MSN_NR 601 FINAL EXAM STUDY GUIDE

FINAL EXAM STUDY GUIDE WEEK 5 Urinary incontinence is a common issue within the older adult community. Urinary incontinence can be distressing and impact the older adult’s quality of life and socialization. Incontinence also increases the risk of skin breakdown and falls and is a leading reason for placement in long-term care. Treatment of urinary incontinence is essential to improve health and quality of life. Living situation: Community 20% of women have incontinence Living situation: Long-term care 75% of women have incontinence Men younger than 85 have a lower incidence of incontinence than women of the same age; incidence rates are similar, however, for men and women aged 85 and above. Urinary incontinence: Involuntary urine leakage Urgency: Sudden need to void Urgency incontinence: Sudden need to void followed by leakage Frequency: Frequent urination Hesitancy: Difficulty in initiating urine stream Straining: Effort to initiate or maintain urine stream Dribbling: Leakage of small amounts of urine after voiding Nocturia: Waking during the night to void Overactive bladder: Urgency, frequency, and nocturia Risk factors for urinary incontinence include female gender, weakness/functional impairment, advanced age, obesity, diabetes, depression, and hysterectomy. Other risk factors for urinary incontinence include neurologic impairment, including past cerebrovascular accident (CVA), cognitive impairment, and fecal incontinence. Assessment for urinary incontinence involves obtaining a detailed history of the onset, duration, and severity of symptoms, including the presence of nocturia and sleep disruption and the impact on quality of life. An intake and voiding diary can help to identify patterns of nocturia. Some older adults, particularly women, may not consider occasional urge or stress incontinence as a health burden. For others, incontinence is distressing and may prevent them from engaging in social activities. Stress incontinence presents as leakage with exertion or coughing, sneezing, or laughing. A pelvic exam, urinalysis, and empty supine stress test are appropriate assessments or diagnostic tests. A pelvic exam is indicated to rule out masses, a mobile urethra, cystocele, or rectocele as possible reasons for incontinence. A urinalysis is indicated for all clients who present with new or worsened incontinence to rule out urinary tract infection or hematuria. An empty supine stress test is indicated and is performed by asking the client to void, then observing the urethra in lithotomy position while the client is bearing down. A post-void residual (PVR) may be appropriate for clients who are suspected to have overflow incontinence; therefore, it is not indicated at this time. The provider’s first step is to establish goals for treatment with the client. Some clients may be satisfied with using protective undergarments for occasional incontinence and refuse additional intervention. Treatment, when indicated, should begin with the least invasive strategy and move stepwise as needed. If the physical exam reveals no abnormalities, referral to urology may be unnecessary unless behavior and medication strategies do not succeed. Treat Comorbidity Comorbidities, such as sleep apnea and diabetes, must be managed before implementing other treatments for urinary incontinence. Current medications should be reviewed to identify those that might precipitate incontinence. Lifestyle Lifestyle interventions include weight loss, reducing consumption of caffeine and alcohol, decreasing fluid intake before bed, and smoking cessation. Behavioral Therapies Behavioral therapies include bladder training and pelvic muscle exercises; both are useful for urgency and stress incontinence. Bladder training includes frequent voiding (i.e., every 2 hours) along with visualization and muscle contractions to help control urgency. As training progresses, the time between voluntary voids is increased. The training process may take several weeks (Mazur-Bialy et al., 2020). Pelvic muscle exercises, or Kegels, help to strengthen the pelvic floor. Exercises may be done throughout the day, with a goal of three sets of 10-12 per day. Exercises may begin to improve incontinence within a month. Prompted voiding may decrease incontinence episodes in cognitively impaired clients. The caregiver should prompt the client to report the need to void throughout the day and assist in toileting every 2-3 hours (Mazur-Bialy et al., 2020). Medications Pharmacologic therapy is not approved for stress incontinence but may be prescribed for the management of urgency incontinence or overactive bladder and includes: Antimuscarinic medications: oxybutynin (Ditropan), tolterodine (Detrol) • monitor for anticholinergic adverse effects • drugs interact with drugs that induce CYP2D6 • the American Geriatrics Society 2019 Beers Criteria recommends avoiding antimuscarinics in clients with dementia or cognitive impairment Beta-3 Agonist: mirabegron (Myrbetriq) • interacts with drugs that induce CYP2D6 • potential adverse effect: increased BP Minimally Invasive Procedures Minimally invasive procedures may be considered for clients who have urgency incontinence that does not respond to behavioral interventions or medications. Referral to urology is appropriate for clients seeking minimally invasive procedures or surgery. Procedures for urgency incontinence include: • onabotulinumtoxinA bladder injections • instilled in office via cystoscope • percutaneous tibial nerve stimulation • electrical stimulation via acupuncture needle • weekly appointments for 3 months Procedures for stress incontinence include: • urethral bulking • botulinum toxin injections Surgery Surgical interventions for stress incontinence include: • midurethral mesh sling Surgical interventions for urgency incontinence include: • sacral neuromodulation: implanted electrode connected to a stimulator Urinary Tract Infections (UTIs) in the Older Adult The diagnosis and treatment of urinary tract infections (UTI) in older adults differ from treatment in younger individuals. UTI is the most common bacterial infection in those over 65 and the most common cause of sepsis in older adults. Swift recognition of the difference between asymptomatic bacterial colonization, which may not require treatment, and symptomatic infection is essential (Langford et al., 2021). Click each of the sections below to learn more. UTIs in Community-Dwelling Older Adults For older adults who reside in the community, symptomatic UTIs are similar in presentation to younger adults and may include dysuria, frequency, urgency, and hematuria. Postmenopausal women may also complain of incontinence, nocturia, low back pain, and constipation (North American Menopause Society, 2020). Older adults may experience changes in cognition, including confusion. Unlike with younger adults, treatment should not be initiated based solely on symptoms, as common symptoms may mimic other disease processes. A urine dipstick to evaluate for bacteriuria and pyuria is required. If nitrites and/or leukocytes are present, using symptomatic treatment until microbiology results are available to direct targeted antibiotic therapy can help reduce antibiotic resistance (Langford et al., 2021). UTIs in Long-Term Care Residents Residents of long-term care facilities may not present with typical signs of UTIs, and they may be more likely to have chronic urinary symptoms such as frequency, nocturia, or incontinence. Change in mental status may be the most common symptom associated with UTI in long-term care (Langford et al., 2021). Other symptoms of a suspected UTI in this population include a change in urine character, fever, declining functional status, and hematuria. Evidence-based consensus criteria should be used to determine when to initiate treatment. Examine the image below to learn more about consensus criteria for diagnosing UTIs in long-term care