Gerontologic Nursing Certification Review Course©

Gerontologic Nursing Certification Review Course©
S S Wexler Consulting, LLC White Plains, NY Sharon Stahl Wexler, PhD, RN, BC © Copyright 2012

Aging Demographics Currently about 33 million persons aged 65 or older
12.7% of the total population “Graying” of America Centenarians are the fastest growing age group in the U.S. By 2050, there may be as many as 1 million people over the age of 100 Of those older adults over 65, the percentage of people of color will grow from 18% in 2004 to nearly 36% by 2050 The population of older adults is growing rapidly. In the United States we speak of the “graying of America”, referring to the growing number of older adults. However, all nations are facing the same issue.

Indicator 1 – Number of Older Americans
This chart for Indicator 1 - Number of Older Americans shows the large growth of the population 65 and older from 1900 to 2008 and the even greater projected growth from 2008 to It also shows the growing numbers of persons 85 and older and their large projected growth to 2050.

Indicator 13 - Life Expectancy
Before 1950, the male population outnumbered the female population. This trend reversed in women make up the majority of the older adult population (58%). Women who reach the age of 65 can expect to live another 19 years, men can expect to live another 16 years. The increase in life expectancy can be attributed to better healthcare, more preventive care, and a healthier life style. The differences in life expectancy between men and women can be attributed to a number of different factors. Greater male exposure to risk factors such as: tobacco, alcohol,and occupational exposure might account for the shorter male life expectancy. It will be ineresting to see, as the years go forward, where women have had more exposure to tobacco, alcohol, and have been in the workforce, if this difference continues to exist.

Indicator 2 - Racial and Ethnic Composition
There has been and continues to be a demographic change in the United States Population. The non-Hispanic White majority is decreasing . It is predicted that by the year 2020, people of color will be the majority population. Also, the foreign born population of the US has growin significantly, and is the highest that it has been since The bar graph above depicts this phenomena. This show that population of older adults of Hispanic origin in 2004 and predicted for 2050,, and illustrates this point.

Gender Issues Older women comprise 58% of the population over age 65, and 70% of the population over age 85 There are many more older women than older men. Older men tend to remarry when their spouse passes away, older women are less likely to do so. a significantly larger number of women of both of these age groups living alone as compared to men.

Indicator 4 - Educational Attainment
Older adults have received more formal education than in the past. This is important when planning patient education.

Indicator 8 - Income This slide shows a little more about the economic situation of older Americans. Since 1974, the proportion of older adults living in poverty and also the proportion of older adults falling into the low income group has declined. The middle income group makes up the largest share. You will also not that the high income group has grown over time.

Indicator 14 - Mortality The leading causes of death among older Americans are: heart disease, cancer, and cerebrovascular disease irrespective of sex, race, or ethnicity.

Chronic Health Conditions
Most older adults have chronic conditions Hypertension Heart Disease Arthritis Diabetes Many older adults have sensory impairments and alterations in oral health 50% over age 65 report trouble hearing 20% report trouble seeing 25% report having no natural teeth

Indicator 19 - Disability
The proportion of older adults with chronic disabilities declined, for both sexes, from Despite the decline in rates, the number of older adults with chronic disabilities increased, however the overall increase in the older adult population offset that number, contributing to a decline in percentage. Functional status has many implications for older adults.

Indicator 29 - Health Care Expenditures
Hospitals and physician services were the largest components of health care costs. The distribution of health care services changed between 1992 and Inpatient hospital care accounted for a lower share of the costs in 2003 as compared to Prescription drugs increased from 1992 to 2003, perhaps reflecting the large # of drugs most older adults take.

Indicator 35 - Nursing Home Utilization

Demographic & Epidemiological Factors
Decrease in infant mortality rates since turn of the century “Control” of infectious diseases Improvement in environmental and social conditions Behavioral or lifestyle changes There are specific demographic and epidemiological factors to be considered when looking at the growing number of older adults. There has been an decrease in infant mortality since the turn of the century, major improvements in neonatal and pediatric medicine. Certain infectious diseases that were common and would kill large numbers of individuals have been controlled. There have been improvements in environmental and social conditions. Behavioral and lifestyle changes-just consider cigarette smoking: years ago, people smoked in restaurants, theatres, airplanes, hotels, offices, etc. Second hand exposure to cigarette smoke was common. Today, there are all sorts of prohibitions and guidelines on where you can smoke.

Geographic Distribution
9 states have more than one million elderly persons: California, New York, Pennsylvania, Texas, Illinois, Ohio, Michigan, New Jersey Florida has the highest proportion of the elderly People age 85+ are clustered in the farm states: Iowa, South Dakota, Nebraska, North Dakota, and Kansas Certain states have large numbers of older adults than others. Florida has the largest number of older adults since it was where individuals retired to.

Older Adults in Hospitals
In hospitals, older adults make up approximately 52% of inpatient admissions, and have longer lengths of stay, and higher rates of readmission within 30 days Elderly hospitalized patients are at increased risk for negative outcomes Elements of hospitalization, including physical environment and nursing care practices contribute to poor outcomes. These elements include: Restraints and restrictive side rail use (Capezuti, 2004) Prolonged bed rest (Inouye, 2000) Use of psychotropic medications (Peterson et al., 2005) Bladder catheters (Gokula, Hickner, & Smith, 2004) Inattention to oral hygiene (Coleman, 2002) Restrictive diets (Amella, 2004) In most hospitals in the US, outside of the pediatric and maternal child areas, older adults make up the largest percentage of the population. Older adults are more likely to have negative outcomes during a hospitalization than younger adults. There are certain things about hospitalization that make the older adult more vulnerable for negative outcomes. The hospital environment itself is a factor, and certain nursing practices, that are instituted in order to “care” for the patient may in fact contribute to negative outcomes.

Attitudes and Stereotypes towards Older Adults
Ageism: Discrimination that often accompanies old age and is based solely on age. The idea that people cease to the same or become inferior based on age Effects: Reduced health care from providers of care Less health education and teaching May be regarded as not eligible for certain therapies or programs ex: rehab, certain types of surgeries Treated socially and medically based on myths and stereotypes We need to encourage older adults to advocate for themselves, we need to advocate for them. We also need to educate everyone that increasing age is not associated with a total decline We need to involve older adults in decision making

Scope and Standards of Gerontological Nursing Practice
ANA responsible for defining scope and standards of practice First combined document published in 1987 Now in its 4th revision A guide for current practice Applicable to practice across the continuum of care While the Scope and Standards of clinical Nursing Practice applies to all professional nurses, this document, the Scope and standards for Gerontological Nursing Practice has specific criteria for the basic practice of gerontological nursing and the advanced practice gerontological nursing. Scope and standards of practice Assumptions of aging Myths of aging Common characteristics of aging Demographics of aging Service trends Gerontological Nursing trends

History of Gerontological Nursing
1904: AJN printed 1st nursing article on care of the aged 1950: First textbook on geriatric nursing 1962: ANA forms conference group on Geriatric Nursing Practice 1966: ANA creates division of Geriatric Nursing 1970: ANA publishes standards for Geriatric Nursing Practice 1974: ANA offers certification in Geriatric Nursing Practice The next couple of slides are some important developments in the history of gerontological nursing. Of note is that there has been a certification exam in geronologcial nursing for over thirty years.

1975: First nurses certified in Geriatrics
1975: Journal of Gerontological Nursing published 1976: ANA renames Geriatric Nursing Division to Gerontological Nursing Division and publishes Standards for Gerontological Nursing to reflect the broad role nurses play in management of health of older adults and move emphasis away from illness focus. 1976: national Conference of Gerontological Nurse Practitioners 1980: Geriatric Nursing published

1981: ANA Division of Gerontological Nursing issues statement on the scope of gerontological nursing encompassing health promotion, self care of older adults 1984: National Gerontological Nursing Association 1987: ANA revises and issues Standards and Scope of Practice of Gerontological Nursing 1989: First ANA exam for certification of gerontological clinical nurse specialists 1991: OBRA recognizes both GNP and GCNS as eligible for reimbursement under Medicare and Medicaid

Levels of Gerontological Nursing Practice
Basic Gerontological Nursing RN who has demonstrated competency in gerontological nursing Practices in a variety of settings Direct care, management, development of professional and other nursing personnel; Evaluation of care and services for the older adult Advanced Practice Gerontological Nursing RN with Masters or Doctorate Advanced knowledge in care of older adult Function as CNS or NP Perform all that basic gerontologic nurse does and has additional knowledge and skills in theory, research, practice There are two levels of gerontological nursing practice, basic gerontological nurse and advance practice. At the advanced practice level there are two distinct roles, the clinical nurse specialist and the nurse practitioner. American Nurses Credentialing Center (ANCC) offers one certification exam at the basic level, which this course is intended to prepare you for, and two at the advanced practice level, one for the CNS and one for the NP

Certification Established by the ANA for the purpose of recognizing professional achievement in specific clinical or functional areas of nursing Current examinations in gerontology Gerontological nurse generalist Gerontological Nurse Practitioner Gerontological Clinical Nurse Specialist

Medicaid Health care for the poor of all ages Federal law, 1965
Income-based State and federally funded Primary and hospital care Nursing home: usually after “spend down” Medicaid in income dependent, and age is not a criteria for qualification Medicaid is jointly funded by state and federal governemnts using tax dollars Medicaid was created in 1965 as part of the Title XIX of the Social Security act at the same time as Medicare. Federal law requires states to provide a certain minimum level of service and states may add coverage. The majority of medicaid funds are used to provide long term nursing home care for older and disabled adults.

