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When it comes to mental health,
what’s normal?
Mental Health Overview for Care Providers.
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 4- Approximate time required: 240 min.
Educational Goal:
To give a basic overview of the most common Mental Health Issues for Care givers.
Educational Objectives:
1. Understand the difficulties in mental health issues.
2. Explain the Basics of Mental health
3. Provide a description of the 10 most common mental illnesses
4. Provide some care giver tips for caring for mental health patients
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
When it comes to mental health, what’s normal?
Mental Health Overview for Care Providers
When it comes to mental health, who is normal and who is crazy? That is a hard question to answer. Aren’t we all a bit off center in some way? Despite our differences, we can, for the most part, fit into society and function well. Unfortunately, there are those who are so far off center that they have difficulty functioning and need help fitting in. Some of these individuals cannot even live by themselves and wind up in your care homes. Caregivers to these needy people would be wise to have at least a basic understanding of what their clients face. Hopefully by the end of this lesson, you will have a better understanding of some of the most common of society’s mental health problems.
Basic Understanding
What is Mental Health?
As care providers you are totally involved in the physical health of your patients. You watch their hygiene, give them their medicine, control their diet, fight off any physical illnesses that crop up, make sure they get enough of what they need, etc. Most of you have got a pretty good handle on your patients’ physical health. But what about their mental health? You may not be used to thinking in such terms. What is mental health? “Mental health is how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others and make choices.” National Institutes of Health, Medline Plus. When a body doesn’t function normally, we say it is in poor health. When a mind doesn’t function normally, we say that person has a mental illness.
The Difficulty in Diagnosing Mental Illness
Our mind is one of our most complex structures, with millions of brain cells with trillions of connections to each other. Those connections can be affected by the way we were born (congenital), environmental assaults (alcohol, drugs, toxins), and outside stresses (emotional abuse, traumatic events, overwhelming stressors) or chemical imbalances. If there are enough changes in our brain cells we begin to think and act abnormally. If the abnormality starts to interfere with normal functioning it is said to be a mental illness. Of course it is not that simple. There is almost limitless variety in brain cell connection structures from one person to another. In addition the specifics of most mental illness can’t be seen or seen only intermittently. It’s easy to see measle spots but can you tell the difference between having a tired down day and major depression disorders? Add to all the above the fact that the mental health patient themselves are probably unaware that there is a mental health issue. They have learned to compensate for their difficulties, thus hiding the true nature of what is going on. These and other factors make mental illness one of the most challenging areas of concern in health care today.
History of Mental Health Care
It seems to be in society’s nature to try to force its members to comply to a set standard of behaviors so everyone gets along with each other. If a member of that society does not comply with its expectations, it has a tendency to push them out of the way until that person decides to come into compliance with normal societal behaviors. It seems a logical way of handling aberrant behaviors. Unfortunately, logic breaks down when that person has difficulty or cannot change their behaviors. It has been a sad fact for most of human history that mental health patients have been looked down upon, shunned, mistreated, institutionalized, and even punished because of their abnormal behavior.
In ancient times, mental illness was viewed as spiritual in nature and the afflicted person was thought to be possessed by demons. Treatments involved trying to exorcise the evil spirit or punish the patient to purge the evil spirit. In medieval to colonial times, doctors tried to balance the humors of the body and mind by bloodletting, burning, or whipping the patient. In post-colonial Darwinian times, mental illness was view as uncontrolled, animalistic behaviors. Treatments involved imprisonment in asylums and restraints until the person got their inner animal under control. As modern medicine started to evolve, doctors tried to find purely physical causes for mental illness. Treatments involved extremes like electric shock therapy and lobotomy (cutting away parts of the brain).
This seems barbaric to us now, but doctors simply did the best they could with the limited knowledge they had at the time. Even now most individuals have very little understanding of what mental illness is and shun those who suffer, expecting them to behave themselves in public. Unfortunately, it is a normal human reaction to avoid things we find disturbing. As caregivers, you are hampered by these same human prejudices and lack of knowledge. You may need to change your reactions to mental illness. By educating yourselves about mental illness, you can fight against these tendencies and become better caregivers to those who need your care.
What really is Mental Illness?
Medical science has been trying to answer that question for a long time. The answer keeps changing as our understanding improves. Shortly after World War II, the U.S. Army tried to standardize the classification of mental diseases. That first attempt has morphed over the years into to the American Psychiatric Association’s DMS IV (Diagnostic and Statistical Manual of Mental Disorders 4th edition). In 2013, they plan to update it to DMS 5.
In the U.S., the DMS IV is now the generally accepted authority concerning mental health issues. In the DMS IV, there are more than 300 recognized types of mental disorders. There is still considerable debate whether this is the most accurate or appropriate approach to mental illness. It is argued that there is still considerable social bias involved that clouds effective therapy. But, for the foreseeable future, it will be the gold standard in mental health issues.
How is DSM IV Used?
Unlike other medical diagnosis systems, mental illness has a multitude of contributing factors that affect the patient’s mental illness. The DSM IV system tries to address all of the contributing factors to the problem. It uses a multiaxial (multidimensional) approach, assessing five different dimensions of a mental illness.
Axis I- Clinical Syndromes
This refers to the primary mental issue, similar to a regular diagnosis, for example, Bipolar, Major Depression, Panic Disorders.
Axis II- Development Disorders and Personality Disorders
This lists any personality disorder that may be shaping the way the patient is responding to the Axis I issue, for example, Mental Retardation, Paranoia, Antisocial Disorders.
Axis III -Physical Condition
This refers to contributing physical conditions that can affect the Axis 1 diagnosis, for example brain injury, HIV/AIDS, severe Asthma, Cancer.
Axis IV –Psychosocial Stressors
This refers to outside stresses the patient has had or is now experiencing. for example, death of a loved one, unemployment, divorce.
Axis V- Level of Functioning
This is numerical ranking of how well the patient is functioning despite the mental illness. It uses the Global Assessment of Functioning (GAF) scale of 100 to 0. Using GAF 100 represents no impairment with a gradual decline to GAF 1-10, in which the patient is a persistent danger to themselves or others.
The multi-axial system of the DSM-IV tries to address "the whole person." It is designed to help the mental health professional intervene successfully in an emotional or psychiatric disorder by considering all conditions that affect the patient’s mental health.
By now you might be thinking, “Why did he write such a lengthy introduction? Just tell us about the disorders already”. What I am trying to convey is there is no clear cut definitions, no easy understandings, just broad categories in which patients’ disorders might fall. Even when a mental illness has been diagnosed, there are other matters to consider, like severity and functionality. The only certain reality is that mental health understanding and treatment will change in the future. There will always be a need for a greater amount of patience and understanding on the part of mental health caregivers.
All that said and done, let’s talk about what medical science knows so far.
Mental Illness: The Big Picture
Prevalence
Mental health issues might be more common than you think. According to an article published in the Archives of General Psychiatry, “ Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%.... CONCLUSIONS: About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life.”
In another article, the School of Social Work- University of Washington stated, “Mental disorders are common in the United States and internationally. An estimated 26.2 % of Americans ages 18 and older – about 1 in 4 adults – experience a mental disorder in a given year…. This figure translates to 57.7 million people. “Most of these people can cope without any help, but the article continues “the main burden of illness is concentrated in a much smaller portion – about 6 %, or 1 in 17 experience a serious mental illness.” The article continued to say about half of those who suffer have two or more disorders, complicating therapy and compounding the seriousness of the issue.
Mental illness is often first seen during adolescence or young adulthood, but all ages are at risk. It appears that the young and the old are particularly susceptible. The World Health Organization reported that four out the 10 leading causes of disability in the U.S. are related to mental disorders.
Severity
The severity of a condition is measured by how much it interferes with normal functioning. Just as with most things in life, mental health issues are not black and white, but several shades of gray. The severity of a condition can range from a mild inconvenience to a total debilitation of functioning and cycle back and forth. Most severe cases have two or more mental illnesses to contend with. The severity of the condition can change over time. For example, some contributing conditions can be resolved or the patient’s ability to cope can fluctuate over time. It is not uncommon for a mental illness to be a lifelong challenge.
Treatments
There has been considerable advancement in the science of mental health. Research confirms that mental illness is a serious medical condition. Mental illness is not a result of an individual’s poor character and cannot be overcome through sheer will power and right thinking. But mental illness is not a purely physical condition, either and, cannot be cut out or drugged away.
Greater understanding has led to more effective treatments. One of the most significant advances is how medical professionals view the resolution of mental illness. We no longer try to “cure the illness.” Instead, there is a focus on the whole person and their mental functionality. With this change of focus, between 70 and 90 percent of serious mental health patients have significant reduction of symptoms and improved quality of life. The most effective mental health therapies are a combination of pharmacological and psychosocial treatments accompanied with supports. Caregivers can play a vital role in the support system of mental health patients.
The following mental health diseases are presented in no particular order. Most were selected because you, the caregiver, requested to know more about them.
Mental Disorders
Bipolar Disorder
Description
Bipolar disorder is a mental illness that causes extreme mood swings to be experienced by the patient. It is also known by its common name of manic depression. This is a cyclic illness characterized by a high (mania) phase and a low (depression) phase, with normal behaviors in between. Each swing through the different phases can last from weeks to months, seriously affecting the patient and those around him. Onset of the disease is often in the teens or early adulthood but can be seen in all ages. Ninety percent of suffers experience their first episode before the age of 50. It is thought to be caused by a chemical imbalance in the brain and may be an inherited tendency.
Symptoms
Cycles may start with either a manic or depressive phase.
Mania:
In mania, the classic symptoms are heightened mood (either euphoric or irritable), flight of ideas, pressure of speech, increased energy, decreased need for sleep, and hyperactivity. Parts of this phase can be enjoyed by the patient and those around them, especially when they are happy and get a lot accomplished. Unfortunately, the condition can also progress to the point of fragmentation of thoughts, poor decision making, risky behaviors, and even delusions. In the absence of developed speech patterns as in mental retardation or youth, symptoms can be expressed as purposeless activity
Manic episodes are often preceded by symptoms warning of an impending cycle. They can last from a few days to a few months. The symptoms are mild and often transitory with indistinct manic symptoms. At times, however, no prodromal warning signs may occur, and the episode starts quite abruptly. When this occurs, patients often wake up during the night full of energy and vigor—the so-called “manic alert.”
Depression
During this “Down” phase, the patient often feels depressed, irritable, and fault finding with themselves and those around them. The patient lacks energy and thoughts become slow and sluggish. The ability to concentrate and comprehend alternatives may become impaired. Patients often feel a need for increased hours of sleep lasting from 10 to 18 hours a day. Even with the extra sleep, they still wake up exhausted. Appetite may increase. This, coupled with lack of exercise, can lead to dramatic weight gain. There are those, though, who are affected in just the opposite, with insomnia and loss of appetite. Symptoms gradually subside in each cycle. Afterward, the patient often feels guilty and is full of self-reproach for his lack of self-control.
Mixed-Manic
A more rare form Bipolar episodes is called a Mixed-Manic episode. During this kind of episode the patient feels both manic and depressive symptoms either together or in very quick cycles.
Treatment
The goal of Bipolar therapy is to balance the brain chemicals that control mood. This is often accomplished with mood stabilizers like lithium, valproic acid, and carbamazipine. Other medications can be added to control symptoms, like antipsychotics and sleeping aids. A psychiatrist made need to be consulted. Counseling can help with stress, family concerns, and relationship problems.
Prognosis
Bipolar disorder is a lifelong condition with time between relapses from weeks to decades. Up to 10- 20 percent of bipolar patients contemplate or commit suicide. Because of the euphoria, added accomplishments, and normal times between episodes many patients are resistant to ongoing therapy. Despite all this, the condition will not get better on its own. The patient is always at risk for another mood swing episode. Without medication, the condition will only get worse over time.
Major Depressive Disorder
Description
Major depressive disorder is a clinical mood disorder that is an all-encompassing low mood. It is characterized by feelings of sadness, loss, anger, or frustration. In order for a depression to be called major depressive disorder, the episode must interfere with activities of daily living for two weeks or longer. It is different from the normal, reactive or chemically induced depression in that it appears to originate in an imbalance of chemicals or improper processes in the brain. The true cause of the disorder is still unknown but it can run in families.
It is estimated that about 5 percent of the general population could be afflicted by the disorder. Depressive events are episodic in nature as shown by a gradual increase of depression symptoms that could last for months. Generally, the patient returns to normal functioning. Twice as many adult females are affected as men.
Symptoms
Though not all patients have them, the basic pattern to major depression symptoms are: a down mood, loss of energy, difficulty in concentrating manifesting in impaired decision making and memory loss, loss of interest in favorite activities, insomnia, and loss of appetite, though there are a minority who experience just the opposite, continual pessimism, agitation with self and others, and non-descriptive suicidal thoughts.
Special caregiver considerations
There are a few symptom patterns that are of clinical significance to caregivers.
1. Patients lack the energy and focus to act on suicidal thoughts, but when they start to feel better they gain those abilities. Caregivers should be more alert to potential suicides as the patient gets better.
2. Some patients experience their worst symptoms in the morning and gradually improve throughout the day.
3. It may appear that some events triggered an episode, but in reality it was the depressive episode that caused the major event. For example, a loss of job or divorce seemed to make a person depressed but in reality they were caused when the patient started to experience the depression symptoms first.
4. In the worst cases, activities of daily living become more difficult if the patient has to make choices, for example what to wear and what to eat.
5. The loss of interest in favorites makes food taste like “cardboard,” contributing to the lack of eating.
6. The lack of movement and proper eating habits commonly lead to constipation.
7. Headaches are a common complaint.
Treatment
Antidepressant medication is the gold standard for therapy. Psychological counseling by itself appears to be less effective. There are many antidepressant medications the doctors can choose from. Depending on how often a depressive episode occurs, the patient may have to take them for the rest of their lives.
Prognosis
It is not clear what causes Major Depression and its occurrence is episodic. Depressive events can occur even in childhood. As of yet, there is no cure. Once an event occurs, the patient will always be at risk for another. Fortunately, for most sufferers, depression can be controlled. The patient can lead a normal life, though they may have to be on long-term antidepressant therapy.
Autism (Autism Spectrum Disorders)
Description
Autism is a group of developmental disorders of the brain that affects nerve cells and how they are connected to each other. It alters the way information is processed in the brain. Those who have Autism Spectrum Disorders are characterized by impaired or underdeveloped social interactions and communication skills and are often accompanied by severely restricted interests and or repetitive behavioral issues.
Autism affects each patient differently along an entire spectrum of behaviors. Each case can be mild to severe. The major types of Autism are 1. Classic or Typical Autism or just Autism, 2. Asperger Syndrome 3. Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) or Atypical Autism.
The exact causes of the disorders are not well understood but start before the age of three. Science has identified some inheritable genetic factors, spontaneous gene mutations, and defects cause by certain toxins and some chemicals. It is generally accepted that autism is probably caused by a combination of factors.
Special caregiver considerations
At one time, it was feared that some vaccinations and poor parenting skills contributed to the risk of the disorder, but studies have proven otherwise.
Symptoms
Autism
In typical care-home environments disruptive behaviors are usually dealt with by helping the patient alter their behaviors. Unfortunately, Autistic patients may not be able to. It is helpful to understand which behaviors are related to the disability.
According to the NIH Medline Plus website:
“People with autism may:
The symptoms may vary from moderate to severe.
Communication problems may include:
Social interaction:
Response to sensory information:
Play:
Behaviors:
source- http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm
Asperger’s Syndrome
Asperger syndrome usually present with milder autistic symptoms. Those with Asperger’s do not have problems with intellectual disabilities but may face some social challenges and unusual behaviors or interests. Clumsiness may also be a factor.
Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)
There are those who have some but not all of the symptoms of Classic Autism and Asperger syndrome. They are placed in the category of PDD-NOS. People with PDD-NOS usually have fewer and milder symptoms that may cause only social and communication challenges.
Treatment/Prognosis
As of yet, there is no medicine that alters the course of the disorder. However, early intervention can greatly enhance a patient’s abilities.
Special caregiver consideration
Because the patient has physical disabilities that affect their behaviors, it is important that caregivers carefully control the patient’s environment and make adjustment in the home as required. Expecting a patient to alter his behavior may be problematic.
Schizophrenia
Description
Schizophrenia is a group of severe mental disorders that impairs the brain from interpreting its surroundings normally. It may result in the patient experiencing hallucinations, delusions, and disordered thoughts that result in unusual behaviors. It is the mental disease that is the closest to the classic term craziness. Left untreated, it is severely debilitating because the patient cannot perceive that anything is wrong. Symptoms first appear most commonly between the ages of 16 to 30.
Symptoms
The causes of Schizophrenia are not completely understood, but there is a strong correlation with abnormal functioning of certain neurons or their associated neurotransmitter chemicals. The symptoms of Schizophrenia have been grouped into three broad categories.
Positive- Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. In other words, they are definite sign of the disease. They include hallucinations (perceiving things that no one else can- ex. hearing voices), delusions (believing ideas that are not true- ex. mind control with magnets), thought and movement disorders (disorganized patterns –ex garbled sentences or made-up words and repeating certain movement over and over again).
Negative- Negative symptoms are disruption of normal functioning, or an absence of regular behavior. They include flat affect (the person’s face does not move or they talk in a monotone voice), lack of pleasure in activities, speaking very little.
Special caregiver consideration
Negative symptoms lead the patient to appear lazy or sloppy. Often they need help with activities of daily living.
Cognitive- Cognitive symptoms are impaired mental functioning. They include reduced ability to understand information and using that information to make decisions, trouble focusing or paying attention, and reduced short-term memory.
Treatment
Treatments for Schizophrenia focus on eliminating the symptoms of the disease not the disease itself. Treatments include antipsychotic medications and various psychosocial treatments. Positive symptoms are more responsive to medication therapy.
Older first-generation drugs are called typical antipsychotics and usually are associated with more side effects. Newer second-generation drugs are called atypical antipsychotics. They generally have fewer side effects but are more expensive. Regardless of the drug, the side effects can include drowsiness or dizziness, blurred vision, rapid heartbeat, skin rashes, and sensitivity to the sun.
Special caregiver consideration
1. Long-term use especially with first generation drugs can lead to tardive dyskinesia (TD). TD causes muscle movements the patient can’t control. They include facial tics, tongue rolling, tremors, and unusual walking gate. It is important for the caregiver to promptly report these side effects to the doctor. Discontinuation of the drug can lead to a recovery from TD, but sometimes the effect is permanent. Discontinuation of an antipsychotic medicine should be done gradually.
2. Treatment can sometimes be problematic because the patient does not recognize that he needs help. Those who are unwilling or unable can get long-acting depot shots of certain medications. These drugs are usually second-line therapy but certainly are a treatment option for caregivers who have difficulty treating residents.
Prognosis
Even though Schizophrenia has been categorized as one of the most debilitating diseases, medication and therapy can help the patient lead a normal life. Continuing research has led to a better understanding of the condition, the patients, and therapies. Because of its unpredictable nature and lack of perception on the part of the patient, therapy usually has to be lifelong.
Panic Attack Disorders
Description
"One day, without any warning or reason, I felt terrified. I was so afraid, I thought I was going to die. My heart was pounding and my head was spinning. I would get these feelings every couple of weeks. I thought I was losing my mind. The more attacks I had, the more afraid I got. I was always living in fear. I didn't know when I might have another attack. I became so afraid that I didn't want to leave my house."
The above quote describes the anxiety disorder called panic attacks. They are episodic events that can appear without warning and last for several minutes, sometimes longer. The disorder is twice as common in women as it is in men. Symptoms usually begin before age 25, but may occur in the mid-30s.
Symptoms
Panic attacks appear suddenly and usually peak in 10 to 20 minutes. Some symptoms may last longer. A diagnosis of panic attack can be made in the presence of four or more of the following symptoms: chest pain or discomfort, dizziness or faintness, fear of dying, fear of losing control or impending doom, feeling of choking, feelings of detachment, feelings of unreality, nausea or upset stomach, numbness or tingling in the hands, feet, or face, palpitations, fast heart rate, or pounding heart, sensation of shortness of breath or smothering, sweating, chills, or hot flashes.
Special caregiver consideration
Many first-time patients think they are having a heart attack and go to the emergency room for treatment. As the panic attacks increase in frequency, many patients alter their behavior that negatively affects their normal functioning.
Treatment
Panic attack can appear without warning but some triggers can be identified and avoided. The goal of therapy is to maintain normal functioning despite the occurrence of attacks. Cognitive-behavioral therapy and medication have been reported to have the best results. Commonly used long-term medications are SSRI antidepressants, (fluoxetine- Prozac). They may take several weeks to reach full effect. Short-term treatments are usually anti-anxiety benzodiazepines, (diazepam- Valium). Cognitive behavior therapy is a psychotherapy especially useful for treating panic disorder. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and fearful.
