Chapter 11

1. Chapter 11 The Older Patient

2. Learning Objectives • Describe the roles of the gerontological nurse. • Determine the extent to which selected myths and stereotypes about older adults are factual. • Describe the biologic and physiologic factors associated with aging. • Explain the psychosocial factors associated with aging. • Describe modifications needed for activities of daily living. • Explain why drug dosage adjustments may be needed for older persons.

3. Definitions of Old Age Most definitions = having lived a long time Aged: defined as old or advanced in years Aging: process of growing older or more mature We all age, but not all of us are old in years, roles, behaviors, health, or physical limitations Aging is an ongoing developmental process that begins at conception and ends in death

4. Gerontology The study of aging

5. Geriatrics The biomedical science of old age and the application of knowledge related to the biologic, biomedical, behavioral, and social aspects of aging to the prevention, diagnosis, treatment, and care of older persons

6. Roles of the Gerontologic Nurse Formal preparation for care of older adults occurs at the master’s degree level Also nursing personnel who have demonstrated competencies as a result of on-the-job training Employment settings for licensed vocational or practical nurses have shifted from traditional hospital-bound positions to a range of community-based long-term care facilities and home health care positions

7. Gerontologic Nurse Professional nurses and advanced-level practitioners, clinical specialists, and nurses holding national certification Incorporates basic nursing methods and specialized knowledge about the aged Increase healthy behaviors in the aged Minimize and compensate for health-related losses and impairments of aging Provide comfort through the distressing and debilitating events of aging, including dying and death Diagnose, care, and treat disease in the aged

8. Ageism Systematic stereotyping and discrimination against people because of their age, most often directed toward older adults Allows for separation and denial of the older person’s humanness Allows those who practice ageism to distance themselves from their own aging Influences the behavior of its victims

9. Biologic and Physiologic Factors in Aging Despite intense interest in longevity by so many cultures, scientists do not agree on precisely why or how humans age Knowledge of the underlying mechanisms of aging is critical to develop a system that considers the special needs and health conditions of an aging population

10. Theories of Aging Theories of aging ranged from the concept of purely genetic control of aging to environmental assaults that result in death Most experts now believe that aging is not explainable by a single theory but represents many processes working simultaneously

11. Error Theories Based on the belief that the rate of aging is directly related to the organism’s rate of living and that external events cause damage to the organism’s cells The damage from all causes accumulates over time, resulting in cellular, molecular, and organ malfunction or errors

12. Programming Theories Based on belief that aging is programmed into cells and is internal to the organism These theories postulate that aging, like prenatal development and menopause, is the natural and expected result of a purposeful sequence of events written internally into gene structure

13. Physiologic Changes in Body Systems

14. Nervous System Essential to know that in the absence of disease, most aged people remain alert, with functional intellectual capability, sound judgment, creativity Only modest impairments in memory and learning after age 70 in most people who are relatively free from major disease Changes may result in a progressive slowing of responses, problems with short-term memory, and altered learning

15. Nervous System Short-term memory loss frequently a concern of the aged; long-term memory may remain intact Stimulus input into the neurons; dependent on adequate tissue oxygenation May not remember planned daily events but easily recall young adulthood experiences Mild cognitive impairment (MCI) Persistent memory problems with otherwise normal cognitive function 40% will develop Alzheimer’s disease within 3 years; others do not progress to more serious impairment

16. Nervous System Strategies to cope with memory problems Mnemonics Stringing together known and unknown information Rehearsal memory training Repetition Temperature regulation Low tolerance for extremes in temperature Pain perception and tactile sensation Some researchers have found dulling of pain and tactile sensation in older persons, but these results are not consistent

17. Respiratory System Forced vital capacity, vital capacity, and maximum breathing capacity thought to decrease progressively with aging Atrophy/weakening of respiratory muscles Increase in the anteroposterior diameter of the chest as a result of kyphosis Vertebral loss of calcium Calcification of costal cartilage

18. Respiratory System Loss of elastic tissue surrounding alveoli and alterations in pulmonary circulation result in decreased diffusion across the alveolar-capillary membrane Pulmonary blood flow Decreases because of a reduction in cardiac output Pulmonary diffusion Thickened capillary walls, and fewer capillaries surrounding the alveoli cause impaired gas exchange