Medicare Health care of older Americans
Social Security Amendments of 1965 Age-based if qualified for Social Security, Railroad Retirement or ESRD Medicare is not income dependent.

Medicare Part A: Hospital stays, skilled nursing care, home visits and hospice No premiums Part B: voluntary; covers outpatient services, labs, diagnostics, & supplies Costs: premiums, deductibles and co-payments “Medigap” policies – private insurance All individuals who qualify for Medicare automatically get part A, without paying a premium. A person automatically receives a Medicare care indicating Medicare part A when he or she turns 65 and has paid Medicare taxes for at least 30 quarters (10 years). Medicare part A is a hospital insurance plan covering acure care and acute and shorter term rehabilitative care. Part B is voluntary, the individual must apply for it through the local Social Security Administration. There is a cost and copayments. Medicare part b covers the costs associated with physicians, nurse practitioners, outpatient services and other services such as speech, PT, and OT. Medigap insurance is private insurance that a person can buy that covers the costs of the copays from medicare part B

Medicare Part D Comprehensive prescription drug benefit
Created as a result of Medicare Prescription Drug Improvement and Modernization Act of 2003 Medicare pays a portion of outpatient prescription drugs through private plans. Plan members still need to pay premiums and co-pays Effective January 1, 2006 All individuals with Medicare part A or B are eligible for Medicare part D This is the newest part of Medicare, it is the prescription drug benefit.

Residential Options in Later Life
Continuum of options based on level of assistance needed Most older adults living in community in their own homes Senior retirement communities Shared housing Residential care facilities Costs of majority of senior retirement communities are borne by the consumer, for elders with limited incomes, there are federally subsidized options available in some areas of the country. HUD (US dept. of housing and urban development) approved construction of low rent housing for elders. Most of these apartments have long waiting lists. The senior tenant pays 30% of his/her adjusted gross income toward the rent and HUD assists with supplementary vouchers to meet the fair market value of the rental. Senior retirement communities Communities designed for older adults Designed to make independent living possible Wide range of services provided Range from simple to very luxurious Shared housing Multigenerational shared housing Group homes Residential care facilities Foster care Assisted living

Nursing Homes Deliver around the clock care
Approximately 18,000 nursing homes in the US Majority are not for profit Medicaid provides most of funding for nursing homes, followed by resident out of pocket Two levels of care Skilled nursing/Subacute care Chronic care Skilled nursing/subacute care: focus on rehabilitation or complex medical needs Chronic care 24 hour personal assistance that is supervised by licensed nurses. Many facilities have both levels of care, usually on separate units. Based on the type of care provided, staffing differs greatly between the two.

Nursing Homes Resident characteristics 1.6 million residents Women
Age 80+ Caucasian Widowed Dependent in ADL and IADL More than 60% are cognitively impaired The above characteristics are the typical profile of a nursing home resident

Nursing Home Reform Act of 1987
OBRA (Omnibus Budget Reconciliation Act of 1987) President Ronald Reagan signed into law the first revision of the federal standards for nursing home care since the 1965 creation of Medicare and Medicaid Creates a set of national minimum set of standards of care and rights for people living in nursing homes Nursing homes are one of the most highly regulated industries in the United States. OBRA and its frequent revisions and updates designed to improve quality of care to residents of nursing homes and has had a positive impact.

OBRA 1987 Emphasis on quality of life and quality of care
New expectations that each residents ADL status will be maintained or improved Resident assessment process leading to the development of an individualized plan of care Training and testing of Nurse Aide Staff (75 hours minimum of training, and standardized testing) Rights to remain in the nursing home (expect for non-payment, dangerous behavior, change in medical condition)

OBRA 1987 New opportunities for residents with mental retardation or mental illnesses for services inside and outside of nursing home A right to safely maintain bank account or personal funds within nsg home, right to return to nsg home after hospital stay or overnight visit with family, right to choose personal MD, access medical records Right to organize and participate in resident or family council

OBRA 1987 Right to be free of unnecessary physical and chemical restraints Uniform certification standards for Medicare and Medicaid homes Prohibition on turning to family members to pay for Medicare and Medicaid services New remedies applied to nsg homes that fail to meet federal standards

Minimum Data Set (MDS) OBRA 1987 regs mandated use of interdisciplinary assessment tool, MDS in nursing homes First used in 1990, along with residents assessment protocols (RAPS) Must be completed within 14 days of admission or when a significant change in condition occurs Each discipline assesses its components Raps identifies problem areas concerning each resident based on information from the MDS

Theories of Aging Theories of aging have been formulated in biology, psychology, and sociology. Biological-encompasses measures of the functional capacity of life-limiting organ systems Psychological-refers to the behavioral capacities of person to adapt to changing environmental demands Social-involves the roles and age-graded behaviors of persons in response to the society of which they are a part Relationships among them are not clear

Biological Theories of Aging
Stochastic (error) Theories: Aging is a result of the accumulation of errors in the synthesis of DNA and RNA Nonstochastic Theories: Changes of aging are attributed to a process that is programmed or predetermined Error theories: DNA and RNA are the basic building blocks of the cell. With each replication, more errors occur until the cell can no longer function and dies. Non-stochastic theories: programmed theories hypothesize that the body’s genetic codes have instructions on the regulation of cellular reproduction and death

Programmed theories Hypothesize that the body’s genetic codes contain instructions for the regulation of cellular reproduction and death. The most popular programmed theory Programmed longevity: Aging is the result of sequential switching on and off of certain genes. Senescence (old age) is defined as the point in time when age associated functional deficits are manifested.

Programmed theories Endocrine theory: Biological clocks act through hormones to control the pace of aging. Immunological Theory: A programmed decline in the immune system functions leads to an increased vulnerability to infectious disease, aging, and eventually death. Endocrine theory: Biological clocks act through hormones to control the pace of aging. Advocates of this theory ascribe to the use of various natural and synthetic hormones, such as the human growth hormone, to slow the aging process. Immunological Theory: A programmed decline in the immune system functions leads to an increased vulnerability to infectious disease, aging, and eventually death. Declines in the immune system can affect the outcomes of many illnesses such as post op infections, urinary tract infections, and pneumonia.

Error theories Environmental assaults and the body’s constant need to manufacture energy and fuel metabolic activities cause toxic by-products to accumulate. These toxic by-products eventually impair normal body function and cellular repair The most popular error theories Wear and tear theory: cells and organs have vital parts that wear our after years of use. A “master clock” controls all organs and that cellular function slows down with time and becomes less efficient at repairing body malfunctions that are caused by environmental assaults. Premature aging can be stimulated by abusing or neglecting a body system

Error theories Cross-link theory: An accumulation of cross-linked proteins resulting from the binding of glucose to protein causes various problems. One the binding happens, the protein cannot perform normally and results in all sorts of problems (ex; cataracts, wrinkled skin, skin aging)

Error theories Free radical theory: Accumulated damage by oxygen radicals causes cells and eventually organs to lose function and organ reserve. The use of antioxidants is believed to slow this damage Somatic DNA damage theory: Genetic mutations occur and accumulate with increasing age causing cells to deteriorate and malfunction. Advocates believe that genetic manipulation and alteration may slow the aging process.

Psychological Theories
Erickson (1963): Series of tasks that individuals perform over course of life Ego integrity vs. despair Ego integrity: acceptance of the way one has lived and is still living one’s life. Life is and was a life of dignity Despair: Conflict over the way one has lived and is living. Dissatisfaction with the course of life and conviction that would do things differently if given another chance Most of the psychological theories state that various coping strategies must occur for the individual to age sucessfully. Erickson: 8 stages of life with developmental tasks associated with each of them Older individuals who have not achieved ego integrity may look back at life with dissatisfaction, anger and be depressed.

Jung’s theory of individualism As a person ages, the shift of focus is away from the external world (extroversion) to the inner experience (introversion). To age successfully, the older person will accept past accomplishments and failures

Peck’s Developmental Tasks of Old Age (1968) Ego differentiation vs. work role preoccupation Body transcendence vs. body preoccupation Ego transcendence vs. ego preoccupation To achieve integrity, one must develop the ability to redefine oneself, let go of occupational identity, rise above bodily discomforts, and establish personal meaning At retirement, any one of the dimensions can be used to replace the work role as the central characteristic for defining self esteem Need to transcend the biological declines to maintain feelings of well being Ego transcendence denotes the acceptance without fear of ones death as the inevitable conclusion to life

Psychological Theories (cont.)
Havighurst’s Theory of Development Tasks (1972) Later maturity is final stage of six Failure to master tasks results in high anxiety, maladjustment and social disapproval Tasks: Adjustment to decreasing physical strength and health Adjustment to retirement and reduced income Adjustment of death of spouse Establish affiliation with one’s own age group Adopt and adapt to social roles in a flexible way Establish satisfactory physical living arrangements

Sociological Theories
Focus on way that older adults adapt during later life and on environmental influences on the adaptive processes Disengagement Theory (Cummings and Henry, 1961) WIDELY ATTACKED AND REPUDIATED Based on premise that given that people inevitably die, but the society to which they belong is continuous, it is necessary to find ways of minimizing social disruption or impact that results from death of its members Persons undergo a disengagement process in middle and later years of life of reduced social involvement, reduced energy level and increased preoccupation with one’s own needs. The older person and society engage in mutual and reciprocal withdrawal, so that when death occurs, neither the person or society are disadvantaged and social equilibrium is maintained.