If panic attacks are common, the patient should avoid alcohol and stimulants like caffeine or illegal drugs. The nicotine in cigarettes is also a strong trigger of panic attacks. These substances may trigger or worsen panic attack symptoms.
Prognosis
Due to the unpredictable nature of the disorder, the possibility of an attack is ever present. Fortunately, most patients respond quite well to treatment.
Phobias
Description
Phobias are a type of anxiety disorder where there is a persistent fear of an object or a situation usually greater than the danger that actually exists. When forced to confront the fear, the patient becomes quite distressed, which can even trigger a panic attack.
Symptoms
The patient has a fear of an item or event that is not based in reality. Since these are irrational fears, one could literally have a phobia concerning every single object and situation that exists. Here is a very abbreviated list.
Acrophobia- Fear of heights
Agoraphobia- Fear of open spaces or of being in crowded, public places like markets, fear of leaving a safe place
Autophobia- Fear of being alone or of oneself
Bacteriophobia- Fear of bacteria
Chiraptophobia- Fear of being touched
Enochlophobia- Fear of crowds
Gelotophobia- Fear of being laughed at
Gerascophobia- Fear of growing old
Hydrophobia- Fear of water
Iatrophobia- Fear of going to the doctor or of doctors
Lygophobia- Fear of darkness
Misophobia or Mysophobia- Fear of being contaminated with dirt or germs
Nosocomephobia- Fear of hospitals
Panophobia or Pantophobia- Fear of everything
Treatment
Medication is of limited use. Antidepressants and short-term anti-anxiety drugs are used but by themselves cannot resolve the issue. Psychotherapy is the first-line therapy with either cognitive behavioral therapy or systematic desensitization therapy or both. A course of 10 to 20 visits with a therapist is typical.
Prognosis
If the patient is cooperative with therapy, the outlook for normal functioning is quite good.
Eating Disorders
Description
Eating is a basic human need but it is more than just satisfying a physical desire. Strong emotional responses can be tied to the experience of eating. In some ways, it’s our way of controlling our environment or at least our reaction to what is going on around us. Eating disorders are illnesses where there is a severe disturbance in thoughts and emotions that lead to out-of-control eating patterns that can cause harm. Victims of these disorders become obsessed and distressed with food and body weight. They also can lose proper perspective about the consequences of their actions.
The main types of eating disorders are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. The exact cause of these disorders is not fully understood. It is believed to be combination of genetic, biological, and environmental factors. It has been described as “Genetics loads the gun but circumstances pull the trigger.” They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. Many sufferers can trace the onset of their disorder to a severe emotional event, like mental abuse, sexual trauma, or severe peer pressure.
Overwhelmingly, more young women are diagnosed with these conditions than men. It is thought to be in part due to bias on the part of doctors and society. Men who have the symptoms are often diagnosed with other conditions instead of an eating disorder, such as depression or obsessive compulsive disorder.
Symptoms
Anorexia Nervosa
Anorexia Nervosa is characterized by the patient’s extreme thinness, at least 15 percent underweight, obsessing about thinness, distorted feeling about self-esteem and body image, intense fear of gaining weight, and denial about the consequences of their eating habits.
These lead sufferers to weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia nervosa may also engage in binge-eating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas.
Bulimia Nervosa
Bulimia Nervosa sufferers have frequent bouts of overeating. They feel ashamed of their behavior and binge in private. Often they feel a lack of control over these episodes and stop only when they are interrupted or become sick. These binges are followed by compensating behaviors, like vomiting, laxatives, and excessive exercise. Unlike anorexia nervosa, people with bulimia nervosa usually maintain a normal weight, some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape.
Binge-Eating Disorders
Binge Eating Disorders occur when people lose control over their eating habits, but binges are not followed by compensating behaviors. This results in obesity.
As a group sufferers of eating disorders often report feeling powerless about their socioeconomic environment, and view eating, dieting, exercise, and purging as an empowering means of controlling their circumstances. The consequences of these behaviors are detrimental to the health of the patient and can be life-threatening. Uncontrolled eating disorders can lead to amenorrhea, tooth erosion from stomach acid, osteoporosis, scurvy, kidney failure, electrolyte imbalance, dehydration, chronically inflamed sore throat, GERD, uncontrolled bowels, cardiac problems, brain atrophy, and suicide.
Treatment
Eating disorders are real, treatable medical illnesses. Successful therapy includes both the physical needs of the body and the emotional needs of the patient. Efforts to achieve and maintain a proper weight is just the first step. Psychotherapy can help the individual identify and address the underlying emotional problem that causes or contributes to the abnormal eating behavior.
Prognosis
Uncontrolled eating disorders can be a serious health problem. Fortunately, therapy has been shown to be quite effective. Individual or group psychotherapy is key to recovery and relapse prevention. An important note is sufferers of eating disorders have the third highest rate for self-abuse and suicide.
Special caregiver consideration
Some antidepressants like Prozac, used to treat the underlying depression and to help reduce the binge cycle, have been linked to an increased suicide risk in teens and young adults. Caregivers are cautioned to monitor their patients for thought of suicide after therapy is started.
Obsessive-Compulsive Disorder (OCD)
Description
Obsessive- Compulsive Disorder is an anxiety disorder where intrusive thoughts are experienced by the patient. It causes uneasiness, fear, worry, and apprehension. These thoughts are hard or impossible to control or ignore. To relieve the distress, the patient will perform rituals that temporarily reduce the anxiety the intrusive thoughts produce -obsessions. The patient is most often aware that the obsessions are not based in reality but feels compelled to act on them anyway- compulsions.
"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a 'bad' number."
"Getting dressed in the morning was tough, because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. I knew that was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me. I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I got treatment."
Symptoms
Those who suffer from OCD experience thoughts or images about things like fear of germs or dirt, acts of violence, hurting themselves or loved ones, sexual acts or conflicts with religion. Typical rituals include hand washing, locking and unlocking doors, hoarding, repetitive acts, ordering, and counting. What sets these symptoms apart from normal actions is that the patient feels no pleasure when performing the rituals, only temporary anxiety relief. They feel that they must act or they experience significant distress. According to diagnostic criteria, the patient will spend at least one hour a day on these thoughts and actions.
Treatment
A combination of psychotherapy and medication has proven to be the most effective treatment for OCD. Psychotherapy may include cognitive behavior therapy and antidepressants and tricyclic antidepressants. Clomipramine is particularly effective but side-effect management may be required.
Prognosis
It is unclear why OCD happens. There may be inherited aspects, physical or chemical damage, or an imbalance in neurotransmitters. Brain scans have shown that the OCD brain functions differently. Therapy has been shown to be effective at reducing symptoms so the patient can regain control of their life. Medication usually takes longer to see the effects, up to three months. Patients should be counseled that when they start to feel better, they should continue to see the medical professional regularly for at least 12 months and notify them if symptoms start to return. Fortunately patients can go on for many years before their symptoms reappear, and some may not get symptoms again.
Post-Traumatic Stress Disorder (PTSD)
Description
Post-Traumatic Stress Disorder is an abnormal response to a stressful event and is classified as a panic disorder. When a person experiences a traumatic event, the body copes with the situation by feeling shock, anger, fear, panic, and even guilt. Over time, these feelings will naturally fade. For some, though, these feeling continue or even get stronger until they interfere with normal living. An example of this is a young World War II paratrooper who was so traumatized by the events of the D-Day invasion that he became temporarily blind. PTSD has also been called shell shock and battle fatigue.
Symptoms
Anyone who experiences a traumatic event can develop PTSD. It depends on their genetics, coping skills, social support network, neurotransmitters, and hormonal make up. Symptoms last at least one month and are often grouped into three categories. Reliving - flashbacks, nightmares, hallucinations, and distressed feeling around reminders of the event. Avoiding- staying clear of people places and things are reminders of the trauma. Increased arousal- excessive emotions, problems relating to others - including feeling or showing affection, difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, and being "jumpy" or easily startled. In PTSD, these symptoms are felt to the point of impairment. The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea, and diarrhea.
Treatment
From a medical perspective, treatment could be summed up as “medicine controls the symptoms and counseling heals.” A wide variety of mental health drugs are available to the doctor. Selection of which medicine is used depends on the predominant symptoms.
Similarly, a variety of psychotherapies could also be utilized, including: Cognitive behavioral therapy- recognizing and change thought patterns that lead to troublesome emotions, feelings, and behavior Exposure therapy- reliving the traumatic experience (done in a well-controlled and safe environment). The goal is to help the person confront the fear and gradually become more comfortable with situations that are frightening the patient and causing anxiety. This has been very successful PTSD treatment. Psychodynamic therapy- focusing on helping the person examine personal values and the emotional conflicts caused by the traumatic event. Family therapy- may be useful because the behavior of the person with PTSD can have an effect on other family members. Group therapy- may be helpful by allowing the person to share thoughts, fears, and feelings with other people who have experienced traumatic events. Eye Movement Desensitization and Reprocessing (EMDR)- is a complex form of psychotherapy that was initially designed to alleviate distress associated with traumatic memories but is now also used to treat phobias.
Prognosis
In most cases, symptoms start to appear within three months after the traumatic event. A few do not have symptoms until years later. Depending upon severity, some people recover within six months, while others suffer much longer. Without treatment, the patient could develop other conditions, like depression, other anxiety disorders, and alcohol or substance abuse. Early recognition and treatment leads to better outcomes. Post-trauma counseling has been proven to be effective in reducing the occurrence of PTSD.
Generalized Anxiety Disorder
Description
Generalized anxiety disorder (GAD) is a pattern of uncontrollable constant worry and anxiety that interferes with normal functioning over a long period of time that is not attributed to another disorder or condition (for example, worry about phobias, about being fat- anorexia. chemical abuse, etc.). It affects twice as many women as men with onset happening from youth to old age. The median age of onset is 31. There is some evidence that the elderly may be more susceptible to GAD as indicated in the increased use of anti-anxiety drugs in this portion of the population. Long-term, constant worry can have a negative effect on the general health of the patient. For example, constant worry and stress reduces the immune system, leads to teeth grinding, increases blood pressure, tends to upset bowels, or leads to constipation.
Symptoms
By definition, GAD is anxiety and worry that is associated with at least three of the following six symptoms (with at least some symptoms present for more days than not for the previous six months). Note: Only one symptom is required in diagnosis for children.
1. Restlessness or feeling keyed up or on edge
2. Easily fatigued
3. Difficulty concentrating or mind going blank
4. Irritability
5. Muscle tension
6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
Treatment
Unfortunately, GAD is quite hard to treat. Often the patient will go to their regular medical doctor who prescribes anti-anxiety drugs. This is no more than a short- term fix, a chemical crutch. The patient starts to rely on the medication to cope with life and becomes addicted, both chemically and behaviorally. This pattern is often seen in the elderly. Those patients who included psychotherapy in there treatments showed a marked reduction in the use of anti-anxiety drugs. Effective psychotherapy could include; relaxation-based treatments or biofeedback, cognitive therapy, relaxation training, anxiety management training, or some combination of these procedures in groups session or alone. Course of therapy can be 12 weeks with follow up every few months.
Prognosis
As of yet there remains a need for greater understanding of what causes GAD. A patient can maintain a functional life most effectively with a combination of psychotherapy and medication, though it is more difficult if there are addiction issues to contend with.
Personality Disorders
Description
There are those individuals who never seem to fit into regular society. They just seem “wrong-headed,” to the point where one would have to wonder how they function day to day. If you were to look closer, some of these individuals could be diagnosed with a mental illness called a Personality Disorder.
Those who suffer from Personality Disorders experience rigid and inflexible thought patterns. They find it difficult to react to the changes and demands of life. This thinking and behavior can lead to significant limitations in relationships and social situations. Often they have a narrow view of life, blaming their troubles on others because they believe their way of thinking is normal.
Symptoms
There are many types of personality disorders, each with their own signs and symptoms. The three main groupings are, Cluster A- Odd or eccentric behavior, Cluster B- Dramatic, emotional or erratic behavior, and Cluster C- Anxious, fearful behavior.
An example of each are;
Cluster A
Paranoid Personality Disorder. The patient interprets the actions of others as deliberately threatening or demeaning. They usually are untrusting, unforgiving, and prone to anger or have aggressive outbursts without justification. They perceive others as unfaithful, disloyal, condescending, or deceitful. They may also be frequently jealous, guarded, secretive, and scheming, and may appear to be emotionally “cold” or excessively serious.
Cluster B
Borderline Personality Disorder. These patients have extreme "black and white" thinking. They experience instabilities in relationships, self-image, identity, and behavior. This often leads to self-harm and impulsivity.
Cluster C
Avoidant Personality Disorder. These personalities are often hypersensitive to rejection and are unwilling to become involved with others unless they are sure of being liked. They experience excessive social discomfort, timidity, and fear of criticism that leads them to avoid social or work activities that involve interpersonal contact.
Treatment
Here again, medication helps manage symptoms and psychotherapy heals. The goals of psychotherapy are to: 1. Help the patient see the unconscious conflicts that are contributing to or causing their symptoms, 2. Help the patient become more flexible with their behavior patterns that interfere with everyday living, and 3. Help the patient recognize the effects of their behavior on others.
Prognosis
The more that is learned about personality disorders, the more effective therapy becomes. There is a strong causal relationship between child abuse and neglect and the development of the disorder. Genetic and other factors may also make a person more vulnerable to these diseases. Unfortunately, diagnosing and treating personality disorders is difficult because of the many factors involved, but a fulfilling life can be achieved with help.
Attention Deficit Hyperactivity Disorder (ADHD and ADD)
Description
Attention Deficit Hyperactivity Disorder has been classified as a brain development disorder where portions of the brain that control the attention attributes develop at a slower rate or have incomplete development. The result is the patient has trouble remaining focused, is easily distracted, and can be impulsive and hyperactive.
Symptoms
Diagnosis can be hard because most symptoms are seen as regular activities in normal children and adults. Each person has their own unique manifestation of conditions but there are three main subgroups: Predominantly hyperactive-impulsive, Predominantly inattentive, Combined hyperactive-impulsive and inattentive. According to the DSM-IV, a diagnosis can be made if there is a manifestation of symptoms that causes a significant impairment for at least six months.
Those symptoms can include:
Inattentive- being easily distracted, missing details, forgetting things, and frequently switching from one activity to another. Difficulty maintaining focus on one task. Becoming bored with a task after only a few minutes, unless doing something enjoyable. Difficulty focusing attention on organizing and completing a task. Difficulty learning something new or trouble completing or turning in homework assignments. Patients often lose things. They don’t seem to listen when spoken to, daydream, become easily confused, and move slowly. Difficulty processing information as quickly and accurately as others. Struggle to follow instructions.
Hyperactive- fidget and squirm in their seats. Talk nonstop. Dash around, touching or playing with anything and everything in sight. Trouble sitting still during dinner, school, and story time. Constantly in motion. Difficulty performing quiet tasks or activities.
Impulsivity- very impatient. Blurting out inappropriate comments, showing their emotions without restraint, and acting without regard for consequences. Difficulty waiting for things they want or waiting their turns in games.
Treatment
The goal of therapy is not to eliminate symptoms but to reduce the impairment the patient experiences. The most effective long-term therapies are a combination of stimulant medications to increase brain level function and behavioral therapies that enable compensating coping skills.
Prognosis
ADHD can't be cured but it can be successfully managed. Treatments therapies are partnerships among the patient who learns coping skills, medical professionals who provides the medication and helps manage side effects, and family/caregiver/mental health professionals who provide training and behavioral support.
Special caregiver note
There is some controversy in the use of addicting stimulant drugs in patients who are children. Long-term studies have shown that addiction is a risk but usually not an issue with proper management. Some studies have shown that without these medications, patients tend to develop substance abuse issues later in life as they try to cope with their impairments.
CAREGIVER’S ROLE
Caregiver Frustration
When I owned and operated my care homes, one of the most challenging aspects of In Home Care was mental health issues. From depression to dementia, it’s just harder to deal with residents in your homes who have impaired ability to reason and think. It is frustrating when your patients don’t think and act the way you expected them to, and you can’t apply normal reasoning to them. I can remember thinking, “I can’t get them act right-no matter what I say. Now what am I going to do? I wish I could just lock them up so I don’t have to deal with them anymore.”
Barriers to Proper Care
My frustrations led me to inappropriate thoughts. These people needed me and my caregiving abilities or they wouldn’t have been in my home in the first place. What helped me turn the corner to proper caregiving was to start to understand what was really going on in their heads and what was going on in mine. You can “turn the corner” to proper caregiving by identifying barriers to proper care and working to remove them.
Patient Barriers
Patients who suffer with mental illness are not stubborn or lazy or grouchy or have other personality flaws. It is an illness that has its roots in a medical condition. The patient has an impairment that prevents them from acting normally.
-Impaired ability to communicate
-Impaired ability to change behaviors
-Impaired ability to understand what is going wrong in them
What may be one of the biggest barriers of all is the fear of being stereotyped as a “crazy person.” It leads the patient to avoid medical providers and be uncooperative with therapy.
Caregiver Barriers:
Caregivers have their own set of baggage that throws up barriers to proper care.
-Lack of knowledge/training
-Unrealistic expectations
-Being unprepared for the challenges of care, both mentally and physically.
Stereotyping, not seeing the patient as a person- just the stigma of “being crazy” prevents proper caregiving.
Mental Health Caregiver Techniques
This article is not a training manual for mental health caregiving that lists all to “dos and don’ts” of in-home care. But I would like to give a few pointers that might smooth the way to proper care for your patients with mental illness issues.
Reflective Practices
The “Practice” of In Home Care giving is how you apply your beliefs, abilities, and resources to meet the needs of the patient. A “Reflective Practice” is to regularly review your past experiences –describe, analyze, evaluate- and use the information to change future practices.
A few questions you might ask yourself and your staff are: What stereotyping is shown in your behavior? How unprepared is your home? Are you professional enough to get past all the difficulties? Are you willing to learn new ways of caring? What was your internal dialog when you last approached the patient? Were you able to provide empathic, compassionate care to this individual? Did you show an unconditional positive attitude toward your patient with a mental illness?
In other words “The first barriers to care to remove are the ones you threw up yourself.”
Develop a Plan of Action:
Find what works, break it down into repeatable steps, write it down in a way that can be used for training, follow the steps, and always improve.
You might find the following a useful part of your plan.
professionals want about the patient and develop methods for getting it to them.
might arise. (examples: What to do if the patient doesn’t follow therapy. How and when to place the patient in the hospital- even against their will.)
boundaries and expectations (both yours and theirs).
Compliance with Therapy:
Treatments are partnerships between the patient, doctor, and caregiver. The best outcomes happen when all understand their part and work as a team. It is vital that early identification of symptoms and consistent follow-through is achieved.
Ideas for the Patient:
Thing to write down include:
- Symptoms experienced and how intense they were.
- Any special events that triggered the symptoms like events, dreams, and
memories.
- Any questions for the doctor.
- What causes them stress.
Suggestions for the Caregiver
Take good caregiver notes. Patients are impaired from seeing things correctly. You can provide proper perspective to the information mental health professionals receives. You can also provide vital information, such as a list of medications and health conditions the patient has or has developed since their last visit.
Be prepared for down turns and have an action plan in place.
Watch for and make note of: marked changes in personality, eating or sleeping patterns, inability to cope with problems or daily activities, strange or grandiose ideas, excessive anxiety, prolonged depression or apathy, thinking or talking about suicide, extreme mood swings or excessive anger, or violent behavior.
Always remember: Many people who have mental illness consider their symptoms a normal part of life. Patients often avoid treatment out of shame or fear. Confronting patients directly about their delusions or hallucinations rarely works because their illness prevents them from seeing them as anything but real.
Laws vary from state to state, and it can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, caregivers may have to call the police to take their patients to the hospital. Contacting the police and hospital before hand and asking about proper procedures can really make a difference in a stressful situation.
Patient Advocacy
With workloads going up and reimbursement rates going down, sometimes the health system breaks down and patient’s needs are forgotten. Sometimes you have to do battle for your client to get what they need. Being respectful gets more cooperation but sometimes pushing until needs are met is in the best interests of your clients and your business.
Care Coordinator
The doctor and case workers may be in charge, but in my experience the best outcomes happen when the caregiver takes responsibility. Caregivers are in the best position to ensure that every needful thing is done, that proper follow up is achieved, that different types of care is coordinated, and communication happens between the different members of the healthcare team. Keeping a check list of important items in the patient’s records is very helpful. Items to include are: immunizations, dental and eye exams, physicals, required blood and other monitoring tests, behavioral, occupational, and physical therapies.
Conclusion
Understanding mental health and how to care for the mentally ill has been a challenge throughout the years. For those charged with the care of mental patients, the realization that the illness is both a physical and a psychological impairment has led to more effective and humane treatments. There is more hope than ever before that those who suffer can feel well again.
