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Gerontological & Community Based Nursing:

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1 Gerontological & Community Based Nursing:
Physiologic Changes of Aging

2 Physiologic Changes of Aging
Biological Theories Normal Aging changes Common Pathologic conditions

3 Aging Aging starts at birth Continues throughout life span
It is: universal, progressive, intrinsic, and unavoidable

4 Biologic Theories of Aging
Genetic Theory Stochastic theories Nonstochastic theories

5 Genetic Theory Aging is an involuntarily process Occurs over time
Alters cellular or tissue structures (belief that life-span, longevity changes are predetermined) Includes DNA theory, Error and Fidelity theory, Somatic Mutation and Glycogen theories. Eg. ↑cancers & autoimmune d/o’s in aging suggest errors in mutation at molecular & cellular levels.

6 Error (Stochastic) Theories
Error (Stochastic): Aging occurs randomly and progresses over time. Error- DNA/RNA transcription causes failure of cellular activity –lead to aging and cell mutation or death.

7 Three types of Error theories
Wear & Tear – Accumulation of metabolic waste → products/nutrient deprivation damage to DNA synthesis→ cells, tissues, organs or body systems deteriorate & malfunction with repeated use of body in specialized functions. Wear & Tear Accumulation of metabolic waste products/nutrient deprivation damages DNA synthesis→ cells, tissues, organs or body systems deterioration & malfunction; repeated use of body in specialized functions.

8 Cross-Link Theory Cross –Link Theory-
Cellular division threatened by radiation or chemical reactions A cross-link agent attaches self-to DNA stands With accumulation over time → dense aggregates form Intracellular transport impaired – Results in systems & organ failure Effect of cross linking of collagen (important connective tissue in lungs, heart, blood vessels and muscle) is the reduction in tissue elasticity --associated with many aging changes.

9 Free Radical Theory Free Radical –
Reactive molecules with an extra electrical charge from Oxygen molecules Oxidation of fats, proteins and carbohydrates creates free radicals These attach to other molecules -proteins, enzymes & DNA and damage them –creating genetic disorders Random damage accumulates, aging results, and eventually death of the “damaged” person. Antioxidants (vitamins B carotene, A,C,E,) can counteract effects

10 Nonstochastic Theories Programmed Aging
Cell aging in is genetically programmed for life. Includes the following: Programmed- “Inner Biological clock” in each cell determines number of replications and eventual death of cell and organism. Immune theory- Alteration in cell is recognized as a foreign body and antibody are produced to fight them just as in autoimmune diseases. Neuroendocrine- Over time, the ability of a cell to auto regulate itself becomes altered or lost resulting in aging and death. Neuroendocrine theory – Specialized VB lymphocytes (humoral) and T lymphocytes (cellular)- protect against infection/other foreign matters. Cells in the immune system –progressively more diversified with age in predictable fashion—lose their ability to self-regulate.

11 Normal Changes of Aging: Integument

12 Normal Changes of Aging: Integument
largest most visible organ of the body; protects, identifies us, temp. regulation & security Integumentary- Skin Changes due to intrinsic and extrinsic factors such as: _____________ Extrinsic causes: cigarette smoking Exposure to sun Harsh weather Intrinsic Genetics The degree and rate of aging in the skin are influenced by genetic and environmental factors, such as cigarette smoking and irradiation from the sun; however, drying and thinning of the skin along with a loss of elasticity are typical. Changes in the production of melanocytes are reflected in the appearance of moles, freckles, lentigo, and seborrheic keratosis. There is an increased risk for skin cancer and, because the inflammatory response is slower, impaired wound healing. Sensitivity to cold occurs because of a loss of fat in the subcutaneous tissue. Diminished activity in sweat glands, necessary to cool the body by evaporation, increase the risk for hyperthermia. Decreased sebum production results in a loss of skin protection and increased risk for skin injury and infection.

13 Normal changes of Aging: Hair and Nails
Hair (head) Thinner Coarser Dryer Facial hair Nails Harder, thicker, more brittle, dull and opaque Hair and Nails Hair on the head thins and becomes coarser and dryer. Leg, axillary, and pubic hair in women diminishes or disappears. Women may develop facial hair because of decreased estrogen relative to testosterone. Nails become harder, thicker, more brittle, dull, and opaque.