clients. McGeer criteria Three of the following: • Fever 38 C • New/increased burning, frequency, urgency • New flank or suprapubic pain • Change in character of urine • New or worsening mental status changes Loeb criteria Acute dysuria OR Fever 37.9 C plus one of the following • Urgency • Frequency • Suprapubic pain • Gross hematuria • Costovertebral angle tenderness • Urinary incontinence Slide 1 Dorothy is an 89-year-old resident of a long-term care facility. She has a history of dementia, diabetes, and two previous UTIs within the past year, treated with trimethoprim/sulfamethoxazole. Her primary nurse calls to report that Dorothy is having increased agitation and periods of incontinence, which is new behavior for her. Her urine smells foul, and she has a temperature of 38 C with chills. Slide 2 Which of the following risk factors for UTI are relevant to Dorothy? Select all that apply. • previous UTI (Correct answer) • resident of long-term care (Correct answer) • diabetes (Correct answer) • dementia (Correct answer) Rationale: Dorothy’s risk factors for UTI include previous UTI, resident of long-term care facility, and a history of diabetes and dementia. The number one risk factor in older adults for UTI is a history of previous UTIs. Other risk factors include: • increased exposure to organisms (long term care or hospitalizations) • genitourinary structural/functional abnormalities • changes in vaginal flora • diabetes • Alzheimer’s disease • Parkinson’s disease Slide 3 Use the McGeer or Loeb consensus criteria to determine if Dorothy meets diagnostic parameters for a UTI. • Yes (Correct answer) • No Rationale: According to McGeer criteria, Dorothy meets 3 criteria for diagnosis: fever, change in the character of urine, and worsening mental status. According to Loeb criteria, Dorothy meets the criteria of fever plus urinary incontinence. Both criteria indicate a positive diagnosis of UTI. Slide 4 Which of the following are appropriate for the NP to order for Dorothy? Select all that apply. • increase fluids (Correct answer) • begin antibiotics after 24 hours of observation • trimethoprim/sulfamethoxazole 800/160 mg orally BID x 7 days • nitrofurantoin 100 mg orally BID x 5 days (Correct answer) • urinalysis with culture and sensitivity (UA C&S) (Correct answer) Rationale: Appropriate orders for Dorothy include increasing fluids to help flush bacteria, a UA C&S to help guide therapy, and nitrofurantoin. Since Dorothy has been treated for UTI with trimethoprim/sulfamethoxazole in the past, there is a high likelihood of drug resistance, and another first-line agent should be tried. Because Dorothy meets clear criteria of a UTI, there is no need to wait and observe before administering antibiotics. For clients with nonspecific symptoms, increased hydration and observation for 24-48 hours are warranted before initiating treatment. If, after the observation period, a urine dipstick is positive for leukocytes and/or nitrates, antibiotic therapy may be initiated. Disorders of the Prostate Benign prostatic hyperplasia (BPH) is a multifactorial disease process involving smooth muscle hyperplasia, prostate enlargement, and bladder dysfunction influenced by signals from the central nervous system. BPH can lead to lower urinary tract symptoms (LUTS) due to hyperplasia of prostate tissue which may anatomically narrow the urethra and obstruct the flow of urine from the bladder as seen below. Age is the most common risk factor for BPH. In the United States, prostate cancer is the second most common form of cancer among men (Center for Disease Control [CDC], 2020a). Age is the most common risk factor. The prostate tends to increase in size in an aging man. The older a man is, the greater his chance of getting prostate cancer. Black men have higher rates of prostate cancer than men of other races. They are also twice as likely to die from the disease and tend to develop it at a younger age. Black men also tend to have a more severe type of prostate cancer than men of other races (CDC, 2020b). Clients are often asymptomatic during the early stages of the disease. Later symptoms include lower urinary tract symptoms. The digital rectal examination (DRE) is an essential assessment for BPH and is used to assess prostate size, contour, and presence of abnormal nodules. The International Prostate Symptom Score IPSS is a validated questionnaire that measures the severity of lower urinary tract symptoms (LUTS). A score of 7 or less indicates mild symptoms, 8 to 19 indicates moderate symptoms and 20 to 35 indicates severe symptoms. Although it indicates prostatic issues, it is not a diagnostic tool for BPH. Question 1 Which of the following risk factors for prostate cancer are relevant to Kylian? Select all that apply. • age (Correct answer) • family history • race (Correct answer) • smoking • alcohol consumption Rationale: Kylian’s risk factors for prostate cancer include age and race. Age is the most common risk factor for prostate cancer. Black men have higher rates of prostate cancer than men of other races. Although a family history of prostate cancer is a risk factor, Kylian does not have a first-degree relative with known prostate cancer. Smoking and alcohol use are not considered risk factors for prostate cancer. Question 2 Is screening for prostate cancer appropriate at this time? • yes • no • further discussion is warranted (Correct answer) Rationale: The United States Preventive Services Task Force (USPSTF, 2018) recommends that providers discuss screening with all men aged 55-69 with a life expectancy of at least 10 years. The American Cancer Society (ACS, n.d.) recommends that conversations begin at age 45 for men at higher risk, including Black men and men with high-risk family histories. Screening risks and benefits should be discussed and shared decision-making used to determine whether screening is appropriate for each client. Death rates from prostate cancer are low; there is no variance in rates among those who are screened and those who are not (Wallace & Anscher, 2021). Prostate cancers are typically slow-growing and do not require treatment. Elevated prostate-specific antigen (PSA). levels may indicate other conditions such as BPH or prostatitis, and some prostate cancers do not cause elevated PSAs. Question 3 Kylian requests to be screened for prostate cancer. Which of the following is the most appropriate recommendation? • PSA and digital rectal exams every two years • PSA and digital rectal exams annually • PSA every two years and digital rectal exams annually • PSA every two years (Correct answer) Rationale: The (USPSTF, 2018) recommends that clients who do choose to screen for prostate cancer do so with biennial PSA-based screening. Question 1 Which of the following findings from Kylian’s medical history and HPI raise suspicion for BPH? • age (Correct answer) • family history • race • smoking • alcohol consumption • difficulty starting and stopping the urine stream (Correct answer) • dribbling (Correct answer) • nocturia (Correct answer) • incontinence (Correct answer) • erectile dysfunction (Correct answer) Rationale: Findings from Kylian’s medical history and HPI that raise suspicion of BPH include age, difficulty starting and stopping the urine stream, dribbling, nocturia, incontinence, and erectile dysfunction. Age is the most common risk factor for BPH. Smoking, alcohol use, and race are not considered risk factors for BPH. Question 2 Which of the following assessments or diagnostic tests are appropriate for Kylian at this time? • prostate-specific antigen (PSA) (Correct answer) • digital rectal exam (DRE) (Correct answer) • International Prostate Symptom Score (IPSS) questionnaire (Correct answer) • stool guaiac • CT scan • urinalysis (Correct answer) Rationale: The following assessments or diagnostic tests that are appropriate for Kylian include PSA levels, DRE, the International Prostate Symptom Score (IPSS) questionnaire, and