For those who cannot make it by themselves in normal society, the support of a Care Home can make all the difference in maintaining therapy. Caregivers who take on the challenge of providing that needed support can best do so if they are properly prepared.
For caregivers in any setting (Adult Foster Care, Mental Health Homes or Developmentally Disabled), understanding the barriers to proper care and working on removing them is a very effective way to be prepared. Gaining underling knowledge can go a long way in understanding and preparing for the challenges the In Home Care provider may face.
References
1. Mental Illness and the Family: Recognizing Warning Signs and How to Cope. Mental Health America.
2. Mental health: What's normal, what's not. Mayoclinic.com.
http://www.mayoclinic.com/health/mental-health/MH00042
3. History of mental disorders. Wikipedia
http://en.wikipedia.org/wiki/History_of_mental_disorders
4. Classifactions of mental disorders. Wikipedia.
http://en.wikipedia.org/wiki/Classification_of_mental_disorders
5. Facts about the prevalence of mental illness, Mental Health Reporting. School of Social Work, University of Washington.
http://depts.washington.edu/mhreport/facts_prevalence.php
6. Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L, Benjet C, Georgiades K, Swendsen J., Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010 Oct;49(10):980-9. Epub 2010 Jul 31.abstract PubMed, National Library of Medicine, National Institute of Health.
http://www.ncbi.nlm.nih.gov/pubmed/20855043
7. Dr. Brian Burke, Abnormal Psychology, Fort Lewis College
http://faculty.fortlewis.edu/burke_b/Abnormal/Abnormalmultiaxial.htm
8. What is Mental Illness: Mental Illness Facts. National Alliance on Mental Health
http://www.nami.org/template.cfm?section=about_mental_illness
9. Bipolar Disorder (DSM-IV-TR #296.0–296.89),Brown University
http://www.brown.edu/Courses/BI_278/Other/Clerkship/Didactics/Readings/Bipolar%20Disorder.pdf
10. Autism. Medline Plus, National Library of Medicine, National Institute of Health.
http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm
11. Facts about ASD, Autism Spectrum Disorders (ASDs). Center for Disease Control and Prevention
http://www.cdc.gov/ncbddd/autism/facts.html
12. Autism. Wikipedia
http://en.wikipedia.org/wiki/Autism
13. Asperger Syndrome. Wikipedia
http://en.wikipedia.org/wiki/Asperger_syndrome
14. What is Schizophrenia, Schizophrenia. National Institute of Health
http://www.nimh.nih.gov/health/publications/schizophrenia/what-is-schizophrenia.shtml
15. Schizophrenia. wikipedia
http://en.wikipedia.org/wiki/Schizophrenia
16. Schizophrenia. BehaveNet.com
www.behavenet.com/schizophrenia
17. Panic Disorder: When Fear Overwhelms. National Institute of Mental Health
18. Panic Disorders, Panic Attacks PubMed Health, US National Library of Medicine.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001922/
19. Panic Disorders. Wikipedia
http://en.wikipedia.org/wiki/Panic_disorder
20. Fred Culbertson, The Phobia List. PhobiaList.com
21. Phobia. Wikipedia
http://en.wikipedia.org/wiki/Phobia
22. Generalized Anxiety Disorder. MayoClinic.com
http://www.mayoclinic.com/health/generalized-anxiety-disorder/DS00502
23. Timothy A. Brown, Tracy A. O’Leary, David H. Barlow, Chapter 4 Generalized Anxiety Disorder.
Clinical Handbook of Psychological Disorders, Third Edition: A Step-by-Step Treatment Manual. Guilford Publication. 2001
http://commonweb.unifr.ch/artsdean/pub/gestens/f/as/files/4660/21992_121827.pdf
24. Eating Disorders. National Institute of Mental Health
http://www.nimh.nih.gov/health/publications/eating-disorders/complete-index.shtml
25. Eating Disorder. Wikipedia
http://en.wikipedia.org/wiki/Eating_disorder
26. Eating Disorders.Healthy Minds, Healthy Lives. American Psychiatric Association
http://healthyminds.org/Main-Topic/Eating-Disorders.aspx
27. Obsessive-Compulsive Disorder: When Unwanted Thoughts Take Over. National Institute of Mental Health
28. Obsessive-compulsive Disorder. Wikipedia
http://en.wikipedia.org/wiki/Obsessive%E2%80%93compulsive_disorder
29. Post-traumatic stress Disorder (PTSD). MayoClinic.com
30. Posttraumatic Stress Disorders, Anxiety and Panic Disorders. WebMD.com
http://www.webmd.com/anxiety-panic/guide/post-traumatic-stress-disorder
31. Posttraumatic Stress Disorder. Wikipedia
http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder
32. Personality Disorders. MayoClinic.com
http://www.mayoclinic.com/health/personality-disorders/DS00562
33. Personality Disorder. Wikipedia
http://en.wikipedia.org/wiki/Personality_disorder
34. Personality Disorder. Mental Health America
http://www.nmha.org/go/information/get-info/personality-disorders
35. Caring for Patients with Mental Health Disorders. RN.com. AMN HealthCare Education Service
http://www.rn.com/getpdf.php/1679.pdf?Main_Session=66bee95ae8fc069ca167b24a01091936
When it comes to mental health,
what’s normal?
Mental Health Overview for Care Providers.
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Dementia:PatientsDon’tActTheWayThey’reSupposeTo
An AFC Overview of Alzheimer’s and other Dementias
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 2.5- Approximate time required 150 min.
Educational Goal:
Present an overview of Dementia and its causes
Educational Objectives:
1. Change the paradigm of the Dementia Care Giver.
2. Define Dementia, Fixed and Progressive Cognitive Impairment
3. Explain the Anatomy and Physiology of the Brain
4. Present an Overview of Alzheimer’s, Vascular Dementia, Dementia with Lewy Bodies, and Parkinsons Dementia
5. Discuss Strokes and Dementia, and 1st aide for Strokes
6. Discuss Caregiver Issues In Dementia Care.
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Dementia: Patients Don’t Act The Way They’re Suppose To
An AFC Overview of Alzheimer’s and other Dementias
Perception is the process by which we humans organize and interpret our sensory input based on the preconceived notions that we have. There is a part based on how our senses and mind function and a part on based on how we function as part of a larger world. What happens when one or both parts aren’t based in the way things really are? We continue on, thinking that we are doing things right, but in essence we are not. Our actions don’t fit. It takes extra effort to exist in the world around us and often our efforts fail.
One of the most challenging aspects of In Home Care is when a patient’s perceptions aren’t the way they are supposed to be. Their perceptions of the world around them aren’t based on reality, but on some alternative version of the world. It’s what we call Dementia. Dementia leads to inappropriate acts and unexpected behaviors. The patient wanders around the house looking for upper floors, basements or people that aren’t there. They argue and act in unusual ways. They escape out the door and wander the neighborhood trying to make reality fit into their incorrect perceptions. Inevitably it causes problems, emotional stress and extra work. You, the caregiver must take care of the patient despite their incorrect perceptions. You must help them fit into reality when their Dementia will not let them. Let me tell you from personal experience, that isn’t easy.
This article will attempt to ease your burden by educating you on the different types of Dementia, including Alzheimer’s. It will teach you how to recognize them and what to do in each case. From time to time I will insert explanations of things from the Adult Foster Caregivers point of view. Hopefully, by the end of the article you will be better prepared and capable to care for those Dementia patients who come into your care.
Adult Foster Care (AFC) and the Dementia Burdened Patient
In Dementia Care the essential first step is to work on your own perceptions. You must change the way you perceive the Dementia patient. In the normal operations of Adult Foster Care you treat everyone in your home as a resident – capable and expected to do things for themselves. The main goal is to provide as normal a home environment as possible. When your resident’s health problems prevent them from do things for themselves, they become patients and you provide the necessary caregiving to meet their needs. In all other circumstances you expect the resident to behave like a normal adult. If they don’t, you reason with them until they do. In Dementia, the health problem is that they can’t act normally. You cannot make your resident act normally because your patient’s mind will not let them. Instead of expecting the resident to act as your other clients do, you must change your caregiving methods to meet the needs of your Dementia burdened patient.
What is Dementia?
Dementia is a syndrome of related symptoms. In general, it is a term relating to the loss or impairment of intellectual function (including memory) serious enough to interfere in the activities of daily living. There are two broad categories: Fixed Cognitive Impairment and Progressive Impairment
Fixed Cognitive Impairment
Some Dementias are the result of brain damage that comes from a causative event. For example, head or emotional traumas, strokes, seizures, alcohol abuse or other toxins. The main characteristic of this category is that the dementia does not get worse after the cause is stopped.
Progressive Impairment
Progressive impairment is caused by a brain degenerative disease. Thus, causes are organic in nature and the condition always progresses into worsening mental conditions. Once mental capabilities are impaired, rarely do they return fully. In most cases, they won’t return at all.
In Progressive Impairment, the beginning of the dementia is usually mild and episodic. The patient can function normally most of the time. As the dementia progresses, abnormal behavior becomes more frequent and severe. Usually, between episodes, the patient can tell that something is going wrong, but during episodes of dementia there is no perception of abnormal behaviors. As the syndrome worsens the patient may become disinhibited and may neglect themselves. Eventually the patient can’t function independently and must receive outside care. In the final and most severe stages mental function deteriorates to the point that it affects other bodily functions. As a result, death usually occurs from other medical conditions, such as pneumonia, infections or malnutrition. In essence, Dementia gradually reduces the quality of life of the patient, first from mental conditions, later with the addition of physical conditions. Risk factors for progressive impairment are age, genetics and, of course, diseases.
The Adult Foster Care point of view.
The prevalence of Dementia is quite high in AFC homes. It could be the main cause of AFC placement or a contributing factor. Even if they don’t have dementia when they move in, because age is a factor, every resident that you receive into your home is at risk for developing dementia. It will be up to you to recognize it when you see it – the earlier the better. Dementia symptoms are variable and can be progressive. This disease will require you to be flexible and adjust your caregiving accordingly. Whether you want to deal with it or not, mental health issues will always be a major factor in Home Care for the aged. At the end of the article I have included a Mini-Cog test that will be helpful in screening your residents.
Brain Function
To more easily understand the different types and causes of Dementia; let us first take a look at the brain and how it functions normally.
Your brain is the organic part of your individual thinking self. It is the engine that drives your personality, will power, reasoning, habits, abilities and the interpretation of what your senses give to you. Some functions are set to happen automatically, while others require conscious action. It is easily the most complex and intricate part of our body.
The Brain weighs about 3 pounds and is made up of millions of specialized cells, called neurons, a huge network of blood vessels, and connective tissue.
The brain has three main parts.
The biggest is the cerebrum and is the uppermost part of the brain. It controls memory, problem solving, voluntary actions and feelings. It’s the thinking part of the brain. The cerebellum sits at the back of your head, under the cerebrum. It controls coordination and balance. The third part is the brain stem. It sits in front of the cerebellum and connects to the spinal cord. The brain stem takes care of most of our automatic processes, like breathing, heart rate and digestion.
The brain is supplied by a very large and intricate network of blood vessels. The vessels carry in resources (mainly oxygen and glucose) and flush away waste products. At any given time, 20 to 25 percent of our blood goes to the brain. It requires a constant 20 percent of the total oxygen and fuel that we take in. When you think hard, that requirement can be as high as 50%. The brain is very dependent on regular supply of blood. It does not store much supply, which makes it very sensitive to any reduction of flow. Any drop in supply and its functioning is reduced. We feel dizzy, lightheaded, and/or confused as a result. If the reduction continues, the cells can quickly die, leading to permanent damage.
The outer layer of the cerebrum is called the cortex. It’s the wrinkly part of the brain’s surface. Specific areas of the cortex are involved in controlling different bodily actions. Science has been able to create a “map” of these functions. It has proven very useful in understanding the effects of brain damaging events.
The brain has two distinct right and left hemispheres. They are connected and communicate to each other through an area called the corpus callosum. The right hemisphere controls the body’s left side movements, while the left side controls the right. It appears that the different spheres can dominate in other functions, as well. For example:
1. When a person has a stroke on the right side, they tend to have problems with spatial perceptions. They misjudge distances, causing falls. It can lead to difficulty in guiding the hands to do actions, like buttoning clothes. It can also affect judgment, which shows up in unusual behaviors. Because they are unaware of this judgment deficiency the right side stoke sufferer can exhibit inappropriate actions and moods. It can even lead to dangerous behaviors.
2. When a person has a stroke on their left side, they have difficulty with language and speaking. They can become slow and cautious, with short attention spans. Often they need frequent reminders and feedback to accomplish tasks.
The work of the brain is accomplished by specialized cells called neurons or nerve cells. The adult brain is very complex with about 100 billion neurons. Each nerve cell has branches that connect to other neurons. All totaled, it is estimated that there are over 100 trillion connections. Each cell communicates with those it is connected to, creating thought and memory.
Communication between cells is an electrochemical signal. When a signal happens, a tiny electrical charge travels down the length of the neuron to its connections with other nerve cells, called synapses. If an electrical charge that reaches a synapse is strong enough it will trigger a release of chemicals stored there called neurotransmitters. There are dozens of neurotransmitters. A few examples are acetylcholine, serotonin, and norepinephrine. When the neurotransmitters travel across the synapse they plug into receptors on the receiving cell. This results in a buildup of another electrical signal in the nerve. When the charge is strong enough the nerve is said to “fire” and off the new signal goes. Some neurotransmitters make it easier to fire, while some make it more difficult. After the chemicals are released, they are either reabsorbed into the cells (call reuptake) or broken down by enzymes in the synapse and the nerve is reset for the next signal.
The brain is set to be very sensitive to stimulus and can react extremely quickly. In fact, it is so sensitive that to protect it from outside stimuli the whole central nervous system is wrapped in 3 layers of membranes called the meninges. Their function is to block anything that will interfere with the normal functioning of the brain. We call these layers the “blood brain barrier”, which is very hard to cross. This is a major factor in any medicine used to affect the brain.
The brain remains isolated from the world and experiences it through sensory inputs. We understand the world by interpreting sensory inputs, which creates experiences. We store these experiences in neural pathways, which create memories. We create conscious reactions to our world as a combination of the various neural pathways. Our reactions and perceptions can be altered if you make a change in one, some or all of the pathways. When that happens it becomes our reality regardless of what really is happening. Examples of this are hallucinations.
You are born with almost all the brain cells you’ll ever have. The brain grows by adding to the structures of the cell and in developing connections between nerves. If a cell is damaged it can possibly be repaired. If it dies, it is lost forever – a new one will not grow in its place.
Cell death happens as a natural result of age. If a particular cell dies, messages can be rerouted through different connections. If more cells die, rerouting may become more complicated, requiring a retraining of the pathway. If too many cells die, it becomes impossible to reroute and the brain action pathway is lost. This results in senile dementia or the natural loss of memory and mental sharpness due to age. Assaults on the brain tissues from fixed sources, like alcohol and drugs, or progressive sources, like disease, add to and speed up this process, causing an earlier and more severe case of dementia.
The Adult Foster Care point of view.
You will have noticed by now in your career that the elderly find it difficult to cope with change. Sometimes strong habits create barriers to change. But as a person ages there is a real chance that they have lost the mental capacity to cope with change. Given enough help the elder can adjust, but patience and understanding is required. Remember, the old coping pathway might be gone forever. If that is the case, behavior adjustment requires a retraining of the neural pathways and it takes time. Repetition and reinforcing proper habits help.If the loss is sudden, like in a stroke, or if the gradual loss becomes too great for the patient and your skills, you can get help from the use of an Occupational Therapist. They are specially trained to help the elder regain some of their lost abilities. Occupational Therapist can be paid for through insurance and can really ease your caregiving burdens.
Causes of Dementia
You are now better equipped to understand the issues in recognizing and treating mental health. The main cause of Dementia in the elderly is the loss of brain function due to cell death. Accelerated cell death comes from fixed events and progressive diseases.
Fixed Cognitive Impairment
There are many things that can cause the early death of a cell. The most common are: trauma that destroys the physical structure of the cell; toxic chemicals that make it past the blood brain barrier; the buildup of the body’s own metabolic waste; and the denial of needed resources. As long as the assault on the brain continues, cell death and functional loss continues. The goal of therapy is to eliminate the assault on the brain and to retrain the mind to utilize what’s left to operate normally. The hope of Fixed Cognitive Impairment treatment is that a normal lifestyle can be regained, if therapy is applied soon enough and retraining efforts are successful.
The Adult Foster Care point of view.
Often caregiving requires the AFC provider to do what is right for the patient, even if the patient gets cantankerous and resists your efforts. You may think, “Has that elderly person lost their mind? What are they thinking, being so ornery?” Your job becomes easier when you realize that this is exactly what might have happened. I remember a case when the care giver called up the pharmacy where I was working to complain about how difficult a medication seemed to be making a patient act. I listened to the frustrated caregiver and asked them to describe the difficult actions. Because of my AFC background, I recognized the pattern and asked the caregiver to look closely at the pupils of the patient. For the first time the caregiver noticed that they were peculiar. One was larger than the other. I quickly informed them to hang up and dial 911 – the patient was experiencing a stroke. Blood flow had been cut off by a clot, causing the brain to act abnormally. Sometimes patients can be difficult because they can’t recognize they are doing things inappropriately. They need your help to compensate for their inabilities and to help them behave correctly, even if they don’t want to.
Neurodegenerative Diseases
There are a number of diseases that cause brain cell death at an unnaturally high rate. Most are not well understood and are hard to detect in their early stages. Quite often, the first recognizable symptom is Dementia. By the time a problem has been detected, significant permanent loss of brain cells has already occurred. After the disease has been diagnosed, the goal is to retain as much normal brain function as possible, for as long as possible. Earlier recognition of symptoms leads to better retention of normal behavior.
The list of neurodegenerative diseases is quite long. Too explain them all is beyond the scope of this article. I’ll concentrate on teaching you just the main ones you might see in your practice setting: Alzheimer’s disease, Vascular Dementia, Dementia with Lewy Bodies, and Parkinson’s disease.
Alzheimer’s Disease (AD)
Alzheimer’s disease (AD) is the most common type of dementia, making it the condition you are most likely to see in your practice setting. AD accounts for 60 - 80% of all dementia cases. Alzheimer’s Association estimates that 1 in 8 older Americans have AD. The prevalence in Adult Foster Care homes is most likely much higher than that.
Alzheimer’s disease was first described over a hundred years ago by Alois Alzheimer, a German psychiatrist and neuropathologist. He recognized that some of his patients showed symptoms that were different from senility. At the time he labeled it Presenile Dementia. Later, other Doctors picked up on his studies and labeled all similar cases Alzheimer’s disease.
Even though AD has been recognized for 100 years, learning about the disease has come very slowly. Research has been difficult. The disease processes happen at the sub-cellular level, behind the blood brain barrier. Early and middle stages of the Alzheimer’s diseases are almost impossible to detect and are difficult to differentiate from regular senile dementia. It has only been in the last 30 years that significant advancement in understanding has been gained. But Medical research has yet to uncover causes of the diseases, cures for them, or even to slow down it progression. A major effort is underway all over the world in the search to find answers. What we have found out so far is;
Epidemiology (Prevalence)
Most of what was once thought to be senility was actually Alzheimer’s disease. Over 5.4 million Americans have AD, of which 5.2 million are older than 65. As people get older its prevalence increases. About 13% of people over 65 have AD, while 43% of the elderly over 85 are afflicted. Every 70 seconds another person will diagnosed with AD by their Doctor. More women have AD than men. Two-thirds of American afflicted by AD are women. No one knows if that is significant or not. It might be that women just live longer than men.
Etiology (What Causes Alzheimer’s disease)
Alzheimer’s is a slow progressive degenerative disease that robs a person of their memory, their recognition of current reality and eventually their personality. Research has deduced that there is probably multifactorial causes. In many of the AD cases researched, scientists have found a higher than normal presence of the following abnormalities:
1 .Amyloid plaques - abnormal clusters of protein fragments between nerve cells. The amyloid fragments are pieces of larger proteins found in the fatty membrane of a neuron. When they break off they are “sticky” and they clump together outside the nerve. Eventually the clumps grow to the point where they start to interfere with the nerve signals between the nerves. The plaques also tend to trigger inflammation responses, which cause immunity cells to come and devour disabled cells.
2. Intracellular tangles - a protein called Tau that normally keeps the supply tracks in a cell straight, collapses into a tangle. The tangle disrupts the flow of supplies and the cell eventually dies.
The Adult Foster Care point of view.
There is a theory that free radicals (rogue atoms that steal electrons from other atoms, disrupting chemical bonds in molecules) may be a contributing culprit in AD. Antioxidants (like in different vitamins) have plenty of extra electrons and can neutralize free radicals. Since there are plenty of other benefits to taking vitamins, it just makes since to use them to protect your clients from free radicals, as well. Be sure that all your residents are regularly taking them.
