Neurological

Neurological Issues in ElderCare

Part of the… ElderCare: Healthcare for the Aging Series © 2002, 2007 TCHP Education Consortium This educational activity expires December 31, 2017 All rights reserved. Copying without permission is forbidden

TTCCHHPP Education Consortium

Neurological Issues in ElderCare © TCHP Education Consortium, 2007

Purpose Statement The purpose of this home study is to review how the neurological system changes with aging and how diseases of this system are treated.

Target Audience This home study was designed for nurses with no familiarity with neurological system changes in the elderly and how diseases of this system are treated; however, all health care professionals are invited to complete this packet.

Content Objectives 1. Review normal neurological changes that occur

with aging.

2. Discuss the treatment for diseases of neurologic conditions.

Disclosures In accordance with ANCC requirements governing approved providers of education, the following disclosures are being made to you prior to the beginning of this educational activity:

Requirements for successful completion of this educational activity: In order to successfully complete this activity you must read the home study, complete the post-test and evaluation, and submit them for processing.

Conflicts of Interest

It is the policy of the Twin Cities Health Professionals Education Consortium to provide balance, independence, and objectivity in all educational activities sponsored by TCHP. Anyone participating in the planning, writing, reviewing, or editing of this program are expected to disclose to TCHP any real or apparent relationships of a personal, professional, or financial nature. There are no conflicts of interest that have been disclosed to the TCHP Education Consortium.

Relevant Financial Relationships and Resolution of Conflicts of Interest:

If a conflict of interest or relevant financial relationship is found to exist, the following steps are taken to resolve the conflict:

1. Writers, content reviewers, editors and/or program planners will be instructed to carefully review the materials to eliminate any potential bias.

2. TCHP will review written materials to audit for potential bias.

3. Evaluations will be monitored for evidence of bias and steps 1 and 2 above will be taken if there is a perceived bias by the participants.

No relevant financial relationships have been disclosed to the TCHP Education Consortium.

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sponsorship received in support of the educational activity,

• Any relationships with commercial interests noted by members of the planning committee, writers, reviewers or editors will be disclosed prior to, or at the start of, the program materials.

This activity has received no commercial support outside of the TCHP consortium of hospitals other than tuition for the home study program by non-TCHP hospital participants.

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Expiration Date for this Activity:

As required by ANCC, this continuing education activity must carry an expiration date. The last day that post tests will be accepted for this edition is December 31, 2017—your envelope must be postmarked on or before that day.

Planning Committee/Editors Linda Checky, BSN, RN, MBA, Assistant Program Manager for TCHP Education Consortium.

Lynn Duane, MSN, RN, Program Manager for TCHP Education Consortium.

Author Susan Bot, BSN, RN, CRRN, Nursing Instructor in Extended Care and Rehabilitation at the Minneapolis VA Medical Center

Content Experts *Susan Bot, BSN, RN, CRRN, Nursing Instructor in

Extended Care and Rehabilitation at the Minneapolis VA Medical Center.

Karen Poor, MN, RN, Former Program Manager for the TCHP Education Consortium

*Denotes reviewer of current edition

Contact Hour Information

For completing this Home Study and evaluation, you are eligible to receive:

1.0 MN Board of Nursing contact hours / 0.83 ANCC contact hours

Criteria for successful completion: You must read the home study packet, complete the post-test and evaluation, and submit them to TCHP for processing.

The Twin Cities Health Professionals Education Consortium is an approved provider of continuing nursing education by the Wisconsin Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Please see the last page of the packet before the post-test for information on submitting your post-test and evaluation for contact hours.


Introduction This self-instruction will inform professionals about the different neurological issues in the elderly. It will include sensory deficits, memory loss, Parkinson’s disease, transient ischemic attacks, and cerebrovascular accidents.

Vision Issues Since you were 10, your eyes have slowly been losing their ability to focus on objects up-close. This transformation goes completely undetected for years, until one day, in your mid 40's, you find yourself holding a menu at arm’s length to order lunch. Names in the phone book start to blur. Soon, recipes, price tags, and golf scorecards are more difficult to decipher. You start cleaning your glasses a couple of times a day. You’ve been “presbyopized.” It’s when your arms start to shrink and you start holding everything farther and farther out. The older you get, the more susceptible you also become to age-related eye diseases such as glaucoma and cataracts. While you can’t do much to prevent them, early detection and treatment can often slow their progress.