19. Respiratory System Exertional dyspnea Shortness of breath with exertion A frequent complaint with the older adult Ability to perform prolonged strenuous work decreases with aging Lung disease: acute or chronic Poses a threat to the older adult Pulmonary secretions handled less effectively

20. Cardiovascular System Resistance to blood flow in many organs increases as people age Aging results in the development of whitish patches, fibrosis, and sclerosis in the endocardium The heart becomes more rigid and myocardial contractility is compromised

21. Cardiovascular System Coronary blood flow may be reduced by as much as 35% because of changes in the vessels Valvular rigidity and incomplete closure of aortic and pulmonic valves may result in murmurs Heart cells have a decreased capacity to use oxygen, which may help explain the aged person’s reduced tolerance for physical work Pulse increases and the pulse pressure widens

22. Cardiovascular System Decrease in resting cardiac output Amount of blood pumped each minute Between ages 25 and 65, resting cardiac output falls 30% to 40% Reduced cardiac output reflects a decreased heart rate and decreased stroke volume Cerebral blood flow maintained, but other body systems, such as the liver and kidneys, receive a diminished blood supply

23. Renal System Kidneys decrease in renal function; decrease in cell mass, and an increase in extracellular fluid Decreases in filtration rate, plasma flow rate, and tubular reabsorption and secretion Blood urea nitrogen tends to increase Ability to concentrate or dilute urine is diminished The bladder capacity may be reduced by half

24. Renal System Response to the stretch receptors in the bladder wall that signal the need to void may be delayed until the pressure is high and the bladder almost filled to capacity Lax muscle tone may lead to incomplete emptying of the bladder Residual volume may cause subsequent urinary tract infections

25. Renal System Incontinence May appear as a symptom of upper or lower urinary tract dysfunction Conservative behavioral treatment is recommended as the first level of intervention Behavioral treatments: scheduled or prompted voiding, environmental adaptation, and pelvic muscle exercises (Kegel exercises)

26. Integumentary System Skin changes can be the most distressing to the older person because they are so visible Skin changes include dryness, loss of elasticity, wrinkles, uneven pigmentation and brown spots, roughness, looseness, thinness, and the development of various skin lesions

27. Integumentary System Wrinkles Occur when the deep layer of the skin loses moisture and elasticity Tiny creases and folds are formed Extent and timing determined by genetics and sun exposure Persons in certain ethnic groups with thicker, oilier skin wrinkle at a slower rate; maintain a youthful, wrinkle-free appearance longer

28. Integumentary System Itching Related to loss of oils in the skin Suggest tepid baths, using moisturizers liberally, avoiding overuse of antiperspirants, soaps, perfumes, and hot baths Generalized itching should be reported to the health care provider; may be sign of diabetes, cancer, kidney disease, or liver disease

29. Integumentary System Hair loss, hair thinning, and color changes Men tend to grow bald, and women experience thinning of the hair on the head and genitalia The number of facial and nasal hairs may increase Gray hair is caused by a slowing of the pigment production in the hair follicles Determined by genetics and tends to be irreversible Nails Become yellow and thicker

30. Gastrointestinal System Oral cavity Deterioration in the teeth and a decrease in the functional taste buds Decrease in saliva secretion Related to medications, inadequate hydration, and illness states rather than normal aging change Saliva tends to become more alkaline as the salivary glands secrete less ptyalin and amylase

31. Gastrointestinal System Muscles associated with chewing weaken, peristalsis is slower, and the risk of formation of intestinal diverticula increases Gastric emptying is slower Gastric glands decrease the volume and concentration of hydrochloric acid, intrinsic factor, and pepsin Less amount of calcium absorbed

32. Gastrointestinal System Constipation Frequent gastrointestinal complaint From decreased intestinal motility, altered bacteria flora, a diet low in bulk and roughage, medications, lack of physical activity Educate about diet, activity, increased fluid intake, and avoidance of laxative abuse

33. Musculoskeletal System Arthritis The most prevalent chronic disease in men More severe in women Leading cause of disability Osteoarthritis Most common form of arthritis Caused by damage to the inside surface of the joint Age, heredity, and obesity contribute to development Large weight-bearing joints (knees, hips, spine) are most affected

34. Musculoskeletal System Kyphosis Curvature of the thoracic spine that gives rise to the bent-over appearance of some older adults Teach benefits of weight-bearing exercises Walking, bicycling, and stair climbing help maintain bone and muscle mass Assistive devices for walking and preventing falls Avoid too much bed rest because of the detrimental effects of immobility