3. A gene called apolipoprotein E-e4 (APOE-e4) - Researchers estimate it may be a factor in 20-25% of AD cases. People who inherit the APOE-e4 gene from both parents are at higher risk. But some patients who have the gene never develop AD.
Researchers have discovered a rare form of Alzheimer’s disease caused by deterministic gene variations called “autosomal dominant Alzheimer’s disease (ADAD)” or “familial Alzheimer’s disease”. Symptoms nearly always develop before age 60, and may appear as early as the 30s or 40s. Deterministic Alzheimer variations have been found in only a few hundred extended families worldwide. True familial Alzheimer’s accounts for less than 5 percent of cases.
Of course all these abnormalities are found on the sub-cellular level using a microscope. The only outward signs and indicators of AD are dementia, age and family history.
Diagnosis (The Signs and Symptoms)
The Adult Foster Care point of view.
For reasons already described, early detection is crucial. But how can you tell the difference between AD and regular senility? Actually, it doesn’t matter, “better safe than sorry” is always the way to go. If you suspect that AD is developing, send the patient to the Doctor every single time. Don’t worry about what the Doctor thinks. Later in the article I will give you some tools that will help you communicate effectively with the Doctor (see Mini-Cog).
The Alzheimer’s association has published a very useful tool in recognizing the signs and symptoms of Alzheimer’s. I pulled this directly from their web site (see Other Resources).
“Memory loss that disrupts daily life is not a typical part of aging. It may be a symptom of Alzheimer's, a fatal brain disease that causes a slow decline in memory, thinking and reasoning skills. Every individual may experience one or more of these signs in different degrees. If you notice any of them, please see a doctor.”
“10 warning signs of Alzheimer’s.
One of the most common signs of Alzheimer’s is memory loss, especially forgetting recently learned information. Others include forgetting important dates or events; asking for the same information over and over relying on memory aides (e.g., reminder notes or electronic devices) or family members for things they used to handle on their own.
Some people may experience changes in their ability to develop and follow a plan or work with numbers. They may have trouble following a familiar recipe or keeping track of monthly bills. They may have difficulty concentrating and take much longer to do things than they did before.
People with Alzheimer’s often find it hard to complete daily tasks. Sometimes, people may have trouble driving to a familiar location, Managing a budget book at work or remembering the rules of a favorite game.
People with Alzheimer’s can lose track of dates, seasons and the passage of time. They may have trouble understanding something if it is not happening immediately. Sometimes they may forget where they are or how they got there.
For some people, having vision problems is a sign of Alzheimer’s. They may have difficulty reading, judging distance and determining color or contrast. In terms of perception, they may pass a mirror and think someone else is in the room. They may not realize they are the person in the mirror.
People with Alzheimer’s may have trouble following or joining a conversation. They may stop in the middle of a conversation and have no idea how to continue or they may repeat themselves. They may struggle with vocabulary, have problems finding the right word or call things by the wrong name (e.g., calling a “watch” a“hand-clock”)
A person with Alzheimer’s disease may put things in unusual places. They may lose things and be unable to go back over their steps to find them again. Sometimes, they may accuse others of stealing. This may occur more frequently over time.
People with Alzheimer’s may experience changes in judgment or Decision-making. For example, they may use poor judgment when dealing with money, giving large amounts to telemarketers. They may pay less attention to grooming or keeping themselves clean.
A person with Alzheimer’s may start to remove themselves from hobbies, social activities, work projects or sports. They may have trouble keeping up with a favorite sports team or remembering how to complete a favorite hobby. They may also avoid being social because of the changes they have experienced.
The mood and personalities of people with Alzheimer’s can change. They can become confused, suspicious, depressed, fearful or anxious. They may be easily upset at home, at work, with friends or in places where they are out of their comfort zone.”
If you notice any of the above, record your observations in their file and send them to their Doctor’s. Once the patient is his office, the Doctor will make a clinical determination that there is indeed Dementia in the patient. Since there is no clinical test for Alzheimer’s yet, he will check for other causes of Dementia. If all other causes have been eliminated, he might take an MRI or CT scan of the patient’s brain to check for AD-like changes. Once he is satisfied with his research, he will make a diagnosis and prescribe therapies.
Therapies
As you now know there is no possible way to cure or even slow down the progression of AD. The goals of therapy are to control further assaults on the brain, retain as much as possible normal activities of daily living and compensate for losses in abilities.
Medications
There are a number of medications that can be used to help retain normal brain activity. I’ll primarily explain how they are used in AD, but they could also be used in other dementia-causing diseases. There are two classes of medicines and five different drugs.
Cholinesterase Inhibitors (ChEIs)
Acetylcholine (ACh) is a very important neurotransmitter used in cognition and memory. It makes the nerves fire. In order to reset the nerve for the next charge, the body uses enzymes to break down ACh. Normally, we have plenty of ACh around so we don’t care if the body gets rid of some of it. In Alzheimer’s and similar diseases, that is not the case. ChEIs slow down those enzymes to help retain more ACh for future use.
The drugs are Tacrine (Cognex), Donepezil (Aricept), Galantamine (Razadyne),and Rivastigmine (Exelon). Tacrine was the first medication developed, but it caused a lot of liver problems and is used less frequently now. Tacrine and Donepezil both are available in generic forms. For patients with swallowing problems or other difficulties taking medications, Exelon is available as a patch. Aricept is available as an ODT (orally disintegrating tablet). Razadyne and Exelon are available as a liquid. Tacrine is the only medicine that can be crushed or chewed. Exelon should be taken with food.
The most common side effects of ChEIs are mild to moderate nausea and vomiting. In most cases the nausea and vomiting subside after 2 to 4 days. Other side effects are muscle cramps, bradycardia (slow heart beat), increased stomach acid and reduced appetite. They may make sleeping and urinary obstruction problems worse.
A major concern of ChEIs is that Acetylcholine is a significant factor in drug regimes. There are many drugs that have anti-cholinergic effects, which would negate the effectiveness of ChEIs medications. The pharmacist or Doctor should review the patient’s medication list to check for this problem. Common drugs known to cause this issue are Amitriptyline, Benztropine, Carisprodol, Chlorphenerimine, Meclizine, Oxybutynin, and Promethazine, and Diphenhydramine (which is found in many OTC cold, allergy and sleep remedies).
NMDA Receptor Antagonist
There is only one drug in this class so far, Memantine (Namenda). It is known that Alzheimer’s changes the way a nerve works. One of the effects is changes in the NMDA receptors. Those changes lead to excessive use of glumatate (another neurotransmitter) that leads to cell death. Memantine prevents the over-stimulation of the glutamate system, preventing the neurotransmitter from causing toxicity.
Namenda comes as a tablet, a solution, and a controlled release capsule. It can be used alone or in combination with other AD drugs. The tablet and capsule should not be crushed or chewed. The side effects are intermittent and mild and include nausea, confusion, dizziness, headache, diarrhea or constipation, sedation and agitation.
The Adult Foster Care point of view.
As the disease progresses the dosage of medication will probably be increased, making it more likely that side effects will occur and become a problem. If you manage the side effects, you will be able to use the drugs for much longer. It will be your job to keep track of their severity and help the Doctor determine when the side effects outweigh the benefits of the drug.
Prognosis (Progression of Alzheimer’s)
The most common measurement of the progression of AD is described in three stages: mild, moderate and severe. Those afflicted go through the stages at different rates. Medications can slow down the progression, but only temporarily. The average effective lengths for the medications are 2-4 years. Once the medications are discontinued, expect a very rapid decline.
In Mild Stage AD the patient lives a more or less normal life, with just a few adjustments. In Moderate Stage AD the patient is significantly affected by the disease. This is the stage where caregiving help will be sought. In Late Stage AD the needs of the patient are very great and specialized institutions should be contacted.
The Adult Foster Care point of view.
No one wants to lose a client. Sometimes you can get very attached to a resident. You will put a lot of effort into retaining every customer you can. Eventually though, every effort will fail and death will ensue. You can’t do anything about that. You can only do the best you can with what you have. When that’s not enough, let go, and move them into more specialized facilities..
AD is a lethal disease. It is the 6th leading cause of death in America. It is the only leading cause of death that is not in decline, as it continues to grow in occurrence. The average duration from recognizable onset to death is 3-9 years. Some cases can last up to 20 years. On average, a person with Alzheimer’s will spend more years (40% of the total number of years with Alzheimer’s) in the most severe stage of the disease. Most AD sufferers don’t die from a lack of brain functioning. Death is usually from secondary disease or causes that have resulted due to the presence of AD. In later stages the afflicted patient becomes immobile, has difficulty swallowing and becomes malnourished. As a result, it is not uncommon to see in the Severe Stage of AD pneumonia, sepsis, urinary tract infections and fractures.
Myths about Alzheimer’s Disease.
Whenever there is a lack of official information, myths often arise. These can lead to inappropriate concerns or, worse, no concern. In these cases knowing what is wrong is just as important as knowing what is right.
Myth- Memory loss is a part of growing older. Truth- Memory loss that interferes with activities of daily living is a sign of AD.
Myth- Only old people get AD. Truth- 200,000 people younger than 65 have the disease.
Myth- Using aluminum products can cause AD. Truth- Studies have failed to show any such connection.
Myth- Aspartame (the artificial sweetener found in products like NutraSweet and Equal) causes memory loss. Truth- After 100 studies, the FDA says, “No, it doesn’t.”
Myth- Vitamins, supplements, NSAIDs, and memory boosters can prevent AD. Truth- There is no scientific evidence that this is the case.
Myth- All people with AD become violent and abusive. Truth- AD can be frustrating and frightening for the patient and they can act out, but with proper caregiving those events can be minimized.
Caregiving and Alzheimer’s
Besides medication administration and side effect control, AD caregiving boils down to proper management of the patient and their environment. Care for the AD patient is essentially the same care you would give any Dementia patient. Because of this, the section on caregiving will be presented after the review of the other Dementia-causing conditions.
Vascular Dementia (VD)
Vascular Dementia is a general term relating to cognitive impairment caused by cell death due to impaired blood flow to the brain. It is usually stroke-related, but could be caused by other events like a botched surgery or any significant loss of oxygen supply to the brain. VD can occur suddenly, as with a major stroke, or gradually over time as a result of multiple “silent strokes” (small strokes that have no outward symptoms). VD can also occur alongside Alzheimer’s disease, in which case the condition is referred to as Mixed Dementia.
Epidemiology
Vascular Dementia is the second most common form of Dementia. The prevalence of VD increases with age, occurring in 1.2 % to 4.2% of people over the age of 65. People who have had a stroke are 9 times more likely to develop VD than those without a stroke. Unlike Alzheimer’s, VD is more common in men than women. People with atherosclerosis (hardening of the arteries) are at greater risk for VD.
Etiology
Vascular Dementia is not a disease. It is a condition that is the result of any vascular problem that deprives the brain of the supplies it needs, mainly oxygen. Post Stroke Dementia may occur in several different ways. Single-infarct Dementia is the result of one massive stroke in a critical part of the brain dealing with cognition. Multi-infarct Dementia is due to strokes in several different parts of the brain leading to the same result. It could be a few larger strokes or several smaller stokes, including TIAs (Transient Ischemic Attacks). A less common stroke dementia is due to hemorrhagic (bleeding) stroke, caused by blood vessels bursting in the brain.
What Exactly Is A Stroke?
To better understand the symptoms and treatment of VD, a brief review of what a stroke is would be helpful. Strokes are due to a blood clot or the bursting of a blood vessel. Strokes are more likely to happen if the blood vessels are damaged or they are narrowed due to lesions or the buildup of plaque.
A TIA is an episode where the patient has stroke-like symptoms that clear up after 1 or 2 hours. It is due to a temporary restriction of blood flow within or leading to the brain.
Some strokes are called “silent strokes” because the area affected is so small they do not lead to any outward signs or symptoms.
Common signs of a stroke are a sudden occurrence of one or more of the following: numbness or weakness of the face, arm or leg – especially on one side of the body; confusion; trouble speaking or understanding; trouble seeing in one or both eyes; inappropriate dilation of the pupils for the surrounding light – especially if one eye is different than the other; trouble walking; dizziness; loss of balance or coordination and severe headache with no known cause.
Time is of the essence in a stroke case. Every second more brain cells are dying, never to be replaced. To save as much brain function as possible, prompt action is required.
Diagnosis (The Signs and Symptoms of Vascular Dementia)
In VD dementia symptoms may occur abruptly, over weeks or months in a stepwise manner, or may appear gradually over years. Dementia problems usually start to appear within 3 months of a stroke. Unlike the gradual, generalized decline as seen in Alzheimer’s memory loss, VD happens as fixed events in any part of the brain. As a result, the signs and symptoms are more variable than for AD. In addition to the signs previously listed for AD, common signs of Vascular Dementia are paralysis, wandering and getting lost in familiar surroundings, psychosis (hallucination and delusions), sudden depression, laughing or crying inappropriately, sudden bouts of aggression and sudden loss of bowel control.
The Adult Foster Care point of view.
It is very hard to tell the difference between the onset of AD versus VD. In the end, it doesn’t really matter. If you suspect any form of dementia, send the patient to the Doctor. In the end you will take the same actions, except after the Doctor diagnoses VD you will pay more attention to cardiovascular health.
Using the right tests, a Doctor can determine if the Dementia is from stroke events or not. He will then prescribe the appropriate therapies. He won’t be able to do anything about the loss of cognitive function, but he can prevent further deterioration by preventing future strokes.
Therapies
The first goal of therapy in VD is to limit the damage caused by a stroke. In strokes, some of the damage to the brain is the result of cell impairment, not cell death. If treatment actions are prompt enough, some of the stroke effects can be reversed. After 1 to 2 hours the damage more or less becomes permanent.
The Adult Foster Care point of view
If one of your residents is suspected of having a stroke, call 911, lie the patient down with the head slightly elevated (on their side if you suspect they’ll vomit). Lie them down in an area where the paramedics can get to faster. Get the medical records ready for review and make a copy for the paramedics. At one time, first aid in strokes was to have the patient chew on an aspirin. Because of possible choking problems caused by neck paralysis, this treatment has fallen out of favor. Because this treatment has saved lives in the past, I would recommend that you discuss the use of aspirin during strokes with every patient’s doctor and put the doctor’s response into their chart as a standing doctor’s order.
The second goal of therapy is to minimize the chances for further strokes. This can be done through anti-platelet meds (blood thinners) and good cardiovascular system health techniques.
The third goal is to recover what functioning was lost through retraining and occupational therapy. AD medications can enhance these efforts. It is important to note that it has been shown that Donepezil (Aricept) has caused an increase of death in VD patients. An increase of confusion at night appears to be more prominent in VD, so sleep therapy interventions may be required. SSRI (selective serotonin reuptake inhibitors) antidepressants can be helpful with depression and emotional incontinences associated with VD.
Prognosis
If the strokes are controlled, the outcomes are quite good for Vascular Dementia. The VD patient may actually improve over time, given proper therapy. Unfortunately, preventing future strokes is difficult and may be unavoidable. If strokes persist mental decline will continue. 50% of people with VD die within 5 years due to the increased risk of further strokes. If dementia symptoms continue to increase, there is a good chance that silent strokes are occurring. TIAs are also major indicators of further serious strokes. The Doctor should be informed in either case.
Dementia with Lewy Bodies (LBD)
Lewy Body Dementia is the second most common form of progressive disease dementia. It is caused by abnormal deposits of a protein called alpha-synuclein inside the brain's neurons. These deposits are referred to as Lewy Bodies, named after their discoverer, Fredrich Lewy. Over 1.3 million Americans have LBD, constituting about 10-15 % of all Dementia cases.
Diagnosis Specific to Lewy Bodies
Lewey bodies can be present in other kinds of Dementias and may be a secondary cause of mental decline. When Lewy Bodies are the primary cause of Dementia, the following symptoms become more pronounced: fluctuating levels of attention, drowsiness, lethargy or staring off into space (attention levels may change throughout the day or change daily), visual hallucinations or delusions, movement disorders (rigidity, shuffling walk, lack of facial expressions, balance and falling issues), and sleep difficulties (including daytime drowsiness). 50% of LBD cases have REM (Rapid Eye Movement) sleep disorder. While sleeping, patients’ movements are not blocked and they act out their dreams. Some people exhibit the above symptoms, yet show no mental impairment when given cognitive assessment tests.
Therapies
LBD patients respond very well to ChEIs Alzheimer’s drugs. Movement disorders can be resolved by the use of Parkinson Disease medications. Sleep meds work very well in REM sleep disorders (avoid OTC sleep aids like diphenhydramine, as they can interfere with ChEIs).
Antipsychotic medication used for hallucinations must be used with extreme caution. Up to 50% of LBD patients who are treated with antipsychotics may experience severe symptoms of worsening cognition, heavy sedation, irreversible Parkinsonism, neuroleptic malignant syndrome (NMS, which is characterized by severe fever, muscle rigidity and breakdown that leads to kidney failure). NMS can be fatal. Typical antipsychotics are Haloperidol (Haldol), and Risperidone (Risperdal ).
The Adult Foster Care point of view
Hallucinations and delusions are some of the most troubling Dementia symptoms for caregivers. They can really wear you down in the long run. If you become desperate you might ask the Doctor to try Quetiapine (Abilify) or Clozapine (Clozaril). Some experts prefer them over other hallucination medications, though Clozapine requires weekly blood tests.
Prognosis
Like other progressive dementias, there is no cure and symptoms will get worse until death ensues. The disease can last from 2-20 years, with the average being around 5-7 years.
Parkinson’s Disease Dementia (PDD)
Parkinson’s is a brain disease that affects a person’s movement. In later stages many patients develop dementia. Lewy Bodies appear to be a major factor. Some experts differentiate the two by when the dementia occurs. Patients whose dementia occurs before or within 1 year of Parkinson's symptoms are diagnosed with LBD. People who have an existing diagnosis of Parkinson's for more than a year and later develop dementia are diagnosed with PDD.
Therapy
Treatments are the same as in LBD, with the exception of paying more attention to movement disorder side effects.
Caregiver Considerations In Dementia
There have been whole books written on the subject of Dementia caregiving. A full discussion on the subject is well beyond the scope of this article. I will, however, pass on some keys points, overviews, and a summary of Adult Foster Care issues I feel are important.
The Family of the Patient
The Dementia patient’s family should be an integral part of their life. They can provide emotional and social support for the patient and for you, the caregiver. They can also supply extra resources that you may need. They are another tool in your caregiver tool box. But, like all tools, they need to be sharpened and utilized with skill.
Educate the family with what is going on and what they can expect out of their relative as the disease progresses. If they know what to expect, visits will be longer and more enjoyable. Remember that they know less about Dementia than you do and need your help to effectively relate to the patient. Teach them how to communicate differently, about the limitations you see in the patient and how to enjoy the relative, despite the handicaps.
Monitor the family’s actions to avoid financial and emotional abuse.
Involve the family with suggested activities, such as recording memories, scrapbooking (making a memory book), supplying family photographs and other memorabilia, greeting card signing and mailing, and car rides. These times will supply enrichment and mental stimulation for the patient and give you a break from the client. Give the family assignments that will motivate them to return and add meaning to their visits.
The Patient
The patient may look normal on the outside, but is handicapped mentally on the inside. As such, they cannot interact in a normal fashion with their surroundings. The caregiver must adjust the caregiving to accommodate this need. Caregiving is best when it is structured, respectful, and friendly.
Some suggestions are:
Establish routines - Doing things the same way each day reduces the complexity in their life that they are no longer able to deal with. It reinforces habits that ensure a greater cooperation from them. It provides a redirection point for agitation moments. You can say, “But this is the way you’ve always done things. You didn’t want to change did you?”
Surround with the familiar - Place in their room, where they sit and where they eat, familiar items from their life. Make sure to provide night lights to avoid night time disorientation.
Reduce complexity - Limit the choices they have to make. Provide clothes that are easier to put on and take off. Break tasks down to one item at a time. Provide finger food and bowls instead of plates. Use straws and serve food a few items at a time.
Communicate differently - Talk slowly, using short, simple words and phrases. Focus on one item at a time. If they become aggressive, acknowledge their feelings. Address them by their name and identify yourself often. If the patient becomes delusional, NEVER confront the delusion directly. Handle the situation by redirection or distraction. For example, if they say the sky is red, respond by saying, “What a lovely shade!” and move the subject to something else. Avoid baby talk and try not to interrupt.
Control the patient by controlling the environment - Use a gentle, calm approach. Reduce distractions. Provide a soothing environment (calm music, fish tanks aromas, etc.). Establish toilet schedules. Provide magazines with pictures instead of words. Don’t expect too much from the patient. Kick start the patient by initiating the task for the patient then letting them finish. Watch for repeating patterns of agitation and rearrange things to disrupt the pattern. Use signs and pictures, clocks and calendars, family photos, and a list of daily activities to reorient the person when he or she gets confused. Monitor TV programs and avoid shows that could lead to paranoia or agitation.
