generalized weakness Neck pain on movement ( R ) Ear dryness and itching SOB on climbing few stairs Occasional B/L ankle swelling Physical Examination: V/S: Tc:98, HR:52, BP:172/102, ( Standing: 154/90 ) Gen.: AAO x 3, NAD, Well nourished HEENT: PERRL, EOMI, No nystagmus, B/L cataract, wax in both ear, OP Clear, few missing teeth Neck: Supple, No JVD, No LAD, Bruit on R. Carotid Chest: Clear lungs, No rales/rhonchi CV: RR with bradycardia, (+) S4, few escape beats Abdomen: Soft, NT, ND, BS+, No HSM Extremity: Cold extremities, Trace edema, Poor capillary Refill, + Hair loss on dorsum of foot, Feeble DP pulses Neuro.: Non focal, CN and sensation intact, DTR 1+, Motor5/5 Lab./Investigations: ABI-Lt.= .99 Rt=1.1 CBC: Hb. 14, Hcr. 43, PLT 179, WBC 6.6 Nl diff Chemistry: NA-138, K-4.1, Cl-97, HCO3-33, BUN-20, Cr-1.1, Glu-100, Ca-8.9, Mg-2, P-2.9 Lipid-TC-298, LDL-214, HDL-38, TSH-2.88, Homoc-17.2 EKG= Sinus bradycardia (52), First Degree AV block Carotid Dopplar= 15% stenosis
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MRI/MRA Brain= Mild gen. atrophy, mild periventricular deep white matter ischemic changes, mild carotid stenosis, Normal Circle of Willis and vertebral arteries. Evaluation of Dizziness: Term Dizziness include 1. Vertigo, 2. Presyncope, 3. Dysequilibrium, and 4. Nonspecific dizziness History: 1.Time course: Acute, short duration and rotational vertigo D/O of peripheral vestibular system - BPPV. Episodes- a few minutes to 1 hour Menieres Dz, presyncope, phobic and anxiety disorders. Episodes- several hours viral or vascular labyrinthitis and sometimes Menieres disease. 2. Relation with position and Motion: - BPPV - with a rapid change in position - Orthostat. hypotension -on standing. - Menieres disease- unrelated to position or motion. 3. Use of medications: -Cardiovascular drugs - Presyncope. -Ototoxic drugs - dysequilibrium and oscillopsia - Psychotropic meds, muscle relaxants and anticonvulsants - dysequilibrium -ETOH /excessive caffeine - Dizziness. 4. Systemic disorders eg. Vasculitis, Cardiac arrhythmia, Valvular diseases
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5. Associate Symptoms, eg. Nausea and vomiting, Hearing loss and Tinnitus and Cranial nerve deficits 6. History of head trauma is also important. Physical Examination: A thorough medical examination Test Battery: Orthostatic blood pressure testing -? Presyncope. Potentiated Valsalva maneuver: ?Presyncope -orthostatic hypotension/ vasovagal attacks / low COP Carotid sinus simulation: (+) syncope - orthostatic hypotension/ vasovagal attacks or decreased cardiac out put. Barany rotation: Produces vertigo in anyone who maintains some vestibular function. Walk and turn: produces dysequilibrium caused by multisensory loss. Seated head turn: dysequilibrium caused by multi-sensory loss. Hyperventilation: Produces non-specific dizziness, may indicate anxiety or a phobic disorder. Dix-Hallpike maneuver: Very important and most common out-pt diagnostic maneuver Pt is seated on a table and is rapidly lowered until the head hangs over the table, for 10 seconds Produces vertigo in BPPV.
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Tests: (If needed) Blood: CBC, Electrolytes, LFT, VDRL, TSH. Audiogram/Auditory evoked potentials: Menieres dz,/8th CN dz- MS, acoustic neuroma. MRI: for tumors Holter monitor; 7% of exam abnormal Carotid and Vertebral artery color Doppler; -TIAs ENG (Electro-nystagmo-graphy) - caloric testing - for unilateral peripheral vestibular deficits / not affected by age. Rotational chair testing/posturography: - vestibular
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Vertigo and Related disorders A sensation of moving, falling or spinning. Often episodic, abrupt Nausea and vomiting. By a disturbance of the peripheral vestibular apparatus (Peripheral vertigo) or connection in the CNS (Central vertigo). Peripheral v/s Central Vertigo
Peripheral Vertigo N/V Latent period before onset of symptoms Hearing loss Neurologic symptoms/ ataxia Severity Postural Instability Compensation Nystagmus; -Direction Nystagmus: -Type Nystagmus: -Effect of visual fixation Severe 2-20 seconds Common Rare Severe Unidirectional, walking preserved Rapid Unidirectional, Horizontal with rotational component, *Suppressed by visual fixation Central Vertigo Moderate None Rare Common Less severe Severe, Pt may fall when walking Slow Reverse direction possible Can be any direction Not suppressed
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Sleep Disorders
A. Demographics
1. Up to 50% of older adults have some kind of sleep complaint, and up to 30% have chronic problems with sleep. 2. Up to half of older adults use some kind of sleeping medicine. 3. Rates of sleep disturbance s in long-term care settings are much higher.
B. Normal Age-Related Sleep Changes