urinalysis. Elevated PSA levels are the most common clinical finding in clients with prostate cancer; PSA levels may also be elevated in clients with BPH or chronic prostatitis. A PSA level above 4 nanograms/mL is considered abnormal and warrants further testing. DRE is an appropriate initial physical examination. BPH typically presents with a smooth, enlarged prostate, while prostate cancer may present with firm nodules. A DRE allows palpation of the posterior portion of the prostate; however, the absence of nodules or abnormalities does not ensure there are no abnormalities on the anterior or lateral sides of the prostate. A urinalysis is also indicated to rule out urinary infection and hematuria. A CT scan is not indicated as a first-line diagnostic test, and a stool guaiac is not indicated at this time. Question 3 Kylian’s DRE revealed a smooth, enlarged prostate and his PSA was 2.3 nanograms/mL. His urinalysis results were within normal limits. His IPSS score was 20. Which of the following are appropriate to include in Kylian’s treatment plan? • discuss lifestyle and behavioral interventions (Correct answer) • refer to an oncologist for elevated PSA levels • prescribe antibiotics for UTI • select pharmacological interventions for BPH (Correct answer) • discuss ejaculatory dysfunction (EjD) and erectile dysfunction (ED) (Correct answer) • refer to surgery for transurethral resection of the prostate (TURP) • refer to urology for follow-up (Correct answer) • order a transrectal ultrasound Rationale: Kylian’s treatment plan should include education on lifestyle and behavioral interventions, a review of pharmacological interventions for BPH, education about ejaculatory dysfunction (EjD) and erectile dysfunction (ED), and referral to urology. According to the American Urological Association BPH/LUTS Guidelines, first-line treatments for all clients with BPH are lifestyle and behavioral interventions (Lerner et al., 2021a). Interventions include limiting fluids before bedtime, diuretics (e.g., alcohol, caffeine), and bladder irritants. Weight loss, pelvic floor training, and timed voiding can also be recommended. An alpha-blocker or PDE5 can be used as an initial trial of medical management over 4 weeks and with a 5-ARI over 6-12 months is suggested in men with bothersome LUTS. Referral to urology is recommended with or without a trial of medication. Prostate imaging and post-void residuals would most likely be completed. Further evaluation by a specialist would be needed if symptoms do not improve with interventions. Surgical intervention may be considered if there is renal insufficiency, urinary retention, recurrent UTIs, recurrent bladder stones, or gross hematuria (Lerner et al., 2021b). Kylian has a secondary problem of erectile dysfunction. This should be addressed as well as possible EjD with alpha-blocker treatment. His sexual activity and impact on life should be assessed. Kylian’s PSA level is normal so referral to oncology is not appropriate. Urinalysis indicates no infection; therefore, antibiotics are not indicated. Erectile dysfunction (ED) is a common problem; ED screening is an essential component of a routine health assessment. ED is a sensitive topic. A candid conversation about ED is more likely to occur when there is trust within the client-provider relationship. Due to the nature of ED and its impact on intimate relationships, a sexual partner may initiate the conversation. Regardless of who starts the discussion, it is important to discuss causes and treatment options. Risk factors for ED include: • cardiovascular (hypertension, coronary artery disease, hyperlipidemia, peripheral vascular disease) • diabetes mellitus • depression • obesity • alcohol use • medication use (antihypertensives, antidepressants, antiandrogenic agents) • history of pelvic surgery/trauma/radiation • neurologic diseases • endocrinopathies (hyper/hypothyroidism, hypogonadism, corticosteroid use) History • International Index of Erectile Dysfunction (IIED) o Composed of 15 questions o Addresses all domains of male sexual dysfunction • Sexual Health Inventory for Men o Short version (five questions) of IIED Physical Exam • Femoral and peripheral pulses for strength and bruit • Assessment for penile plaques • Hair growth patterns, gynecomastia, or small testes • Cremasteric reflex • Visual field defects may indicate pituitary tumors Diagnostic testing such as hemoglobin A1c, thyroid function studies, and lipid panel may reveal the underlying cause (Ma et al., 2021). All men with ED should have at least two morning serum total testosterone tests to identify testosterone deficiency. The cremasteric reflex is used to determine if the cause of the ED is neurological. Alzheimer’s disease, stroke, and certain medications can interfere with nerve signals. • Tim has ED-related anxiety with sexual situations. o Management strategy: ▪ Referral to a mental health professional • Cory is recovering from depression but continues to have problems with ED. o Management strategy: ▪ Referral to a mental health professional ▪ Oral PDE5i • Arian has had ED ever since his nerve-sparing radical prostatectomy. o Management strategy: ▪ Referral to a mental health professional ▪ Oral PDE5i ▪ Vacuum therapy • Omar has ED due to low testosterone. His prolactin level is normal. o Management strategy: ▪ Referral to a mental health professional ▪ Oral PDE5i ▪ Testosterone replacement • Wu takes hydralazine with isosorbide dinitrate for congestive heart failure. He also has ED. o Management strategy: ▪ Referral to a mental health professional ▪ Refer to cardiology Rationale: According to the American Urological Association Erectile Dysfunction Guidelines, treatments for these clients is as follows (Arthur et al., 2018): A referral to a mental health professional should be considered for all men treated for ED to support treatment adherence and integration into sexual relationships. • Tim has a suspected psychological etiology and should be referred to a mental health professional for sexual counseling. • Cory’s underlying medical condition is being treated but ED is still an issue. He should be informed of PDE5i medications which are FDA approved for ED. • Since Arian had a prostatectomy, studies have shown that vacuum devices, along with oral PDE5i medications, are associated with higher rates of client and partner sexual satisfaction (92%) compare to using oral PDE5i medications alone (57%). • Omar has low testosterone and normal prolactin so he is a candidate for testosterone replacement. However, testosterone alone is not an effective therapy for ED. A PDE5i should be included. • Wu takes a nitrate-containing medication. PDE5i medications are contraindicated since they can cause hypotensive episodes if taken with nitrates. The underlying cause of his ED could be cardiac related therefore he should be referred to cardiology. If a PDE5i is contraindicated, non-effective, or there is a preference to avoid oral medications, other treatment options include intraurethral (IU) alprostadil (a pellet delivered into the urethra with successful intercourse rates ranging from 29.5% to 78.1%); intracavernosal injections (ICI) of alprostadil or combination medications (success rates of 53.7% to 100%; however, injection site pain is common with erection); and surgical implantation of a penile prosthesis (client and partner satisfaction rates of 83% to 89%). Follow-up visits 6-8 weeks after initiating medical treatment are recommended. Treatment failure for at least four sexual attempts is indicated before changing medications or treatment modality. Referrals to urology or endocrinology are warranted for complicated cases or treatment failure. Menopause occurs when menstruation permanently ceases and is a significant milestone in the female life cycle. For most women, menopause occurs at an average age of 51 years (Santoro et al., 2021). It is preceded by a transition state called