Control wandering - Put alarms or bells on doors. Place child safety covers on door knobs. Make exiting complicated. Inform neighbors about the potential of wandering so they can help you keep watch. Place an identification card on the patient at all times, including at night. Provide a routine of walks. Be ready with plenty of distractions.
Control sleeping - Physical activities will help the person feel more tired at bedtime. Walk with the person during the day. If the person seems very fatigued during the day, give them a short rest in the afternoon to regain their composure. This can lead to a better night’s sleep. But don’t let them sleep too long – too much daytime napping can increase nighttime wakefulness. Also, limit the patient’s caffeine intake. Ask the person if they would like a small snack before bed. Use sleeping medication with caution, because some interfere with their dementia medications and other may cause Parkinson’s disease-like symptoms.
The Adult Foster Care point of view.
As cognition declines, inhibitions will also be reduced. The patient may become aggressive, abusive or swear more. Other abnormal behaviors may arise that normally would be inhibited, like wandering, taking things apart, getting into other people’s property and undressing in public. Do not take things at face value. Don’t be shocked, or take things personally. Have a plan before these things arise. Train your staff and the family as well. Remember that you cannot use physical or chemical restraints until you get a doctor’s order.
The Caregiver
You are a major part of the Dementia equation. You must manage yourself just as well as you manage the patient and your home. Here are a few thought and tools that you can use.
Stress - A major source of stress comes from what we expect from the patient’s behavior. If you realign those expectations, stress will be reduced. Stress also comes when you push yourself too hard. Take care of yourself. Get plenty of rest, pace your duties, and eat properly. Recognize the warning signs in yourself and head things off before they become a problem. Taking walks with the patient or doing yard work are good stress relievers. Get plenty of help from outside sources. Utilize the family to help relieve the burdens. Talking with caregivers helps. Join a caregiver forum on the internet.
The Adult Foster Care point of view.
Since you live with the patients, getting time away is very important. Hire part-time help and get away for a few hours (and not just to go grocery shopping). Make it a part of your budget as an operating expense. That way, going to the movies becomes a tax deduction.
Observation/ Assessment Tools
Observing and describing behaviors is very subjective. It is also hard to track the changes in a slowly progressive disease. Here are a few tools to help.
Mini-Cog
A Mini-Cog is a test that you give the patient. It helps to quantify behaviors and tracks changes over time.
1. Ask the patient to listen carefully to and remember a list of three words.
Example: Fish, House, Truck
2. Instruct the patient to draw a simple clock or put in the numbers on an already drawn circle. Ask the patient to draw in the hands of the clock to read a specific time, such as 9:10. Allow 3 minutes for the task. If they can’t complete the task, move on to step 3.
3. Ask the patient to recall the list of words from step one.
Scoring:
Give 1 point for each word remembered. Give 2 points for a normally drawn clock. No points for an incorrect clock.
Evaluation:
Keep scores in the patients chart and track them over time. Use the test and it’s scores when communicating with the Doctor. Be sure to give the doctors a full copy of your test so they can understand your scoring method. Give the test to all your patients on a regular basis to help in earlier detection of dementia-related diseases.
Stroke Detection
Sudden dementia might actually be a stroke. Prompt recognition is vitally important.
Pupil Test.
Look at the pupils to see if they are dilated correctly for the light or if one is big than the other.
F.A.S.T. test (recognizing stroke symptoms)
F = FACE Ask the person to smile. Does one side of the face droop?
A = ARMS Ask the person to raise both arms. Does one arm drift downward?
S = SPEECH Ask the person to repeat a simple sentence. Does the speech sound slurred or strange?
T = TIME If you observe any of these signs, it’s time to call 9-1-1
Other Resources:
Book: The 36-Hour Day A Family Guide to Caring for People With Alzheimer’s by Nancy L. Mace M. A. and Peter V. Rabins. M.D. John Hopkins University Press
Websites:
Alzheimer’s Association. http://www.alz.org/index.asp
NIH Senior Health. http://nihseniorhealth.gov/alzheimerscare/homecare/01.html
HelpGuide.org. http://www.helpguide.org/
National Stroke Association http:www.stroke.org
Conclusion:
Dementia is an inevitable part of elderly care today. All indicators points to its prevalence becoming greater as the population continues to age. Maybe in the future there will be a cure, but for now Care Providers and their skills are the best chance Dementia patients have in living out their lives with as much peace and dignity as they can. Caregivers must become familiar with the different causes of Dementia and their associated therapies to ensure the best possible quality-of-life outcomes. Be patient with their oddities, be firm with their routines, and be flexible in your attitudes and diligent in your watchfulness.
References:
1. Alzheimer’s Society.
http://www.alzheimers.org.uk/
2. Alzheimer’s Association.
3. Dementia. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Dementia
4. Stroke. Brain Foundation.
http://brainfoundation.org.au/a-z-of-disorders/107-stroke
5. Erick H. Chudler, University of Washington. Brain Development Neuroscience for Kids. http://faculty.washington.edu/chudler/dev.html
6. Alois Alzheimer. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Alois_Alzheimer
7. Kristi Monson, PharmD, Namenda. eMedTV health information brought to life. http://alzheimers.emedtv.com/namenda/namenda.html
8. Stroke risk factors and prevention. Medline Plus National Institute of Health. http://www.nlm.nih.gov/medlineplus/ency/article/007418.htm
9. Multi-Infarct Dementia Medline Plus. National Institute of Health.
http://www.nlm.nih.gov/medlineplus/ency/article/000746.htm
10.Rod Brouhard. First Aid Facts About Stroke . About.com .
http://firstaid.about.com/b/2006/07/13/first-aid-facts-about-stroke.htm
11. Multi-infarct Dementia. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Multi-infarct_dementia
12. NINDS Multi-Infarct Dementia Information Page. National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/multi_infarct_dementia/multi_infarct_dementia.htm
13.Ole Davidsen, MD. Multi-Infarct Dementia NetDoctor.
http://www.netdoctor.co.uk/diseases/facts/multiinfarctdementia.htm
14.Howard A. Crystal MD, Dementia with Lewy Bodies. MedScape Reference.
http://emedicine.medscape.com/article/1135041-overview
15.Stroke Related Dementia eMedicine Health. Web MD.
http://www.emedicinehealth.com/stroke-related_dementia/article_em.htm
16.Vascular Dementia. Mayoclinic.com.
http://www.mayoclinic.com/health/vascular-dementia/DS00934
17.Stroke 101. National Stroke Association.
http://www.stroke.org/site/DocServer/STROKE_101_Fact_Sheet.pdf?docID=4541
18.Lewy Body Dementia Association.
http://www.lbda.org/category/4132/treatment-options.htm
19.Lewy Body Dementia MayoClinic.com.
http://www.mayoclinic.com/health/lewy-body-dementia/DS00795
20.Caring for Someone with Alzheimer’s, Home Care NIH Senior Health. National Institute on Aging. http://nihseniorhealth.gov/alzheimerscare/homecare/01.html
21.Alzheimer’s Behavior Management Helpguide.org.
http://www.helpguide.org/elder/alzheimers_behavior_problems.htm
22.Nursing Care Plans for Dementia Life Nurses.com
http://www.lifenurses.com/nursing-care-plans-for-dementia/
23.Dementia and Alzheimer’s Care, Preparing and Planning for the Road Ahead. HelpGuide.Org http://www.helpguide.org/elder/alzheimers_disease_dementias_caring_caregivers.htm
24.Edward M. DeSimone II RPh, PhD, FAPhA, Laura Viereck PharmD. Alzheimer’s Disease Increasing Numbers, But No Cure. US Pharmacist. Jan 2011.
25.Kristin S. Meyer PharmD, CGP, CACP, FASCP, The Pharmacist’s role in recognition and management of Alzheimer’s. Drug Store News Pharmacy Practice. March/April 2010
26. Greg Pelegrin, PharmD, Understanding Alzheimer’s. Pharmacy Times, Central Nervous System Issue. March 2010.
27. Nancy l Mace MA, Peter V. Rabins MD MPH, The 36 hour Day a Family Guide to Caring for Persons with Alzheimer’s Disease, Related Dementia Illness, and Memory Loss in Later Life. John Hopkins University Press Third Edition ISBN 0-8018-6148-9
Dementia: Patients Don’t Act The Way They’re Suppose To
An AFC Overview of Alzheimer’s and other Dementias
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Author: Mark Parkinson RPh: President AFC CE
Credit Hours 2.5- Approximate time required: 150 min.
Educational Goal:
To give a basic overview of in home diabetic care.
Educational Objectives:
1. Explain the role of the care giver in diabetes care.
2. Enumerate and explain the step in diabetes.
3. Explain what and how to monitor events in diabetes care
4. List was is involved in routine care for diabetics
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Diabetic in My Home – Now What Do I Do?
The prevalence of diabetes in older persons is going thru the roof. According to the Center for Disease Control, 10.9 million U.S. residents aged 65 or older have diabetes - that’s 26 percent or 1 in every 4. Last year alone, 390,000 new cases were reported. What that means to Adult Foster care, Developmental Disabled and Mental Health Homes is that sooner or later, you will probably have a diabetic in your home and will have to deal with it. So, let’s deal with it.
The Team Approach
One of the first things that will impact your operations as you take care of a diabetic patient is being overwhelmed by all the things you have to know and do. There is an overwhelming amount of information on diabetes because it affects every aspect of a patient’s health. Diabetes is so complicated that the only good way to manage it is with a team approach. Who’s on the team? Doctors, nurses, podiatrists, dentists, eye doctors, dietitians, diabetic educators, social workers, pharmacists, insurance carriers - that’s who. And now, you’re on the team.
The Role of the In-Home Caregiver
First. In- Home care is where the actual work is done, where the rubber meets the road, so to speak. All those wonderful people willing to help with resources and knowledge won’t mean a thing without you, the caregiver. There is work to do and caring to be done. You have to see that the diabetic patient is taking care of everything that they need to do or you have to do it for them. Bottom line, if things slide, a price will be paid later. There is no getting around it. The patient will eventually get sicker.
Second. Somebody has to coordinate the efforts of all the team members. Usually it’s the patient who’s in charge, but now you are in charge on their behalf.
Third. Everyone is supposed to be for the patient, but in my experience people get busy and things get in the way. It’s too bad that patients in care homes sometimes become second-rate medical concerns. It is in your business’s best interest to keep everyone on their toes. Battle for your clients if you think any of the care team is slacking. All of the effort will be worth it because your client will live longer and require less work if they remain healthy.
The Work of Diabetes Care
There is no “best practice” way of taking care of diabetes. There is no program that details every step to take in keeping a diabetic healthy. Every attempt to make such a program has ultimately failed because everyone is so darn unique. It is now the prevailing medical wisdom to establish general guidelines and let the care team individualize each course of therapy and monitor for results. The care coordinator’s job is starting to sound more important, isn’t it?
The Center for Disease Control and Prevention, National Institute of Health, and the National Institute of Diabetes and Digestive and Kidney Disease recommend a general four-step plan.
Step 1: Learn About Diabetes
It’s important for you and the patient to know what is going on. Knowing the whats, helps with the whys, which helps with the doing of diabetes care. I recommend communicating with a diabetes educator about the subject In brief, diabetes is a condition where the body has lost control (automatic self-regulation) of how the body produces (and sometimes stopped making) and uses insulin, which in turn affects blood glucose (blood sugar- the fuel that drives us) and blood lipids (fats like triglycerides and cholesterol ), which combined in turn affects—everything.
When things get out of “diabetic” whack, bad things eventually happen. Bad things like heart attack, stroke, eye problems, nerve damage, kidney problems, gum disease, amputations, lowered immune system, and incontinency. There is no such thing as a “slight case” of diabetes. Every case is serious and is causing now or will cause infirmity and death in the future.
Those who take care of the elderly might hear, “I’m old, it’s just doesn’t matter.” They just want to let things slide until they kick the bucket. But unfortunately things rarely go so smoothly. Most commonly, letting things slide for a person of any age results in a long, drawn-out period of progressively worsening condition and suffering. Nobody really wants a long, drawn-out period of suffering. The patient is just overwhelmed like everyone else. If you get one of these ‘ornery old coots who doesn’t want to change, you will have to help them change.
Let me end this section on a more positive note. When blood glucose is kept normal, patients feel better with more energy, are less tired and thirsty, have fewer skin and bladder infections, have fewer problems with their eyes, feet and gums. Everyone wants to feel better.
Step 2 Know the Diabetes ABCs
When the body doesn’t function automatically, you have to do things manually. In order to make the correct manual adjustments, you have to know how things are going. That means monitoring. The diabetic monitoring ABCs are:
A is for A1C. or HbA1C. Some glucose sticks to the hemoglobin molecule in the blood stream. The more glucose floating around, the more it sticks to the hemoglobin and becomes HbA1C. Counting up the A1C shows what your blood glucose has been over the last three months. The A1C goal for many people is below 7 percent. The doctor will determine what the patient’s individual goal should be. A more day-to-day or even minute-by-minute monitoring is done by home blood glucose monitoring devices. That’s the “finger stick and put blood on a test strip” machine. They are really helpful in the day-to-day, normal living efforts of diabetics and their care givers. Finger stick readings should be recorded for future references. Up and down patterns and individual readings will help you with things like diets and determining if meds are working (or working too good) or how much to exercise.
B is for blood pressure. The goal for most people with diabetes is below 130/80. If you have a home blood pressure machine or use one of those machines at the drug store or mall, keep in mind that blood pressure machines vary in reading all the time. At home you’re looking for long-term trends. Individual recordings are less important, unless there is a significant spike up or down. These fluctuations can be minimized if the blood pressure is taken under the same conditions every time. Keeping a long-term record of readings and sending it to the doctor will be of value. High blood pressure makes the heart work too hard, and is bad for the eyes and kidneys, too.
C is for cholesterol. Cholesterol readings can be kind of confusing. There are several kinds blood lipids (blood fats) that all are important to keep track of. Fortunately, the doctor worries about the individual tests and readings. Your main concern is how close to the goal is the patient. For your general reference, the LDL goal for people with diabetes is below 100. The HDL goal for men with diabetes is above 40. The HDL goal for women with diabetes is about 50. Sorry, guys, women can tolerate more fats in the blood stream than we can. LDL means Low Density Lipids and it is the bad cholesterol. Think of LDL like big fluffy cotton molecules that can easily clog up the veins and arteries. HDL means High Density Lipids or good cholesterol. These are more compact pellets that easily slip through blood vessels.
The CDC didn’t mention it, but I would include weight in my measurements and goals. I guess the ABCWs didn’t sound too good (just joking). Seriously, though, 85 percent of type 2 diabetes patients are overweight, 54 percent are obese. That just adds to the problems later on.
Step 3 Manage your Diabetes
This is where we roll up our sleeves and get to work. I have my own set of letters. DEHM -Diet, Exercise, Hygiene, Monitoring. Diabetes care is a marathon, not a sprint. Just keep at it. If you fall behind or stop, don’t worry, just start up again. No matter how many time you have to, keep starting up again, keep going. All your efforts do have an impact on the overall health of the patient. My number-one caregiving recommendation is to start and stick to a routine. Work at establishing patterns. They turn into habits. In-Home caregivers have the advantage of controlling the environment of the home. Bad habits are more easily broken when you take advantage of the turmoil that is caused when a person moves in and tries to adapt to the new surroundings. If routines are already in place and enforced, change will come faster. A couple of words of caution. The elderly have had a very long time to ingrain habits. Also and more importantly, they have physically lost some of the abilities to cope with change. DD and mental health homes have their own behavioral challenges to deal with. Including the patients into the education process and goal planning will go a long way. Be patient, but stick to it.
Diet
Let me start out by saying don’t get freaked out about cooking for a diabetic. You won’t have to cook an entirely separate meal for your diabetic resident. Yes, you will have to make some adjustments, but we’re not talking about much. We’re just talking about cooking with a little bit more thought process in the menu plan. My wife is diabetic and has her blood sugar is under control. and guess what, I’ve gained weight. In reality, the average In Home caregiver, for the most part, cooks the way you’re supposed to cook any way. Plus, you’re not alone in this. Most insurances will pay for a diabetic educator and a dietician to consult with about your meal planning. I hope that takes care of some of the fear of the unknown for you cooks out there.
To help prepare you for your dietician consultation, let’s cover some food basics. Our body tries to convert most of what we eat into glucose. When the glucose concentration rises in the blood stream, our body starts to pump out insulin to take care of it. Some of the unused glucose is stored away as body fat. Some foods are readily converted to glucose while others have to go through a couple of steps and it takes longer. Parts of the foods we eat can’t turn into glucose or anything useable so it passes through our gut undigested as bulk fiber. We count on this bulk for proper intestinal function.
Glycemic Index
The glycemic index is a measure of the effects of carbohydrates in food on blood sugar levels. Foods that are quickly converted to glucose result in a quick jump in your blood glucose concentrations. This is known as high on the glycemic index. In diabetics, their impaired insulin system is easily overwhelmed by the sugar spike, which results in all the unhealthy consequences of diabetes. For the most part, this type of food is carbohydrates - breads, pasta, potatoes, white rice, table sugar, etc. If the food takes longer or is harder to digest, it results in a delayed or lower glucose spike. This means the food is lower on the glycemic index and the impaired insulin system is better able to handle it. I bet you have already guessed what some of these foods are. Yep, fruits, vegetables, whole grains, etc.
To Eat Fat or Not to Eat Fat, That Is the Question.
We are learning more and more about fats all the time. After decades of research, we have found that a totally fat-free diet doesn’t really offer the benefits that people once thought. For some, it even caused some health problems. So fat free is out. Is fat “in” now? Yes and no. Let me explain.
There are different kinds of fats. There are saturated, unsaturated, and trans fats. Saturated fats are big fluffy molecules that don’t compact easily in the blood stream. They are one of the contributors of LDL molecules (remember the cotton molecule). Unsaturated fats compact easier and result in HDL. HDL has been called the garbage truck because they can scavenge LDL and take them to the liver for disposal. Trans fat is the bad fat. We can’t use trans fats very well and they float around collecting in places. Trans fats are strongly associated with diseases. Of course, it’s a lot more complicated than this, but the take-away message is unsaturated fats- good. Saturated fats –so so, trans fats –bad. Good sources of the unsaturated fats are olive, peanut, canola, sunflower oil, nuts, fish, soybeans. Sources of saturated fats red meat, lard, butter, whole milk products like ice cream. Trans fats are found in margarines, deep fried fast foods, processed snack goods. Yep, you’re right- good fats are in vegetables and lean meats. Bad fats are in highly processed convenience and fast foods.
Let’s Wrap Up All This Talk About Food
That’s enough talking about individual nutrients. After all, people don’t eat nutrients, we eat food. In general, a diabetic diet is just good old wholesome home cooked meals. Heavy on the vegetables, fruits, whole grains, moderate on the meats, whole dairy products, and controlled portions of high glycemic index foods like breads, pasta, potatoes, table sugar, and avoid fast and convenience foods. That is not much of a stretch from the menu that most of you cook right now. Your dietician or diabetic educator will explain things in more detail and help you tweak what you’re doing now. You’ll probably find that it’s a good idea to keep all of your residents are on a diabetic-inspired diet.
Exercise
Another way for caregivers to help manage their patient’s diabetes is through enabling them in exercise therapy. Exercise manages diabetes by: 1. Improving the body’s use of insulin. Continued moderate exercise can help the muscles take in glucose up to 20 times their normal rate. 2. Helps to eliminate excess body fat (a major determinant in diabetes). 3. Increases energy levels to help maintain a more active lifestyle. 4. Reduces stress and thus reduces stress hormones that influence insulin and glucose release. 5. Improves the patient’s circulation. Exercise even lowers bad LDL lipids and increases good HDL lipids.
How to Start
Exercise is therapy and a doctor should be consulted before starting. The CDC recommends 30 to 60 minutes of physical activity on most days of the week. But you don’t have to start out that way and you don’t have to do it all at once. It is recommended that you start low and go slow, gradually working your way up to the target exercise goal. Working your exercise program in this way is easier to start, easier to maintain, and easier to establish good habits. One suggestion on low and slow is to exercise in spurts, for example 10 minutes three times a day.
Precautions
Adult Foster Care geriatrics, Developmentally Disabled and Mental Health Homes all have their own set of challenges stemming for the unique characteristics of their client base. Use your own skills to adjust the program to meet the needs and abilities of your residents. There is no magic one-fits-all routine, and in all honesty, therapy doesn’t even have to be set exercises. Gardening, dancing, and washing a car are exercise, too.