1. Aging is associated with decreased sleep continuity. Studies have shown that older individuals have less of a sleep drive and spend more time awake at night. Older people are also more sensitive to external factors such as noise, bright light or unfamiliar surroundings. 2. Many older people make up for lost nighttime sleep with daytime sleep. There is increased napping as people age. 3. The time required to fall asleep (sleep latency) increases with age. 4. Older people average an increased number of arousals during sleep. 5. EEG changes: older age reduces the amplitude in the low frequency or NREM sleep. Older individuals appear to have less slow-wave sleep and seem to lose the deepest part of this sleep. 6. Circadian rhythm changes with age. The pineal gland secretion of melatonin diminishes with age. The result of this is less sleep at night and more during the day.
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C. Sleep Disturbances:
1. Dyssomnias: disorders of initiating sleep, maintaining sleep and of excessive sleepiness. 2. Parasomnias: disorders that primarily do not cause sleep-related complaints. 3. Disorders associated with medical or psychiatric disorders. 4. Proposed sleep disorders: disorders that continue to be studied to become more well defined.
D. Causes
Common causes of sleep disorders may include periodic limb movements, restless legs syndrome, sleep-related breathing disorders such as apneas, illness, pain, nocturia, dementia and alcoholism. Depression is the most significant cause of insomnia.
E. Assessment
1. Sleep History: the impact of the sleep complaint on the individuals daily life. 2. Medical History: various medical conditions may contribute to sleep disturbances. 3. Diet and Drug History: include prescription and non-prescription medications as well as alcohol, caffeine, and nicotine. 4. Psychosocial History: should begin with psychiatric illnesses, such as anxiety, depression and dementia, and then assess social history including grieving the illness or loss of friends and family and translocation.
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F. Treatment
1. Non-Pharmacologic Treatments a. Remove the suspected contributing factors: treat the underlying illness, discontinue or change medication, discontinue alcohol, caffeine or nicotine use. b. Change Habits: develop a sleep-preparation routine, use the bedroom for sleep only, develop a sleep story to promote a restful state of mind, reduce daytime napping, and develop a daily exercise routine. 2. Pharmacologic Treatment a. Only recommended for short-term use in older patients. b. Benzodiazepine with a short or intermediate action such as Temazepam (7.5 to 15 mg), with a two-week maximum time period in order to avoid dependence. c. Antihistamines are acceptable for occasional use, but lose efficacy quickly d. Sedating anti-depressants, e.g., Trazadone, are a good choice for chronic insomnia
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Pressure Ulcers
A. Epidemiology
1. The prevalence varies widely as a function of care quality, venue, patient population, and the rigor with which pressure ulcers are identified. 2. Prevalence of pressure ulcers in acute care ranges from 3% to 32%, with an overall prevalence of 10%. 3. Prevalence in skilled care and nursing homes is estimated at approximately 23%. 4. Incidence among all elderly people at home is less than 1%; however, among those who receive nursing care in their homes, incidence is 4-5% , with prevalence 10-15%
B. Risk Assessment
1. Extrinsic Risk Factors: pressure, friction, shear, chemical effects of moisture, urine, and stool. 2. Intrinsic Risk Factors: dermal thickness, subcutaneous adiposity, collagen tensile strength, and skin elasticity all decrease with aging; nutrition and hydration; conditions associated with immobility, impairment of sensation and reduced level of consciousness. 3. Assessment Tool (included): see the Braden Scale for Predicting Pressure Sore Risk.
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C. Pathophysiology
1. There are four physical factors that can lead to the development of pressure ulcers: (a) Pressure Mild pressure can produce ischemia in tissue after only two hours. This ischemia can then lead to tissue necrosis (b) Shear - A shearing force is produced where the skin is against a fixed exterior surface while the subcutaneous tissues are subjected to lateral forces (c) Friction When the skin moves across another surface, abrasions can occur and cause burns (d) Moisture Moisture can lead to tissue maceration. If urinary or fecal incontinence is present, this can add a chemical irritant
D. Prevention (The National Pressure Ulcer Advisory Panels Summary of the AHCPR Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention)