35. Figure 11-1

36. Sensory System Presbycusis Hearing loss associated with age 25% of adults older than age 69, and half of adults older than age 85 are hearing impaired Conduction deafness Blockage of the ear canal caused by excessive wax buildup, abnormal structures, or infection Sensorineural deafness Damage to nerve tissue as a result of exposure to loud noises, disease, and certain drugs

37. Sensory System Macular degeneration Affects the macula, the part of the eye responsible for sharp central vision Cataract Clouding or opacity of the normal transparent lens within the eye Surgical removal of the clouded lens

38. Sensory System Presbyopia Affects the shape of the lens Reading and other close work become difficult Glaucoma Atrophy of the optic nerve usually associated with elevated pressure of the fluid in the eye Optic nerve carries visual impulses from the eye to the brain

39. Sensory System Chemosensory disorders Involves taste and smell Causes: nasal obstruction, allergies, certain drugs Some scientists believe that the decline in smell is due to a decrease in olfactory nerve fibers Major changes in ability to taste most often caused by diseases or side effects of certain drugs Dentures, hormonal changes, medications, and changes in chemicals needed to transmit taste are causes of older person’s diminished sense of taste

40. Psychosocial Factors Associated with Aging Older adults show cumulative developmental effects that produce unique personality styles, coping mechanisms, challenges, and growth That a person has survived to old age is one marker of successful adaptation Effective adaptation: meeting environmental and functional needs; attaining sense of well-being Maturity: optimal psychological, social, and biologic adaptation achieved during midlife years, arbitrarily set between 45 and 65 years of age

41. Figure 11-2

42. Psychosocial Factors Associated with Aging Movement toward Erikson’s ego integrity is facilitated when the older person Recognizes and accepts changes in physical and mental capabilities Gives up some roles and develops new ones Develops new activities that can be carried out successfully with aging Develops a different self-concept Revises life goals Adapts to new lifestyles

43. Coping and Adaptation Old age has been described as the season of losses Roles, statuses, physical abilities, and deep personal losses through the deaths of friends and the disruption of family networks Real, threatened, or imaginary loss a stressor; requires adaptation, flexibility, and resiliency to cope successfully

44. Coping and Adaptation The older person may cope with these losses with positive or negative adaptation Positive adaptation Include rational action, perseverance, positive thinking, intellectual denial, restraint, drawing strength from adversity, and humor Negative adaptation Lose sense of personal identity and fulfillment and suffer from deterioration in self-esteem, an altered self-concept, and a loss of meaningfulness in life

45. Coping and Adaptation: Family Most older adults in the U.S. occupy a variety of family roles; come from multigenerational units Marital relations and the relationships between parent and child seem to be most important Although family responsibility appears to be an internalized value for most people, it is important to know that more than half of the states have legal statutes that can require children to provide financial support for needy parents

46. Coping and Adaptation: Family The combination of personal limitations, competing roles, and stresses generated by the care recipient’s behavior and the physical demands created by various levels of emotional, physical, financial, and family strain places enormous stress on informal caregivers Caregivers frequently report symptoms of depression, anxiety, helplessness, low morale, and emotional exhaustion

47. Coping and Adaptation: Family In part because of caregiver stress, more than 1 million older adults are abused physically and psychologically or are neglected each year by their caregivers Education for learning and positive adaptive behaviors can assist caregivers and recipients Families must be part of the holistic approach in the assessment and care of the aged

48. Functional Assessment Activities of daily living; environmental, financial, family, economic, and community resources Data useful during times of health, at the onset of illness, at the beginning of treatment, and following therapeutic interventions Knowing what activities an individual performs alone, what activities require assistance, and what activities the person is totally unable to perform or to perform safely is essential to define care needs

49. Functional Assessment The older person’s database should describe both basic and instrumental activities of daily living Basic Grooming, bathing, dressing, eating, elimination, and mobility Instrumental Prepare a meal, shop for groceries, use the telephone, negotiate transportation, take medications, housekeeping and laundry tasks

50. Drug Therapy and Older Adults 88% of older adults who reside in the community use 1 or more medications In long-term care facilities, more than 75% receive 4 or more medications and 33% receive 7 to 10 medications Age- and disease-related changes slow the clearance of drugs, which increases the risk of adverse effects