It is possible to exercise too much. Long bouts of intense exercise can actually increase blood glucose. Some patients are extra sensitive to exercise and it makes their blood sugars crash down to dangerous levels -hypoglycemia . Hypoglycemia usually happens gradually. Look for increasing signs of feeling shaky or anxious, light headedness, or sweating abnormally. These are signals that the body needs more fuel and is easily managed with a high glucose tablet or snack. It is wise not to exercise during the peak effect of medications, especially short-acting insulin. Supply plenty of water during and after exercise sessions. If the patient exercises away from home, be sure to have a diabetic bracelet and emergency supplies with them. Always warm up and cool down with more intense routines.
Integrate in Normal Routines
Some insurances pay for health club memberships, and some patients’ family have memberships. Take advantage of such resources. Outings to community pools are also a good (and cheap) activity. You certainly don’t have to turn your home into a spa. It is interesting to note that newer residential care and nursing facilities all have exercise facilities and they tout such in their advertising materials, (hint- hint). A cheap way to do this in your home is to go to Goodwill and pick up a used tread walker or stationary bike. Place the equipment by the TV and have a scheduled exercise period. Of course, walks are always a winner on many levels.
It is important to make exercise a part of the scheduled routine. Routines become habits and habits are easier to maintain. Remember that you can substitute other activities to combat exercise boredom.
Regular exercise helps manage diabetes, but there are other benefits as well. It improves muscle tone and balance ( fewer falls). It reduces stress and increases mental health, it improves self-esteem and combats depression, it strengthens the heart and bones, and it lowers blood pressure. The patient will realize these benefits even if they never lose a pound of excess fat. Bottom line, just start and keep at it. You will be doing good care for your residents.
Hygiene
Taking care of oneself is much more important for the diabetic patient. The consequences of letting things slide are just too great. For example, poor foot care in diabetes can lead not just to smelly feet but infection and gangrene. Diabetes is the leading cause of amputations. Of course, I don’t have to say it, but good personal care is the bread and butter of any successful Care Home.
Smoking
It is common knowledge that smoking is bad. Smoking and diabetes (and a lack of exercise) don’t mix well. Don’t smoke - enough said. You can get medication to help combat the addiction. You, the caregiver, can control the environment, which certainly goes a long way. Make it very inconvenient to smoke. Those working in mental health environments will have the roughest time because there is a strong correlation between several mental illnesses and smoking. Get help from the doctors.
Hygiene
Proper hygiene is one of the essential duties for any In Home caregiver, but it is particularly important for diabetics, who present problems with circulation, hydration, nerves (especially in the extremities), and immune system. Minor cuts, skin abrasions, or gingivitis can quickly turn into major problems. Regular, full inspections, especially of the feet, are “must-dos” in diabetes care.
Oral
Use a soft bristle toothbrush (medium and hard can lead to cuts and abrasions). Brush at least twice a day and floss daily. Replace the toothbrush every three months. Remove and clean dentures daily. Chronic bad breath may be a sign of mouth infections and tooth decay.
Skin
Dry, flaky skin is a constant issue with the elderly and diabetics. Applying lotion on a regular basis helps solve this problem and provides an opportunity to inspect the skin. The act of applying lotion soothes the skin and promotes blood flow. Warm and red patches are early signs of infection. Moisture on the skin leads to early breakdown. Adult diapers must be properly and frequently changed. Sedentary patients who never change positions can experience a lack of blood flow to the skin. Portions of the skin die and open wounds (“bedsores”) result. This can be managed by shifting the patient’s body position frequently. A rolled-up towel alternately placed under one side and then the other works well.
Feet
Foot problems are a particular challenge for diabetics. Numbness and lack of circulation put the diabetic at greater risk for infections in an area of the body that sees a lot of wear and tear. Remember: diabetes is the leading cause of amputations. Daily foot inspections are a very good idea.
How to inspect
Look at the top and bottom of each foot. Check between the toes and look at the toenails. A mirror might speed the process for self-inspections. Look for cuts, blisters, ingrown toenails, or any signs of infection, such as moist or wrinkly skin between the toes. Don’t be surprised if the patient can’t feel the problems that you find. Numbness in diabetes is common.
Corns and calluses are caused by friction or pressure against the skin. They can become dry and cracked, providing an opportunity for infections to develop. They should be removed by the gentle use of a file or pumice stone. If they keep returning, think about changing shoes and watch how the patient walks.
Thick toenails might be caused by a toenail fungus and they become a site of future athlete’s-foot infections. If you intend to tackle the thick toenail fungal infection yourself, plan on at least 12 months of treatment. Toenail infections are particularly hard to get rid of. Of course you’re not alone on the care team. Podiatrists have the knowhow and proper tools.
Tingling and sensitive feet are a problem for diabetics. You can get soft, seamless diabetic socks and special shoes. Some insurance plans will pay for them. Keeping the feet elevated can also help. There are numbing creams and mild capsaicin lotions that might also help and you could have a discussion with the doctor or podiatrist about them.
Monitoring
Signs and Symptoms
Diabetes has been called a silent disease because the initial signs are not seen or felt. You as a caregiver must learn to see the early warning signs. Being cranky, bad tempered, or confused might be the result of hyperglycemia or hypoglycemia. Other signs of hyperglycemia (too much blood sugar) are frequent urination, extreme thirst, blurred vision, or unusual fatigue. Signs of hypoglycemia (low blood sugar) are frequent yawning or lacking energy, an inability to speak or think clearly, loss of muscle coordination, sweating, twitching, seizure, fainting, feeling like you’re going to pass out, or becoming quite pale. Have the doctor include in your care plan what to do in both cases . Make sure all substitute caregivers are trained in the details.
Blood Glucose Monitoring
Diabetics have been called “lucky” as far as chronic diseases go, because the patient can use a home glucometer to get a near-instantaneous blood-sugar reading to see how well they are doing. Finger sticks can take a lot of the guess work out of caregiving. If there are any unusual signs, symptoms, or changes in your patient’s condition, you can take a finger stick and see whether the blood sugar is too high or low.
Readings can also help you tweak a menu for optimal results. For example, my wife found out that dishes with rice and ham sharply elevate her blood sugar, so she eats smaller portions of that combination and fills up on vegetables.
Home monitoring of blood-sugar levels can also help you manage optimal exercise times, determine medication effectiveness , and decide a new medication is doing what it is supposed to do.
Monitoring also gives you a common point of reference when communicating with other members of the care team and the patient’s family. For example, the ideal communication might be, “Mr. Smith is not doing very well today. After a period of confusion, I checked his BG and found it was 60. I gave him a glucose tablet as per instructions in the care plan. This has happened several times this week. Doctor, I think you should review his medications.” Compare that to “Doctor, my patient is feeling cranky and acting strangely, What can you do about it?”. See how powerful BG monitoring results are and how professional they make you appear.
Blood Sugar Monitors (Glucometers)
Most often, your resident will already own their own glucometer. If so, find the owner’s manual and read it. Unlike other manuals, these are written so that anyone can use them. I recommend finding the toll-free help desk telephone numbers. The help desk operators are really quite helpful. If you don’t have an owner’s manual, go to the company’s website, find the help desk number, and ask for a new manual. Or just get a new machine (more about that later).
Next, inspect the machine. Does it work? Is it clean? Do you have all the parts? Use the manual as a point of reference for answering these questions. If it doesn’t work or starts to act strangely, check the battery (usually a watch/hearing aid-style battery. You can usually find replacements in the electronic sections of department stores. Etched on the battery are identifying marks that tell which type to buy.
If error messages appear, refer to the owner’s manual. Clean the meter with soap and water using a wash cloth. Alcohol pads are ok, but it can be tedious to use those to clean. Wear gloves (after all, you’re dealing with blood). Look for the lancet device and lancets (the needle-like tools you place in the device that usually looks like a pen). Unused lancets have a twist-off top. You can buy the lancet device and lancets separately if they are missing. When making such a purchase, be sure the device and lancets match.
Every machine will be different but the basic instructions are:
New Machines
There are more than 25 glucometers on the market. When it comes right down to it, the brand really doesn’t matter as long as you learn how to use it and are comfortable with it.
The cost of the machine is almost irrelevant. Insurance plans typically pay for the machine or you can get one free from the manufacturer. If you do have to shell out some cash, pay particular attention to the cost of the test strips. Insurance plans also typically pay for the strips.
Determine which brand the insurance company prefers and you’ll save yourself a lot of hassle. On the back of the insurance card, you’ll find a toll free number that you can call and ask about brand preferences.
If you want the insurance plan to pay for testing supplies, you need a prescription. To save you some troubles, have the doctor write generically. For example, it’s better to write “Diabetic testing machine and supplies, refills for a year.” When the doctor writes the Rx like this, the pharmacy has greater latitude and they can make brand adjustments as needed if any difficulties arise or the patient switches insurance carriers.
Newer glucometers have many features. Don’t get caught in the “Shiny New Object” syndrome. If you’re never going to use all the doodads, why buy a machine that has them. Overall though, just relax. You’re going to have plenty of time to learn to use and become comfortable with this technology. The diabetic educator will be useful in helping you learn about the whole testing process. The rest of the care team can help, too.
Final Note on BG Testing
The doctor will help you decide when and how often to test. Be sure to cover the subject with him or her and get it in the care plan. There will be times when you need to test outside the regular schedule. I recommend getting an extra box of “just in case” strips so you don’t have to dip into the regular supplies. Insurance companies can be an awful pain when it comes to early refills.
Other Monitoring
BP and Weight
Other signs to monitor at home include blood pressure and weight. Many aspects of diabetes affect the blood system. Monitoring the BP can help you manage diabetes and the patient’s overall health. Monitoring weight is useful for assessing the long-term effects of care. Be sure to record all your readings in the care plan.
Medications
Don’t forget to monitor the effects of the medications. Are they working? Your finger stick readings will help determine if they are. The timing of medicines is an important factor as well, especially with short-acting insulin. Learn about the whens of dosing. The timing will affect when to exercise, when to eat, and when to travel outside the home. Medication timing can even affect the therapy itself. For example, sometimes just changing the administration time can solve therapy problems . Keep in touch with the doctor about any such concerns.
Are there side effects? The paperwork from the pharmacy will tell you what to look for. Communicate any observations to the doctor. Don’t be surprised if the doctor says they’re not going to do anything because the side effect doesn’t outweigh the benefit of the drug. Of course, you have a different perspective: You live with the patient and the doctor doesn’t. Don’t be afraid to battle for your client, but be professional about it.
Environment
And the final factor to monitor is the home environment. Watch for things that can nick or cut “at-risk” feet. Stress affects diabetes. Be aware of the overall stress of the home or the stress level when visitors arrive. It is wonderful for loving friends and family to visit, but they can also attempt to slip the patient a few extra unplanned treats and snacks. In diabetes, loving someone to death takes on a whole new meaning.
Step 4 Get Routine Care
As part of the overall care strategy, you must track routine scheduled visits to other health providers. A diabetic should see their prescriber at least twice a year. the A1c level should be tested at least twice a year as well. Annually, the patient should receive a lipid panel, a foot exam, a dental checkup, and an eye exam (although not all at once, of course). Immunizations should also be performed according to recommendations, such as annual flu shots every year, and pneumonia vaccinations every five years. That is a lot to keep track of. The most logical place to manage all these visits, records, events, and schedules is in the diabetes care plan in the patient’s folder. It is an excellent place to keep all the necessary records and schedules. You can pull it out whenever the patient goes to the doctor, or when other healthcare professional visit your home.
Conclusion
As a member of the diabetes healthcare team, the caregiver must learn the special needs of the patient and how to take care of them. The four-step plan from the Centers for Disease Control is an excellent starting point. Working with other team members, the caregiver can establish an individualized care plan that will help the patient remain healthy for a long time. I hope this CE has started you path of good caregiving.
Mark Parkinson RPh.
References:
1. National Diabetes Fact Sheets 2011, Center for Disease Control
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
2. Diabetes diet: Create your healthy-eating plan, MayoClinic.com
http://www.mayoclinic.com/health/diabetes-diet/DA00027
3. Easy Menu Planning , Save Time and Money with Meal Planning Squidoo.com
http://www.squidoo.com/easy-menu-planning
4. Type 2 Diabetes: Meal Planning, University of Michigan Health System
http://www.med.umich.edu/1libr/aha/ummp2.htm
5. The Basics of a Healthy Diabetes Diet, Diabetes Health Center. WebMD.com
http://diabetes.webmd.com/diabetes-diet-healthy-diet-basics
6. Margaret Farley Steele, The Diabetes Caregiver: Diet. Caring Today .com
http://www.caringtoday.com/deal-with/the-diabetes-caregiver-diet
7. Sarah Henry, How to Help Someone With Diabetes Stick With Diet Recommendations. Caring.com
http://www.caring.com/articles/food-recommendations-for-diabetics
8. Fat, Wikipedia.org
http://en.wikipedia.org/wiki/Fat
9. Blood glucose monitoring, PubMed Health, US National Library of Medicine
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003911/
10. Vegetable Fats and Oils. Wikipedia.org
http://en.wikipedia.org/wiki/Vegetable_fats_and_oils
11. Fats and Cholesterol: Out with the Bad, In with the Good. The Nutrition Source, Harvard Public School of Heath. Harvard.edu
http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-full-story/index.html
12. Diabetes: Keeping Up With Your Active Life. WebMD.com
http://diabetes.webmd.com/active-life/slideshow-managing-diabetes-10-tips
13. Type 2 Diabetes and Exercise, Diabetes Health Center, Web MD.com
http://diabetes.webmd.com/guide/exercise-guidelines
14. Food and drug administration, Diabetes: Choosing and Using Your Glucose Meter, MedicineNet.com.
http://www.medicinenet.com/script/main/art.asp?articlekey=20554
15. Diabetes, Diabetes and Exercise.The Family Doctor.org
16. Major depression, Depression and anxiety: Exercises eases symptoms. MayoClinic.com
http://www.mayoclinic.com/health/depression-and-exercise/MH00043
17. Diabetes, Helping a Family Member Who Has Diabetes. The Family Doctor.org
18. Hygiene, Bayer Diabetes
http://www.bayerdiabetes.ca/en/diabetesinfo/control/hygiene/
Diabetic in my Home – Now What Do I Do?
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“Ouch”, it hurts when I smile.
Those darn cold sores!
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To give an instructional overview of cold sores
Educational Objectives:
1. Give a description of what is a cold sore.
2. Tell how to treat cold sores.
3. Tell when care giver should respond to a cold sour outbreak
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer - The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
“Ouch” it hurts when I smile.
Those darn cold sores!
Those darn cold sores!
Cold sores, fever blisters, or recurrent herpes labialis are those annoyingly painful blisters that form around the lips. They break out, leak fluid, and crust over. Before they go away, scabs form that are none too flexible. They often crack when you move your lips, adding to the painful annoyance. Just what are cold sores? Where do they come from? Can I get rid of them? Can I prevent them from happening in the first place? As a care provider, should I even care?
What are cold sores?
Cold sores are lesions that are the result of a reoccurring infection of the Herpes Simplex Virus (HSV). That’s right, herpes. You might have heard that name before associated with a sexually transmitted disease. You’d be wrong to worry, though, because there are two types of HSV. Simply named HSV-1 and HVS-2. HSV-2 is the bad one; HSV-1 is the more common form that causes most of the cold sores.
Where do they come from?
Unfortunately, HSV is a very common, very contagious virus. It has been estimated that by age 50, 80-90 percent of adults carry the virus. More than 50 million people in the U.S. will have at least one outbreak this year. Everyone who has an outbreak can potentially spread the virus to anyone they come in contact with.
It can be spread by direct contact, like kissing, or indirect contact. It can be passed along by sharing a drink or lip balm, or if the patient rubs the sore with his hands then spreads it by touch. The virus can even spread through air-borne droplets of saliva from a sneeze. It is pretty safe to answer the question, “Where do they come from” by answering “from anywhere and anyone.”
How does the infection progress?
Most people get their first exposure as a child or adolescent. It manifests itself as a fever with a severe sore throat, possibly with lesions that on the cheeks or gums. The body quickly develops antibodies to the virus and the symptoms fade. But the virus never completely goes away. There are places where it can hide and go dormant, waiting for optimal conditions to multiply and spread again. Its primary hiding place is the sensory facial nerves around the mouth.
When a virus invades a cell, it will start to take over and make the cell produce more viruses. Eventually the cell dies or bursts, releasing thousands of new viruses. For the most part, the body’s defenses will swoop in and take care of things. That is why we are symptom-free, although we all carry the virus. But there are times when our defenses are down or busy elsewhere and a local outbreak happens and symptoms reoccur.
Cycle of an outbreak
Symptoms typically follow an eight-stage cycle.
What triggers an outbreak?
In about one-third of those who carry the virus, a reoccurrence of cold sores can happen. In most people, the blisters form in the same area each time and are triggered by the same factors. Common trigger factors or “stressors” include overexposure to the sun and other UV radiation sources; mouth surgeries; facial procedures like laser treatments, tattoos, and chemical peels; psychological stress; menstrual cycles; and immunosuppression. Cold sores that are sun-induced tend to be more severe in pain and duration.
What can you do for cold sores?
There is no known cure for HSV-1, but since patients are largely symptom-free, it just doesn’t matter. But what do you do about those annoying cold sores when they pop out?
Cold sore treatment options
A. Do nothing. Cold sores are self-limiting and they resolve themselves after about 14 days.
B. Treat yourself. There are several OTC medications you can use to feel better. There is no “one-drug-does-all” medicine, so you must know what each one does and chose your therapy wisely. Here is a list of the different kinds of OTC medication by group.
C. Prescription antivirals. Topical (acyclovir cream, penciclovir cream) and oral (valacyclovir, famciclovir) antiviral agents are effective in reducing the viral load of an outbreak and reducing the severity of the infection. But for maximum effect, therapy should start within the first two days of infection. A quick response becomes problematic when doctor appointments are involved. Because the of self-limiting nature of cold sores, there are those who say that doctors should only be called when there are serious complications or reoccurrence is very frequent.
Can you prevent cold sores?
The answer is yes and no.
Yes: By avoiding “stressors,” it is conceivable that you could avoid some cold sores. Of course that would mean that you have to know what events trigger your individual outbreaks. You’ll need to pay attention and keep good records. If you have frequent outbreaks, it might be worth the effort.
No: Sometimes bad things just happen and you have no control. Certainly, a healthy lifestyle goes a long way, but who can completely control everything that happens to them?
As a caregiver, should I even care?
From a caregiver’s point of view, the real question is, when should I care? A cold sore can be painful and embarrassing, but it’s not a serious infection. From my perspective, I take care of those who are under my charge. Their condition is a direct reflection on my caring skills. The way a client looks and feels is the most potent advertisement of my skills. Beside, that’s what I do - care for people.
Still, there are those times when even a cold sore can be a serious infection.
One Final note to the care giver. The main cold sore battle happens in the first two days. It’s a priority that therapies should start then. Since the site of the cold sore and the symptoms are predictable it shouldn’t be too difficult to be prompt with therapy. To cover bases, if cold sores happen often I would get some standing doctors in the records on what to do.
Conclusion
HSV-1 infections are not usually serious but often painful and annoying. The infection will usually resolve itself in about 14 days. There are several things a patient or a caregiver could do to lessen the severity of an outbreak. Prompt action within the first two days of a cold sore is the most effect therapy. Rare but serious complications and look alike conditions should be handled by a doctor.
References:
1. Elena Beyzarov, PharmD,,Addressing Common Oral Ailments: Current and Emerging Treatments for Herpes Labialis, Aphthous Ulcers, and Xerostomia. Pharmacy Times ACPE Program 0290-0000-12-86-HO1-P
https://secure.pharmacytimes.com/lessons/201209-01.asp
2.The Free Dictionary by Farlex
http://medical-dictionary.thefreedictionary.com/cold+sore
3. Wm Opstelten MD, Arie Neven MD, Just Eekhof MD, Treatment and prevention of herpes labialis, Canadian FamilyPhysican 2012
http://www.cfp.ca/content/54/12/1683.full
4. Herpes labialis. Wikipedia The Free encyclopedia
http://en.wikipedia.org/wiki/Herpes_labialis
5.Cold Sores: Patient Education Series, Brown University Health Services
http://www.brown.edu/Student_Services/Health_Services/library/documents/ColdSores11.pdf
6. Barbara Sax, Cold sores and canker sores? What is the difference?,Pharmacy Times.Nov.1 2004
http://www.pharmacytimes.com/publications/issue/2004/2004-11/2004-11-4707
7. Mohamad El Mortada MD, MaryAnn Tran MD, Corrine Young PharmD, Mary Nettleman, MD, Cold Sores.EMedicineHealth.com
http://www.emedicinehealth.com/cold_sores/page6_em.htm
8.Melanie Cupp,PharmD. PL Detail-Document, Treatment of Cold Sores. Pharmacist’s Letter/Prescriber’s Letter. May 2011. Melanie Cupp, Pharm.D.,
“Ouch”, it hurts when I smile.
Those darn cold sores!
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Author: Mark Parkinson RPh: President AFC CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To instruction on medication guidelines not normally given to care givers.