perimenopause where hormonal changes start causing noticeable symptoms. The process can last over a decade and usually starts around age 40. Menopause has four stages: premature menopause, perimenopause, menopause, and postmenopause. Menopause is considered premature if it begins before the age of 40. Correct matches and rationale “In my late 40s, I changed jobs and started to experience nausea and migraines. I would go work out and feel extremely dehydrated. I thought it was just the stress of my new job. Now, at age 52, I haven’t had a period for a year. I stopped working out because I had so much joint pain! It was unbearable.” Allie's correct stage is menopause. “At age 43, I went to the clinic for my annual exam. I found myself listing off problems like feeling tired, hot flashes, and irritability with the world. Even my hair seemed to be thinner. The provider asked if I was having periods. I was but they have been irregular and sometimes heavy or light.” Jasmin's correct stage is perimenopause. “I was 34 when I had a total hysterectomy with bilateral salpingo oophorectomy. I started taking hormone replacement therapy (HRT) as instructed by my provider and at first, I felt fine. Then I started with night sweats, fatigue, anxiety, memory problems, insomnia, and mood swings. They were intense!” Eva's correct stage is premature menopause. “I haven’t had my period for years. My sex drive and libido is decreased and I have issues with vaginal dryness and an occasional hot flash. My provider says I am more at risk for osteoporosis now.” The correct stage for Mercedes is postmenopause. Rationale: According to the Women’s Health Research Institute (n.d.) and the North American Menopause Society (n. d. a.), there are four stages of menopause: premature menopause, perimenopause, menopause, and postmenopause. Allie is in menopause which is marked by no menstruation for 12 straight months without experiencing other causes. The ovaries have stopped producing eggs. Symptoms vary widely. Every woman experiences menopause differently. Jasmine is in perimenopause, the transition years before menopause. Perimenopause typically occurs in the late 40s. Symptoms like hot flashes, mood changes, fatigue, and irregular periods are common. Eva is experiencing premature menopause. The absence of ovaries has dropped her estrogen level and the HRT is not compensatory. Symptoms of premature menopause are similar to those of menopause. Premature menopause can occur due to illness, surgical procedures, or genetics. Women with hysterectomies often experience gradual symptoms, whereas women undergoing an oophorectomy experience immediate symptoms. Premature Ovarian Failure (POF) or Primary Ovarian Insufficiency (POI) can also cause premature menopause. Mercedes is postmenopausal. Symptoms that are experienced during menopause may linger. Due to a drop in estrogen, there is a higher risk of osteopenia, osteoporosis, and heart disease. Symptom management includes pharmacologic and nonpharmacologic approaches. Choice of therapy depends on the severity of symptoms, the effectiveness and safety of treatments for the individual client, and client preference. Although menopause is a natural part of aging, symptoms may have a negative impact on well-being. The body will adjust to hormone changes and symptoms typically ease after a couple of years. In the meantime, however, there are ways to management the symptoms. Click the + on each image to learn more. Hot flashes and night sweats • Avoid triggers- spicy foods, hot drinks, alcohol, and caffeine • Maintain a cool environment, layer clothing • Increase exercise Vaginal dryness • Vaginal estrogen • Vaginal moisturizer • Lubricants during sex Mood changes • SSRIs Osteoporosis • Calcium and vitamin D supplements • Bone density scans H o r m o n e R e p l a c e m e n t T h e r a p y Nonhormone therapies provide sufficient relief for most women with mild symptoms (North American Menopause Society, n. d. b.). Hormone replacement therapy (HRT) may be indicated for more severe symptoms and helps to prevent bone loss. There are two types of HRT: estrogen-only (ET) or estrogen plus progestin (EPT). EPT is indicated for women who have not had a hysterectomy to help prevent uterine cancer. HRT is delivered systemically (e.g., oral tablets, patches, injections) or locally (e. g., creams, vaginal rings); the lowest effective dose should be prescribed for the shortest amount of time to minimize risks. Risks include stroke, blood clots, and breast cancer. Each woman should be assessed individually, and the benefits should outweigh the risks. Selective estrogen receptor modulators (SERMs) block or activate estrogen receptors in certain areas of the body and is an alternative treatment for women with a history of breast cancer or those with concerns about using HRT (North American Menopause Society, n. d. c.). Postmenopausal Bleeding Postmenopausal bleeding is genital tract bleeding in a woman who is not on HRT or non-cyclical bleeding in a menopausal woman on HRT. The most common cause of postmenopausal bleeding is benign vaginal atrophy. Atrophy is easily recognized on physical exam by the presence of a thin, pale vaginal epithelium along with narrowing of the introitus. Subjectively, the client will complain of dyspareunia and possibly post-coital bleeding. Other conditions cause postmenopausal bleeding. Vaginal atrophy • Local or systemic estrogen Endometrial atrophy • Short course of systemic estrogen Endometrial polyps • Surgical removal Uterine fibroids • Surgical removal Endometrial hyperplasia • Medical management to prevent the progression to endometrial cancer including systemic progesterones or hormonal IUD to thin uterine lining Cancers (endometrial, ovarian, cervical, vaginal) • Total hysterectomy • Radiation Genitourinary syndrome of menopause (GSM) is a new term to describe vulvovaginal atrophy, atrophic vaginitis, or urogenital atrophy due to estrogen deficiency and is characterized by a broad spectrum of signs and symptoms (North American Menopause Society, 2020). Sexuality and intimacy are integral parts of life. Assuming older adults are sexless is part of ageism in our society. Most older adults still prefer sexual contact despite age or physical health barriers. Older adults with active and satisfying sex lives tend to have a greater enjoyment of life. It is also associated with better cardiovascular health, greater self-esteem, and a sense of comfort and security. Sexuality later in life is subject to stigmas and reduced emphasis on sexual practices (Towler et al., 2021). The true statements are: • Physical signs of sexual arousal differ in older adults. • All forms of intercourse are appropriate for older adults. The false statements are: • Sexual interest declines with age for both males and females. • Older adults must have sex to be intimate. Rationale: Physical signs of sexual arousal, such as immediate erections for males and lubrication for females, decrease with age (Towler et al., 2021). Interventions should be discussed as needed. Older adults are not limited to the types of intercourse (e.g., oral, vaginal, anal) they can have. It is based on client and partner ability and preference and not age. Sexual interest does not naturally decline. People who enjoyed sex in their younger years continue to remain active as older adults. Although rates of sexual intercourse may decline with age, other forms of intimacy do not. Older adults maintain intimacy with both sexual and non-sexual physical contact. Sexually Transmitted Infections and the Older Adult A growing epidemic of sexually transmitted infections (STIs) is occurring within the U.S. older adult population (Centers for Disease Control and Prevention [CDC], 2019). The CDC (2019) reports that in 2019 primary and secondary syphilis rates have increased from 600 in 2010 to 2,927, chlamydia rates have increased from 4,477 cases in 2010 to 16,767, and