Glaucoma Over 2 million people in the US have glaucoma and of that 2 million 80,000 people are legally blind. It is the leading cause of preventable blindness in the US and the most frequent cause of blindness in African-Americans, who are at about a three-fold higher risk of glaucoma than the rest of the population (Gale Encyclopedia of Medicine, 2002).

Glaucoma results from a blockage in the drainage of the fluid (the aqueous humor) in the anterior chamber of the eye. Normally this fluid drains through a canal and is transported to the venous circulation system. If the fluid is formed faster than it can be eliminated, an increase in eye pressure results. Pressure is then transferred to the optic nerve, where irreversible damage, possibly even total blindness, can result (Leuckenotte, 2000). Translated: Think of a water dam. The huge dam (or blockage) holds back all the water (aqueous humor). The spring rains cause an increased

pressure on the dam (optic nerve), which causes the dam to break under the excess water load.

There are 3 types of glaucoma:

Chronic Open-Angle Glaucoma

This is the most common type of glaucoma and makes up 90% of glaucoma cases. It occurs by degeneration changes in the canal, which in turn obstructs the escape of aqueous humor, resulting in increased intraocular pressure.

This type of glaucoma can damage vision so gradually and painlessly that a person is unaware of a problem until the optic nerve is badly damaged. Visual loss begins with deteriorating peripheral vision.

Angle-Closure Glaucoma

This type is acute glaucoma that occurs suddenly as a result of complete blockage. It requires prompt medical attention to avoid severe vision loss or blindness.

Signs and symptoms that occur rapidly are:

Severe eye pain Redness in the eye Clouded or blurred vision Nausea and vomiting Rainbow halos surrounding lights Pupil dilation

Secondary Glaucoma

This type occurs when there is an eye injury or other specific conditions, such as medication use (ie. steroids), tumors, inflammation, or abnormal blood vessel which all of these cause damage to the drainage angle.

Treatment Treatment is focused mainly on pharmacologic management. Miotic drugs, such as pilocarpine, cause the pupil to contract and the iris to draw away from the cornea, allowing fluid to drain. Carbonic anhydrase inhibitors (e.g. Diamox) decrease production of aqueous humor. Topical

medications such as Trusopt decrease production of


aqueous humor. If taking more than one topical drug, the drugs should be administered at least 10 minutes apart.

Surgical procedures that may be done include laser trabeculoplasty and trabeculectomy surgery.

Prognosis is good if glaucoma is detected before vision loss occurs. Diagnosed patients need to follow a prescribed medication regimen daily for the rest of their lives. Once visual loss occurs, it is irreparable.

Cataracts Cataracts are the most common disorder found in the aging eye. They occur in 65% of patients ages 50-59 and in 100% in patients older than 80 (Lueckenotte, 2000). The occurrence of cataracts with accompanying visual loss increases with advancing age.

A cataract is a clouding of the normally clear and transparent lens of the eye. Normally the lens focuses light on the retina to produce a sharp image. When a cataract forms the lens can become so opaque that light cannot be transmitted to the retina. The lens is made up of 35% protein and 65% water. As people age, degenerative changes in the lens’ proteins occur. Changes in the proteins, water content, enzymes, and other chemicals are some of the reasons for the formation of a cataract.

Symptoms of cataracts include: Gradual, painless onset of blurry, filmy, or

fuzzy vision Poor central vision Frequent changes in eyeglass

prescription Changes in color vision Increased glare from lights,

especially oncoming headlights when driving at night

Poor vision in sunlight Presence of a milky whiteness in the pupil as

the cataract progresses

Treatment No treatment is necessary if the patient is only having minor or no visual changes. The patient will need continued monitoring for changes in the cataract. A new prescription may be required for increased strength of glasses or contact lenses.

Cataract surgery is the only option to correct the eye. It is only used when the vision interferes with normal ADLs, especially reading and driving.

Surgery to remove cataracts is performed on an outpatient basis. A local anesthetic is used and the procedure lasts for about an hour. There are three types of cataract surgery:

• Extracapsular cataract extraction. This type of cataract extraction is the most common. The lens and the front portion of the capsule are removed. The back part of the capsule remains, providing strength to the eye.

• Intracapsular cataract extraction. The lens and the entire capsule are removed. This method carries an increased risk for detachment of the retina and swelling after surgery. It is rarely used.