Educational Objectives:
1. List the drugs with special handling instructions.
2. List the drugs that have to be refrigerated.
3. Example how to use spay inhalers
4. Tell how to legally dispose of drugs
5. Give instruction about which drug that shouldn’t be crushed
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer - The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
How often do you talk in-depth with the doctor about the medication your residents use? How much time have you spent with the pharmacist when your patient gets a new drug? How many times have you read through the literature that comes with the meds every month? If you’re like the vast majority of caregivers, the honest answer is probably- never, just enough time to pay for the drug and get home and “What literature? Oh, you mean those papers I throw away.” Of course you’re not the only one who isn’t up to speed. How often has the doctor called you? How much time does the pharmacist spend with you? As for the literature- what is significant and what’s not? There’s a ton of boring reading that doesn’t seem important.
The truth is, I should know better. I’m a pharmacist but I fall into the same traps myself time after time. Not enough and too much info at the same time. Unfortunately, it’s just something you’ll have to deal with. That’s the world of medicine we live in. The following article offers a few items I think are important that you may not know. I hope it helps in your caregiving.
The skin is a pretty good barrier to the vast majority of drugs that might come in contact with your skin, but there are a few you should watch out for. Pregnant females or those of child-bearing age are at most risk. Surgical gloves, medicine dispensing cups, and common sense are probably all the protection that is needed.
Those drugs are:
All chemotherapy drugs. These are power drugs specially designed to kill cells. If you’re required to dispense them, don’t, not until you get detailed instructions.
Finasteride (brand names: Proscar and Propecia) can cause birth defects and feminization of the male fetus.
Testosterone and Estrogen can come in creams and patches and are designed to be absorbed through the skin – anyone’s skin, not just the patient’s. Testosterone brand names include: Androderm, AndroGel, Axiron, Fortesta, and Testim. Females and children should avoid even touching the application sites on the male. Estrogen brand names include creams such as Estrace vaginal and Premarin cream . Patches include Alora, Climara, Estraderm, Estradiol Patch, Vivelle, and Vivelle-Dot.
Nitroglycerin brand name patches– include Minitran. The cream is NitroBid. These can cause headaches as a side effect even in caregivers who give careless applications.
A caregiver note about nitroglycerin sublingual (under the tongue) meds.
Nitroglycerin is considered by some medical professionals to be addicting. it is supposed to be a rescue medication for angina or heart attack – not a routine medication. If your resident insists on using them on a regular basis, they may be addicted. If they do need them all the time, time-released capsules or patches might be more appropriate choices.
There are a few drugs that break down quicker at room temperature. You see them stored at the pharmacy in their refrigerator. Ever wondered if you have to keep them in your fridge?
Commonly used meds that need to be refrigerated and what you need to know once you get them home:
Calcitonin nasal, brand name –Miacalcin. - Opened bottles may be stored at 59oF to 86oF in upright position for 35 days. –Fortical - After opening, store bottle in use in an upright position for up to 30 days at 68o to 77°F.
Benzoyl peroxide/clindamycin, brand name –Duac - Good for 60 days, unrefrigerated.
Latanoprost brand name –Xalatan - Can store at room temperature not to exceed 77°F for up to six weeks. Off-label information indicates unopened bottle stable when maintained at continuous room temperature 77oF for 12 months.
Lorazepam intensol oral concentrate (liquid) - Off-label information indicates stable when maintained at continuous room temperature 77oF for 30 days.
Becaplermin cream brand name –Regranex - Off-label information indicates that unopened tubes left out of refrigerator are stable up to 86oF for up to six days or less, one time only.
Promethazine suppositories, brand name –Phenergan - Should always be stored in the refrigerator.
Insulin-type meds
Insulin is injected straight into the body, so special care has to be taken in its storage and use:
For a more complete insulin storage guide, go to: http://www.dhs.wisconsin.gov/rl_dsl/publications/GudStrgInsulin.pdf
Inhalers must be used correctly for maximum benefit, and it’s your job to see that they are used correctly. You can’t assume that the patient knows how to use them. There are a lot of people who think they know how but don’t. Inhalers are packaged with instructions. Become familiar with them.
A few instructions that are easily missed:
Pretty straightforward, but what if your residents chew up meds despite what you tell them, or what if you have to put the meds down a g-tube? If you have these or other cases that involve pill crushing or chewing, go over each med with the doctor. In general, medications you should be concerned about are pills that say extended, sustained, controlled, timed or slow release, enteric coated, sublingual (under the tongue), and all potassium pills. For most of these medications, if you have to crush them there are alternatives with the same therapeutic results.
Special note about g-tubes and meds. Some medications adhere to the plastics of a g- tubes. Not all pharmacists and even doctors know which ones. Hospital and long-term Care pharmacies should know more about which meds wouldn’t clog a g-tube.
For a more complete do-not-crush list, go to: http://www.ismp.org/tools/donotcrush.pdf
There is an ever-growing group of very stupid people who swipe prescription drugs and use them to try to get a buzz. It doesn’t seem to matter if it’s a heart medication or laxative. Unused meds must be disposed of correctly. It used to be acceptable to dump them down the toilet, but all those drugs in the sewer system started to affect the environment and gum up the public sewer system. The federal government issued the following guidelines:
Do not flush prescription drugs down the toilet or drain unless the label or accompanying patient information specifically instructs you to do so. For information on drugs that should be flushed, visit the FDA’s website.
To dispose of prescription drugs not labeled to be flushed, you may be able to take advantage of community drug take-back programs or other programs, such as household hazard waste collect events that collect drugs at a central location for proper disposal. Call your city or county government’s household trash and recycling service and ask if a drug take-back program is available in your community.
If a drug take-back or collection program is not available:
Here is a website that lists drug collection locations for Oregon cities.
http://www.deq.state.or.us/lq/sw/hhw/DrugTakeBackSites.pdf.
I hope you can use the information in this article for the betterment of your clients. If my words have made a difference in the lives of those who need help, I sleep better at night. Remember to get educated about the medications. They are powerful tools to help keep your patients healthy and functioning properly.
1. Pharmacist’s Letter Detail-Document#: 220339 Detail-Document#: 240406 Proper Use of Dry Powder Inhalers (DPIs)
2. Medication and Drugs. EMedicine Health
http://www.emedicinehealth.com/drug-estradiol_transdermal/article_em.htm
3 Stability of Refrigerated and frozen Drugs Pharmacist’s Letter detail-Document#:241001. October 2008. Volume 24. Number 241001
http://www.ashp.org/DocLibrary/Policy/PatientSafety/FrozenDrugs.pdf
4. Guideline for Insulin Storage. Department of Health Services .State of Wisconsin
http://www.dhs.wisconsin.gov/rl_dsl/publications/GudStrgInsulin.pdf
5. Proper Disposal of Prescription Drugs. Office of National Drug Control Policy 2009
http://www.nodakpharmacy.com/pdfs/prescrip_disposal2009.pdf
6. John F Mitchell, Oral dosage forms that should not be crushed. Institute for Safe Medication Practices Mar 2012
http://www.ismp.org/tools/donotcrush.pdf
7. Insulin Safety in Your Home. Consumer MedSafety .org
http://www.consumermedsafety.org/insulin-safety-center/item/497
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Leg Cramps
A Discussion on Causes and Cures
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 1- Approximate time required: 60 min.
Educational Goal:
To provide insights into the cause and resolution of Muscle Cramps.
Educational Objectives:
1. Present an explanation on what muscle cramps are and what causes them.
2. Describe one possible care plan for leg cramps.
3. Provide insight into possible actions by the doctor.
4. Explain the concept of Homeopathy and list Homeopathic remedies for leg cramps.
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Leg Cramps
A Discussion on Causes and Cures
Adult Foster Care Home providers are caring people. They get a lot of pleasure and satisfaction out of helping their residents live a comfortable life. The job also comes with its moments of frustrations. Leg cramps, for example. Cramps aren’t really serious and are usually easily dealt with, but if cramping happens over and over again, it presents a challenge not so easily solved. The frustrating part is trying to solve the problem when you don’t have all the answers. Hopefully by the end of this article you will have some answers and a useable plan of action that will assist you in maintaining a good quality of life for your elderly resident.
What exactly is a muscle cramp anyway?
Muscle cramps or “charley horses” are involuntary severe muscle contractions. They are quite painful and can happen to any skeletal muscle group. Cramping occurs most often at night in the lower legs and feet. Up to 70% of the elderly are painfully afflicted at one time or another. Once you’ve had one, there is no doubt that you don’t want another.
What Causes Leg Cramps?
No one is quite sure the exact mechanism that results in a charley horse. Sometimes the causes can be identified. Other times they just happen for no apparent reason. One thing that science has been able to figure out is that the root of the problem is not in the muscles themselves. It’s in the nerves that control them. Something causes the nerves to fire, causing a strong muscle contraction.
What triggers the nerves to fire?
Normally, nerves under our conscious control only fire when we want them to. As we think about using a muscle, an electro-chemical signal starts to build up. When that signal reaches a certain level the nerves are triggered and off the signal goes. In leg cramps, either the signal is boosted or the trigger threshold is lowered in the nerves that control the afflicted set of muscles. Fortunately, it is only a temporary anomaly that is easily reversed by relaxing the muscle through stretching or massage.
Why do they happen most often at night?
During the day our mind and muscles are alert and have tone. It is thought that as the anomaly starts to develop the body’s systems are able to compensate before a cramp develops. It happens automatically without us knowing about it. At night, when the body is relaxed, the compensating mechanisms are not there to prevent the charley horse.
What are the causes of muscle cramps?
The answer to that question is only partially known. Some causes just continue to remain a mystery. Following are some causes we do know about:
There are some behaviors that can contribute to these causes. In the elderly, common contributory behaviors are:
Here is a typical elderly care scenario: Henrietta sits in her chair all day long. She never wants to move a single muscle, even for basic things like getting a drink of water. She takes blood pressure pills and water pills (both can cause cramps). She has poor circulation in her legs. Her nervous system is worn down due to old age and long term diabetes. It’s small wonder that she also complains of reoccurring leg cramps and she is getting real grouchy about it, too.
What are the treatments for Leg Cramps
Muscle cramps are rarely a major health concern. Most of the time, the resident can take care of the problem by himself or herself, by massaging or stretching the offending muscles. Particularly painful occurrences can be helped by applying an ice pack. When the patient has multiple cramping events, it becomes a bit more serious. The more often charley horses occur the lower the quality of life becomes. You, the care provider, can either do nothing (and get increasingly frustrated with each new cramp your resident suffers) or you can have a plan in place that will help you determine when and how much medical intervention is required.
Leg Cramp Prevention Strategy
It is always good to be prepared with a flexible plan. This one has 3 levels of intervention. Each level is determined by the impact the cramps have on the quality of life of the patient.
Mild Impact
Mild impact = infrequent occurrence. The occasional charley horse has no real lasting impact on the patient. Each cramp is remedied in normal fashion as they occur. No future intervention is needed.
Moderate Impact
Moderate impact = frequent occurrence. If there is a high probability of recurring episodes, prevention efforts will be required. The care provider will have to decide how frequently cramping is occurring before intervention is required. Individual patient reactions and the severity of each event have to be taken into consideration. At this level non-pharmaceutical intervention is the most appropriate therapy.
Non-Pharmaceutical Intervention:
Often patient behaviors are the contributing factor causing the recurring cramps. You, the care provider, can find out what they are and assist in altering the behavior.
1) Proper hydration – Ensure the resident has easy access to fluids throughout the day. Flavored or unflavored ice water with a straw should always be close at hand. Watch caffeine consumption, however, because of its diuretic effect.
The body’s thirst impulse can be reduced with age. It’s a good idea to keep an eye on how much your patient is drinking. If the volume is low a gentle reminder may be helpful. The daily amount of liquid is individualistic and should be determined by the doctor.
2) Proper physical activity and blood flow - Elderly patients are naturally more sedentary. Their inactivity often comes with a price tag of poor blood flow to the legs and impinged nerves. You can solve this problem by:
Monitor the frequency of occurrences so you can tell if your efforts are succeeding. If they aren’t having the desired effects then move to the next level.
Sever Impact
Severe impact = regular occurrences or failed non-pharmaceutical therapy. At this level of cramping there are probably larger issues that need to be addressed. It’s time to get a doctor involved with a phone call or a visit. Before you do that, it’s best to be prepared. Here are a few thoughts and methods that will help you get the most benefit out of interactions with the doctor.
I have included an example of what I would do. You may copy this and modify it for your own uses.
______________________________________________________________________________________________________________________________________________
Your Name Care Home
Doctor Visit Information File
Date ________
Patient: Henrietta Smith Age: 86
Medications
|
1) med 1 |
3) med 3 |
|
2) med 2 |
4) med 4 |
Known Conditions
Arthritis, high blood pressure, Diabetes
Reason for visit
Henrietta is suffering from frequent leg cramps that are having a negative effect on her life.
Symptoms
Henrietta’s leg cramps happen exclusively at night. They’ve happened about 3 times per week for the last 2 months, starting 2 months ago.
Relief Efforts:
She gets 4-8 glasses of water a day. She takes regular daily walks of 15-30 min. We massage her legs with lotion each night before she goes to bed. We apply a heat pad for 10 minutes to her calves. We also stretch the calves and feet muscles before sleep.
Despite all these efforts the cramps continue. Please advise us what to do to alleviate this problem.
P.S. Would it be appropriate to use an OTC Homeopathic product called Hyland’s Leg Cramps? (More about this remedy will be presented later.)
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Doctor’s Response:
______________________________________________________________________________________________________________________________________________
Adult Foster Care providers are part of the Health Care continuum. As part of that team it’s good for you to know what the other team members are doing. The doctor will probably review the medications, take a blood sample and do a patient assessment. Considering all the facts, he or she will then choose a therapy.
Review the medications
The doctor will reevaluate the patient’s current medications in light of these new conditions. The doctor may or may not change things.
Note: Every drug has side effects. Choosing a medication for a patient is really a balancing act of benefit vs. risk of injury due to the side effects. A medication may indeed cause muscle cramps, but the benefits far outweigh the cramping. The doctor always has the option of continuing the offending medication and trying to manage the resulting charley horses another way.
Medications that can cause muscle cramps are donepezil (Aricept), raloxifene (Evista), tolcapone (Tasmar), nefedipine (Adalat, Procardia), terbutaline (Brethine), albuterol (Proair, Provental, Ventolin) and statin drugs like lovastatin (Mevacor).
Often, drugs cause muscle cramping indirectly by throwing off the mineral balance of the body. Of major concern are the Diuretics, like furosimide (Lasix) and Hydrocholrothiazide (HCTZ). These water pills can make the body lose a lot of potassium. Low potassium is a known cause of cramping. The doctor will want to see if too much potassium is being lost, which leads to our next point.
Blood samples
The doctor will probably take a blood sample and measure all the important minerals and electrolytes. If deficiencies are seen in the key minerals (potassium, calcium, magnesium, iron), then supplements can be ordered.
Note: Potassium is sometimes written down using its chemical abbreviation, K+.
Health professionals are aware that lack of potassium causes muscle cramps. Patients have also learned this fact, but don’t know all the details, so some myths have arisen.
Myth – Eating bananas will help leg cramps.
Truth – Bananas are a good source of K+, but not that good. I was taught in pharmacy school that you would have to eat 5 feet of banana every day to fulfill the minimum daily requirement. It turns out that orange juice has more potassium than bananas. Also, potato skins and raisins have twice as much as bananas.
Myth – OTC potassium is all you’ll need.
Truth – Overdosing on potassium can lead to some major problems. To prevent this from happening, the FDA has severely restricted the amount of potassium in OTC preparations (potassium picolate). The FDA will only allow between 2% and 4% of the daily requirement in each dose. You would have to ingest a lot of tablets to get what you need.
There are better sources of non-prescription potassium. One can of V-8 vegetable juice has 19% of your daily requirements. Nutritional drinks (Ensure, Boost, etc…) and weight loss drinks (Atkins, Weight Watchers, etc.) also have higher amounts. Reading product labels will enable you to find your own nutritional sources of potassium. There is also a salt substitute product called No-Salt. Instead of sodium chloride (salt), it contains potassium chloride.
Myth – Because you can buy potassium OTC, it’s not dangerous.
Truth – In addition to messing with the brain and nerves, it can also give you a really sour stomach. In the lining of your gut there are tiny glands that pump out stomach acid. They are activated into action by potassium. More potassium in the stomach results in more stomach acid.
Note: If you intend to use No-Salt to reduce sodium intake or increase potassium intake you should monitor for sour stomach reactions in you patients. Ant-acids are a convenient therapy. Don’t forget to chart there use in your PRN drug log.
Physical Assessment
Even though charley horses are not medically significant, they can be an indicator of more serious issues. The presence of continued cramping may lead the doctor to discover a new disease or previously diagnosed condition that is not under control. The doctor will appreciate the detailed information you give him or her.
Choosing a Therapy
Unfortunately, there is no FDA-approved therapy for leg cramps. Quinine has been used in the past, but the FDA has decided that it’s not safe to use. Because of this ruling, Quinine prescriptions have become very limited and are usually not covered by insurances. There are other medications that the doctor can try, like muscle relaxers or gabapentin (Neurontin), but their use is definitely “off label”.
Because there are no FDA-approved therapies, all sorts of remedies have popped up. Everything from putting a bar of soap under the covers to extra vitamin supplements. No one really knows how or even if they work. None of these so-called cures has any scientific basis, except one. Homeopathy.
Disclaimer – This author is not proposing you rush out and get some homeopathic remedies for leg cramps. This is a pharmaceutical therapy and has to be reviewed and approved by the doctor before its use. Since there are so few good alternatives out there, I will tell you about it.
What is Homeopathy?
Homeopathy is not herbs or naturopathy. It is a medical discipline that has been around for more than 2 centuries. It approaches the practice of medicating in a totally different way. Regular medical disciplines (allopathic) rely on direct intervention on body systems. For example, large doses of drugs are used to either destroy a pathogen (antibiotics) or reduce symptoms directly (anti-inflammatory, antidepressants). Naturopathic medicine does the same thing, except with herbs instead of drugs.
The Homeopathic approach is different. It tries to solve the problem by stimulating the body into certain responses. Then the body cures itself through these responses. In leg cramps, Homeopathic medicine is given in hopes that it will stimulate a “resolve the cramping” response before there is a cramp to fix, thereby reducing the problem before it happens again.
Homeopathic doses are very small compared to regular medicines. Homeopathy has been described as “tricking the body to respond”. Practitioners claim that even though the doses are very small, they are very potent because of the way they are prepared. Smaller doses also produce the benefit of reduced side effects, thus creating a safe, easy-to-use product. This has led the FDA to allow several potent remedies to be marketed over the counter.
Homeopathy is considered an alternative medicine. For a doctor schooled in allopathic approaches, it wouldn’t be a first choice of therapy. They are just not familiar with this approach and are concerned by the tiny amount of drugs used. In order for it to be considered for therapy, it will most likely have to be brought to their attention by you (see sample Doctor Visit Information File, above).
Homeopathic Medicines for Leg Cramps
There are three OTC Homeopathic formulations for the doctor to consider. Hyland Leg Cramps, Hyland Leg Cramps with Quinine and Hyland Leg Cramps PM. The company claims there are no side effects and that they are safe to use with other medications. If the doctor decides to use this medicine, it should be under the same Adult Foster Care rules as the resident’s other medications.
Charley horses are never fun to experience. If they occur on a regular basis, it can be an indicator of a more serious problem. The care provider should have a plan in place to deal with the condition if it arises. That plan should be flexible enough to consider the frequency of occurrence, effective communication with the doctor, non-pharmacological and pharmacological remedies. Even though there is not an FDA-approved therapy for leg cramps, the caregiver does have several options at their disposal.
References:
1. Molly Punzo, MD, Assessment and Management of Leg Cramps: A Homeopathic Approach. March 15 2010. Power-pak C.E. UAN: 0430-0000-10-009-H01-P; 0430-0000-10-009-H01-T
2. Night Leg Cramps- Mayo Clinic.com
www.mayoclinic.com/health/night-leg-cramps/MY00410
3. Nighttime Legcramps: What causes muscle spasms and Late-Night Leg Cramps?
www.webmd.com/sleep.../nighttime-leg-cramps-topic-overview
4. Muscle Cramp Causes, Cramping Prevention and Treatment
ttp://www.medicinenet.com/muscle_cramps/article.htm
5. Jonatham Cluett MD, Leg Cramp, Orthopedics, About.com
http://orthopedics.about.com/cs/sprainsstrains/a/legcramp.htm
6. Joe Graden, Leg Cramps: Home Remedies and Treatments YouTube video
http://www.youtube.com/watch?v=zVzbIC_zG-s
7. Leg Pain- Leg Cramps- Causes- Symptoms- Diagnosis- Treatment. About.com http://arthritis.about.com/od/legpain/Leg_Pain_Causes_Symptoms_Diagnosis_Treatment_Pain_Relief.htm
8. Hyland Homeopathic- Leg cramps with Quinine
http://www.hylands.com/products/legcramps.php
Leg Cramps
A Discussion on Causes and Cures
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Osteoporosis the Silent Thief
Author: Mark Parkinson RPh: President AFC CE
Credit Hours 2- Approximate time required: 120 min
Educational Objectives:
1. Define Osteoporosis.
2. Present the anatomy and physiology on the Bone
3. Explain the natural aging process of bone loss
4. Expound the details of Osteoporosis.
5. Set forth the Roll of Adult Foster Care Providers
6. Present principle of fall prevention.
Procedure:
1. Read the course materials. 2. Click on exam portal [Take Exam]. 3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate). 4. Log in 5. Take exam. 6. Click on [Show Results] when done and follow the instructions that appear. 7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records.