Sociological Theories
Activity Theory (Havighurst, Neugarten, & Tobin, 1963) Assumes that successful aging involves the maintenance of high activity levels during old age Happiness and satisfaction with life are from a high level of involvement with the world and continued social interaction. Continuity Theory (Neugarten, Havighurst, & Tobin, 1968) Successful aging involves maintaining previous values, habits, preferences and other linkages that formed structure of adult life. The way to predict how a person will adjust to old age is to examine how they adjusted to changes throughout life This theory contradicts disengagement theory

Preventive health screening for older adults: Covered by Medicare
Annual physical exam Mammography: Baseline screening between ages 35-39, annual mammogram after age 40 Pap smear: Every 24 months unless high risk. Colon cancer: fecal occult blood test q 12 months after age 50, flexible sigmoidoscopy every 4 years, colonoscopy every 10 years (every 24 months if high risk) Prostate CA: digital rectal exam and PSA q 12 months Osteoporosis: bone mineral density tests every 24 months for women United States Preventive Services Task Force: formed in 1984 to reduce confusion among clinicians regarding effectiveness of screening interventions Controversy: some sources say annual mammogram until age 70, and longer for those who are at high risk. AGS recommends mammogram until age 85, or for those with life expectancy of at least 5 years, or for whom the benefit of screening outweighs the risks. ACS:Can stop annual pap smears after age 70, if have three or more normal paps within last ten years. Prostate CA: screening for prostate CA at any age remains controversial. No prospective trials to date have shown decreased morbidity and mortality from screening for prostate Ca.

Immunizations in older adults
Influenza: Flu shot yearly for all older adults. Pneumonia: At least once after age 65, and repeated every 6 years for those at highest risk. Hepatitis B Vaccine: for those at increased risk Tetanus: Tetanus booster every 10 years

Age-related changes Skin
increase in time for cellular renewal-increase in healing time decrease in moisture content dermis: marked elastosis. Aggregates of amorphous elastic fibers, decrease in collagen content skin appears wrinkled, yellowed, lax, rough, leathery The skin is an organ that serves many different functions. It protects the entire body from the external environment. It also contributes to the immune function, it regulates temperature also. It serves as the vehicle for synthesis of vitamins and also for sensory input from the nervous system. Regulation of temperature and body fluids: The epithelial cells are a barrier that prevents loss of body fluids from the deeper layers of the skin. The epidermis helps to regulate body temperature by dilating during warm temperatures and contracting during cold temperature. The skin serves as a barrier to infection, to invasion from bacterial organisms. The epidermal layer of the skin provides the vehicle for the synthesis of vitamin d. There are specialized receptors in the skin for touch, temperature, pressure and pain. There are many age related changes in the skin. Many are cosmetic in nature, and a lot of money is spent trying to prevent these changes, or to “correct” them. However, these changes are far more than cosmetic when one considers the many functions of the skin. Another important factor to consider when thinking about age related changes in the skin is that because they are so visible, they can contribute to the individual’s self perception and self esteem.

Subcutaneous tissue decreases in some areas of the body: face, neck, hands, and lower legs.
Subcutaneous tissue increases in other areas of the body leading to an overall increase in the proportion of body fat in older adults Appearance of senile keratoses: raised, dark areas on trunk, neck, face, and hands, and “age spots”: flat brown macules on arms, hands, neck, and face In older women, fat distribution is more pronounced in the abdomen and thighs, and in the abdomen in older men.

Hair thins and becomes finer with aging Hair looks gray or white
Gradual loss of hair in the pubic area and axillary area Balding pattern Nails hypertrophy, appear yellow and hard Decrease in size and number and function of eccrine and appocrine glands Increase in size of sebacious glands, but decrease in production of sebum Hair looks gray or white due to a decrease in the number of functioning melanocytes and the replacement of pigmented strands with nonpigmented ones. Decrease in eccrine (sweat) glands results in a decreased ability to regulate body temperature through sweating. Decrease in production of sebum hastens the evaporation of water leading to dry skin.

Muscular Systems From age muscle masses decreases in relation to body weight by 30-40% Loss accelerates with age Strength decreases. From age a persons strength of grip decreases 60%. However, activity plays a role. Persons who use their grip over their entire life span do not lose any strength.

Bones become stiff, weaker, more brittle Changes in height
Skeletal system Bone loss Type I: Menopausal bone loss Type II: Senescent bone loss Bones become stiff, weaker, more brittle Changes in height Changes in posture Menopausal bone loss: rapid phase of bone loss that affects women in the first 5-10 years after menopause Senescent bone loss: slower phase that affects both women and men after midlife After age 50, the long bones of the arms and legs appear disproportionate in size due to shrinking stature. Average loss of 1-2 cm every two decades from ages Changes in height are due to shortening of the vertebral column. As person enters 80-90’s, rapid decrease in the vertebral height due to collapse of the vertebra due to osteoporosis. Postural changes: kyphosis and a backward tilt of the head to make eye contact which results in a forward bent posture with the hips and the knees assuming a flexed position.

Innervation and contraction of muscle is altered.
Loss of muscle is not uniform. Within any muscle group, size and number of myofibrils decrease. Innervation and contraction of muscle is altered. Skeletal muscle-altered energetics. Exercise has been shown to decrease these changes Joints, Ligaments, and Cartilege Decrease in water content in tendons and ligaments-stiffness Hyaline cartilage erodes and tears with advancing age Lower extermity muscles tend to atrophy earlier than those of the upper extremities. Hyaline cartilage lines the inside of the joints. When it erodes, the bones are in direct contact with one another.

Neurological system Decreased weight of brain
Decreased blood flow to the brain Age related loss of neurons Response time slows Sensations in hand and feet decrease Decreased response to pain Generalized slower reflexes Changes in brain enzymes, receptors and neurotransmittors

Vision Periorbital tissues atrophy Upper eyelid is droopy, lower eyelid is loose Decrease in lacrymal gland function Atrophy of conjunctiva, iris becomes more rigid, lens yellows, shrinkage of vitreous humor Cornea clouds with aging

Hearing External auditory canal atrophies Walls thin
Cerumen drier and more tenacious Tympanic membrane becomes thicker Inner ear: Loss of hair cells in organ of corti, loss of cochlear neurons, stiffening of basilar membrane and calcification of auditory mechanisms, thickening of capillaries, and degeneration of spiral ligament. Leading to: loss of both high and low frequency hearing

Taste and Smell The number of lingual papillae decrease and atrophy
Acuity of olfaction decreases Detection thresholds increased by 50% by age 80. Recognition of smells decreased by 15% Subsequent decrease in enjoyment of food, and age related difficulty in sorting taste of mixed or combined food Taste buds on the tongue decrease in number resulting in the loss of ability to taste

The Mouth and Oral Cavity
Decrease in taste buds Decrease in production of saliva Gums recede Enamel on surface of teeth worn away Missing teeth Maloclusion With missing teeth, malocclusion results because remaining teeth become misaligned with use in chewing

Cardiovascular System
Myocardial hypertrophy Increase in left ventricle muscle Decrease in sinus node cells Increase in calcium deposition in valves: Valves thicker and stiffer Increase in recovery period after exertion Increase in systolic and diastolic BP due to increased vascular rigidity Left ventiruclar wall thicker By age 75, only 10% of the original pacemaker cells, the SA node cells, are functional. This, however, can support cardiac function under usual conditions. Blood pressure elevation frequently occurs with aging due to the changes in the vascular system, however, this is not considered normal aging. Normally, in a younger person , the arterial wall diameter is controlled by a balance of systems, including the autonomic nervous system and the beta adrenergic stimulation. With aging, there is a decreased response to beta adrenergic stimulation.

No specific EKG changes with aging
Impact of age related cardiac changes minimal in resting state. Recovery after exertion markedly prolonged in older person

Respiratory System Normal aging changes
Stiffening of elastin and collagen connective tissue that supports the lungs Changes in alveolar shape that results in increased alveolar diameter Decreased alveolar surface area available for gas exchange Increased chest wall stiffness These age related changes lead to: Lung elasticity and elastic recoil are decreased as a consequence of changes in collagen and elastin, resulting in an increased residual volume Decreased vital capacity Early airway closing

Increase in diameter of trachea and central bronchi
Mucociliary clearance is slower and less effective Number of bronchoalveolar macrophages is decreased Pulmonary functional reserves decrease with age Increase in diameter of trachea and central bronchi Tracheal cartilage becomes calcified, mucous glands hypertrophy Enlargement of alveolar ducts, resulting in a loss of surface area for gas exchange Pulmonary defenses against infection decreases cough is less vigorous

Kyphosis may be present from osteoporosis, and collapse of vertebrae
Inspiration is less deep, and decreased inspiratory reserve volume Expiration requires active use of accessory muscles

Peripheral Vascular System
Arteries may be tortuous, feel stiff, appear kinked Decreased venous return Pallor may indicate arterial insufficiency Edema Varicosities Trophic changes: Decreased hair on distant extremities

GI System: Normal Age Related Changes
Changes in mouth Decreased esophageal motility Decreased gastric motility Increased stomach emptying time Decreased ability of gastric mucosa to resist damage from bacteria or medications Insufficient hydrochloric acid in stomach Small intestine- impaired motility in response to a food bolus

Absorption of Vitamin A, K, and cholesterol is faster
Absorption of calcium, irons, lactose, xylose, and vitamin D is decreased. Lactase levels decline, as does calcium absorption from the gut. Absorption of Vitamin A, K, and cholesterol is faster Decreased production of intrinsic factor Slowed transit time, and altered contraction of large intestine. Mass of liver decreases with age, decreased hepatic blood flow. Synthesis of clotting factors decreased Decreased pancreas size Other factors to consider related to GI systems are if there are cognitive changes in the older adult which may result in decreased thirst and hunger drives Also need to consider the large number of medications that older adults take many of which have GI implications

Genitourinary System Renal system
Between ages renal mass decreases by 25-30%. Loss in renal cortex, nephrons with the longest loops, the ones able to maximally concentrate urine are preferentially lost

Diffuse sclerosis of glomeruli: 30% destroyed by age 75
Loss of capillary loops, decrease in epithelial cells = filtering surface is reduced. Reduction of urine acidification and an impairment in excreting an acid load Impaired ability to maximally dilute urine and excrete water Impaired ability to retain amino acids and glucose. Decreased renin response to volume depletion or salt restriction

Bladder and urethral changes Bladder:
More fibrous Decreased bladder capacity Autonomic enervation of bladder decreases Detrusor muscles less contractile and more unstable Age related instability of pelvic floor muscles Urethral changes Women: External sphincter muscle thinner and less able to resist pressure of urine from bladder Men: Prostate enlargement may constrict urethra Increased post void residuals Older adults have both the issue of the inability to completely empty bladder and also involuntary contractions of the bladder Weakened pelvic floor muscles make it difficult to control release of urine from the urethra Older adults less able to delay urination and therefore predisposed to urinary incontinence and UTI Urinary incontinence is NOT a normal part of aging.