gonorrhea from 2,714 cases in 2010 to 16,333 cases in 2019. Condom use is less than 10% in this population. Sexual Health Assessments in Older Adults Providers often assume that older adults are not sexually active, or that a discussion of sexual health is not necessary (Malta, 2020). If sexual health is discussed it is more often addressed with men than women and with individuals rather than couples. Sexuality is more likely addressed as an effect of a medical problem or medication and not as a pleasurable aspect of aging. Question 1 Which of the following is the most appropriate action? • Obtain Irene and Ed’s consent and discuss related safety issues (Correct answer) • Review State laws and regulations about intimacy in long-term care facilities • Obtain consent from family members • Gather opinions of the staff Rationale: Irene and Ed’s cognitive capacity to consent to sexual activity should be assessed to ensure the safety of both parties (Metzger, 2017). The provider must obtain knowledge of the nature of the activity and the relationship. If consensual, risks should be addressed. Risks may include falling, infection, and cardiac events. State laws and regulations do not address specific guidelines for intimacy in the long- term care environment except that it must be consensual, not a public display, and does not harm the individuals involved. Consent is not required from family members and the opinions of the staff are not relevant. Question 2 The facility does not have a resident-centered approach to addressing sexual or intimate activities among residents. Which of the following are appropriate actions for the NP to take in establishing this type of approach? Select all that apply. • Hold staff education sessions (Correct answer) • Construct educational materials for residents and families (Correct answer) • Have sexual aids available (e.g., lubricants, condoms) (Correct answer) • Develop individualized plans detailing approaches to maintain safety and privacy (Correct answer) • Consult with an ethics committee (Correct answer) • Form a committee to draft guidelines (Correct answer) • Develop guidelines for notifying guardians/power of attorney (POA) Rationale: Appropriate actions the NP can take to establish a resident-centered approach to intimacy among residents include holding staff education sessions, constructing educational materials for residents and families, having sexual aids available (e.g., lubricants, condoms), developing individualized plans detailing approaches to maintain safety and privacy of sexually active residents, consulting with an ethics committee, and forming a committee to draft guidelines. It is important to preserve the privacy and dignity of long-term residents while monitoring safety. Individual plans should be constructed. For example, some facilities utilize “do not disturb” signs or specially designated rooms for intimacy (Metzger, 2017; Board on Aging and Long Term Care - Ombudsman Program, 2014). Staff should be designated for these rooms. Education of staff, residents, and families should emphasize safety and address common misconceptions. Sexual aids should be available to residents as consensual relationships are a resident right and should be respected. A committee should be formed to draft guidelines to ensure residents' needs are met regardless of sexual identity. An ethics committee should also be consulted as ethical dilemmas can arise such as relationships with residents with dementia or if one or more residents are non-consenting. Regardless of the guardian or power of attorney (POA) status, it is a resident’s choice to engage in a relationship if consenting; notification is not required. Key Points • Urinary incontinence is a common issue within the older adult community and may include nonpharmacologic, pharmacologic, and invasive interventions. • BPH is a multifactor issue involving smooth muscle hyperplasia, prostate enlargement, and bladder dysfunction that is influenced by signals from the central nervous system. BPH can lead to lower urinary tract symptoms (LUTS) due to an anatomical obstruction of urine from the bladder and hyperplasia of prostate tissue which also narrows the lumen of the urethra. BPH urinary conditions increase as a man ages, with the highest risk for men over the age of 50. • Urinalysis, prostate-specific antigen (PSA) levels and American Urological Association (AUA) Symptom Index scores are first-line diagnostic tests when used in the appropriate client groups. • The goal of treatment for BPH is in controlling or improving LUTS to protect and promote quality of life. Treatment of BPH involves three strategies: watchful waiting, pharmacological interventions, and surgical interventions. • ED may result from cardiovascular, endocrine, urologic, or psychological issues and should be considered in the assessment. • In the U.S., prostate cancer is the second most common form of cancer among men. Age is the most common risk factor. • Menopause is a normal process of maturation, but symptoms can be distressing to clients. Primary care providers provide education and symptom relief for clients throughout menopause. • Rates of STIs in older adults are rising. Chlamydia and gonorrhea are the two most prevalent STIs in the United States. Week 6 Cognitive Function Like most other body systems, cognitive decline is seen with age. Approximately 50% to 75% of adults aged 65 and older notice subjective memory issues and report minor concerns (U.S. Preventive Services Task Force [USPTF], 2020). Older adults also have other factors that decrease cognitive abilities such as cardiovascular disorders, decreased physical activity, and low social engagement. Cognitive impairments have a direct burden on the client, their caregivers, and society; early screening and treatment are essential to reduce this burden and improve the quality of life. • Delirium: Acute onset with memory deficit, disorientation, and attention disturbance; symptoms fluctuate based on the situation; may point to a medical condition; reversible. • Dementia: Insidious onset with progressive decline in cognitive abilities; irreversible. • Depression: Acute or insidious onset; symptoms fluctuate based on the situation; may become chronic without treatment. Cognitive Assessment Tools Cognitive assessments help to determine brain health and provide baseline assessment data for monitoring cognitive changes over time. Cognitive assessment tools range in complexity from simple to multifactorial. Simple tools featuring only two or three questions may be used as a preliminary assessment to determine if a more thorough assessment tool is needed. Regardless of the approach, it is important to utilize cognitive assessment tools systematically and consistently. Once a set of tools is used to assess a client, the same tools should be used as a basis for comparison over time. Discover More The Mini-Cog™Links to an external site. is a three-item recall test and a scored clock-drawing test that can be used effectively with minimal training. This short tool can be used as part of routine screenings for dementia. The Montreal Cognitive Assessment, Saint Louis University Mental Status Examination, General Practitioner Assessment of Cognition Screening Test , Mini-Mental State Examination are more in-depth tools to assess the level of cognitive impairment in symptomatic client. Question 1 A Mini-Mental State Examination Links to an external site. was completed. Miguel's score was 20. Which of the following statements best describe these results? • Miguel’s score is normal indicating no cognitive impairment • Miguel has a mild cognitive impairment which may impact daily activities like driving and shopping (Correct answer) • Miguel has moderate cognitive impairment indicating moderate Alzheimer’s disease • Miguel’s score is indicates severe cognitive impairment Rationale: Miguel’s score of 20 indicates mild cognitive impairment