• Phacoemulsification. This type of extracapsular extraction needs a very small incision, resulting in faster healing. Ultrasonic vibration is applied to the lens to break it up into very small pieces, which are then aspirated out of the eye with suction by the ophthalmologist.

♦ A replacement lens is usually inserted at the time of surgery. A plastic artificial lens called an intraocular lens (IOL) is placed in the remaining posterior lens capsule of the eye

♦ Contact lenses and cataract glasses are prescribed if an IOL was not inserted.

♦ A folding IOL is used when phacoemulsification is performed to accommodate the small incision.

♦ Antibiotic drops to prevent infection and steroids to reduce inflammation are prescribed after surgery.


Patient Education Post Cataract Surgery Avoid rubbing or pressing on eye

Avoid bending at waist or lifting heavy objects for 1 month

Avoid straining with bowel movements

Avoid taking showers and shampooing hair as instructed by physician

Limit reading (back and forth movement may loosen stitches)

Hearing Loss Another sensory deficit in the elderly includes hearing loss. Hearing loss is so common that many accept it as inevitable. One in three people older than 60 and half of all people older than 85 have significant hearing loss (www.mayoclinic.com/health/aging). Hearing loss is not a normal part of the aging process and should be further evaluated for proper treatment.

Age-related changes in the external ear can be seen in the auricle, which appears larger because the ear’s cartilage formation continues and loss of skin elasticity. The auditory canal narrows as a result of inward collapsing. The hairs lining the canal become coarser and stiffer. In addition, cerumen glands atrophy, causing the cerumen (earwax) to be much drier. In the middle ear, the tympanic membrane results in a dull, retracted, and gray appearance. Finally, changes within the inner ear result in decreased vestibular sensitivity.

Patients often deny their hearing loss and need much encouragement and support to explore the various methods to improve hearing. Some sign and symptoms of hearing loss are:

Increased volume on TV or radio

Tilting head toward person speaking

Cupping hand around one’s ear

Watching speaker’s lips

Speaking loudly

Not responding when spoken to

Types of Hearing Loss Conductive-results from interruption of the

transmission of sound through the external auditory canal and middle ear. Causes of conductive hearing loss are:

-cerumen impaction

-otitis media

-otosclerosis (fixation of auditor ossicles)

Sensorineural-results when the inner ear, auditory nerve, brainstem, or cortical auditory pathways do not function properly so those sound waves are not interpreted correctly.

Mixed-is a conductive hearing loss superimposed on a sensorineural hearing loss.

The most common form of hearing loss in older adults is presbycusis. This hearing loss is a sensorineural type of loss. Changes in the structure and function of the inner ear make it difficult to understand certain types of speech sounds and produce an intolerance for loud noise. The sounds that are usually lost first are f, s, th, ch, and sh. As hearing loss progresses, the ability to hear the sounds of b, t, p, k, and s is also impaired. Typically, the loss is bilateral, resulting in difficulty hearing high-pitched tones and conversational speech. It affects men more than women. The cause of presbycusis remains unclear. Studies designed to identify a direct cause have proven no clear correlation. Therefore the diagnosis is one of exclusion by ruling out other causes of hearing loss. Other causes of hearing loss include the following:

Noise induced hearing loss

Infection

Head injury

Metabolic disease (of the kidneys or diabetes)

Vascular disease

Heart disease

Genetic factors


Treatment for Hearing Loss

• Hearing aides-amplify sound but do not improve the ability to hear.

• Auditory training-teaches the patient to listen to a speaker by differentiating among gross sounds.

• Speech/reading includes lip reading and speech skills.

• Assisted –listening devices

-Microphones placed close to sound

source

-Amplifiers for the telephone,

television, or radio

-Closed-captioned TV

-Teletypewriters

-Doorbell and telephone that light as

well as ring

-Flashing smoke detectors and alarm

clocks

-Burglar alarms that both light up and

sound

Memory Loss Common memory concerns for older adults include forgetting names, misplacing items, and poor recall of recent events or conversations. Short-term memory may decline with age, but long-term recall is usually maintained. Memory impairment as a sole symptom may be caused by an amnesic syndrome requiring continued monitoring.

The significance of progressive memory loss-the possibility that it represents early Alzheimer’s, particularly in the oldest age group-is now widely recognized and emphasized in the media. Whereas controversy still reigns about whether age-associated memory impairment is a separate syndrome or simply an expression of early Alzheimer’s. The complaint of memory loss (whether from the patient or a family member) must lead to searching questions to find other conditions that may cause it.