Hematopoietic Function
Bone marrow mass decreases and bone marrow fat increases Hematopoietic response to phlebotomy or hypoxia is slower and less vigorous

Glucose and Insulin Changes in glucose response to meals: Post meal glucose levels higher Changes in body composition Decrease in insulin clearance Peripheral tissues less responsive to insulin

Thyroid Thyroid gland decreases in volume and becomes more nodular
Antidiuretic Hormone Higher basal levels of ADH Increased vasopressin response to osmotic stimuli decreased vasopressin response to volume change Kidney less responsive to circulating ADH, producing urine that is poorly concentrated and high in sodium Because of the decreased responsiveness of the kidney to ADH in older persons, older adults are more at an increased risk of hyponatremia. This is even a bigger issue for individuals who are on diuretics

Reproductive System Women Men Men and Women
Anatomic changes in the ovary, uterus, vagina and breast Decreased estrogen Increased time for arousal Men Gradual decline in male reproductive ability Amount of total testosterone decreases Benign prostatic hypertrophy present in about 90% of men over age 85 Increased time for arousal, ejaculation and refractory period Decreased firmness of erection Decreased force of ejaculation Men and Women Pubic hair thins and grays in both females and males In women: menopause Estrogen levels decrease dramatically with menopause and remain at low levels for rest of life Estrogen impacts: mucous membranes of the GU tract, vaginal tissue thins and becomes less elastic, vagina shortens, less vaginal lubrication, uterus shrinks, cervix and urethra atrophy, breasts become less firm, In men, the secondary sex characteristics supported by testosterone diminish: muscle mass, body hair, facial hair

Standard Lab Values that Change with Age
Hemoglobin and Hematocrit: Decrease to lower limits of normal Creatine and BUN: Increase Albumin: Decreases Potassium: Increases Glucose: Mild increase TSH: Increase

Common cardiovascular problems in the elderly
Arteriosclerosis and artherosclerosis Thickening and hardening of walls of vessels Arteriosclerosis Thickening of arterioles Frequently seen in hypertension Arterosclerosis Systemic May affect aorta It is often difficult to distinguish between changes in the cardiovascular system that are a result of normal aging and those that are a result of disease processes. A wide range of changes exist from person to person and there are a wide ranges of changes with aging. Deconditioning has a major impact on cardiac functioning. There are many older persons who have lived a healthy lifestyle and have a good family history that have better cardiac functioning than individuals who are much younger

Categories Risk factors Coronary Cerebral Peripheral Hypertension
Smoking Family history Diabetes and hyperglycemia Obesity Male gender Aging Hypercholesterolemia

Hypertension Most prevalent cardiac disorder in older adults
Approximately 50% of older adults have some degree of hypertension Cutoff readings for diagnosis of hypertension revised based on research Optimal systolic BP is <120 Optimal diastolic BP is <80 A quick review: Age related changes that are important to remember when talking about hypertension: Age related factors Thickening/fibrosis of insides of arteries causing increased vascular resistance Rigidity of arteries from thinning elastin Estimated 43 million Americans have hypertension, Only 69% of people with elevated blood pressure were aware of the fact that they had high BP (National heart, blood, and lung institute (2004). The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (2003) has guidelines that define hypertension in stages, including a stage for prehypertension, and have treatment recommendations for each stage.

Hypertension Interventions
Gradually reduce blood pressure Check BP regularly Check BP if person complains of headache, dizziness or visual disturbances Limit saturated fat, salt, sodium Lose weight if obese Smoking cessation/reduction Regular exercise as tolerated Limit alcohol intake Medications Important to check BP in both upper extremities and in lying, sitting, and standing positions. Diagnosing hypertension requires multiple readings on multiple occasions. A major part of managing hypertension is teaching modification of lifestyle. Medication management can be complication because of the many different choices as well as the many comorbidities that most older adults have as well as the often atypical response of older adults to specific medications. A major role of the RN is medication teaching and stressing that the individual needs to stay on the medications even though they do not feel symptoms of hypertension or note a difference in how they feel when they are on the medications.

Orthostatic Hypotension
Symptoms include dizziness and lightheadedness on rising from bed or chair May cause falls or short term confusion Risk factors Cardiovascular problems, medications, central/peripheral nervous system disorders Because of age related changes which make the baroreceptors less efficient, it is important to check orthostatic blood pressures. As a person gets older, the ability to autoregulate blood pressure can decrease. Decrease in muscle tone in the lower extremities can also contribute to orthostatic hypotension. Medications that can cause orthostatic hypotension include: alpha-adrenergic blockers, centrally acting antihypertensive drugs, psychotropics and NSAIDS

Orthostatic Hypotension: Interventions
Dorsiflex feet before standing TEDS/Elastic stockings Rise slowly: From lying to sitting to standing elevate head of bed at night Be alert for drop in BP after eating (postprandial hypotension)

Hyperlipidemia Elevated cholesterol is a risk factor for development of cardiovascular disease Guidelines for treatment include managing risk factors Target LDL goals based on risk factors Recommendations include medications for those with no cardiovascular disease but with positive risk factors Guidelines are from : Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults, 2001. Review: Lipids High density lipoproteins (HDL): have been shown to have an overall beneficial effect on vascular health because they mobilize cholesterol from the blood vessels and carry it back to the liver for processing. Low density lipoproteins (LDL): type of cholesterol associated with increased risk for mortality Triglycerides High fat diet and hereditary can result in elevated serum lipids.

Coronary artery disease (CAD)
Angina pectoris Presenting symptoms in more than 80% of older adults with CAD Stable angina Chest pain that is relieved with rest Precipitated by activities that increase heart’s workload Unstable angina Not relieved with rest or medication Many older adults do not experience the typical symptoms of chest pain but may instead complain of fatigue or weakness, sweating or dizziness.

Assessment Dyspnea (may be a major symptom rather than chest pain)
Syncope with exertion Sudden coughing during emotional stress Palpitations with effort Sweating with exertion Atypical chest pain

Non-anginal causes of chest discomfort
Esophageal disease Chest wall pain Anxiety Pulmonary embolism Cervical spine disease Abdominal emergencies

Symptoms Associated symptoms Pressure like discomfort Diaphoresis
Suffocating, strangling, crushing Heavy sensation under the sternum Pain may radiate down left arm, neck, jaw, throat, epigastric area Associated symptoms Diaphoresis Shortness of breath Anxiety Fatigue

Interventions Rest Remove precipitating factor Oxygen Meds Nitrates
Beta Blockers Calcium channel blockers

Surgical interventions
PTCA (angioplasty) CABG Lifestyle changes No smoking Avoid heavy meals, caffeine, intense cold weather Avoid emotional and physical strain Major role of nurse in educating and supporting lifestyle changes and medication usage.

Acute Myocardial Infarction
In older adults… May be precipitated by other problems: infection, bleeding, hypotension Presenting symptoms may not be “typical”, and therefore not responded to as quickly as younger individuals who present with more “typical” symptoms Ischemic heart disease is #1 cause of death in the US

Presenting Symptoms of MI
Typical presentation Acute crushing chest pain Hypotension Sweating No relief with Nitroglycerin No relief with rest Atypical Presentation in older adults Sudden dyspnea Acute confusion Persistent vomiting Severe weakness Vertigo Syncope

Interventions This is a medical emergency!!!!
Thrombolytic therapy in first few hours. Thrombolytic therapy (clot dissolving) can prevent permanent loss of myocardial cells, but must be used within short time period of the acute event. Thrombolytics used cautiously because they dissolve all clots in the body and can cause bleeding. Older adults are considered candidates for thrombolytic therapy.

Post MI Care Medications Beta blockers ACE inhibitors
Anti-platelet therapy with low dose (baby) aspirin Beta blockers reduce workload of heart. Calcium channel blockers used in patients who cannot tolerate beta blockers. ACE inhibitors can reduce afterload. Anticoagulants such as ASA or coumadin prevent new clots from forming.