and possible early Alzheimer’s disease. He could have problems with driving and shopping. Scores 24-30 indicate no cognitive impairment. Scores 18-23 indicate moderate cognitive impairment. Scores under 0-17 indicate severe impairment. Question 2 Further diagnostic testing will help narrow the list of possible diagnoses for clients who present with cognitive deficits. Which of the following diagnostic tests is most appropriate for Miguel? Select all that apply. • comprehensive metabolic panel (CMP) (Correct answer) • complete blood count (CBC) with differential • thyroid function test (Correct answer) • cobalamin level (Correct answer) • folate level (Correct answer) • erythrocyte sedimentation rate (ESR) • c-reactive protein • urinalysis with culture • chest x-ray Rationale: To eliminate underlying common medical conditions such as dehydration, B12 deficiency, and hypoglycemia, a CMP, thyroid function panel, cobalamin level, and folate levels should be ordered. There is no data to indicate Miguel has an infection or inflammatory process; therefore, a CBC, ESR, c-reactive protein, urinalysis with culture, and a chest x-ray are not indicated. Question 3 The correct matches are: Alzheimer’s disease • most common cause of dementia • insidious onset with gradual progression • memory loss is the most common symptom even in early stages • may also have impairments in executive function, language, and/or visuospatial skills Vascular dementia • second most common dementia • history of stroke-like symptoms • cognitive domains affected depends on the location of the injury • deficits include memory loss, emotional lability, and focal neurologic deficits • cardiovascular risk factors may or may not be present Dementia with Lewy bodies • third most common dementia • vivid visual hallucinations and delusions with Parkinsonian features • progression is more rapid than Alzheimer’s disease Frontotemporal dementia • most people diagnosed in their 40s – 60s • symptoms include behavioral disturbances such as impulsivity, socially inappropriate behavior, and marked apathy • personality changes • language involvement Parkinson’s disease dementia • occurs approximately 10 years after the onset of Parkinson’s disease • motor symptoms are consistent with Parkinson’s disease • well-formed visual hallucinations, delusions, paranoid ideas • changes occur in memory, speech, and judgment Creutzfeldt-Jacob disease (CJD) • rare, fatal prion disease • rapid onset and decline • prominent psychiatric/behavioral symptoms • early neurologic signs such as myoclonus, paresthesia, progression to incontinence, and loss of speech Question 4 Findings raise suspicion for Alzheimer’s disease. Which of the following orders is the most appropriate next step in the management and diagnosis of this client? • order a computed tomography (CT) or magnetic resonance imaging (MRI) • refer Miguel to a neurologist for further testing (Correct answer) • start Miguel on donepezil • give Miguel and his family information about local Alzheimer’s disease support groups Rationale: A diagnosis has not yet been determined; therefore, a full neurocognitive exam is warranted by a neurologist or neuropsychologist. A neuropsychological exam will help identify areas of cognitive impairment and aid in the creation of a comprehensive management plan. CTs and MRIs are ordered by neurology to support diagnosis. Placing Miguel on a cholinesterase inhibitor for mild Alzheimer's symptoms or referring him to a support group is not appropriate before diagnosis. Treatment for Alzheimer's Disease There is no cure for Alzheimer’s disease; however, pharmacologic and nonpharmacologic interventions can help improve quality of life. Pharmacological Interventions Pharmacologic treatment for Alzheimer’s disease includes N-methyl-D-aspartate (NMDA) or cholinesterase inhibitors to treat symptoms related to memory and thinking. The U.S. Food and Drug Administration (2021) recently granted accelerated approval for aducanumab, an intravenous drug that changes the disease progression to reduce cognitive and functional decline. Click each tab below to learn more about pharmacological interventions for Alzheimer’s disease. • N-methyl-D-aspartate (NMDA): Memantine is used for clients with moderate to severe dementia associated with Alzheimer’s disease. This drug selectively blocks the effects of abnormal glutamate release, an excitatory neurotransmitter. • Cholinesterase Inhibitors: Donepezil, rivastigmine, or galantamine may be used for clients with mild, moderate, or severe dementia associated with Alzheimer’s disease. These drugs act by inhibiting acetylcholinesterase, thus improving cholinergic function, and increasing the circulation of acetylcholine. • Anti-amyloid: Aducanumab has been used with clients with mild dementia in clinical trials. This drug acts by binding to and reducing amyloid-beta plaque in the brain Miguel is prescribed donepezil. Which of the following findings indicates the treatment was effective? improved memory and thinking (Correct answer) Rationale: The effect of donepezil is to increase the availability of acetylcholine, which results in enhanced transmission and improved cognition. Donepezil does not cure Alzheimer’s disease, result in a complete return of cognitive function, or prevent further decline, although it may slow progression. Nonpharmacological Interventions include: • physical activity • consistent surroundings and routines • diet (Mediterranean) • memory aids (calendar) • cognitive stimulation (puzzles, word games) • cognitive behavioral therapy • support groups • alternative therapies (aromatherapy, music, dance, animal) Client and Family Education Dementia can be overwhelming, especially for clients, family, and caregivers. Physical, emotional, and financial pressures may cause strain, and support is needed in the day-to-day management of the disease. Education is essential to raise awareness and understanding of dementia, reduce stigmatization and stress, ensure safety, and optimize care. Family members and caregivers may detect symptoms of major neurocognitive disorder before the client; navigating conversations about deteriorating cognitive function can be challenging. The key to successful management involves building trust while advocating for the safety and protection of client independence as long as possible. Caregivers face many challenges. Education is needed on the disease process, supportive resources, treatment options, and resources such as Alzheimer's AssociationLinks to an external site., National Institute on AgingLinks to an external site., and the Family Caregiver's AllianceLinks to an external site., which provide extensive caregiver education and support. Education is also needed regarding advanced directives and healthcare proxy, as caregivers must be empowered to discuss end-of-life care. Regular follow-up is recommended to assess the clients' condition and cognitive and noncognitive symptoms. More frequent appointments may be required if behavioral concerns arise. Parkinson's Disease Background Parkinson's disease (PD) is one of the most common progressive neurodegenerative diseases. Although it can present at any age, PD is more common in older adults. PD progression is variable, and the course of the disease is unpredictable for clients. As the disease progresses, clients encounter increasing physical, psychosocial, and spiritual concerns. The disease also causes difficulty for family members. Motor Symptoms: Cardinal features tremor bradykinesia rigidity postural instability Motor Symptoms: Craniofacial hypomimia (masked facial expression) decreased spontaneous eye blink speech impairment (dysarthria, hypophonia dysphagia Motor Symptoms: Visual blurred vision impaired upward gaze and convergence eye-lid opening apraxia Motor Symptoms: Musculoskeletal dystonia myoclonus stooped posture kyphosis Motor Symptoms: Gait shuffling freezing Non-motor Symptoms