1. Risk Assessment (see above) 2. Skin Care and Early Treatment a. Inspect the skin at least daily and document assessment results. b. Individualize bathing frequency, use a mild cleansing agent, avoid hot water and excessive friction. c. Assess and treat incontinence. d. Use moisturizers for dry skin; minimize environmental factors leading to dry skin. e. Avoid massage over bony prominences. f. Use proper positioning, transferring and turning techniques to minimize skin injury. g. Use dry lubricants (cornstarch) or protective coverings to reduce
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friction injury. h. Identify and correct factors compromising protein / calorie intake and consider nutritional supplement / support for nutritionally compromised persons. i. Institute a rehabilitation program to maintain or improve mobility / activity status. j. Monitor and document interventions and outcomes. 3. Mechanical Loading and Support Surfaces a. Reposition bed-bound persons at least every 2 hours, chair-bound persons every hour. b. Use a written repositioning schedule. c. Place at-risk persons on a pressure-reducing mattress / chair cushion. Do no use donut-type devices. d. Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning persons in chairs or wheelchairs. e. Teach chair-bound persons, who are able, to shift weight every 15 minutes. f. Use lifting devices to move rather than drag persons during transfers and position changes. g. Use pillows or foam wedges to keep bony prominences such as knees and ankles from direct contact with each other. h. Use devices that totally relieve pressure on the heels i. Avoid positioning directly on the trochanter when using the sidelying position. j. Elevate the head of the bed as little and for as short a time as possible.
4. Education
a. Implement educational programs for the prevention of pressure ulcers. b. Include information on etiology and risk factors, risk assessment tools, skin assessment, support surfaces, skin care, positioning, and documentation.
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E. Staging Definitions (National Pressure Ulcer Advisory Panel NPUAP) 1. Stage I: A stage I pressure ulcer is an observable pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness); tissue consistency (firm or boggy feel); sensation (pain, itching); and color. Specifically, the ulcer appears as a defined area of persistent redness in a lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues. 2. Stage II: Partial thickness skin loss involving epidermis and / or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. 3. Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue. 4. Stage IV: Full-thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g., tendon, joint capsules, etc.)
F. Treatment
1. Assess the whole person, not just the pressure ulcer, including physical health, pain, psychosocial health, and pressure ulcer complications. 2. Attempt to use established measures of wound healing (PUSH) (NPUAP, 1997). 3. Maintain principles of wound care relevant to pressure ulcers:
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a. Debride wound b. Clean wound c. Use solutions that DONT kill cells; DONT use solutions that are cytotoxic i.e. hydrogen peroxide, Dahens Solution, or Betadine d. Irrigate wound, using minimal force e. Cover wound with appropriate dressing VI. Suggested Reading: Evans, J. M., Andrews, K. L., Dhutka, D., Fleming, K. C., & Garness, S. L. Pressure Ulcers: Prevention and Management. 1995. Mayo Clinic Proc., 70: 789-799.
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Braden Scale for Predicting Pressure Sore Risk* Date of Assessment________________ Patients Name________________ Evaluators Name_______________
SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort 1. Completely Limited: Unresponsive (does not moan, flinch, or grasp) the painful stimuli because of diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface. 2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR has a sensory impairment that limits the ability to feel pain or discomfort over _ of the body. 2. Very Moist: Skin is often, but not always moist. Linen must be changed at least once a shift. 2. Chairfast: Ability to walk severely limited or nonexistent. Cannot bear own weight and / or must be assisted into chair or wheelchair. 2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 2. Probably Inadequate: Rarely eats a complete meal and generally eats only about _ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding. 2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 3. Slightly Limited: Makes frequent though slight changes in body or extremity position independently. 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. 4. No Impairment Responds to verbal commands. Has no sensory deficit that would limit ability to feel or voice pain or discomfort.