14 Age related skin changes Change---------------Effect
Flattening of the dermoepidermal junction ↓collagen & elastin ↓ epidermal cell turnover rate ↓vascular responsiveness ↓subcutaneous fat ↓epidermal cells Atrophy of eccrine & sebaceous cells ↓resistence to shearing forces, thinning of skin Wrinkling Prolonged healing time ↓vasodilation (cooling effect) & ↓ transdermal absorption ↓protection-bony prominences & thermporegulation Delayed hypersensitivity response ↓sweating & oil→ ↓thermoregulation

15 Aging process

16

17 Hand & nail changes

18 Normal changes of Aging: Musculoskeletal
Influencing Factors Age Gender Race Environment Average loss: 2 inches between ages 40-80 Musculoskeletal Structure and posture change with a loss of height and vertebral disk thinning. Kyphosis may result because of reduced bone mineral density, which may accelerate into osteoporosis. Muscle mass decreases, and lean tissue is replaced with adipose tissue. Ligaments, tendons, and joints become less flexible. Arthritis is the number-one cause of disability in persons older than 65 years.

19 Normal Musculosketal Aging Changes Change-----------------Clinical Implication
Progressive ↓ height Stiffening of thoracic cage ↓production of cortical & trabecular bone ↓lean body mass w/loss subcutaneous fat Prolonged time for muscular contraction & relaxation Stiffening of joints & ligaments Stooped posture Barrel-chest ↑risk –hip fracture Sharp body contours & ↓muscular strength ↓ reaction time ↑risk for injury

20 Normal changes of Aging: Musculoskeletal
Bone strength/Bone mineral density This graph shows how the bone density of the total hip decreases with age. The units are standardized bone density in (mg/cm2). The lines show the average values, and for each age, race and gender a range of values occurs in the ordinary population. A bone mineral density (BMD) test can help your health care provider confirm a diagnosis of osteoporosis . The test can help in several ways: BMD testing is one of the most accurate ways to assess your bone health. When repeated over time, it can be used to monitor your rate of bone loss. It can detect osteoporosis at its earliest stage, so treatment can begin sooner. If you are being treated for osteoporosis, BMD testing can help your health care provider monitor your response to the treatment.

21 Osteoporosis Kyphosis
Osteoporosis is a condition characterized by progressive loss of bone density, thinning of bone tissue and increased vulnerability to fractures. Osteoporosis may result from disease, dietary or hormonal deficiency or advanced age. Regular exercise and vitamin and mineral supplements can reduce and even reverse loss of bone density.

22 Osteoporosis Affects women 4x more often than men
♀ Estrogen loss after menopause ♂ Long term steroid use

23 Normal Changes of Aging
Ligaments, Tendons, Joints =>rigid, hardened, stiff Arthritis is the #1 cause of disability in elderly

24 Did you know? During the course of your lifetime, your heart will typically beat 2.5 billion times--about once a second, every minute of your life. The heart pumps about five or more quarts of blood a minute, nearly 2,000 gallons of blood throughout your body. A healthy heart is strong enough to drive a single drop of blood throughout your entire body in about 24 seconds

25 Normal Changes of Aging: Cardiovascular System
Presbycardia=normal changes in the healthy heart  stroke volume  cardiac output Left ventricle wall thickens As much as 50% by age 80 Left atrium enlarges (to compensate) Possible development of a fourth heart sound (S4) Cardiovascular Cardiovascular changes include decreased stroke volume and cardiac output. Although the left ventricle wall thickens and the left atrium may increase slightly in size, these changes normally do not affect function and they become significant only in situations when the older adult is challenged by the need for a greater oxygen supply. Cardiovascular disease is the number-one cause of death for elders. Myocardial infarctions are commonly manifested by “silent” symptoms. Because of changes in the peripheral vascular system, many older adults experience isolated systolic hypertension—the result of calcium deposited in the vessels and a loss of elasticity. Increased peripheral resistance occurs at a rate of about 1% per year.