Cardiac Rehab Need to consider in the elderly patient!
Goal: Preserve and maintain physical function and capacity, strength and coordination

Dysrhythmias Disturbances in cardiac rhythm
Results from a disturbance in impulse formation, a disturbance in impulse conduction, or from both mechanisms Classified according to their site of origin

Sinus tachycardia Heart rate exceeding 100 beats per minute Results from increased sympathetic stimulation OR A compensatory response to decreased cardiac output or blood pressure

May be asymptomatic except for an increased pulse rate
Assessment Chest discomfort/pain Fatigue and weakness Shortness of breath/Orthopnea Neck vein distention Decreased blood pressure Restlessness and anxiety Decreased urinary output

Intervention If chest pain: oxygen, rest, nitroglycerin and thrombolytic therapy If heart failure: Diuretics and cardiac glycosides If infection/fever: Antipyretics and antibiotics

Atrial fibrillation Seen in patients with a history of rheumatic heart disease, mitral stenosis, s/p MI, heart failure, and hypertensive heart disease May be intermittent or chronic Atria quiver in a totally disorganized manner no atrial contractions totally irregular ventricular response No p waves Atrial rate cannot be counted Ventricular rate beats/minute Most common sustained arrythmia Incidence increases with age

Persons are at risk for systemic emboli, particularly embolic stroke
Approximately 1/3 of people have thromboemboli Most emboli cause permanent severe neurological damage or death Assess for changes in mental status, speech, sensory and motor function NOT a life threatening arrhythmia, but morbidity increases because of the risk of stroke, which is five times higher for someone with atrial fibrillation

Interventions Oxygen Medications: Cardioversion Ablation
Conversion to sinus rhythm: antiarrhythmic drugs Slow rapid ventricular response: beta blockers, calcium channel blockers, digoxin Anticoagulants Short term: heparin Long term: coumadin Cardioversion Ablation Ablation: eclectrophysiologic studies to determine if one particular area of atria is responsible for initiating irregular rhythm. If it is, radio frequency waves used for ablation.

Heart failure Inability of the heart to pump sufficient blood to meet the demands of the body Loss of contractility of the myocardium Encountered with increasing frequency in the older adult population Most common risk factors: CAD and hypertension Heart failure: 4.8 million Americans have heart failure, 500,000 new cases per year (CDC, 2004). Other risk factors: family history, drugs that are cardiotoxic-like some chemotherapy drugs, smoking, ETOH use, obesity and diabetes

Classification systems developed to guide treatment options
Onset may be abrupt as after an acute MI, or clinical manifestations may begin gradually and progress Classification systems developed to guide treatment options Left vs. right Left sided ventricular failure is most common Typical causes: Hypertensive heart disease, CAD, valvular disease Classification system from NY Heart Association and the American College of Cardiology and the American Heart Associations. It is not important for the purpose of this exam to know the different classifications, but know that they are used to guide recommendations for therapy.

Left sided failure Indicated by decreased tissue perfusion from poor cardiac output and pulmonary congestion from increased pressure in pulmonary vessels Breathlessness is most common presenting symptom and varies with position and activity

Left sided heart failure: Assessment
Fatigue Weakness and effort intolerance Oliguria during the day Angina Confusion and restlessness Dizziness Tachycardia Palpitations Hacking cough Dyspnea/ breathlessness Crackles in lungs Frothy pink-tinged sputum Tachypnea

Left sided heart failure: Intervention
Goal: Remove underlying cause, remove precipitating cause and treat clinical manifestations Treatment of clinical manifestations includes: Improve contractility of failing ventricle Cardiac glycosides: Digoxin

Reducing cardiac workload
Physical and emotional rest correction of obesity vasodilators (nitrates and ACE inhibitors) Controlling salt and water retention Diuretics Dietary sodium restriction Monitor for/prevent potassium deficiency Daily weight (same scale, same time of day, same amount of clothes)

Valvular Heart Disease
Two types of disorders Stenosis Incompetence Signs and symptoms vary with disorder and severity Aortic stenosis most common Clinical presentation Fatigue Syncope Angina Heart failure Stenosis: Can occur in all heart valves and causes reduced blood flow across a valve with increased pressure in the chamber from which the blood is being pumped Incompetence: The valve fails to close completely which allows blood to flow backward when pressure in the chamber rises Vavular heart disease can be congenital or it can be acquired, from an event such as an MI. Age related changes in connective tissue can also cause changes in valves in heart.

Valvular Heart Disease: Interventions
Medications Non-surgical option: Percutaneous Transluminal Valvuloplasty Surgery Valvuloplasty: during a cardiac catheterization, a balloon is used to open the tight valve. Improves function but does not correct the underlying problem.

Venous Disease Varicose veins
Valvular incompetence in superficial veins Generally asymptomatic Major contributors: Obesity, tight fitting garments Common in women Family history Intervention: Elastic stockings

Chronic venous insufficiency: Incompetence in deep venous system, due to previous inflammatory process May lead to ulcer formation Assessment Chronic aching Brownish discoloration of skin, or bluish color in non-Caucasians, primarily on medial aspect of lower leg

Chronic venous insufficiency: Interventions
Elastic stockings Elevate legs intermittently Avoid prolonged standing Excellent skin care Continuous assessment and reassessment for skin breakdown

Thrombophlebitis Obstruction/inflammation of leg vein due to thrombus, infection, trauma or hypercoagulability Risk factors Surgery Varicose veins Trauma Prolonged bed rest Venous stasis

Thrombophlebitis: Assessment
Reddened area Warmth Pain Tenderness Thrombophlebitis: Interventions Below knee: Heat, decreased ambulation, NSAIDS, elastic stockings Above knee: short course of heparin

Deep Vein Thrombosis (DVT)
Thrombus in a deep vein First indication may be in connection with a pulmonary embolus Assessment Unilateral leg swelling Unilateral pitting edema Mild to moderate increase in skin temperature Measure leg circumference at ankle, knee, hip, thigh, compare with other measurements over time

Deep Vein Thrombosis (DVT): Risk factors
Immobility/decreased physical activity Previously damaged vein (trauma, varicosity) Obesity Heart failure Malignancy Hip fracture Dehydration Hypercoagulability

Deep Vein Thrombosis (DVT): Interventions
Anticoagulation Bed rest Prevention is essential!!!!! Early and frequent mobilization, range of motion exercises, activity for all patients!

Arterial disease Usually the result of atherosclerosis
Occlusion of specific vessels causes pain and loss of function in areas perfused by the artery Without therapy can progress to necrosis and gangrene Ankle brachial index Treatment Medications Surgical bypass Ankle brachial index (ABI): measurement of the pressure of blood flow, to determine adequacy of circulation. Measurement of the systolic pressure of the ankle divided by the diastolic pressure of the brachial artery. Normal reading is about 1. Medications: antithrombotic agents, prostoglandins and calcium channel blockers

Respiratory System Many age related changes in respiratory system
Changes in other systems that affect respiratory: cardiovascular, immune, and neuromuscular Other factors that affect respiratory function: Smoking/Second hand smoke Obesity: Reduced lung and chest wall compliance, increased work of breathing Immobility: Predisposes individual to early airway closing and atelectesis Malnutrition: Leads to shallow breathing and poor ventilatory responses Cardiac changes that can impact respiratory: increased stiffness of blood vessels making them less compliant to demands for increased blood flow, decreased cardiac output Immune function: decrease in nature and # of antibodies produced, decreased effectiveness of cilia of respiratory system Neuromuscular: loss of muscle tone and deconditioning Osteoporotic changes to the spine Increased anteroposterior diameter of the thorax-barrel chest

Non allergic type is more common in older adults
Asthma Increased responsiveness of bronchi and bronchioles to various stimuli, manifested by a widespread narrowing of airways Non allergic type is more common in older adults Common precipitating factor is URI Higher hospital admission rates for asthma in African Americans than Caucasians Higher hospital admission rates for women than men of all races (20-40% higher) (American Lung Association, 2003)

Asthma assessment Chest tightness Expiratory wheezing Varying degrees of dyspnea Increased secretions, thick and tenacious Productive cough Tachypnea Tachycardia

Classification of asthma severity to determine appropriate treatment
Classification on basis of days and night with symptoms and spirometry results Severe persistent Moderate persistent Mild persistent Mild intermittent Treatment: Medications for older adult do not differ significantly from younger adult Spirometry may be more difficult for an older adult: increasing rigidity of chest wall, anxiety, weakness in upper extremities, poor eye-hand coordination and perhaps even cognitive impairment. An individual’s classification may change over time. Medications might not change significantly from those of a younger person, however the older adult’s reaction to the medications might change. Also, major role for nurse in education and follow up to make sure individual is taking medications in the manner prescribed.

COPD (Chronic Obstructive Pulmonary Disease)
Term applied to two pulmonary conditions characterized by an increased resistance to airflow from one or more pathological process Chronic bronchitis Cough and sputum production on most days for at least 3 months for at least 2 years Emphysema Abnormal and permanent dilation of terminal air spaces combined with destruction of alveolar wall Symptoms slow in onset, initially resemble normal age related changes in respiratory system Estimated # people with chronic bronchitis is 12.1 million Americans, emphysema: 2 million Americans (National Heart Lung and Blood Institute , 2002) Chronic bronchitis and emphysema can occur together COPD more common in men than women. Although greatest increase in COPD is in African American women.

Assessment for Emphysema
Barrel chest (non specific because of aging) Pursed-lip breathing Dyspnea that fluctuates little day to day but increases on exertion Minimal sputum May or may not have cough Anxious appearance Thin/emaciated Prolonged expiratory phase May or may not wheeze Normal arterial PaCo2

COPD Interventions Smoking cessation Breathing retraining
Exercise program to limit deconditioning Energy conservation: Simplify ADL, frequent rest periods Adequate hydration/nutrition: 3L fluid/day (unless contraindicated) Avoid caffeine and alcohol

Medications to Treat COPD
Bronchodilators Corticosteroids Antibiotics Expectorants Other drugs to treat associated symptoms Bronchodilators: open narrowed airways and improve airflow and gas exchange Corticosteroids: lessen inflammation of the airway Antibiotics: at first sign of infection Expectorants to loosen mucus and clear airways Other drugs: Diuretics if heart failure, cough suppressants, antianxiety drugs.