MOISTURE degree to which skin is exposed to moisture ACTIVITY degree of physical activity
1. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. dampness is detected every time patient is moved or turned. 1. Bedfast: Confined to bed
4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. 4. Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. 4. No Limitation: Makes major and frequent changes in position without assistance. 4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
MOBILITY ability to change and control body position NUTRITION usual food intake
1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance. 1. Very Poor: Never eats a complete meal. Rarely eats more then 1/3 of any food offered. Eats 2 servings or less protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NOP and / or maintained on clear liquids or IVs for more than 5 days. 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.
FRICTION AND SHEAR
3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
________________________ Barbara Braden and Nancy Bergstrom. Copyright, 1988. NOTE: NPO = Nothing by mouth; IV = Intravenously; TPN = Total parenteral nutrition
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Sources Cited 1. Mariano, C., Gould, E., Mezey, M., & Fulmer, T., (Eds.). (1999). Best nursing practices in care for older adults: Incorporating essential gerontologic content into baccalaureate nursing education (2nd ed, Topic 12, p. 2). New York, NY: The John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, School of Education, New York University. 2. Cassel, C. K., Cohen, H. J., Larson, E. B., Meier, D. E., Resnick, N. M., Rubenstein, L. Z., & Sorensen, L. B. (Eds.). (1997). Geriatric Medicine (3rd ed.). New York: Springer. 3. Abrams, W. B., Beers, M. H., & Berkow, R. (Eds.). (1995). Merck Manual for Geriatrics. Whitehouse Station, NJ: Merck Research Labs. 4. Jessup M & Brozena S. (2003). Heart Failure. N Engl J Med 348; 20:2007-2018. 5. Cobbs E. L., Duthie, E. H., & Murphy J. B., (Eds.). (1999). Geriatric review syllabus: A core curriculum in geriatric medicine. (4th ed. p. 145). Dubuque, IA: Kendall/Hunt Publishing Company for the American Geriatrics Society. 6. Langemo, D., Olson, B, Hunter, S., et al. (1991). Incidence and prediction of pressure sores in five patient settings. Decubitus 4 (3) 25-28. 7. Cobbs E. L., Duthie, E. H., & Murphy J. B., (Eds.). (1999). (p. 155). 8. Yoshikawa, T. T., et al. p. 256. 9. HCPR Publication No. 92-0047. Rockville, Maryland. May 1992.
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Case Analysis: Read and discuss the case of Ms. R. Case Analysis: Ms. R Ms. R is a 79-year-old woman who lives with her husband in their own home. She is taking medication for hypertension, but has no other medical problems. She had one daughter who passed away five years ago with lung cancer. Three weeks ago, at her urging, Ms Rs husband participated in a free prostate cancer screening at the local senior center and was diagnosed with the disease. He is scheduled for surgery next week. Over the last several weeks, Ms. R has been seen at the Senior Center, falling asleep in the middle of the morning and again in the afternoon. Many of the seniors have commented that this is not the place to sleep and reported it to the director. The nurse for the center made a visit one afternoon and interviewed Ms. R about her frequent napping at the center. On assessment, Ms. R stated that she had not been sleeping well at night. She stated that it took her about two hours to fall asleep and then she usually woke up about 2:00 AM and stayed up until 5:00 AM. She finally manages to fall back to sleep for a few hours, before her husband awakens her at 6:30 AM for morning mass. She admitted that she told her physician and he prescribed her a little purple pill but she didnt want to take it. Further assessment revealed that Ms. R was very upset about her husbands impending surgery. She cried when she discussed the possibility of losing him and being alone in the world. On review of the assessment, the nurse found no medical or pharmacological reason for Ms. Rs insomnia. It appeared that her sleep disorder was most likely related to her anxiety over her husbands impending surgery. The nurse provided Ms. R with education about her husbands surgery. This helped Ms. R to gain some control over the future events. In addition, the nurse instructed Ms. R to avoid napping during the day and to add a program of physical exercise to her daily routine. Ms. R was assured that the low
