Comprehensive Geriatric Assessment Document - Case Study Example

?Comprehensive geriatric assessment paper Comprehensive geriatric assessment paper Comprehensive geriatric assessment paper The following paper is a study of the geriatric assessment of Mrs. Lily Rozario, 75 years and born on the 12th of October, 1937. She was married but was now a widow. Her eldest son reliably assisted with the history. The chief complaints were that she was “not being able to walk ably due to pain and was not capable of doing her daily functions”. Both complaints had been troubling her for the past 3 years apart from her hypertension which had been present for the past twenty years and other “general problems of aging”. Presenting complaints For the past five years Mrs.Rozario had been having an increasing memory loss and difficulty to move around for her daily functions. Previously she could walk or board the bus to town for shopping or to church. Her memory too became poorer. Executive functions slowly dwindled and she was unable to do many things herself. Help was needed on occasions. Sleep became disturbed. Moreover she seemed to withdraw from her friends and family whom she used to meet frequently and spend her time laughing and conversing with in better days. Recently she had a fall and had broken her femur. This had upset her further though that phase had been successfully passed over. Winter aggravated her mobility problem. Even with multiple complaints and problems she had been reluctant to approach anyone for help. She attributed her complaints to aging. It was at the behest of her son that she had now agreed to come. With the son’s assistance, the problems were all hopefully revealed. Past Medical history It said that she had been taking anti-hypertensives for the last twenty years. She used to be regular in her appointments with the physician but had lost that regularity of late. Previous medical history did not reveal any significant issue. Her pregnancies terminated normally and she has two children. Significant childhood diseases or history of immunizations were not remembered. Hospitalization had been only for her deliveries and her recent fracture femur. With no history of allergies, she could take any medicine. She was on 25 mg. Atenolol daily and had antacids occasionally. Analgesics and pills for sleeping comfortably had been prescribed at the local care center as and when she found it difficult to walk because of pain or could not sleep. She had ill-fitting dentures as she had lost weight recently. Cognitive impairment was present. Nutrition Her diet included more of cereals and porridges with small quantity of fruits and vegetables. Her dentures did not fit well due to her loss of weight and so she would rather have a diet easily swallowed. She was having a diminished appetite. The history of constipation was elicited. Her son claimed that financial resources were not a hindrance to nutrition as he was looking after her. However she was staying alone and inability to cook her meals and have them could be the reason for the limited nutrition. Current weight was 50 kg. while her expected weight was 65 kg with reference to the Body Mass Index. Recent change in body weight had been noticed after she recovered from the fracture of the femur. Her current medications could have affected her appetite or digestion. Loneliness could be a factor which had limited her nutritional status. Vitamin or mineral supplementation was not her habit. She had mild depression for which she was not being treated. She used to read widely but her vision was failing and she had not met an ophthalmologist for assessment and reading had been stopped. There were no independent transportation facilities unless her son arrived. She was not motivated enough to look after herself. It could be due to her failing cognitive functions. Consumption of her anti-hypertensive drug or other medicines was irregular and consisted of more than 3 drugs. The nutrition assessment was completed with a checklist. Mrs. Rozario agreed to most of the suggestions in the checklist. She ate less than two meals a day and did not drink alcohol. She could not move out of the house to buy her food as she was not physically up to it. Mrs. Rozario provided information about her typical day where nutrition was concerned. Blood pressure was within normal limits. Upper extremity mobility was restricted. Laboratory Tests prescribed for Mrs. Rozario included the serum albumin test to note the immune status. The result indicated lesser immunity as was expected. The serum cholesterol level and lipid profile were normal. Serum cholesterol was 220 mg/dl . The blood glucose level was showing a borderline reading probably because Mrs. Rozario could be going in for intolerance like all aged people. Her haemoglobin level was 9gm/ml. This was lower than the minimum of 10gm./ml and could be anemia due to malnutrition. Diet had not been sufficient for Mrs. Rozario. Social history revealed a good family life before and after marriage. Mrs. Rozario was financially secure but was living alone. The death of her spouse a few months earlier had made her lonely and thus made her life risky. Death of a spouse was associated with higher morbidity and mortality. Mrs. Rozario ran the risk of illness or death. She did not exercise even though exercise obviously helped in reducing hypertension. Mrs. Rozario had difficulty to sleep and it lasted only for a few hours. Cognitive dysfunction, mood disorders and immunologic disorders could account for the disturbed sleep. The only recreational activity that Ms. Rozario indulged in was watching television. She used to read five years ago. Now with failing vision and cognitive impairment, she had gradually lost that habit. She was not addicted to alcohol or drugs. The risk of falls was possible and accounted for the fracture femur. The lighting in the house had been improved by the son after the fracture incident. She could move around