There are many techniques for preventing memory loss in itself from ruining a person’s ability to cope with life:

Making lists

Posting reminder notes

Telephone calls to remind of appointments to take medications

Computer-based reminder systems

Have the patient introduce self to the unknown person prompting the other person to say their name

Parkinson’s Disease Parkinson’s disease (PD) affects 10% of those over the age of 65, with the usual age of onset between 55 and 60 years of age. More than 1 million Americans have PD, which makes it one of the most common neurological diseases. One in every 100 persons will have PD by age 55 (Easton, 1999).

The pathology of PD can be briefly summarized as resulting from the death of dopamine-producing neurons in the brain. Dopamine is a critical chemical messenger that controls body movement and balance (Hogstel, 2001). The cause of PD has not been clearly identified. There are several theories. Some of the causes could be genetic, environmental toxins, poisons, viruses, or medications. Drug-induced PD is usually reversible when the cause is removed. Some drugs that have been implicated as potential causes of PD symptoms include prolonged use of tranquilizers such as Thorazine & Haldol, the antihypertensives reserpine & methylodopa, and the GI stimulant Reglan (Hogstel, 2001).

The diagnosis of PD involves a careful medical history and a neurological exam to look for characteristic symptoms. There are no definitive tests, but a variety of lab tests may be done to rule out other causes of symptoms, especially if only some of the identifying symptoms are present. Tests for other causes of Parkinsonism may include brain scans, blood tests, lumbar puncture, and x rays.


Signs & Symptoms

• Tremors: commonly occur at rest, when stressed, or when the arms are stretched in front of the body. They disappear during sleep or activity. The tremor is often described as a “pill rolling” tremor where the thumb and first finger appear to be rolling a pill between them.

• Muscle rigidity and weakness: are present when the limbs are still and are thought to be caused by the constant tension of opposing muscle groups. Early symptoms of rigidity include jerky movements and as the disease progresses, they may develop a masklike face and dysphagia. The voice often becomes softer and difficult to understand.

• Bradykinesia: or slow movements which may involve slowing down or stopping in the middle of familiar tasks such as walking, eating, or shaving. This may include freezing in place during movements.

Treatment

Treatment is based on symptoms, not on cure. Drugs are not begun until symptoms interfere with ADLs. Some of medications used to treat Parkinson’s disease are:

Levo-dopa: it provides raw material to be converted to dopamine.

Sinemet, Atamet Madopar, CD/LD: more effective than L-dopa alone but does not slow neuron loss. Over time, action is less predictable and larger doses are needed.

Deprenyl, Eldepryl seligiline: blocks enzymes responsible for the chemical breakdown of dopamine so it remains in the brain longer. May slow neuron destruction and death.

Tolcapone: blocks major enzyme that breaks down L-dopa.

Bromocriptone, pergolide, ropinirole, pramipexole, Lisuril: mimics effect of dopamine.

Amantadine: increases amount of dopamine released with each nerve impulse.

Surgery is reserved for patients whose disease has progressed to later stages. The current surgeries are thalamontomy (destruction of part of the thalamus)

and pallidotomy (motor communications center of the brain).

Transient Ischemic Attacks (TIA’s) A transient ischemic attack or TIA is often described as a mini-stroke. Unlike a stroke the symptoms can disappear within a few minutes. TIA’s are caused by a disruption of blood flow to the brain caused by a blood clot blocking one of the blood vessels leading to the brain.

Symptoms Sudden weakness or numbness on one side of the

body.

Sudden dimming or loss of vision.

Difficulty speaking or understanding speech.

If the symptoms are caused by a TIA, they last less than 24 hours and do not have permanent brain damage. TIA’s can serve as an early warning sign of stroke and require immediate medical attention. At least 10% of all strokes are preceded by a TIA (Easton, 1999).

Treatment Aspirin or other drugs that thin the blood

Carotid endarterectomy to remove fatty deposits within the artery

Changing lifestyle

-Stop smoking

-Eat foods low in fat

-Manage stress

-Control diabetes

Cerebrovascular Accident (CVA) A cerebrovascular accident (CVA) is also called a brain attack or stroke. Stroke is the leading cause of disability in older adults and the third leading cause of death behind heart disease and cancer. Hypertension is the number one risk factor for stroke and is known to be a major chronic health problem for those older than the age of 65 years (Easton, 1999). Stroke is a recurring disease that can have


lifelong effects on the person and the family in every area of life.