cognitive dysfunction and dementia psychosis and hallucinations mood disorders (anxiety, depression, apathy) sleep disturbances fatigue autonomic dysfunction olfactory dysfunction gastrointestinal dysfunction pain and sensory disturbances dermatologic issues Differential Diagnosis The key to narrowing the differential diagnosis involves tremor identification. Tremors can be categorized into three categories: postural, intentional, and resting. Postural tremors occur during movement or holding a position against gravity. These tremors can be invisible to the naked eye but accentuated with muscle fatigue or anxiety. Postural tremors can be an effect of tricyclic antidepressants and beta-agonists. Intentional tremors occur and worsen with movement. These tremors are seen in Multiple Sclerosis and cerebellar infarctions. Resting tremors occur when a limb is supported and stationary. This is the most common tremor associated with Parkinson’s disease. For an accurate diagnosis, tremors must be distinguished from dyskinesias and tics. Treatment According to the American Academy of Neurology guidelines for the treatment of early Parkinson’s disease, clients should be counseled on the benefits and risks of pharmacological treatment (Pringsheim et al., 2021). Treatment should be determined by the level of functionality and client choice. A tremor that does not impact activities of daily living does not warrant medications. For motor symptoms that affect function, levodopa is the first-line treatment. However, clients may have side effects of dyskinesia during the first five years of treatment. The lowest, most effective dose of medication is recommended. Dopamine agonists can also be prescribed, but are more likely to cause impulse control disorders, daytime fatigue, and hallucinations. Monoamine oxidase B (MAO-B) inhibitors also cause dyskinesia and insomnia is common. Clients are more apt to discontinue treatment if started on dopamine agonists or MAO-B inhibitors due to adverse effects. The progression of PD varies. Treatment should be considered when functional independence is affected. Which of the following are most appropriate to include in Donna’s plan of care? Select all that apply. referral to a speech-language pathologist (Correct answer) referral to an occupational therapist (Correct answer) referral to physical therapy (Correct answer) dietary consult (Correct answer) increase carbidopa-levodopa to 50-200mg sustained release metabolic panel (Correct answer) complete blood count (Correct answer) start fluoxetine 10mg daily weights (Correct answer) Rationale: Donna’s care plan should include: Referral to a speech-language pathologist Parkinson’s disease affects muscles used for speech and swallowing evidenced by her slurred speech. Nutritional deficits could be caused by impaired swallowing. Referral to an occupational therapist Donna currently has challenges with activities of daily living and occupational therapy can assist her in maintaining some independence. Referral to physical therapy Parkinson’s disease causes impaired mobility. Exercise helps neuroplasticity which is the brain's ability to reorganize and repair itself. Dietary consult Nutritional needs should be assessed. Tremors can impact the ability to feed self. Also, Donna has experienced many life changes recently and she should be screened for depression as this may be a contributing factor in decreased nutrition. Metabolic panel Donna should be checked for electrolyte imbalances caused by weight loss and dehydration Complete blood count Donna should be checked for anemia due to nutritional deficits Daily weights Since Donna has lost 10 pounds in the last month, her weight should be monitored to ensure consistent nutrition and no further weight loss. Since there is no evidence of worsening Parkinson’s symptoms, there is no need to increase carbidopa-levodopa. Donna has been through many recent life changes and some symptoms may indicate depression. Donna should be screened for depression before initiating treatment of fluoxetine. Medical conditions like Parkinson’s disease can be worsened by a tricyclic antidepressant. Common Neurological Disorders in the Maturing and Older Adult Background Dizziness is a nonspecific symptom that requires careful investigation to determine its cause. There is a high prevalence of dizziness in the older adult population, especially in those individuals who have co-morbidities and take multiple medications. Dizziness increases the risk of falls, functional disability, institutionalization, and death. A systematic approach is required to evaluate dizziness and maximize outcomes Types of Dizziness: Floating sensation and Presyncope 2.7% Floating sensation 8.1% Vertigo and other types of dizziness 13.5% Presyncope 16.2% Imbalance 24.3% Vertigo 35.1% Often multiple causative factors contribute to dizziness in the older adult. Dizziness may be caused by any or a combination of many factors. • Anxiety • Depression • Impaired balance • Past myocardial infarction • Postural hypotension • Polypharmacy (5 or medications) • Impaired hearing Many medical conditions may cause dizziness in the older adult Peripheral vestibular • Benign paroxysmal positional vertigo • Vestibular neuritis • Bilateral vestibular loss • Late-onset Meniere's disease or decompensation • Labyrinthitis • Occlusion of the anterior vestibular artery Central nervous system Vestibular migraine Transient ischemic attack of vertebrobasilar artery Stroke Neurodegenerative disorders Downbeat and upbeat nystagmus syndromes Cardiovascular • Arrhythmia • Postural hypotension • Congestive heart failure • Heart valve failure Medications Antihypertensive Benzodiazepines Hypnotics Anxiolytics Antiepileptic Multimodal balance disorder Presbystasis Others Primary and secondary neoplasia (breast and prostate) Somatoform vertigo and psychiatric dizziness Musculoskeletal system disorders Proprioception and somatosensory loss Dizziness complaint Complete history, including list of medications • If there are signs or symptoms concerning for stroke o Referral to emergency department (ED) for urgent evaluation and neuroimaging • If there are no signs or symptoms not concerning for stroke o If the history not consistent with BPPV ▪ If there is a suspected otologic etiology; auditory symptoms ▪ Is there episodic vertigo? ▪ If yes, Meniere's disease of labyrinthitis ▪ If no, vestibular neuritis ▪ Appropriate treatment and/or referral to otologist/neurologist ▪ If there is a non-otologic etiology ▪ Vestibular migraine ▪ Progressive disequilibrium of aging ▪ Appropriate treatment and/or referral to neurologist ▪ Underlying medical condition ▪ Appropriate treatment and/or referral to specialist o If the history is consistent with BPPV ▪ Particle repositioning maneuvers Learn more about particle repositioning maneuvers: Learn more about particle repositioning maneuvers: Dix-Hallpike Maneuver, Head Impulse Test, and the Fukuda Stepping Test Dizziness can be caused by non-otologic conditions such as heart disease, anemia, blood glucose levels, dehydration, and infection. Therefore, an ECG, BMP, and CBC are appropriate. Although dizziness may accompany thyroid issues and allergies, no data in the client’s history or physical exam support testing. A CT scan can be used as a diagnostic tool; due to expense, it is not ordered until other diagnostics yield inconclusive results. A notable difference between supine and standing blood pressure readings and an elevated blood sugar (240 mg/dl) suggest orthostatic hypotension secondary to uncontrolled diabetes. Clients with this disorder complain of dizziness while changing positions (postural dizziness). A lack of auditory symptoms eliminates otologic causes, and negative spinning sensations eliminate benign paroxysmal positional vertigo. No clinical data indicates cardiac or neurologic causes. Treatment of the hyperglycemia is key. Establishing tight glycemic