Disclaimer
The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.
Osteoporosis, the Silent Thief
About 20 years ago when I had my Adult Foster Care Homes, one of my residents was an 80-something resident named Martha (named changed). Martha was a typical adult foster care client. No major health concerns, not wobbly on her feet. She pretty much took care of herself and continually stayed in a little alcove which we had set up for her. Overall, she was a quiet, stable patient with just the occasional grouchiness. Just the kind of client you want to fill your home with.
One day I was in the kitchen doing my duties when I heard what sounded like a bag of potatoes that had been dropped on the floor. Being an experienced caregiver, I knew what the sound was – one of my clients had fallen. I hurried to where the sound came from and found Martha on the floor of her room. Martha was a bit embarrassed and started babbling that she did not lose her balance or trip on anything. She had just stood up and heard a click, and down she went. I asked her if she was hurt anywhere and she said that she was okay. I assured her that it wasn’t all that bad and I would help her up. I couldn’t have been more wrong.
When we couldn’t get her up I knew that things were a bit more serious than I had originally thought. We ended up sending her to the hospital, where an x-ray showed a broken hip. After further examination the Doctor concluded that the hip had broken before she had fallen. He explained further, saying that the hip was very fragile and just snapped when she stood up. He diagnosed Martha as having a spontaneous fracture caused by a severe case of osteoporosis. I was shocked. I thought, “How was that possible? How can you break a hip just by standing up.”
The doctor fixed the hip and put her in a nursing home to recover. She did not do well, there. She never came back home again and died in that nursing home within a year. It was hard to lose a stable, easy-to-care-for patient. I did not know what more I could have done to prevent this tragedy. It was not until many years later that I finally found out what more I could have done. Now, I am passing that info on to you. Hopefully, it will help you to prevent future Marthas happening in your home.
The Bantam Medical Dictionary defines osteoporosis as a “loss of bony tissue, resulting in bones that are brittle and liable to fracture… Generalized osteoporosis is common in the elderly.”
Bones are the support system of our bodies. They allow us to stand erect, move and do work. The skeletal system serves as scaffolding that provides anchors for our muscles and supports and protects our organs. It also acts as a storehouse for many vitally important minerals, like calcium, phosphorous and magnesium. Each bone is a hard, semi-rigid material derived mainly from connective tissue covered with dense inorganic mineral deposits. Normally, they are made to be strong and not easily broken, but in osteoporosis their strength has been robbed.
Osteoporosis literally means porous bone. Viewed under a microscope the osteoporotic bone is a matrix full of holes – voids where bone material is suppose to be. It’s as if something came along and stole the bone material. As a result, the bone is robbed of its strength. It becomes brittle and prone to fracture. Activities and impact occurrences that were once considered of no consequence are now considerable risk factors for broken bones. Where did the bone material go and how did it happen?
Let’s begin with a short lesson in bone anatomy and physiology and how it relates to the mystery of osteoporotic bone loss. As you know, your bones are the semi-rigid skeletal organs of your body. Most of us think of our bones as solid, hard, unchanging objects. Really, bones are a living part of your body, complete with a rigid, mineralized structure, marrow, a blood supply, a slight nervous system presence and cartilage. The hard part of the bone is a complex matrix of minerals, caliginous material and several different types of bone cells. The mineral portion of the bone is composite material formed mostly of calcium phosphate. All together, the bone is referred to as osseous tissue. When properly formed and maintained, our bones are lightweight, yet hard and strong.
It may surprise you to know that your bones are not static, but are in constant flux. They are going through a perpetual turnover of material called remodeling. It is a continuous process of bone formation and bone breakdown. Remodeling is done by specialized bone cells, of which there are three main types.
Each cell operates constantly and their numbers and functions are balanced based on the needs of the body. When we are young the balance is tipped toward bone formation, which peaks in our early 20’s and starts to level off in our 30’s. After the formation and growth period, the balance tips toward maintenance. The bone is broken down and built up at about the same rate. If we need stronger bones (like in heavy work), stimulation tips the balance toward formation again. If we aren’t working hard the formation stimulus is turned off. The balance tips back toward maintenance and the unneeded bone mass is reabsorbed .
If the balance tips too far toward reabsorption for too long, we start to lose too much bone material. The osteoclasts eat away at the bone, leaving behind ever increasing voids. Your bones don’t shrink, so the continued bone loss results in more and more porous bones. If too much bone mass is lost, we fall into the condition of osteoporosis. The mystery of osteoporosis is that our own body processes are robbing us of the bone strength we need.
There is a natural loss of bone strength over the length of our lives. Up to 10% of all bone mass may be undergoing remodeling at any point in time. As we age, a number of factors combine that prevent us from replacing what is lost.
Reduced Bone Builders
As we age, the number of new osteoblasts starts to decline.
Reduced Hormone Activity
The hormones estrogen and testosterone are very important in maintaining our bones. They are part of the signals involved in increasing the amount of bone material being deposited, while decreasing its breakdown. When we age there is a natural reduction in hormone production. Women are particularly at risk after menopause, when estrogen production plummets to low levels. With reduced hormone levels, the reabsorption process begins to dominate.
Physical Inactivity
As we age we are less likely to engage in physical activity, reducing the need for bone mass. The old saying goes, “When you don’t use them, you lose them.” Plus, natural decline is felt in other body processes, hampering efforts at exercising our bodies at previous levels.
Poor Nutrition
Our bone cells need materials to make bones. If the minerals like calcium aren’t in the foods we eat, new bone cannot be made. Our diets in general are veering away from calcium rich foods, such as dairy products, broccoli and spinach. The eating habits of the elderly tend to be deficient and they tend to eat less.
Another area of poor bone nutrition comes from an unusual source. In order to absorb calcium into our system we need plenty of vitamin D. Sunlight hitting our skin is a major source of vitamin D. The elderly are less likely to have sufficient exposure to the sun. Even if they do go out, they hide themselves from the sun under layers of clothes, sweaters and hats.
Bone mass loss is a natural part of the aging process, but Osteoporosis does not happen to everyone. Osteoporosis develops when there is an inadequate peak bone mass to offset natural bone loss, excessive bone reabsorption, and inadequate formation of new bone during remodeling. To some it just randomly occurs, while others make choices that allow problems to arise. Factors that can increase the likelihood of an individual developing this condition are lifestyle choices, body size, genetics, gender, certain medicines and diseases.
Lifestyle choices
These are factors that are under our conscious control. They are choices we make regardless of their negative impact on our health.
Alcohol Use
High levels of alcohol use speeds bone loss through several different factors. It changes protein and calcium metabolism, decreases hormone production, reduces the activity levels and leads to a poorer diet. Alcohol also has direct toxic effect on the osteoblasts.
Cigarette Smoking
Smoking leads to weakened bones. The exact reason for this is not well understood. Smoking does lead to a reduced body size. It also promotes an early onset of menopause and may speed up the breakdown of the estrogen.
Sedentary Lifestyle and Improper Diet
An inactive lifestyle and poor diet at any age contribute to the lack of bone build-up, reducing the peak bone mass an individual will obtain. It is noteworthy that eating disorders like anorexia put people at particular risk.
Inherited Factors
Some factors are not under our control, but are due to the characteristics of the body we were born with.
Body size
People who are small or very thin may not develop sufficient peak bone mass to draw from as their bodies age.
Genetics
You are at greater risk if you are White, Asian or have a family history of Osteoporosis.
Gender
It is estimated that men will lose 4% of their bone mass every decade. Unfortunately, women will lose 15% per decade after menopause.
Health Related Factors
Reduced activity levels due to chronic illness certainly contribute to reduced peak bone mass. In addition, there are certain illnesses and medications that have a more direct effect on bone loss.
Chronic Illness
Diseases prevent the body from functioning normally, which can have an ill effect on our bones. The diseases that effect bones the most are Hyperthyroidism, Rheumatoid Arthritis, Chronic Kidney Diseases, and eating or digestion disorders (as many as 30% to 60% of people with Crohn's disease or ulcerative colitis have lower-than-average bone density).
Medication
As we get older we tend to use more medications, which sometimes have the unfortunate side effect of depleting our bone mass . The culprit medicines are the corticosteroids (prednisone, methylprednisolone, dexamethasone ), anti-convulsants (phenytion), chemotherapy agents (methotrexate, aromitase inhibitors), aluminum containing antacids (Amphojel, Maalox, Mylanta),long term blood thinner use, and excessive thyroid replacement therapy.
In the United States today it is estimated that 44 million people have osteoporosis. More than half of all adults aged 50 and older have the condition. Another 34 million have osteopenia, a precursor of osteoporosis. The actual number might be even higher, because the condition is considered a “silent disease”, meaning that there are no obvious signs or symptoms. Often patients are unaware that they have significant bone loss until they experience a fracture.
The main consequence of weak bones is fractures. Broken bones are responsible for considerable pain, decreased quality of life, and disability. Up to 30% of patients suffering a hip fracture will require long-term nursing-home care. Osteoporosis has even been linked with an increased risk of death. Some 20% of women with a hip fracture will die within a year as an indirect result of the fracture. Most often fractures are due to falls and are seen most often in the hip, legs or wrist.
Some fractures just happen and are due to the bone being too weak for the weight put on them. Some can be dramatic, as in the case of Martha, but most are not. They are called spontaneous, collapse or compression fractures. They are often seen in the spine. Between 35-50% of all women over 50 have had at least one vertebral fracture. Compression fractures can be very small without any signs that they have occurred. As the fracturing continues their effects start to accumulate and outward symptoms may occur, such as unexplained pain, height loss or curving of the spine.
How Can You Tell If A Person Has Osteoporosis?
A body can’t feel bone loss. So many people go about life with extremely fragile bones and don’t know about it. If the problem was known, then therapy could be applied before bones are broken. So how can you tell if a person suffers from major bone loss, so you can give them therapy?
The proper question is, “How can you tell which one of your clients is at risk for bone loss related problems?” The answer would be, “All of them are at risk!”. Because age and inactivity are risk factors, it can be assumed that most of the elderly in Adult Foster Care homes either have or, without proper therapy, will have significant bone loss.
Naturally, some have more bone loss than others. Those you can expect to have more problems are clients who have one or more of the following:
1) family history of broken bones
2) weight less than 127 lbs.
3) significant loss in total height
4) unexplained lower back or neck pain
5) have been on long term oral corticosteroids
6) suffer from Kyphosis (an abnormal curvature of the spine that makes you look like a hump back)
If you suspect that any of your clients are at greater risk of a major fracture they should be sent to the Doctor.
Doctors today have a wide variety of tests that they can do to measure the density of our bones. Medicare pays for these tests every 2 years. They are painless and as easy to do as an X-ray.
The gold standard test is the dual-energy X-ray (DXA). Using X-rays, bone mineral density is measured and divided by the volume of the measured bones. The doctor then compares the measurement to the population average – either a T-score or a Z-score. A T-score (young normal score) is calculated by comparing density measurements to a healthy same-gender 30-year-old. The lower the score, the worse it is. A T-score of 1 or higher indicates normal bone density. A scores of -1 to -2.5 indicates Osteopenia, while a score of -2.5 or lower indicates Osteoporosis. The Z-score (age-matched) is a comparison with a healthy same-gender person of the same age as the patient.
Doctors could also take some blood tests to measure the amounts of calcium, phosphorous and vitamin D in the blood to see if anything is lacking. Once the examinations are complete, the Doctor can prescribe the appropriate therapies.
Unlike 20 years ago, in cases like Martha’s, considerable advances have been made in the management of Osteoporosis and the outlook is very good. There are better diagnostic tools for the Doctors, better medicines that treat the underlying causes, and better aids to help the patient improve bone health.
Though vertebrae that have already collapsed cannot be reversed, new techniques have been developed that can minimize the pain and reduce the disability. A procedure called Vertebroplasty injects fast hardening glue into the small fractures in the spine, strengthening the area. Even with severe Kyphosis physiatrists (rehabilitation physicians), physical therapists and occupational therapists can help the patient learn to control the pain and manage their disability. If a major fracture occurs, newer surgical techniques have been developed that have shorter recovery times. As a result, death rates associated with indirect problems arising from Osteoporosis are falling.
There are a number of Osteoporosis therapies available to the patient’s Doctor and caregivers. Some manage the underlying health problems that have occurred, while others attempt to modify behaviors that have contributed to the problem. The goals of therapy are to eliminate or slow down events that accelerate bone loss, maintain proper bone health, prevent fractures, and control the consequences of fractures that have already happened.
Medicines
There are two types of medicines that help in treating Osteoporosis: medicines that treat the underlying causes, and supplements to replace essential nutrients and hormones that are lacking.
Bisphosphonates
Bisphosphonates slow the bone breakdown process and are considered drugs of first choice by most doctors (1st line agents). They are Alendronate (Fosamax), Risendronate (Actonel), Ibandronate (Boniva) and Zoledronic acid (Reclast). Food interferes with Bisphosphonates. Also an additional concern is if the pill gets lodged in the throat, it can cause serious harm. Therefore Bisphosphonates should be taken on an empty stomach and the patient must remain upright for 30 minutes. Do not crush or chew theses meds. The main side effects are nausea and heartburn.
Alendronate is the only available generic med. Alendronate (Fosamax), and Risendronate (Actonel) come in a daily or weekly tablet. Ibandronate (Boniva) comes as a monthly tablet or an IV (intravenous) that lasts for 3 months. Zoledronic acid (Reclast) is a once-a-year IV infusion. For those who have difficulty chewing or swallowing medications, Fosamax liquid or the IV preparations should be considered.
Estrogen (Hormone Replacement Therapy- HRT)
Replacing the missing hormones is quite effective at reducing fractures, but is not used as a primary osteoporosis medication anymore, because of the increased risk of cancer, strokes or venous thrombosis.
Selective Estrogen Receptor Modulators (SERM)
SERMs mimics estrogen in the body, but its use reduces the dangerous secondary effects of the hormone. Raloxifene (Evista) is the only available osteoporosis SERM and it comes as a generic. The major side effects are hot flashes and leg cramps. Raloxifene can be crushed.
Calcitonin
Calcitonin (Miacalcin or Fortical) is a drug that binds to osteoclasts and slows them down. It comes as a nasal spray or as an injectable and is available generically. If used within a month it can be stored at room temperature. Storage longer than 30 days requires refrigeration. Side effects are headaches and nasal problems. Calcitonin appears to reduce bone fracture pain.
Parathyroid Hormone
The synthetic parathyroid hormone teriparatide (Forteo) stimulates bone formation in addition to reducing reabsoprtion. There is no generic for Forteo and it may cause bone cancer. Side effects are insomnia, nausea and dizziness. Forteo is a once-a-day injection and should be refrigerated in between uses.
Calcium Supplements
Adequate Calcium intake is essential to bone heath and patients should receive 1200 to 1500 mg a day, considering all sources. Along with a proper diet, supplementation may be required. There are many forms of calcium supplements. Many are available in OTC preparations, including chewables and a liquid form of coral calcium. In my opinion, unless there is a specific metabolic need, any calcium supplement would be adequate. The major side effect of calcium is constipation.
Vitamin D (Calciferol)
Vitamin D is needed in order to absorb calcium in the intestine. Our bodies produce it when sunlight shines thru fat reserves in our skin. Supplements are measured in international units (IU) and it is recommended that we get 400 IUs a day. If supplements are required, they can be obtained in several OTC strengths. There are several Rx versions, including a mega dose of 50,000 IU. Vitamin D is well tolerated.
Nonpharmaceutical Therapies
Many factors under our control affect the development of Osteoporosis and its occurrence is the result of a lifetime of choices. Long term therapies are based on control of these factors and attempt to build up as much as possible our peak bone mass. Therapies utilized in geriatrics concentrate mainly on proper diet, sun exposure, bone-building exercises and fracture-reducing movement and posturing.
Adult foster care can play a very important role in keeping our graying population healthy and strong. But in my opinion, adult foster care is a largely an underutilized and underappreciated segment of our healthcare industry. Who else actually lives with their patients 24/7? Who else can implement and maintain the necessary lifestyle changes and therapies that are required, and do so month after month, year after year?
Adult Foster Care providers are particularly useful in the treatment of osteoporosis. Bone building and bone health are long term processes and consistent long term efforts are needed. Proper medication management, diets and exercise must be encouraged for the rest of the patient’s life. In addition, supervision is needed to ensure the use of walking aids that prevent falls and the correction of improper postures that cause fractures. AFC providers must also maintain a safe “slip and trip” free environment while still maintaining a homelike lifestyle. It is in this safe and supportive lifestyle that the AFC home provides what is truly needed by the osteoporotic patient.
I would recommend that every resident of your homes gets a bone density screening at least every two years. It would also be beneficial to question each resident to see if there is a family history of broken bones.
Each year about one-third of all persons over age 65 will fall. Fall prevention is a basic part of your caregiving responsibilities. If you have patients that are osteoporotic, fall prevention is particularly important. In some cases it could be the difference between a comfortable life and a slow, lingering death. Remember the Martha story?
Your Home
You must make you home free from slip and trip hazards. Because things get moved around, you must periodically inspect your home for these hazards.
Outdoor safety
Install stair hand railings or wheelchair ramps. Keep sidewalks free of leaves, clutter, snow and ice. Make sure that home approaches are well lit and maintained. Have a loaner wheelchair the resident can borrow for outside trips. Inexpensive ones can be obtained at second-hand stores.
Indoor safety
Remove all loose wires and cords. Watch the placement of footstools, end tables, magazine racks and other trip hazards. Maintain proper lighting day and night. Keep a clutter-free floor. Install grab bars by the tub, shower and toilet. Keep commodes close to the bed at night and promptly remove them in the morning. Use skid-free area rugs on slick floors and replace them when they are worn. Clean up spills promptly. Use a shower or tub chair for bathing. Mark the top and bottom of steps with bright tape.
The patient
Watch the patient for signs of drowsy or dizzy behaviors. Regularly monitor blood pressures, blood sugars and oxygen levels, if required. Make sure the resident has proper foot wear. Discourage feet shuffling. Escort residents with walking problems. Assist in transferring. Place items within reach so the patient doesn’t have to bend, stoop or reach too high. Consider the use of toilet risers, transfer boards or long-handled grasping devices. Encourage the resident to get up slowly.
Make sure the patient has proper and clean eyeglasses.
Conclusion
As our population grows older, elderly bodies start wearing down. Some even break. The Adult Foster Care industry must step up to meet this ever-increasing need. It will take caring, well-educated professionals, who know what to do, how to do it and do it consistently. Adult foster care can play a very important role in keeping our graying population healthy and strong.
More resources can be found at the National Osteoporosis Foundation (NOF)
References
1. National Osteoporosis Foundation.
2. Osteoporosis. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Osteoporosis
3. Osteoporosis, Thin Bones . Pub Med Health.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001400/
4. Human Skeleton. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Human_skeleton
5. Bone, Answer.com Reference answers
http://www.answers.com/topic/bone
6. R.L Jilka, Osteoblast Progenitor Fate and Age-related Bone Loss, J Musculoskel Neuron Interact 2002; 2(6):581-583 http://www.ismni.org/jmni/pdf/10/28Jilka.pdf
7. Osteoporosis. MedicineNet.com
http://www.medicinenet.com/osteoporosis/page2.htm
8. Jane E. Brody, Osteoporosis. Health Guide, New York Times (May 9, 2011). http://health.nytimes.com/health/guides/disease/osteoporosis/overview.html
9. Drugs A-Z RxList the Internet drug Index.
10. Vitamin D. Wikipedia The Free Encyclopedia.
http://en.wikipedia.org/wiki/Vitamin_D
11. Osteoporosis MedLine Plus NIH National Institute of Health.
http://www.nlm.nih.gov/medlineplus/osteoporosis.html
12. Joanne Fleuer PharmD MSPH Osteoporosis: “Need-to-Knows” for Pharmacists About Bone
Health. Pharmacy Times Special Issue: Women’s Health. (06,2009)
Osteoporosis the Silent Thief
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