Physiology The two main arterial systems that supply the brain are the carotids and the vertebrobasilar arteries. The circle of Willis is a ring of arteries formed by the junction of these major blood vessels that supply the cerebrum. There are four major lobes of the brain. The frontal lobe regulates behavior, emotions, and some motor function. The temporal lobe affects the ability to hear, smell, and taste. The parietal lobe controls sensory and perceptual functions. The occipital lobe affects vision. The speech center is located in the left hemisphere, particularly in the frontal and temporal lobes.

Warning Signs of Stroke

• Numbness/Tingling

• Speech difficulties

• Headache

• Blurred vision

• Dizziness

• Loss of consciousness

• Sudden inability to speak or move

Types of Strokes

Thrombotic

This type is the most common type of stroke. It means a blockage originating in the brain. This is caused by atherosclerosis and narrowing of the arterial lumen, which can also be referred to as stenosis. These causes are associated with modifiable risk factors. Most strokes are a result of local thrombotic occlusion of the carotid or cerebral arteries, resulting in brain infarction in the areas supplies by those vessels.

Embolic

This type of stroke is often the result of heart disease. Those persons with atrial fibrillation or flutter are more likely to experience a stroke. When no other cause of stroke is immediately apparent, the patient’s

cardiac history should be suspected. With atrial fibrillation, the heart does not maintain a normal sinus rhythm, allowing tiny clots to form. These may break off and travel to the brain as emboli, resulting in stroke. Other causes of embolic stroke include fat or tumor cells, sepsis, endocarditis, and deep vein thrombosis.

If a stroke due to clot or thrombus has occurred within 3 hours, and the patient has no contraindications, a tissue plasminogen activator (tPA) may be administered. The tPA has the potential to dissolve the clot that caused the stroke and potentially quickly restore cerebral blood flow. After tPA the patient is started on IV heparin. If the patient did not receive treatment until after 3 hours, the following treatments may be used. Surgical treatment may include a carotid endarterectomy to remove blockage in the carotid artery. Anticoagulant therapy, including heparin or Coumadin may be initiated. The initial treatment for a brain attack is maintenance of life support functions by preventing aspiration and reducing intracranial pressure.

Hemorrhagic

Hemorrhagic stroke occurs when a blood vessel in the brain leaks or bursts. A rupture or leaking aneurysm or hypertension can be causal factors. This type of stroke usually occurs without usual warning signs, but the person may present with a sudden onset of severe headache, followed quickly by symptoms of stroke. Hypertension is considered the number one risk factor for stroke; over time it weakens the vessel walls, making the person more likely to experience a stroke of this kind. Diagnostic tests may include a lumbar puncture to detect blood in the spinal fluid, a sign that the stroke is caused by hemorrhage. A CT scan or carotid angiography could also be used.

Uncontrollable Risk Factors for Stroke Age

Gender

Race

Heredity


Modifiable Risk Factors for Stroke

Hypertension

Cholesterol

Smoking

Obesity

Stress

Diabetes

Prognosis Multiple reasons for brain attacks account for the resulting differences in severity and symptomology. Recovery is affected by the severity of the brain attack. If a brain attack was severe, with maximum neurologic deficits at onset, the symptoms do not disappear. A high percentage of mortality occurs in the first month following a brain attack. Recovery may take several months, depending on the extent of brain damage. Few brain attack survivors live 10 years (Lueckenotte, 2000).

Nursing Care of the Stroke Patient o Encourage use of affected side to reduce neglect

o Use a variety of teaching modalities during educational sessions to promote learning

o Minimize distractions during educational times. Keep sessions short & relevant

o Use terms such as “affected/unaffected” side or “weak/strong” side instead of “good/bad” side

o When a patient is alone place items like a call light or tissues on the unaffected side to promote self-care and safety and to avoid isolation

o Alternate rest & activity

o Build endurance slowly. Remember, a stroke is exhausting to the patient

o Include patient and family in the plan of care

o Assist the patient and family in setting reasonable goals

o Make early referrals to stroke services

o Connect family with a stroke support group or club

Left Hemisphere Stroke Deficits • (R) hemiparesis or hemiplegia • (R) Homonymous hemianopia (visual loss in the

nasal half of one eye and the temporal half of the other)