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dose of Halcion prescribed for her was safe for a period of two weeks. The nurse requested the staff and other visitors of the senior center to take frequent opportunities to discuss her feelings of fear and loneliness and scheduled an appointment to come back and reassess Ms. R in two weeks. When the nurse made her follow-up appointment, Ms. R revealed that her husband was home recovering well from the surgery. She no longer had problems sleeping and had discontinued the sleeping medication two days after her husbands return.
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Discussion questions: Please provide answers to the following questions and return it to:
Tony DiNuzzo, Ph.D. 301 University Boulevard Galveston, Texas 77555-0460 Fax: (409) 772-8931
1) What were the major steps taken by the nursing staff that may have helped Ms. R overcome her sleeping problems?
2) How would you assure that her problems with sleep do not reoccur?
3) Discuss other common examples of sleep problems & its causes among older populations?
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Module 3: Congestive Heart Failure, Dizziness, Sleep Disorders & Pressure Ulcers EVALUATION OF ETGEC MODULE 3 Geriatric Syndromes
Now that you have completed the module, please take about 5 minutes to answer a few questions that will help us continue to improve our offerings. When you have answered all of the questions, mail the form to the address at the bottom of this page. Please circle a number for each item that best represents your opinion. For each item, the left side of the scale is the most positive and the right side the least positive.
familiar
NOT AT ALL
VERY familiar
Before you began this module, how familiar were you with the information presented in each of the modules major topics?
Congestive heart failure Dizziness in the Elderly Sleep Problems in the Elderly Pressure Ulcers
4 4 4 4
3 3 3 3
2 2 2 2
1 1 1 1
0 0 0 0
NOT AT ALL relevant
VERY relevant
How relevant to your learning needs was this modules content, taken as a whole?
This modules learning objectives listed what you should be able to do after working through the module. How good a job did the module do in helping you to meet each objective listed below? Describe the prevalence and risk factors associated with CHF, dizziness, sleep disorders and pressure ulcers in the elderly. Identify the components of evaluation for CHF, dizziness, sleep disorders and pressure ulcers: history and physical examination. Discuss interventions for CHF, dizziness, sleep disorders and pressure ulcers in the elderly.
VERY GOOD 4 3 2 1 4 4 3 3 2 2 1 1
STRONGLY AGREE DISAGREE NEUTRAL AGREE
VERY BAD 0 0 0
STRONGLY DISAGREE
Please indicate how much you AGREE or DISAGREE with the following statements. The modules presentation of concepts was clear and understandable. I had no difficulty maintaining my interest level as I worked through The module.
4 4
3 3
2 2
1 1
0 0
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TOO MUCH The amount of information presented in the module was [check one] Please use these questions to comment on other aspects of the module. (1) What concepts presented in this module need additional explanation or examples in order to be useful to you? ABOUT RIGHT TOO LITTLE
(2) What additional topics in geriatric syndromes would you like to be able to study in this format?
(3) What else do you want to tell us about the module? We welcome your suggestions and comments.
THANK YOU! Mail or fax the completed form to Tony DiNuzzo, Ph.D. 301 University Boulevard Galveston, Texas 77555-0460 Fax: (409) 772-8931
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Module 3: Congestive Heart Failure, Dizziness, Sleep Disorders & Pressure Ulcers

Stages of Heart Failure

Ventricular Remodelling after MI and in Diastolic and Systolic Heart Failure

Copyright 2003 Massachusetts Medical Society. All rights reserved.

Heart Failure Disease Process

CHF may result from either systolic or diastolic ventricular dysfunction

Factors That Precipitate Congestive Heart failure

Primary Targets of Treatment in Heart Failure

Copyright 2003 Massachusetts Medical Society. All rights reserved.

Copyright 2003 Massachusetts Medical Society. All rights reserved.

Management Principles for Patients with Diastolic Heart Failure

Treat and prevent myocardial ischemia

Source: Aurigemma GP et al. (2004). N Engl J Med 351:1097-1105.

Common Clinical Problems in patients with HF and Recommended Solutions

The patient has hyperkalemia.

Start beta-blocker therapy if there are no contraindications.

B. Normal Age-Related Sleep Changes

FRICTION AND SHEAR

NOT AT ALL relevant

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