26 Age-related changes Cardiovascular System Cardiac Change -------------------Effect
↑mass & fibrosis ↑thickness –L Ventricle ↑pericardial stiffness Thickened valve leaflets ↓ # of pacemaker cells ↓responsiveness to catecholamines Reduction in ventricular filling→ ↓cardiac output Impaired flow access valves Dysrhythmias common ↓ HR with exercise The maximum heart rate decreases and it takes longer for heart rate and blood pressure to return to normal resting levels after exertion. The aorta and other arteries becomes thicker and stiffer which may bring a moderate increase in systolic blood pressure with aging. In some individuals, this may result in hypertension. The valves between the chambers of the heart thicken and become stiffer. As a result heart murmurs are fairly common among older adults. The pacemaker of the heart loses cells and develops fibrous tissue and fat deposits. These changes may cause a slightly slower heart rate and even heart block. Aberrant heart rhythms and extra heart beats become more common. The baroreceptors which monitor blood pressure become less sensitive. Quick changes in position may cause dizziness from orthostatic hypotension

27 Peripheral Vascular Changes
Arteries become less elastic and more brittle Calcium leaving the bones is deposited in the blood vessels Lumen size of the vessels is d May lead to increased blood pressure

28 Changes in nasal structure ↓in # of submucosal glands
Age-related Changes in the Respiratory System Change Effect Upper Airway Changes in nasal structure ↓in # of submucosal glands ↑obstruction of nasal breathing Thickened mucus gets trapped in nasal pharynx Respiratory In spite of reduced lung capacity and efficiency in ventilation and gas exchange, changes in the respiratory system go unnoticed until demands for oxygen increase, primarily because respiratory muscles weaken and chest wall compliance is decreased. Kyphosis also contributes to decreased expansion. Blood oxygen level remains fairly constant at about 80 mm Hg from the age of 65 to 90 compared with 90 to 95 mm Hg in the younger adult. Diminished elastic recoil makes gaseous exchange more difficult The lungs become stiffer, muscle strength and endurance diminish, and the chest wall becomes more rigid. Total lung capacity remains constant but vital capacity decreases and residual volume increases. The alveolar surface area decreases by up to 20 percent. Alveoli tend to collapse sooner on expiration. There is an increase in mucus production and a decrease in the activity and number of cilia. The body becomes less efficient in monitoring and controlling breathing.

29 Age-related Changes in the Respiratory System Change ----------------------------Effect
Lower Airway ↓ in cilia Calicification of ribs/vertabrae Atrophy of respiratory muscle Enlargement of aveolar duct & resp bronchioles ↑residual vol. ↓tidal vol. ↑ventilation & perfusion ↓in the mucocillary escalator ↓compliance –thorasic cage ↓respiratory effort ↓surface area for gas exchange Prolonged expiration time ↓response to hypoxia & hypercapnia ↑alveolar arterial gradient Gradual decrease in PO2,

30 Kidney changes in aging
↓size & efficiency ↓nephrons ↓blood flow ↓ glomerular filtration rate; renin-angiotensin system ↑arterial pressure ↑NA, H2O retention

31 Age-related Changes in the Renal System Change ----------------------------Effect
Kidney mass ↓ % # glomeruli ↓ 30 to 40 % ↓ hormonal response (vasopressin) & impaired ability to conserve salt ↓Bladder capacity & ↑residual urine and frequency. ↓ ability to filter/ concentrate urine & clear drugs ↑risk for dehydration ↑ risk for fluid & electrolyte imbalances, UTI’s, incontinence, and urinary obstruction.

32 Changes in lower urinary track-bladder Change-----------------------Effect
↓bladder capacity atrophy of bladder pelvic relaxation &reduced estrogen ↑residual volume ↑prostate size ↑urinary retention frequency in urination; ↑involuntary bladder contractions ↑nighttime urine flow rates ↑risk for UTI’s

33 Age-related Changes in the Endocrine System
Insulin resistance ↓ in aldosterone and cortisol Effect may prevent efficient conversion of glucose into energy. may affect immune and cardiovascular function

34 Major Gastrointestinal Changes with Aging Change---------------------------Effect
Decreased peristalsis Increased stomach pH ↓liver function weakened intestinal walls in the colon. ↓ peristalsis of colon reflux and hiatal hernias ↑susceptibility to gastric irritation & ulcers. Drugs metabolized slowly;↓ repair of liver cells. Diverticuli / pain can increase risk for constipation.