COPD Interventions Avoid URI and other infections
Bronchial hygiene: Chest percussion therapy, postural drainage, oral hygiene, adequate fluid intake Low flow oxygen (if hypoxemic) Drug therapy aimed at reducing dyspnea, controlling cough and sputum production Avoid completely suppressing cough FLU VACCINE YEARLY

Lung Cancer Major disease in older adult population
Most common fatal malignancy in elderly men May have cancer long before symptom development Persons at high risk: Cigarette smokers, occupational exposure to carcinogens, geographic location high in air pollution Continuing to rise in women

Lung Cancer Symptoms seen as lung cancer progresses Dyspnea Coughing
Fatigue Anorexia Wheezing Recurrent URI Hemoptysis

Lung Cancer Interventions Chemotherapy Radiation Surgery

Pneumonia Inflammation of lung parenchyma, usually associated with the filling of alveoli with fluid Most common severe bacterial infection in older adults Mortality rate for elders is approximately 40% Older adults residing in nursing homes are at highest risk

Pneumonia High morbidity and mortality related to:
Age related decline in immune defenses Changes in pulmonary function that occur with aging Presence of chronic illness with subsequent debility Decreased mobility Late diagnosis

Pneumonia Assessment Cough Fever Sputum production In elders:
Confusion Tachypnea Fatigue Lethargy Chest x-ray will probably be ordered. Physical symptoms precede the presence of an infiltrate by about 24 hours, and after the pneumonia is resolved, chest x ray will not appear normal for about 6 weeks. Sputum for analysis is often hard to obtain in an older person, the cough is less vigorous as part of normal age related changes. Many sputum specimens just reveal the bacteria that have colonized the person’s mouth.

Interventions Antimicrobial agents: Dependent on identifying infectious agent Respiratory support: oxygen and chest PT Hydration and nutrition Need to remember to closely monitor the older adult’s response to antibiotics. Many age related changes. Drug interactions are more common because older adults take so much more medication.

Pneumococcal Vaccine Recommended for all adults over age 65
Recommended for all adults with immunosuppression or chronic disease Covers 23 most common serotypes of pneumococci that cause pneumonia Revaccination every 6 years for those with HIV/AIDS Renal failure Splenectomy If unsure of vaccination status recommendation is to vaccinate

Aspiration Pneumonia Aspiration of food, fluids, water, or vomitus causing airway irritation and inflammatory response Persons at risk: Feeding tubes Impaired swallowing or cough mechanisms Altered level of consciousness Decreased mobility

GI System: Review of age related changes
Oral cavity Decline in taste buds Wearing down of grinding surfaces of teeth Decrease in salivary gland secretion Decrease in thirst response to maintain fluid needs

GI System: Review of age related changes
Esophagus and stomach Reduced tone and motility of stomach and esophagus Decrease in hydrochloric acid production in stomach with risk of impaired digestion and absorption of iron, vitamin B12 and protein Atrophy of gastric mucosa Lower esophageal sphincter may be incompetent gastric reflux and esophagitis

Dysphagia Most common esophageal disorder in older adults
Difficulty in any part of the process of swallowing food or fluids

Who is at risk for dysphagia?
Patient : reports having difficult swallowing has problems sitting upright for any period of time drools, food falls out of mouth has cognitive impairment Has decreased level of consciousness Has slurred speech Chokes when eating or drinking Pocketing of food in the mouth

Causes of Dysphagia Neurological problems Muscular problems
Stroke Parkinson’s disease CNS degenerative diseases Muscular problems Muscular dystrophy Frailty Anatomical problems Tumors Anatomical problems of esophagus Neurological problems: Any disease that impacts movement or sensation can cause dysphagia. CNS degenerative diseases include Alzheimer’s disease Muscular problems: inhibit muscular function. Frailty in the very elderly can also fall into this category.

Feeding a Patient with Dysphagia
Proper positioning during feeding Have patient remain upright for 1 hour after feeding Minimize distractions Make sure the patient has swallowed food before offering next bite Oral hygiene before and after meal Food and fluid consistencies as recommended by speech pathologist

GERD (gastroesophageal reflux disease)
Assessment Heartburn: Substernal burning sensation with an upward moving character Acid regurgitation: Refluxed material flows into the mouth, especially after meals and when making postural changes Dysphagia GERD may present with symptoms not immediately referable to the GI tract such as chest pain, chronic cough, recurring aspiration pneumonia

GERD (gastroesophageal reflux disease) Interventions
Elevate head of bed Dietary modifications (fats, chocolate, excessive alcohol impair esophageal sphincter function, other foods are direct irritants Several small meals per day Stop smoking Weight reduction if obese Avoid medications that lower sphincter pressure or interfere with gastric or esophageal emptying Some drugs that can worsen reflux: caffeine and alcohol, calcium channel blockers, nitrates, NSAIDS, theophyllline, tetracycline

Drugs for GERD Antacids Histamine blockers: tagament, zantac
Proton pump inhibitors: lansoprazole, esomeprazole Mucosal protective agents: carafate Antisecretory agent: misoprostol Prokinetic agents: reglan Watch for confusion in older adults on tagamet

Peptic Ulcer disease Gastric ulcer predominates in elderly
May be related to chronic aspirin use, NSAIDS, steroids May be from Helicobacter pylori bacterium Gastric ulcers are prone to be cancerous In older people, the classic signs of peptic ulcer disease are rare. The classic abdominal pain is usually not present. The most common presenting symptom is iron deficiency anemia from blood loss. Because of this atypical presentation, complications including bleeding and perforation are common and older adults have a higher mortality rate.

Assessment Pain less typical/poorly localized, or may be left sided or lower chest discomfort Anorexia/weight loss Anemia Nausea Painless vomiting

Peptic Ulcer Disease Interventions
Antacids (watch contents/interactions with other drugs) Proton pump inhibitors Mucosal protective agents Diet as tolerated If H. pylori, treat with antibiotics Usually treated with more than one antibiotic due to limited effectiveness and potential for stimulating antibiotic resistance.

Disorders of large intestine
Constipation Contributing factors in elders Reduced mobility Reduced fluid intake Poor nutrition/decreased fiber intake Systemic diseases Medications Medications known to cause constipation include any with anticholinergic properties (antidepressants, antihistamines, neuroleptics, antiparkinson drugs), calcium supplements, aluminum containing antacid, opiates, iron supplements. Patients on these medications need to be closely monitored and a bowel regimen needs to be considered.

Interventions Increase activity High fiber diet Increase fluids Stool softeners Enema if necessary Treat underlying disease

Clostridium difficile (C. Diff)
A common cause of diarrhea common in frail elders Elders on antibiotics (esp. Clindamycin) especially susceptible Highly infectious Treatment: Flagyl Aggressive nursing interventions to prevent dehydration Occurs during or shortly after administration of antibiotics. C. difficile is part of the normal flora of the intestine but overgrows as a result of elimination of other bowel organisms Can be spread on hands of caregivers. Hand washing critically important Treat and identify the cause BEFORE treating the symptoms. Need to send stool specimen to verify that it is c-diff.

Nursing Interventions
Treat and identify the cause BEFORE treating the symptoms Handwashing Contact Isolation Antibiotics Fluid repletion

Colon Cancer Very common in older adults Risk factors Over age 40
Family history History of breast or uterine cancer Inflammatory bowel disease Dietary practices throughout life

Colon Cancer Assessment Change in bowel habits Mucous discharge
Rectal bleeding Intestinal obstruction Epigastric pain Anorexia/nausea

Colon Cancer Interventions Surgery
Prevention: Hemocult and routine colonoscopies

Diverticulitis Bowel contents accumulate in diverticula, decompose, and cause infection and inflammation Contributing factors Overeating Straining during BM Alcohol Irritating foods

Assessment Pain in left lower quadrant-severe, persistent, and sudden Nausea, vomiting, anorexia Constipation Diarrhea Low grade fever Blood or mucus in stool Abdomen distended with diminished bowel sounds

Attacks may be acute or slowly progressive Interventions
Reduce infection-broad spectrum antibiotics Acute: Hospitalization with NPO, IV fluids Rest High fiber diet after acute phase Surgery: Bowel resection

Dehydration: Demographics
Reported to be the most common fluid and electrolyte imbalance in older adults Responsible for large number of hospitalizations Responsible for significant morbidity and mortality rates

Dehydration Definition: There is no one universal definition. Many, depending on different parameters Weight: “Rapid weight loss of more than 3% of body weight” Laboratory parameters: Serum sodium greater than or equal to 148 and BUN (blood urea nitrogen) greater than or equal to 25

Diverticular Disease Diverticulosis
Pouches of intestinal mucosa in weakened wall of large intestine Usually asymptomatic Common in older adults Contributing factors Chronic constipation Increased age Lifelong low fiber diet Increase in collagen and elastin in aging colon

Older Adults Increased Risk For Dehydration
Body Water Decreases With Age Medications Increase Water Loss Thirst Mechanism Not As Effective Self Limit Fluid Intake Decreased Mobility To Reach Fluids

Traits of Elders at Highest Risk for Dehydration
Female Over age 85 More than 4 chronic medical conditions More than 4 medications Bed bound Laxative use Chronic infections

Living in a long term care setting can increase risk for dehydration
Availability of fluids Functional ability and access to bathroom

Risk factors for dehydration
Draining wounds and fistulas Medications Any medication that increases fluid loss Diuretics Laxatives Some enteral and total parenteral nutrition formulas alter fluid balance NSAIDS: alter kidney perfusion ACE inhibitors: alter kidney perfusion

Dehydration: Assessment
Poor skin sunken eyes dry mucous membranes muscle weakness Mental status changes Confusion Irritability Lethargy Lab values: Elevated levels: Sodium BUN (blood urea nitrogen) Hemoglobin/hematocrit Urine specific gravity Weight loss of 2 or more pounds (.9 kg) over a few days Decreased urine output increased heart rate fever orthostatic hypotension Poor skin turgor-on the forehead or sternum (hand or arm not reliable in elderly due to skin changes)

Interventions to prevent/treat Dehydration
Monitor fluid intake and output Watch for decreasing intake and increasing output Monitor lab values Monitor mental status Review care plan Medications Fluid restrictions Functional status Encourage fluid intake: Schedule for offering fluids, availability of fluids

Renal Failure Significant decrease in renal function in normal aging, GFR declines in mid-life, by age 70 the BUN doubles. Kidneys unable to concentrate and excrete urine, maintain fluid and electrolyte balance, acid base balance, and filter nitrogenous wastes Acute renal failure: abrupt steadily increasing azotemia with decreased urine output <500 ml/day, caused by poor perfusion, infection, obstruction. Occurs in elderly due to marked volume depletion from hypotension, major surgery, antibiotic use.

