What are suboptimal transitions of care?
Transitions that are poorly managed, leading to increased costs, patient safety risks, and decreased satisfaction
Steps to improve transitions?
- set expectations for both sending an receiving provider teams (needs, patient/caregiver preferences, care planning)
- tailor communication strategies (electronic, verbal or written pt & caregiver included
- Target specific outcomes for improvement using QI methods (med reconciliation, follow-up appointments, transfer summaries, timely communication, healthcare utilization)
Key outcomes/costs of suboptimal transitions
30 day and 90 day readmissions? one in 5 older adults discharged from the hospital is rehospitalized within 30 days
-1/3 are rehospitalized within 90 days
$15B/year cost to Medicare
↑ adverse events, medication errors, delays in care
Risk factors for med non-adherence
not that the patient does not want to take the meds
-cost
-remembering to take it
age related changes in oral tissues tooth dentin and salivary gland
• Increased dentin thickness
• Pulp chamber becomes smaller
• ↓ permeability of dentinal tubules → sclerosis
• ↓ sensitivity
• Teeth become more brittle
Secondary dentin continues forming throughout life.
may have less pain with dental disease
- Less bacterial penetration due to sclerosis
- Caries progress w/o obvious symptoms
salivary glands: fatty replacement of acini, less physiological, reserve, and dry mouth
Causes of edentulism
Partial edentulous/edentate: one or more missing teeth is.
Complete edentualism: toothlessness. absence of all natural teeth
causes most often: cavities, poor oral hygiene, gum disease, bone loss, and other periodontal issues.
How to prevent dental decay in older adults?
Good daily oral hygiene with a fluoride toothpaste,
limit sugar intake (especially at night),
routine regular dental exams (essential regardless of discomfort or pain).
Treatment of dental decay?
Topical high-potency fluoride to remineralize the tooth; removal of demineralized tooth structure (drilling)
replacement of removed tooth with fillings or crowns for repair
If caries are deep and involve dental pulp → root canal treatment or tooth extractions is necessary
Components of the periodontium?
Gingiva (gum line), alveolar bone (gives structure to the tooth), periodontal ligament (collagenous sleeve between tooth and root that surrounds the bone)
How periodontal disease occurs.
Microorganisms form colonies called plaque; plaque sits on teeth near gingiva, between gingiva and root surface in the gingival sulcus.
REM assoc factor and predisposing?
meds/alcohol abuse = predisposing factor
assoc w/neurodegenarative disorder (parkinson/lewy body dementia)
REM sleep disorder tx?
env safety (mattress on floor, cushion on floor/protecting windows)
Maintaining REM/deep sleep is important for OA
Factor contribute to insomnia in hospital/nonpharm interventions.?
illness, meds, changes from usual nighttime routine, sleep-disruptive env
N- daytime bright light exposure, back rub/warm drink/relaxation tape at night
- change med time to allow pt to sleep later in morning
Sedating antihistamine (benadryl) shouldn’t be used. opioids can worsen sleep related breathing disorder.
sleep apnea pt: continue CPAP use when hospitalized
cause of sleep difficulty?
multiple physical illness
psychoactive med use
debility/inactivity
large amt of time spent in bed during daytime
env factor (noise/light/disruptive nursing care)
dec exposure to bright light during the day
Irregular sleep wake cycle is common w/dozing and waking off/on over 24 hrs
Neurologic Disease and ED
Disorders that afiect the brain and spinal cord
• MS
• most common neurologic causes destroys myelin sheath around the nerves
• Parkinson’s disease- affects level of dopamine which plays a massive role in sexual desires
• Stroke
• Spinal cord injury
Peripheral nerve damage
• DM
• Pelvic surgery or radiation (prostatectomy)
• Chronic alcoholism leads to texic neuropathy damaging nerves
Anticholinergic effects (ED meds)
May block parasympathetic-mediated penile artery vasodilation and trabecular smooth muscle relaxation
• Antidepressants
• Antipsychotics
• Antihistamines
* All block acetylcholine that is essential for peripheral VD & nerve signaling necessary for erection
Other dyspareunia causes
Inadequate lubrication
• Localized vaginitis
• Cystitis
• Bartholin’s cyst
• Retroverted uterus
• Marked uterine prolapse
• Pelvic tumors
• Excessive penile thrusting
• Vaginismus (painful contraction of the vagina)
Treatment of ED
Lifestyle modification
• Trial of phosphodiesterase inhibitors (e.g., sildenafil (Viagra) or Tadalafil (Cialis) or vardenafil) is first line therapy
• Initial dose should be low
• Tadalafil has longer half-life (up to 36 hrs) allows for daily dosing
• Testosterone Replacement Therapv (TRT)
• ONLY if low serum testosterone
• Plays a larger role with libido
ED Treatment- 2nd Options
• For patients who fail or have contraindications to oral meds
• Intracaverosal injections (ICI)-pt inject vasoactive drug, may be hard with arthritis
• Medicated urethral system for erection (MUSE) (intraurethral
• Small pellets of drug (alprostadil) placed in urethra
• Vacuum tumescence device (external)
• Mechanical pump that creates a vacuum causing negative pressure to pull blood into corpora caverosa, then constriction ring is place at base of penis to trap blood and maintain erection
• Surgery-inflatable penile prosthesis (IPP)
Antimuscarinic Agents
Antimuscarinics are sub-type of anticholinergic that target muscarinic receptors (common in glands, smooth muscle, and brain)
• NOT effective for pure stress incontinence bc they don’t address pelvic floor muscle problem
Mirabegron
Stimulates B-receptors located in detrusor muscle of the bladder to relax and increases bladder capacity
Dosing: 25-50 mg/d
Similar moderate efficacy as antimuscarinics
NO cognitive adverse effects
May raise BP (activation of beta receptors)
Surgery
Highest cure rates for stress Ul in women
• Most common
• Colposuspension (Burch operation)
• Slings (midurethral and bladder neck)
• Periurethral injection of a bulking agent for short term (one year or less)
• Artificial sphincters for refractory stress incontinence from sphincter damage (e.g., after radical prostatectomy)
Age associated sexual changes in women: Menopause
associated with decreased sexual function.
• Decreased sexual interest,Decreased responsiveness & Dec coital frequency
• Increased urogenital symptoms, often not discussed with the provider
Dental pulp age related changes
↓ pulp volume (because dentin increases)
• ↓ vascular supply
• ↓ nerve fibers
• ↓ connective tissue
• ↓ reparative capacity
• Less sensitivity to temp and pain
- less chance to repair tooth after trauma or infection
- Slower healing
Older adults have decreased pulp vitality and regenerative capacity.