in her wheelchair and had been able to get up the stairs if necessary with the arrangement on the staircase. Her walker was at the top of the staircase. Grab bars had been fixed at strategic points. Rugs had been removed from the places where she had to walk. Community support or social networks had not been arranged for her yet. She had been covered by Medicaid. Impact of aging Mrs. Rozario was suffering from the impacts of aging. She was just one of the aging population which had several problems needing solutions. Dependence was an associated issue. While the aged people accounted for 15% of the population in the US, the dependence ratio (comparison of the number older than 65 to the number between 20 -64 years) was expected to rise from 22% to 46%. Co-morbidity and disability were causing the frailty of older people like Mrs. Rozario. “Frailty, a primary pathway to disability, has been defined as a pathological condition that results in a constellation of signs and symptoms and is characterized by high susceptibility to adverse health outcomes, impending decline in physical function, and high risk of death” (Ferruci, 2004). Chronic illnesses contributed to disability and poorer quality of life as in Mrs.Rozario’s life (Alexeyev, 2009). Mrs. Rozario’s aging problems could be due to any of the reasons indicated in research. Aging processes within the human body had been identified through researches. Some researches had indicated that a reduction in innate and adaptive immune responses was involved (Gouin et al, 2008). The response to stimulatory cytokines was poorer in the aging when compared to the young. The proliferation and activation of T and B-lymphocytes were defective. On the other hand inflammatory mediators had shown an increase in the aging. These were some of the reasons for the aging like Mrs. Rozario to become prone to several age-related diseases (Gouin et al, 2008). The association of chronic illnesses with decreased immunity put the older generation at higher risk. Chronic stress was another factor which influenced the immune status and increased the risk of the older people (Gouin et al, 2008). Mrs. Rozario was also expected to have a decline in physiological functions (Alexeyev, 2009). The defects occurred in the metabolic pathways. The reactive species that showed an alteration were the free radicals hydrogen peroxide and singlet oxygen which were found in the mitochondria, also a site for their damaging effects (Alexeyev, 2009). Self-restriction of calories could be another reason for Mrs. Rozario exhibiting physiological and behavioral changes when her requirement had not been met (Redman et al, 2008). Deficits in cognitive functions and poor memory could be due to this self-restriction. They could be due to changes in the energy metabolism and functional differences in the neuro-endocrine system with oxidative damage. The sympathetic nervous system had been implicated too. Research had identified biomarkers of longevity which could be manipulated for preventing aging processes (Redman et al, 2008). “Calorie restriction (CR), a dietary intervention that is low in calories but maintains proper nutrition, is the only intervention known to date that consistently decreases the biological rate of aging and increases both average and maximal lifespan” (Redman et al, 2008). Death rate was found to be lower in the calorie restricted group 12 years after a study in 1976. Mrs. Rozario could have a calorie-restricted diet which would nourish her and keep her weight down. The human interleukin IL-6 was implicated in the association between the aging process and pathophysiology of chronic morbidity (Maggio et al, 2006). It was found to be a major signaling pathway in the association. Excessive formation or reduced removal of oxygen-free radicals stimulated the production of IL-6 in the aging population. These were not in any way connected with gene polymorphisms. Another significant finding was that the IL-6 declined in production and function from the seventieth year of age. When IL-6 was elevated, the physical frailty worsened marked by reduction of walking speed, impaired muscle strength, poor performance of legs and anemia (Maggio et al, 2006). Mrs. Rozario’s decline of physical functions could be associated with increased level of IL-6. Research into the modulation of IL-6 could be a possible solution for reducing frailty in the future. Mrs. Rozario’s coping mechanisms Mrs. Rozario probably coped with her impairments in her own way. However they were mostly negative in nature. She just withdrew gradually, probably intending to reduce the risks of danger to her health. The thought of troubling her son was something she may not have wanted. Believing that all her illnesses and pain were part of aging, she just coped as well as she could without approaching a medical center. She had a medical center she could go to when in need but her mobility problem prevented her from accessing it. Pain was borne most of the time. The picture of loneliness and depression, inadequate nutrition, long-standing illness producing functional limitation, mobility impairment, and limitation of daily activities including instrumental ones had been the key determinants for the poor quality of life in Mrs. Rozario (Netuveli et al, 2006). Identification of the problem areas, nursing diagnoses, interventions and care plan Mobility impairment and cognitive dysfunction could be surmised as two major problem areas in Mrs. Rozario. Nursing diagnoses relevant to Mrs. Rozario were impaired physical mobility, ineffective health maintenance, ineffective individual coping and constipation. Physical activity was believed to prevent or reverse frailty (Peterson et al, 2009). It was believed to produce significant positive benefits to the mental attitude, physical well-being and cognitive functions (Physical Activity Guidelines Advisory Committee, 2008 in Rosenberg, 2011). Mrs. Rozario needed to attain optimal well-being