35 Age-related Changes in the Female Reproductive System
Ovulation ceases and estrogen levels drop by 95%. Vaginal walls become thinner and lose elasticity Most women experience a decrease in the production of vaginal lubrication.

36 Age-related Changes in the Male Reproductive System
testosterone levels may drop by up to 35%. size of testes decreases. decline in sperm production - the extent varies among individuals. erectile dysfunction (impotence), in occurs in15% of men by the age of 65 ↑to 50% by age 80

37 Age-related Changes in the C N S
Brain is resilient ∆ in cognitive function---NOT normal Delayed neurological function NOT the loss of cognitive function Intellectual performance remains intact Performing tasks may take longer ↓levels of neurotransmitters - choline,acetylase, Catecholamines,↑MAO

38 Age-related Changes in the Neurological System Change-----------------------effects
↓peripheral nerve conduction ↑lipofuscin along neurons ↓thermo-regulation by hypothalamus Differential rate/distribution of dopamine ↓deep tendon reflex w/↑ reaction time ∆ in vasodilation & constriction Heat/cold intolerance Slowing motor movements & fine motor skills

39 ↓neurons in cerebral & cerebellar cortex ↓sensorimotor processing
Age-related Changes in the Neurological System Change effects ↓ neurons in autonomic nervous system ↓neurons in cerebral & cerebellar cortex ↓sensorimotor processing Impaired barorecpetor responsiveness,vaso-constrictor & postural response ↓visual/auditory reaction time;↓Short –memory,↓visual/spatial ↓neurotransmitter coordination ↓reaction time /↑ risk for falls

40 Normal Age-related Changes in the Peripheral Nervous System
 in tactile sensitivity Loss of nerve endings in skin risk for injuries and burns Altered kinesthetic sense (one’s position in space) risk for falling

41 Normal Age-related Changes in the Eyes
Drooping eyelids (senile ptosis)  orbicular muscle strength Arcus senilis Gray/white/silver ring inside the outer edge of iris Decrease in number of goblet cells producing eye lubrication Eyes and Vision With age there is drooping of the eyelids and a decrease in orbicular muscle strength that can result in ectropion or entropion. The appearance of a gray-white ring (arcus senilis) is a normal finding. The eye receives less lubrication, and dry eye syndrome may result.

42 Age related changes of eye

43 Normal Age-related Changes in the Eyes cont’d
Presbyopia-the crystalline lens accumulates tissue built up that becomes stiff →iris muscles work harder to bring near objects into focus ↑ accommodation - light ↑ sensitivity to glare ↓ in pupil size require ↑lighting Presbyopia and diminished peripheral vision accompany aging. Accommodation to changes in level of light slows; there is an increased sensitivity to glare and a need for a greater amount of light to maintain usual visual clarity. Color discrimination is compromised; reds, yellows, and oranges are more easily seen than blues and greens, especially in those who develop cataracts, a common problem. Risk of glaucoma is increased as reabsorption of the intraocular fluid becomes less efficient. Even though changes to the eye take place as a person ages, many older people have good-to-adequate vision. Nevertheless, beginning in the late 30s and early 40s, an individual may begin to notice some changes. She or he may have to hold the paper farther away to read it due to changes in the ability of the lens to change its shape to accommodate to distance. With aging, peripheral vision is reduced. A person may need to turn her or his head to see to the sides. The flexibility of the eye decreases and it takes an older person more time to accommodate to changes in light. Adaptations in lifestyle and behaviors must be made to cope with this change. An individual might give up driving at night. Placing more lights evenly around the room so that the entire room is lit is also helpful. Degeneration of eye muscles and clouding of the lens are associated with aging. Several changes in vision result from this. Older people tend to have trouble focusing on near objects, but eyeglasses may correct this problem. In addition, the ability to see colors changes with age as the lens yellows. Red, yellow, and orange are easier to see than blue and green. This is why fabrics in warmer shades may be more appealing to the older person. Serious vision impairments such as cataracts, glaucoma, and blindness affect between 7% and 15% of older adults. If someone you know must learn to cope with blindness or near blindness, you can play a critical role in helping them maintain their independence. To help a person with any visual impairment, or to make your own life brighter: Light the room brightly and use more than one non-glare light in a room. Use blinds or shades to reduce glare. Keep a night light on in the bedroom, hallway, and bathroom to maintain an equal level of light. Increase lighting on stairwells and steps. Use concentrated light for sewing and reading. Turn lighting away from the television to avoid glare. Provide printed materials with high contrast between the background and lettering. Use contrasting colors in the home, such as colors between the doors and walls, and between the dishes and table coverings. Mark the edge of steps with a brightly colored tape or different colored paint, and paint the handrails. Provide audiotaped books and music for the elder's cognitive stimulation, entertainment, and relaxation. Wear a hat with a wide brim and sunglasses while outside. This will protect the eyes against too much sunlight, which can lead to cataracts. Know the warning signals of possible vision problems, including pain in or around the eyes, excessive tearing or discharge, double vision, dimness or distortion of vision, flashes of light, halos or floating spots, swelling of the eyelids or a protruding eye, changes in eye color, and changes in vision or movement of one eye. Make sure the older person has regular eye exams, including a glaucoma screening, at least once every 1-2 years.