Renal Failure Chronic renal failure: Persistent alteration in and insufficiency of renal function with decreased renal blood flow. Occurs in elderly due to BPH, UTI, hypertension, heart failure, DM, connective tissue disorders. Chronic renal failure much more common in older adults. Chronic renal failure is caused by permanent damage to the kidneys. Many common chronic conditions in older adults such as diabetes, hypertension, BPH, contribute to chronic renal failure. Long time use of NSAIDS can also be a contributing factor.

Renal Failure: Signs and symptoms
Acute Renal Failure Fatigue, drowsiness Nausea, vomiting Scant urine output Flank pain Chronic Renal Failure Asymptomatic Fatigue, drowsiness Anorexia Pruritis Mental status changes Uremic frost: crystallized perspiration on the skin Renal failure has different presentation in older adult than in younger adult. In younger persons, markedly decreased urine output is usually first sign of acute renal failure. In an older person, first sign might be orthostatic hypotension

Renal Failure: Physical Findings
Acute Renal Failure Plasma creatine: recent increase of at least .5mg/dl if baseline level is <3.0 or 1.0 mg/dl is baseline is >3.0 BUN /plasma creatine level >20:1 Serum k, phosphate, mg++ elevated Serum Na, Ca,HCO3 decreased ABG: Acidosis Chronic Renal Failure K.6.0 BUN>70-80 Creatinine >6 Calcium decreased Normochromic, normocytic anemia ABG: Metabolic acidosis

Acute Renal Failure: Treatment
Rule out urinary cause Treat underlying cause Reevaluate medication regimen: Limit drugs excreted by kidneys Fluid restriction (600ml/day) Limit sodium and potassium intake Daily weights Patient education: Dietary, medications, fluid restrictions

Chronic Renal Failure: Treatment
Identify reversible cause Control hypertension Reevaluate medication regimen: Limit drugs excreted by kidneys Treat anemia Nutritional status Monitor fluid balance Dialysis Kidney transplantation Patient Education: Dietary, medication, fluid restrictions Treatment for chronic renal failure should be modified for older adults. Dietary restrictions and fluid restrictions may need to be tailored for the older adult since many older adults do not consume large amounts of fluids to begin with, and many do not have high intakes of protein and sodium. Of note is that constipation, which we already discussed as being a major problem for older adults can make hyperkalemia worse. Need to use all the interventions previously discussed to manage constipation. Older adults in the US are underrepresented among those who receive dialysis and kidney transplantation (US Renal Data System, 2002).

Common Urinary Problems in Older Adults Urinary Tract Infections (UTIs)
Second most common infection (URI #1) 8 million office visits 100,000 hospitalizations Important anatomical difference between females and males: female urethra is 2.5 inches vs. male urethra is 8 inches

Nursing Assessment Atypical Presentation in Older Adults:
Non-specific signs and symptoms such as change in functional status, fatigue, anorexia, nausea, vomiting, mental status changes, hypothermia, afebrile Typical Presentation: Frequency, urgency, suprapubic or low back pain, burning on urination, fever & malaise

Risk Factors In women: In men Both: Use of Pessary Atrophic Vaginitis
Short Urethra Cystocele In men Prostate enlargement Lack of Circumcision Both: Catheterized Immobility, Incontinent Bladder stones

Interventions for a UTI Drug Therapy
Antibiotic Therapy based on C & S Topical Estrogen for atrophic vaginitis Duration of therapy depends on organism.

Indwelling Urinary Catheters
Avoid use of catheters If you must use them, do for shortest period of time possible Always need to weigh risks versus benefits Establish protocols for use UTIs in older people with catheters often are difficult to treat because they have more than one bacteria Catheter associated urinary tract infections are among the conditions that CMS (Centers for Medicare and Medicaid Services) have listed as conditions that they will not reimburse hospitals for.

Urinary Incontinence Involuntary loss of urine
Affects over 13 million adults in the US (Hu, et al, 2004) 1/3 community dwelling women (Ouslander, 2000) 1/5 community dwelling men (Ouslander, 2000) 50% of men and women in long term care setting (Ouslander, 2000) Very costly: $19.5 billion dollars annually (Hu, et al, 2004) New onset urinary incontinence is a nursing priority. When encounter an older adult with incontinence need to ask questions, first being: “Is this new or old” and then go from there Urinary incontinence has a major impact on quality of life in older adults.

Infection, Inflammation, Impaction
Causes of Transient UI TOILETED Thin, dry epithelium Obstruction Infection Limited mobility Emotional Therapeutic medications Endocrine disorders Delirium DRIPP Delirium Restricted mobility Infection, Inflammation, Impaction Polyuria Pharmaceuticals There are several mnemonics which may be used as memory aids to recall common causes of transient UI. Two examples are TOILETED and DRIPP. TOILETED Thin, dry epithelium Obstruction (e.g., fecal impaction, enlarged prostate) Infection Limited mobility Emotional Therapeutic medications Endocrine disorders Delirium DRIPP Restricted mobility (e.g., illness, injury, gait disorder, restraint) Infection, Inflammation, Impaction Polyuria Pharmaceuticals

Chronic UI UFOs U rge F unctional O verflow S tress

Urge Incontinence Occurs when the detrusor muscle contracts unexpectedly and forcefully and the internal sphincter is unable to retain urine in the bladder Example: Overactive bladder Older men somewhat more affected than older women

Functional Incontinence
Chronic physical or cognitive impairments that impair the ability of the person to get to the toilet. Symptom: “I can’t get to the bathroom” Mechanism: Inability to toilet self Causes: severe dementia, arthritis, hip fracture Functional incontinence may be one of the hazards of hospitalization. The older adult may know that they need to void but cannot get to the toilet because they need assistance, or it can even be that they have some cognitive impairment and do not know where the toilet is. Functional incontinence is one type of continence that nurses can greatly impact by focusing on toileting.

Overflow Incontinence
Involuntary loss of urine associated with over-distention of the bladder Can be a result of blockage of the urethra which causes the bladder to overfill and the bladder muscles become stretched beyond the point of contractility. Can also due to lack of innervation of the bladder muscles due to spinal cord injury of diabetes Symptom: “I just go a little bit. I am always leaking” Causes: Outlet obstruction, hypotonic bladder

Stress Incontinence Sphincter failure associated with increased abdominal pressure, Involuntary relaxation of sphincter due to sphincter damage Occurs during a laugh, cough or sneeze Can be caused as a result of pelvic surgery

Treatment Behavioral Drug Therapy Surgery Lifestyle modifications
Biofeedback Kegels exercises Drug Therapy Look at current drug regimen Drugs for urge UI, for stress UI, overflow UI Glycemic control Surgery Lifestyle modifications Weight reduction Smoking cessation Caffeine reduction Management of fluid intake Toileting regimens Timed voiding Bladder training Absorptive products Condom catheters These are just a few interventions to treat urinary incontinence Kegels exercises are to strengthen pelvic floor muscles

Benign Prostatic Hyperplasia (BPH)
Enlargement of prostate gland, prostate increases in its fibromuscular stroma and encroaches on the urethra obstructing the urine flow Common in men over age 50, associated with aging, majority of men have some degree of BPH Etiology unclear, as prostate enlarges, there is a change in the urinary pattern of elimination, the bladder initially compensates, but eventually becomes non-compliant and hypotonic BPH classified (Chow, 2001): Microscopic: histologic changes Macroscopic: palpable prostate enlargement during rectal exam Clinical BPH: Individual has symptoms related to BPH

BPH Symptoms Difficulty initiating stream of urine Weak stream
Straining to urinate Feeling of incomplete bladder emptying Urinary retention Nocturia Urge incontinence As prostate continues to enlarge, symptoms progress

Treatment of BPH Alpha adrenergic blocking medications
Manage urge incontinence Surgery: TURP Alpha adrenergics: tamsulosin and doxazosin Complications of TURP: erectile dysfunction, hemorrhage, infection

Prostate Cancer Second most common cancer death in males over age 75
Prognosis dependent on stage when cancer is detected Incidence is 50% higher in African Americans, and relatively uncommon in Orientals Most prostate cancers are adenocarcinomas When metastasizes, frequently to the bones and pelvis, spine or femur Screening for prostate cancer is digitial rectal exam along with PSA (prostate specific antigen) testing

Prostate Cancer Signs and symptoms Initially may be asymptomatic
In advanced stages: Impotency, symptoms of urethral obstruction, back pain, weakness Labs: Serum acid phosphatase-seen in prostatic cancer with bone metastases PSA CBC: Anemia CXR Bone Scan CT Scan PSA: protease produced by both benign and malignant prostatic epithelium. Rate of change in PSA is a clinical marker for prostate cancer. Normal PSA is less than 4, greater than 10 is suggestive of neoplasm

Prostate Cancer: Treatment
Prostatectomy Hormonal manipulation (delayed until evidence of disease progression) Orchiectomy Leuron (leuprolide)-blocks release of FSH and LH and decreases testosterone production Antiandrogrens

Prostate Cancer: Treatment
Radiotherapy Pain management Chemotherapy Patient and family education Radiation therapy can be applied externally or through implants in the prostate.

