Health Alterations in Older Adults Janet Duffey, RN, MS, APRN, BC

Think About This….  A group of Florida senior citizens were talking about their ailments.  "My arms are so weak I can hardly hold this cup of coffee."  "Yes, I know. My cataracts are so bad I can't even see my coffee."  "I can't turn my head because of the arthritis in my neck."  "My blood pressure pills make my dizzy." "I guess that's the price we pay for getting old."  "Well, it's not all bad. We should be thankful that we can still drive."

General Changes  Non regeneration  Loss of neurons in cerebral cortex  Decreased oxygen, blood flow  Impaired thermoregulation  Susceptibility in choline  Dopamine  Alteration in functional mobility

Neurological Diseases  Parkinson’s: pill rolling, tremors, forward gait, mask like expression, depression  Stroke (CVA): location, right brain, left brain, motor tracts  Hemorrhagic, occlusive, thrombotic  TIA’s – mini-thrombotic episodes resolving in 24 hours or less

CVA’s  Effects of CVA’s – language – Speech – Sensation – perception – behavioral style – memory and – holistic assessment  Expressive aphasia (Broca’s) frontal lobe damage  Receptive aphasia (Wernike’s) left hemi in temporal lobes

Impact of CVA

Overlooking Confusion  Poorly understood event  Multiple causes  Misdiagnosis as “untreatable”  Range of causes from age related memory loss to pathological change in brain  Physical dysregulation: sleep, temperature, electrolytes, sensory overload

Nursing Interventions for Confusion  Baseline mental status exams  Detect and report: insomnia, distractibility, hypersensitivity, c/o poor recall, nightmares  Structure environment for moderate mental and physical stimulation  Limit duration of activity  Evaluate new / added meds carefully

Confusion

Causes of Acute Confusion  Metabolic  Drug toxicity or side effects  Drug withdrawal  Electrolyte imbalance  Endocrine dysfunction  Hypoxia  Infection and sepsis

Alzheimer’s Disease  Genetic predisposition  Presence of amyloid plaques & neurofibilary tangles (key finding on scans & autopsy)  Reduced presence of choline required for cognition (major biochemical change)

Dementia: Early Stage  Mood change  Poor judgment  Getting lost  Difficulty with numbers & money  Withdrawal or depression

Middle Stage AD  Gross memory impairment  Aphasia: speech disturbance  Loss of impulse control  Anxiety  Wandering  Confabulation  Progressively lowered stress threshold  Impaired self-care due to judgment

Late Stage AD  Dysphagia with risk for aspiration  Impaired speech, little or no communication  Immobile, non-ambulatory  Totally dependent in all activities of daily living  Morbidity by aspiration pneumonia or sepsis common

Rx: Cholinesterase Inhibitors  Cholenergic Drugs: Cognex, Aricept Rivastigmine, improving concentration of acetylholine  Memantine: newly approved  Side effects: nausea, bradycardia, elevated liver function studies  Used in early to middle stages

Behaviors in Dementia  Perseverance  Tactile wandering  Recreational  Purposeful  “Sundowning”  Gross agitation  Hallucinations  Delusions

Interventions for Behaviors  Determine underlying need  Check for pain, hunger, toileting issues  Decrease stress if possible  Encourage rest periods  Engage in activities related to premorbid personality and role  PRN medications as a last resort, sparingly

Non-AD Dementias  Pick’s Disease  Lewy Body Dementia  Vascular Dementia – Risk factors – MRI. CT findings – Prevention – Treatment of symptoms similar to AD

Renal / Urinary System  Renal function  Hydration  Obstructive conditions  Incontinence – Stress – Urge – Overflow – Functional

Interventions  Moderate fluid intake  Regular toileting  Treatment of infection  Estrogen therapy  Timing of diuretics  Medication assessment for contributors  Bladder retraining

Changes in Skin  Easily torn & blistered  Decreased sensation leads to risk for injury  Impaired thermoregulation  Dryness  Photo aging, cancers, basal cell epitheliomas, squamous cell carcinomas, multiple melanoma  Increased risk for fungal infections  Implications for nursing care: - Teaching to prevent sun exposure - Avoid excessive bathing - Role of nutrition and hydration - Pressure relief measures - Assessment: Braden Pressure Scale

Pressure Ulcers in Elderly  Prevalence varies by setting  Risk factors for elderly – Acute immobility due to illness – Paralysis – Hip fracture – ICU/Critical care units – Nutritional state

Braden’s Conception of Risk  Decreased mobility  Decreased activity  Decreased sensory perception  Increased: moisture, friction, shear  Poor nutritional intake  Advanced age  Impaired circulation

Alterations in GI Function  Decreased GI acidity  Constipation  Changes in appetite  Role of dental problems  Diverticulosis  Colon cancer  Self management of colostomy

Interventions for Constipation  Constipation vs. obstruction  Definition of “regularity”  Establish fluid intake of 2000cc daily  High fiber diet: bran, fruits, vegetables, whole grains  Limit use of enemas and stimulants which cause more dehydration

Alterations in MS Status  Osteoarthritis  Rheumatoid arthritis  Osteoporosis  Falls  Fractures: vertebral, pelvis, hip, shoulder, wrist  Normal: decreased muscle mass, less elastic, shrinking height

Interventions for MS  Diet, calcium, vitamin D  HRT: estrogen  Exercise  Safety measures – Hazards of immobility – Identification of appropriate activities – Fall prevention & home safety

Risk Factors for Falls  Sensory deficits  Cardiac contributors  Neurological  Urological  Pharmacological  Alcohol  Environment  Fall history

Interventions for Falls  Identify fear of falling  Increase activity  Strengthening exercises  Orthostatic monitoring  Use of assistive devices  Safe, non-skid footwear  Correct sensory deficits  Plan how to get help after a fall  Remove known hazards: rugs, clutter  Identify activities requiring supervision / assistance  Teach caregivers proper lifting or transfer techniques