44 Intraocular Changes of Eye

45 Common Diseases Affecting Vision
Cataracts—heredity & advanced age ↑risk high exposure to sunlight, diabetes, hypertension, Kidney disease, eye trauma Glaucoma- 2nd most common eye disease Macular Degeneration Detached Retina

46 Cataracts A cataract is a clouding of the normally clear lens of the eye. It can be compared to a window that is frosted or "fogged" with steam. Common symptoms of cataract include: Painless blurring of vision Glare, or light sensitivity Frequent eyeglass prescription ∆ Double vision in one eye Needing brighter light to read Poor night vision Fading or yellowing of colors

47 Age related eye disorders

48 Age related disorders of eye Cataract

49 Nursing Interventions Post Cataract Surgery
Most common surgical procedure in U.S. Lens is removed-replaced with plastic intraocular lens Patient teaching: Avoid heavy lifting, straining, bending at the waist Can resume activities within a day

50 Intraocular Changes of Eye
Sclera may become yellowish (imitating jaundice) Floaters—bits of vitreous that have broken off the retina Retina becomes dull Glaucoma is a degenerative abnormal condition resulting when intraocular pressure (IOP) becomes higher than what is healthy for the optic nerve Sclera: The sclera forms the posterior 5/6 of the eyeball. In young and middle-aged adults, the sclera is white; in elderly people, it may have a yellowish tinge mimicking jaundice. The change results from dehydration and lipid deposits. Other age-related changes may include yellowing or browning due to exposure to ultraviolet light, wind, and dust; more random splotches of pigment, which often occur in people with a dark complexion; and a bluish cast due to thinning of the sclera that may occur with some diseases (eg, rheumatoid arthritis). Conjunctiva: The conjunctiva is a thin mucous membrane that lines the eyelids and the anterior surface of the eyeball. Its goblet cells produce mucin, which lubricates the eyelids (enabling eyelids to move more smoothly) and provides a protective layer to slow evaporation of the tear film. With aging, the number of mucous cells decreases, contributing to dry eyes. Capillaries in the conjunctivae become more fragile with aging and burst more easily, resulting in pooling of blood in the space between the sclera and the overlying conjunctiva (subconjunctival hemorrhage). Subconjunctival hemorrhages, while alarming in appearance, are benign and resolve without treatment within 2 wk. Limbus: The limbus is the junction between the sclera and the cornea. Although it is only 1.5 to 2 mm wide, the limbus contains the trabecular meshwork and the Schlemm's canal, which are important in maintaining correct intraocular pressure. Aqueous humor: The aqueous humor is a fluid filtrate of blood plasma continuously produced by the ciliary body. It flows around the lens and is reabsorbed through the Schlemm's canal in the limbus back into the blood. The aqueous humor exerts outward pressure (intraocular pressure) that varies throughout the day, being highest in the morning and lowest in the evening (at the resting level). With aging, resting intraocular pressure can rise over time by as much as 25% without damaging vision. The mechanism for this normal increase is unknown, but it may be caused by an increase in the production rate of aqueous humor or a partial obstruction of the Schlemm's canal over time. Glaucoma results if intraocular pressure becomes higher than is healthy for the optic nerve. The composition of aqueous humor does not change with aging. Vitreous humor: The vitreous humor is a clear, gelatinous substance consisting of collagen and sodium hyaluronate that fills the eyeball between the retina and the lens and helps maintain sufficient intraocular pressure to keep the eyeball from collapsing. It is firmly attached anteriorly at the peripheral retina and posteriorly at the optic nerve. The vitreous humor is normally clear, but with aging, discrete opacities (floaters) or structural changes such as cholesterol deposits (synchysis scintillans) may cause glare or a general haziness. With aging, vitreous fibrils become more demarcated, followed by the formation of liquid-filled pockets as the sodium hyaluronate separates from the collagen and liquefies. These pockets eventually enlarge and become confluent because the cortical vitreous also degenerates with aging and disintegrates. The liquefaction of the vitreous and the destruction of the cortex that holds the vitreous in place allow collected fluid to empty into the space between the retina and the vitreous, thereby causing vitreal detachments. If the vitreous liquefies, normal eye movements can produce intermittent tension at the attachment points on the retina. This tugging can stimulate the peripheral retina mechanically, sometimes causing vertically oriented flashing lights, almost always in the far temporal visual field. These flashing lights may not be normal and may indicate that the retina is at risk of detaching. Cornea: The cornea is transparent and forms the anterior 1/6 of the eyeball; it is the most important refractive portion of the eye. Arcus senilis (a deposit of calcium and cholesterol salts appearing as a gray-white ring at the edge of the