in her physical structure, mental make-up and cognitive functions. She could thus prevent any secondary chronic illnesses from appearing as there was a risk in her present mobility-impaired situation. Her son did not want a cardiovascular illness taking over and increasing the risk of an earlier death (Rosenberg et al, 2011). The physical activity further had a positive impact on the hypertension. It could prevent any further decline in mobility and lead to health benefits. Research had indicated that people with and without disabilities had the same health benefits (Rosenberg, 2011). Pain and fatigue which accompanied poor mobility could also be reduced and lesser pain killers would be used subsequently. Her mild cognitive impairment would show a reversal over time (Rosenberg et al, 2011). Mrs. Rozario could use a walker more frequently and the wheelchair less. She could be encouraged to count the number of hours she used each and then gradually use the walker more. A goal could be set each month by the son so that she started with twelve hours of wheelchair mobility and slowly reduced it by four hours every month and shifted to walker mobility for the rest of the time. She could build up her activity, confidence and health herself. The son or the therapist could keep track of her activity with the use of a GPS to measure her activity while she was moving about in the house. Sensors were also available for measuring the physical activity at home (Rosenberg et al, 2011). The ineffective health maintenance could be managed by periodic visits by a doctor, a nurse, a social worker and a health aide. Regular checking of BP and general health could help Mrs. Rozario to change the nursing diagnosis of ineffective health maintenance to effective health maintenance. The health staff visits could provide an access for medical services at home itself. Mrs. Rozario would not have to move out of the house to gain medical access. The ineffective individual coping problem could be resolved using support from different sources. Community-based health care services could provide support. Wherever she was, social relationships and availability of health support would have positive effects on the quality of her life. Children could provide much comfort and trusting relationships; even one relationship would be sufficient (Netuveli, 2006). Her son’s children could provide her this support. She could renew her contacts with friends through her son’s assistance. Fostering close relationships provided an impetus for living. Constipation could be treated with laxatives but the nurse had a duty to teach Mrs. Rozario how to prevent constipation. A change of diet to one including more servings of fruits, dairy products and vegetables could prevent her constipation and add to her health as well. Implications for nursing research. Preventing aging processes is a sound subject for nursing research. As more research revealed the physiology of aging, nurses got more ideas on the prevention of aging. Nutritional advice for the early aging population in the fifties could perhaps prevent the aging processes from progressing fast. This paper has suggested that life could be extended with calorie-restriction. This restriction worked better in non-obese individuals. Researches needed to be done to verify the effect of calorie-restriction. Organic or inorganic compounds which mimicked the effects of Calorie-restriction in the body were to be searched for. Reduction of stress could be another subject. This could reduce the speed of the aging mechanism. Future studies needed to focus on the resilience of the brain to stress. The effect of aging on immunological response is another subject for research. Research into the modulation of IL-6 could be a possible solution for reducing frailty in the future. Research should also focus on the advice that could be given to people above fifty who were progressing into the aging process with the goal of preventing or delaying the aging process. References: Alexeyev, M.F. (2009). Is there more to aging than mitochondrial DNA and reactive oxygen species? FEBS J. 2009 October ; 276(20): 5768–5787. doi:10.1111/j.1742- 4658.2009.07269.x. Ellis, G. and Langhorne, P. (2005). Comprehensive geriatric assessment for older hospital patients. British Medical Bulletin 2005; 71: 45–59 DOI: 10.1093/bmb/ldh033 The British Council Ferrucci L , Guralnik J , Studenski S , Fried L , Cutler G , Walston J . Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report . J Am Geriatr Soc. 2004 ; 52 : 625 – 634 . Gouin, J-P., Hantsooa, L. and Kiecolt-Glasera, J.K. (2008). Immune Dysregulation and Chronic Stress Among Older Adults: A Review. Neuroimmunomodulation. 2008 ; 15(4-6): 251– 259. doi:10.1159/000156468. Maggio, M., Guralnik, J.M., Longo, D.L. and Ferruci, L. (2006). Interleukin-6 in Aging and Chronic Disease: A Magnificent Pathway., J Gerontol A Biol Sci Med Sci. 2006 June ; 61(6): 575–584. Netuveli, G., Wiggins, R.D., Hildon, Z., Montgomery, S.M. and Blane, D. (2006). Quality of life at older ages: evidence from the English longitudinal study of aging (wave 1) J Epidemiol Community Health 2006;60:357–363. doi: 10.1136/jech.2005.040071 Redman, L.M., Martin, C.K., Williamson, D.A. and Ravussin, E. (2008). Effect of Caloric Restriction in Non-Obese Humans on Physiological, Psychological and Behavioral Outcomes. Physiol Behav. 2008 August 6; 94(5): 643–648. doi:10.1016/j.physbeh.2008.04.017. Rosenberg, D.E., Bombardier, C.H., Hoffman, J.H. and Belza, B. (2011). Physical Activity Among Persons Aging withMobility Disabilities: Shaping a Research Agenda. Journal of Aging Research, Volume 2011, Article ID 708510, 16 pages doi:10.4061/2011/708510 Williams, S.R. , Pham-Kanter, G., & Leitsch, S.A. (2009). Measures of chronic conditions and diseases associated with aging in the national social life, health, and aging project. Journal of Gerontology: Social Sciences, 64B(S1), i67–i75, doi:10.1093/geronb/gbn015. Read More