• Aphasia (especially expressive) • Reading/writing problems • Dysarthria • Dysphagia • Anxious when trying new tasks • Tends to fret & worry • Slow, cautious behavior • Easily frustrated • Memory deficits related to language

Right Hemisphere Stroke Deficits • (L) Hemiplegia or hemiparesis • (L) Homonymous hemianopia • Difficulty with spatial-perceptual tasks • Difficulty following multi-step directions • Difficulty writing • May not acknowledge or accept limitations • May overestimate abilities • Impulsive • Quick & often care less movements • Anosognosia or (L)-sided neglect • Socially indifferent • Sometimes euphoric, with inappropriately low

anxiety • Higher risk for falls because of lack of safety

awareness • Deficits less easily recognized by others • Memory deficits related to performance

Common Characteristics of Both Sides • Emotional lability • Some memory impairment • Depression • Weakness/paralysis • Sensory deprivation or alteration • Social isolation • Fatigue


• Insomnia

Think about it: If you were forced to have a CVA, which would you rather have, a (R) hemisphere CVA or have a (L) hemisphere CVA? Would you be the one to have a (R) side and be impulsive and socially indifferent? OR Would you be the one to have a (L) side and be cautious and have difficulty communicating?

Summary In summary, elderly people can have several neurological changes related to aging. Including hearing, vision, memory, and strokes. We hope that you can take this information from this packet and incorporate it into your practice when caring for the elderly patients.

References 1. Burke, M.M. & Walsh, M.B., (1997).

Gerontologic Nursing Wholistic Care of the Older Adult. St. Louis: Mosby.

2. Easton, K.L., (1999). Gerontological Rehabilitation Nursing. Philadelphia: W.B. Saunders Company.

3. Hogstel, M.O., (2001). Gerontology Nursing Care of the Older Adult. United States: Delmar Thomson Learning.

4. http://www.findarticles.com Gale Encyclopedia of Medicine 7/5/02

Recommended Reading 1. American Nurses Association. Scope and

Standards of Gerontological Nursing Practice, 2nd ed. Washington, DC: ANA, 2001.

2. Ebersole P, Hess P. Geriatric Nursing & Healthy Aging. St. Louis: Mosby, 2001.

3. Eliopoulos C. Manual of Gerontologic Nursing, 5th ed. Philadelphia: Lippincott, 2001.

4. Fulmer T, Foreman MD, Walker M, eds. Critical Care Nursing of the Elderly, 2nd ed. New York: Springer Publishing Co.; 2001.

5. Hogstel MO, Zembruski CD, Wallace M. Gerontology: Nursing: Care of the Older Adult. Albany NY: Delmar, 2001.

6. Lueckenotte A. Gerontologic Nursing, 2nd ed. St. Louis: Mosby, 2000.

7. Maas ML, Buckwalter KC, Hardy MA et al. (eds.). Nursing Care of Older Adults: Diagnosis, Outcomes, and Interventions. St. Louis: Mosby, 2001.

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1. The most common type of glaucoma is: a. Angle-Closure Glaucoma

b. Chronic Open-Angle Glaucoma c. Secondary Glaucoma d. Primary Glaucoma

2. After cataract surgery, the patient should be

instructed to follow these precautions except:

a. Avoid rubbing or pressing on eye b. Limit reading c. Strain to have a BM d. Avoid bending at waist

3. Which type of hearing loss is caused by cerumen impaction? a. Conductive

b. Sensorineural c. Mixed d. Genetic

4. Signs of Parkinson’s Disease could include: a. Tremors

b. Muscle rigidity c. Bradykinesia d. All of the above

5. At least 10% of all strokes are preceded by a transient ischemic attack (TIA).

a. True b. False

6. Some of the warning signs of stroke are:

a. Headache b. Blurred vision c. Dizziness d. Numbness/Tingling e. All of the above

Expiration date: The last day that post tests will be accepted for this edition is December 31, 2017—your envelope must be postmarked on or before that day.


Evaluation: Neurological Issues in ElderCare Please complete the evaluation form below by placing an “X” in the box that best fits your evaluation of this educational activity. Completion of this form is required to successfully complete the activity and be awarded contact hours.

At the end of this home study program, I am able to: Strongly Agree

Agree Neutral Disagree Strongly Disagree

1. Review normal neurological changes that occur with aging.

2. Discuss the treatment for diseases of neurologic conditions.

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Expiration date: December 31, 2017

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