cornea, 1 to 2 mm inside the limbus) is extremely common after age 60 and has no clinical significance. Corneal sensitivity to touch decreases with aging, with the biggest changes occurring after age 40. The patient does not typically notice the change, and the change is sufficiently small that susceptibility to abrasions is not increased. Iris: The iris comprises 2 sets of muscles that work together to regulate pupillary size and reaction to light. With aging, these muscles weaken, and the pupil becomes smaller (more miotic), reacts more sluggishly to light, and dilates more slowly in the dark. As a result, people > 60 may complain that objects are not as bright (smaller pupils admit less light), that they are dazzled initially when going outdoors (slower pupillary constriction), and that they experience difficulty when going from brighter to darker environments (slower pupillary dilation). If visual acuity is not decreased, the patient should be reassured that these changes are normal. Both pupils should be the same size when they receive equal light. If the pupillary response is absent, the patient may be taking a drug (prescribed or over-the-counter) that causes pupillary constriction or dilation. Unequal pupil size is cause for concern, especially if the pupils were known to be of equal size, because unequal size indicates the possibility of a brain lesion in any number of places, such as the retina or the optic nerve (optic neuritis), the midbrain (pinealoma), the intercalated neuron (Argyll Robertson pupil), the optic nerve (an aneurysm), and the ciliary ganglion or short ciliary nerves (tonic pupil); referral to an ophthalmologist is indicated. Lens: The lens is a transparent, metabolically active mass of proteins and water which, along with the cornea, refracts the light coming into the eye. Lens thickness and surface curvatures are changed by the actions of the ciliary muscle and zonule of Zinn (suspensory ligaments). The lens continuously grows during life, increasing in density and weight and decreasing in elasticity. Between the age of 40 and 50, the lens usually becomes so inelastic that close objects can no longer be brought into focus without the assistance of corrective lenses (presbyopia). The lens may also develop opacities that can cause glare and other visual changes. Retina: The retina becomes less reflective of light with aging. The optic nerves tend to have less distinct margins and may appear slightly paler than they do in younger people because of a loss of capillaries due to small-vessel disease secondary to atherosclerosis. The macula, which in younger people usually has a bright central foveal light reflex, may have no foveal reflex in elderly people. Also, yellowish white spots (drusen) often appear in and around the macula, representing granular subretinal deposits of extracellular material. The retinal layers may become disrupted, resulting in pigmentation showing through and obscuring the view of underlying blood vessels. Unless these macular changes are accompanied by a distortion of edges of objects or a measurable decrease in visual acuity unexplained by other causes, they are not clinically important. Retinal signs of atherosclerosis include slight narrowing of the retinal arteries and an increased light reflex from thickened vessel walls. In addition, the retinal veins may show marked venous indentation (nicking) at the arteriovenous crossings with slight proximal distention. Eyelids: The eyelids are controlled by the orbicularis oculi muscles, which squeeze the eyelids shut. With aging, the muscles in the lower eyelid may decrease in strength, resulting in ectropion (outward and downward turning of the eyelid away from the eyeball). Spasm of the muscles may cause entropion (inward turning of the eyelid margin), especially of the lower eyelid, resulting in trichiasis (the eyelashes contact the eyeball, rubbing it with each blink), and chronic irritation Lacrimal gland and tear drainage: Tear production by the lacrimal gland may decrease with aging, resulting in fewer tears available to keep the surface of the eye, especially the cornea, well moistened. This change, combined with an age-related decline in conjunctival mucin production by the goblet cells, and decreased production of stabilizing surface oil by the Meibomian glands (located on the underside of the upper eyelid), may cause aqueous tear-deficient keratoconjunctivitis sicca. Abnormalities of the lacrimal system may result in either decreased or increased tear production. The excessive dryness caused by decreased tear production can often be treated by vigilant application of artificial tears. Referral to an ophthalmologist is indicated when the patient complains of excess tears and the punctum of the lower eyelid is not in contact with the eyeball. These tears spill over the lower eyelid and down the face, promoting excessive bacterial growth in the skin and eyelids, which can cause unsightly inflammation. Orbit: With aging, there is a loss of the periorbital fat that surrounds and cushions the eyeball. This loss of fat often causes enophthalmos (sinking of the eyeball into the orbit), an asymptomatic condition that often poses a cosmetic problem and may be corrected with surgery.