control may alleviate Abraham’s dizziness. Consultations are not required at this time. If dizziness persists after glycemic control, consultation may be warranted. A cardiology consult is warranted to evaluate Abraham's persistent dizziness and orthostatic hypotension, which did not subside after establishing tight glycemic control. Question 1 Based on clinical data, which of the following findings require immediate action? Select all that apply. • glucose: 145 mg/dL • episodes are increasing in severity (Correct answer) • family history of MI • dizziness accompanied by headache and facial tingling (Correct answer) • headache is in the same spot during episodes (Correct answer) • cough related to smoking Rationale: Episodes of dizziness with headache in the same spot and facial tingling that are increasing in severity are concerning findings that need to be addressed immediately. Question 2 Based on clinical data, which of the following diagnoses is the most likely diagnosis for Jack? • labyrinthitis • benign paroxysmal positional vertigo • migraine • transient ischemic attack (Correct answer) Rationale: Dizziness and vertigo are the most common vertebrobasilar transient ischemic attack (TIA) symptoms that precede stroke. Unilateral sensorineural hearing loss and nystagmus may also occur. Ischemic stroke is the most common form of stroke in individuals aged 65-79 years of age (Powers et al., 2018). Menière disease or labyrinthitis is eliminated through risk factors, worsening symptoms, and numbness/tingling eliminate. Lack of photophobia or phonophobia eliminates a migraine, and the client’s history does not support benign paroxysmal positional vertigo. Question 3 Suspicion is raised that TIAs are the cause of Jack's dizziness based on clinical data. Which of the following actions is the logical next course of action in Jack's plan of care? • refer to a neurologist • refer to an endocrinologist • refer to a cardiologist • refer to the emergency room (Correct answer) Rationale: Jack requires urgent evaluation and neuroimaging as he could have an impending stroke. It may take days or weeks to get an appointment with a neurologist. A cardiologist and endocrinologist do not treat stroke. Question 4 Six months later, the nurse practitioner (NP) is notified by the stroke team at the local hospital that Jack just had an ischemic stroke. He has responded well to acute treatment and has completed his program at the rehabilitation center. He is ready for discharge and has been told to follow up within two weeks with the NP for ongoing management post-stroke. Which of the following actions should the NP include when developing Jack’s plan of care? Select all that apply. • prescribe antithrombotic therapy (Correct answer) • refer Jack to post-stroke community resources (Correct answer) • assess for post-stroke complications (Correct answer) • provide smoking cessation information (Correct answer) • establish an age-appropriate exercise plan (Correct answer) • repeat head CT scans monthly • provide client with educational information on eating a heart-healthy diet (Correct answer) Rationale: The following actions should be included in Jack’s plan of care to prevent subsequent stroke: prescribe antithrombotic therapy; refer Jack to post-stroke community resources; assess for post-stroke complications; provide smoking cessation information; establish an age-appropriate exercise plan, and provide Jack with educational information on eating a heart-healthy diet. Jack's pharmacologic management includes: • antithrombotic therapy for secondary stroke prevention (aspirin or clopidogrel) • antihypertensives (dramatically decrease the risk for recurrent stroke) • statin therapy • antidiabetic medication • anticoagulation with warfarin or dabigatran, apixaban, edoxaban, and rivaroxaban to prevent thromboembolic stroke Psychiatric Disorders in the Maturing and Older Adult Major Depressive Disorder Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders. It is estimated that more than 280 million people suffer from MDD; it is the leading cause of disability worldwide (World Health Organization [WHO], 2021). According to the Centers for Disease Control and Prevention (CDC, 2021), approximately 1% - 5% of older adults have a major depressive disorder but this number jumps to 11.5% if hospitalized and 13.5% if the person requires care in the home. Treatments for depression vary by diagnosis and individual. There is no "one size fits all" treatment. The family nurse practitioner (FNP) plays an important role in promoting mental health through the early identification, assessment, and individualized treatment of depression. Which of the following clients are at an increased risk for depression? Select all that apply. • 45-year-old female with multiple sclerosis (Correct answer) • 68-year-old male with a history of coronary artery disease (CAD), stroke, and lung cancer (Correct answer) • 50-year-old female with 2 children in a stable marriage • 86-year-old male who recently lost his wife to cancer (Correct answer) Rationale: Multiple risk factors are associated with MDD. These include but are not limited to: • female gender • chronic health problems • disabled • non-white populations • family history of MDD, suicide attempts, and completion, substance abuse • history of abuse/neglect • alcohol or substance abuse • stressful life events such as loss of a spouse or loved one, financial loss, divorce, caring for a spouse or loved one, change in environment • low socioeconomic status • lack of relationships and support systems Certain conditions are associated with depression, including: • epilepsy • post-stroke • Parkinson's disease • multiple sclerosis • degenerative brain disease • Alzheimer's disease • coronary artery disease • depression in malignancy • hypothyroidism • hyperthyroidism • hyperparathyroidism • Cushing's syndrome • Addison's disease • diabetes mellitus Clinical Presentation The key symptoms of depression are a depressed mood and a loss of interest or pleasure. Depression may also present with physical symptoms, including fatigue, inattention, poor appetite, decreased libido, psychomotor retardation, or agitation. Clients with depression often report difficulty sleeping, lack of motivation, or trouble completing tasks. They may use words like "sad," "down," or "blue" to describe their feelings. In severe cases, depressed clients may report delusions or hallucinations. The primary feature of MDD is the occurrence of at least one episode of major depression lasting at least two weeks. A person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode. • Feeling low most of the day for most days • Decreased interest in activities • Substantial weight loss, significant change in appetite • Fidgeting, random movement (i.e. pacing) • Decreased energy • Sense of guilt or worthlessness • Lack of focus or ability to make decisions • Repeated thoughts of death and suicide The Diagnostic and Statistical Manual of Mental Disorders (DSM–5-TR) classifies MDD by severity: mild, moderate, or severe, with or without psychotic features (American Psychiatric Association [APA], 2022). The severity of the depressive disorder should be included in the diagnosis. Severity is based on the number and severity of symptoms. Mild The intensity of symptoms is manageable with minimal impairment in functioning. There are few symptoms beyond those required for diagnosis. Moderate The number of symptoms, intensity, or impairment in functioning is between mild and severe. Severe The intensity of symptoms is unmanageable and distressing. Symptoms interfere with functioning. The number of symptoms is beyond what is required for diagnosis Screening tools are helpful to determine the severity of depression, including: Patient Health Questionnaire (PHQ)Links to an external site. Beck Depression Inventory-II (BDI-II) (available for purchase) Hamilton Depression Rating Scale (HAM-D)Links t