51 Glaucoma Occurs after 40 years of age Major cause of blindness
Risk factors: Family history (any type of glaucoma) Diabetes, Endocrine imbalance, cardiovascular disease, steroid use, past eye injury Older women 2X’s incidence than men Japanese ancestry African American Mexican Americans

52 Types of Glaucoma Chronic – open-angle glaucoma (morecommon)
80% asymptomatic until late stage Gradual impairment in peripheral vision Signs/symptoms: bumping into items at their side Frequent ∆ of eye glasses Changes in central vision c/o tired feeling in eyes, headaches, misty vision, halos around lights, (worse in the morning)

53 Treatment –Chronic- Open Angle Glaucoma
Miotic and carbonicanhydrous inhibitors Surgery – to create a channel to filter the aqueous fluid (eg. Iridectomy,iridencleisis,cyclodialysis, corneoscleral trephining)

54 Interventions Miotics (azetazolamide) eye gtts- use tear duct occlusion technique (increases amount of med absorbed by 50%) Do NOT USE Mydriatic ,stimulants or other agents that ↑ blood pressure. Instruct to carry a medical card or wear bracelet Avoid abuse/overuse of eyes Patient teaching re: compliance with regime. Frequent re-screening

55 Acute -Closed Angle Glaucoma
Rapid rise in (IOP) intraocular pressure S/Sx: redness & severe eye pain, blurred vision, headache, nausea, vomiting Path of aqueous humor is blocked IOP ↑’s to 50mm Hg. Edema of ciliary body & dilation of pupil Blurred vision –followed by blindness if not corrected within two days!

56 Interventions-Acute – closed angle glaucoma
Effective medications include: carbonic anhydrase inhibitors (reduce formation of aqueous fluid) Mannitol, urea or glycerine (reduce fluid -ability to increase osmotic tension in circulating blood) Iridectomy – may be performed- prevents future episodes of acute glaucoma

57 Age-related Macular Degeneration(AMD)
Most common cause of visual impairment & legal blindness in persons >50 y/o Damage /breakdown of the macular→loss of central vision Risk factors: aging process, injury , infection, exudate macular degeneration White Women > 80 & Asian Americans more vulnerable than African & Mexican Americans

58 Macular Degeneration Early Signs/symptoms: Two forms of AMD: Dry & Wet
Difficulty reading, driving, ↑need for bright light, Colors appear dim /gray, blurry spot in middle of vision. Two forms of AMD: Dry & Wet “Dry” AMD – 3 stages “Wet” AMD –abnormal blood vessels behind retina grow under the macula (more rapid >legal blindness within 2 years)

59 Aging Changes in Ears & Hearing
Function of Ears Hearing Maintenance of balance Ears and Hearing Aging changes in hearing With aging, ear structures deteriorate. The eardrum often thickens and the inner ear bones and other structures are affected. HEARING Your ears have two jobs. One is hearing and the other is maintaining balance. Hearing occurs after vibrations cross the eardrum to the inner ear. They are changed into nerve impulses and carried to the brain by the auditory nerve. Balance (equilibrium) is controlled in a portion of the inner ear. Fluid and small hairs in the semicircular canal (labyrinth) stimulate the nerve that helps the brain maintain balance. As you age, your ear structures deteriorate. The eardrum often thickens and the inner ear bones and other structures are affected. It often becomes increasingly difficult to maintain balance. Ears may elongate, especially in men. Presbycusis is a normal age-related hearing loss. Ossicle joints develop calcification; tinnitus may occur as a result of normal aging or may be caused by medications, infection, cerumen accumulation, or a blow to the head.

60 Aging Changes in Ears & Hearing
Presbycusis age-related hearing loss  hearing acuity  speech intelligibility  auditory threshold  discrimination of pitch Hearing may decline slightly, especially that of high-frequency sounds, particularly in people who have been exposed to a lot of noise when younger. This age-related hearing loss is called presbycusis . The sharpness (acuity) of hearing may decline slightly beginning about age 50, possibly caused by changes in the auditory nerve. In addition, the brain may have a slightly decreased ability to process or translate sounds into meaningful information. Impacted ear wax is another cause of trouble hearing and is more common with increasing age. Impacted ear wax may be removed in your doctor's office. Some hearing loss is almost inevitable. It is estimated that 30% of all people over 65 have significant hearing impairment. Conductive hearing loss occurs when sound has problems getting through the external and middle ear. Surgery or a hearing aid may be helpful for this type of hearing loss, depending on the specific cause. Sensorineural hearing loss involves damage to the inner ear, auditory nerve, or the brain. This type of hearing loss may or may not respond to treatment. Persistent, abnormal ear noise ( tinnitus ) is another fairly common hearing problem, especially for older adults.

61 Age related Hearing changes
Slow decline in sensoneural function (presbycusis) Conductive hearing loss r/t cerumen impaction, otosclerosis, chronic exposure to loud noises loss of hearing acuity, especially sounds at the higher end of the spectrum. ↓ ability to distinguish sounds when there is background noise

62 NURSING DIAGNOSIS OF THE ELDER ADULT IN THE COMMUNITY
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63 NURSING DIAGNOSIS OF THE ELDER ADULT IN THE COMMUNITY
Impaired Physical Mobility Self Care Deficit Care-giver Role Strain Anxiety Fear Knowledge Deficit Altered Thought Process Ineffective Health Maintenance Social Isolation Disabled Family/Individual Coping

64 Age related sensory changes Change --------------------Effect
Taste - decreased taste buds and saliva; loss of taste cells (papillae on tongue) Smell & Touch – Loss of olfactory sensory neurons; decreased sensory nerve fibers Decreased discrimination of sweet, salt, bitter, sour. Decreased sense of smell; decreased sensitivity to touch; altered pain perception

65 Changes of Aging Activity Goal: to simulate the feeling of some of the physical changes of aging and the potential difficulties they can produce. Stand with feet apart at least 14 inches (to provide a wide base) and do the following: Round the shoulders and upper back Tuck the buttocks and relax the abdominal musculature, making the umbilicus point toward the ceiling Remaining in this position, take a deep breath (simulating the change in respiratory function that accompanies change in stature)

66 Still remaining in this position
,Bend the knee while keeping the foot of that leg on the ground Take a few steps forward (simulation of slowed mobility with aging) What they you feeling, physically and emotionally, and thinking during various steps of this exercise. Share with the rest of the class how you might feel if these physical changes were permanent. What challenges do you anticipate these physical limitations will cause?


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