Bladder Cancer One of the more common malignancies of older adults
Older men more likely than older women Common risk factors: cigarette smoking and occupational exposure to certain chemicals Signs and symptoms similar to those of other urinary tract diseases Treatment depends on which structures involved and how invasive

Genital Prolapse Varying degrees of vaginal relaxation causing displacement of bladder (cystocele), lower rectum (rectocele), uterus (uterine prolapse), and/or vaginal wall (enterocele) Etiology: multiple childbirth, relaxation of pelvis is influenced by loss of estrogen, atrophic changes with muscles and ligaments causing loss of tone Incidence is gradually decreasing in US due to decreased parity and earlier surgical intervention Treatment: Surgery or Pessary Patient Education: avoid heavy lifting, weight loss if necessary, avoid constipation

GYN Malignancies Ovarian, uterine and breast cancer more prevalent in older women than younger women Ovarian cancer Vague symptoms including abdominal pain and GI distress Late diagnosis and poor prognosis due to vague symptoms No specific screening tests Treatment Surgery Chemotherapy Obvious symptoms of ovarian cancer such as a mass or ascites not present until there is lymph node involvement and/or metastases CA-125 blood test for tumor marker that is sensitive and specific. Not recommended as a screening tool because there is not enough evidence that it would reduce mortality from ovarian cancers (National Cancer Institute, 2003)

GYN Malignancies Uterine cancer Risk factors Symptom: Uterine bleeding
Most common GYN cancer in older women Risk factors Late menopause Obesity HTN Diabetes Symptom: Uterine bleeding Diagnosis: endometrial biopsy Treatment: Surgery Chemotherapy Pap smear recommendations for older women: women over age 65, who have had a regular history of normal pap smears and who are do not fall into the high risk category (HIV,, many sex partenrs) do not need regular pap smears. Women who have had a total hysterectomy with cervix removed for non cancer reasons do not need to be screened with pap smears Recommendations from US Preventive Services Task Force, 2003)

Breast Cancer Affects 1 in 4 women over age 60 (American Cancer Society, 2002) Risk factors Advanced age Early menarche Late menopause Estrogen replacement therapy None or late pregnancy Abdominal obesity Screening Mammography Clinical breast exam Breast self exam Treatment depends on stage when diagnoses Annual mammography for women over age 40 (US Preventive Task Force, 2003) Age alone should not be the deciding factor for treatment for older adults.

Neurological Disorders
TIA (Transient Ischemic Attack) Definition: Brief episode of focal neurological dysfunction caused by ischemia that resolves completely without any residual deficit within 24 hours Etiology Recurrent embolism due to heart disease Cerebrovascular insufficiency (atherosclerosis of major neck arteries)

Vertebrobasilar - Must have one of first four
Signs and symptoms Carotid Monocular blindness Contralateral weakness and sensory symptoms Often localized to hands and face Speech disturbance Vertebrobasilar - Must have one of first four Vertigo Dysarthria Diplopia Bilateral paresthesias Dizziness Ataxia Visual blurring Assessment Artherosclerotic changes in fundi (eyes) Hypertension Carotid bruit Arrhythmia Diagnostic testing will include: Complete physical exam Urinalysis CBC, Blood Chemistries, PT/PTT/INR EKG, EEG, CT Scan Doppler flow studies

Treatment Management of risk factors for stroke
Recurrent embolism: Anticoagulate with coumadin Cerebrovascular insufficiency: Aspirin Patient Education: Risk factor reduction, medication dosage and side effects, anticoagulation - bleeding, bruising, safety issues Anticoagulation: need to consider the risks versus the benefits. Important to prevent future neurological events, but need to assess if the patient is a frequent faller and what safety measures have been put into place. Is he risk of a future neurological event greater than the risk of falling and hitting the head? Need to consider

Stroke (CVA): Dysfunction in sensory, perceptual, communication, or motor function as the result of a impaired blood flow to an area of the brain May be sudden and massive in onset or develop over a period in time

Etiology: Classified as either due to ischemia (80% of strokes), or hemorrhage (20% of strokes) Thombosis: Obstruction of blood flow due to local occlusive process within blood vessel (usually atherosclerosis). Most common Embolism: Material formed proximally, lodges in vessel and occludes blood flow. Majority of emboli occur in heart

Decreased systemic perfusion: Decreased blood flow to brain caused by low systemic perfusion pressure, usually caused by cardiac pump failure Subarachnoid hemorrhage: Blood leaks out of vascular bed onto brains surface and is disseminated quickly via spinal fluid pathways into spaces around brain (usually from anuerysms) Intracerebral hemorrhage: Bleeding directly onto brain substance, usually from hypertension, but can also be from trauma

Risk factors for thrombosis:
TIA, coronary artery disease, diabetes, hypertension, hypercholesterolemia, cigarette smoking, family history Risk factors for embolism: heart valve disease, endocarditis, atrial fibrillation, family history Risk factors for hemorrhage Hypertension, alcoholism

Incidence: More than 500,000 strokes annually; 150,000 die from strokes each year, there are more than 2 million stroke survivors Third leading cause of death in older adults, a significant cause of both short and long term disability

Common physical findings in stroke
Hemiparesis Vision impairments Aphasia receptive: difficulty in understanding speech or writing expressive: difficulty in expressing thought global: both receptive and expressive Dysarthria: difficulty speaking Dysphagia: difficulty swallowing Vertigo Sensory impairment: usually unilateral Decreased superficial pain Decreased position sense Deep pain is not impaired

Common physical findings in stroke
Loss of perception of body and environment on one side Gait or balance disturbances Apraxia: Inability to carry out purposeful movement Memory deficits Cranial nerve signs Loss of consciousness Emotional lability

Management/treatment
Acute - hospitalization Basic emergency measures Monitor cardiovascular status Monitor fluid and electrolytes Assess gag reflex before feeding Osmolar therapy to treat cerebral edema Anticonvulsants for seizure activity

Chronic/rehabilitation (most recovery occurs within first 3-6 mths) Rehab needs to be started ASAP Assess and prevent complications of immobility Manage nutritional status Manage sensory-perceptual alterations Manage impaired communication Manage cognitive problems Manage bowel/bladder problems Manage psychological/emotional responses Assist with plans for long term rehabilitation

Parkinson’s Disease: A degenerative disorder of basal ganglia and extrapyramidal nervous system. Patients lack normal concentrations of dopamine due to cell loss Etiology: Unknown Possible etiology: viral infections, chemical toxicity, cerebrovascular disease, drugs, structural

Signs and symptoms Tremor Rigidity of muscles
Present in 2/3 of patients Decreases with intention and sleep Increases with stress and cold weather Rigidity of muscles Increased resistance to passive movement occurs primarily in shoulders, neck, face decreased arm swing when walking, decreased blinking and facial expression

Bradykinesia: slowness in movement
Akinesia: difficulty in initiating movement shuffling gait difficulty in getting out of chair reduced voice volume slowness in eating

Assessment in Parkinson’s Disease
Gait and postural reflex impairment lead to increased risk of falling mental changes passivity confusion depression dementia Autonomic symptoms orthostatic hypotension urinary retention constipation seborrheic dermatitis ***Clinical diagnosis based on complete history and PE***

Treatment: Symptomatic, not curative Pharmacologic:
Sinemet - most effective treatment for symptoms for patients Anticholinergics- to relieve tremor Dopamine agonists- directly stimulate the dopamine receptors (bromocriptine, permax) Sinimet is a combination of carbidopa/levodopa. Usual starting dose is 25/100 three times per day increasing to 25/250 four times per day. Important to give on an empty stomach to enhance absorption and facilitate crossing the blood brain barrier. Side effect is postural hypotension, need to institute fall precaution measures and do patient education. Side effects of anticholinergics: dry mouth, constipation, blurred vision (all of which might be a problem as a result of the parkinson’s disease alone)

Non-pharmacologic exercise program physical therapy
maintain functional status safety issues

Type II Diabetes (NIDDM)
Abnormally high glucose levels Relative insulin deficiency and resistance to insulin action **NIDDM is distinguished by the absence of ketosis, which signifies the presence of at least some insulin** NIDDM accounts for about 80% of all diabetes cases in elderly Incidence in over age 65 group 88.7/1000 persons in the US

Type II Diabetes Risk Factors Obesity Familial pattern
Sedentary life style Lower socioeconomic background Lower educational level Symptoms Symptoms are usually subtle Rarely are there ketones in urine Rarely have polydypsia, polyphagia, polyuria Increased susceptibility to infections Fatigue and weakness Decreased level of consciousness, confusion Arterial disease Impotence Obesity: an increase demand on the beta cells, with an impaired insulin production in response to the beta cells OR post cell receptor defects impairing glucose transport OR insulin resistance mediated by decreased insulin receptors in the traget cells

Type II Diabetes: Treatment
Patient education Diet teaching: Protein: % CHO: % Fat: 30% max High fiber diet and low to moderate salt Exercise Life style modification: Decrease or eliminate smoking, decrease or eliminate alcohol, integrate glucose monitoring into routine

Type II Diabetes: Treatment
Long term monitoring: Large vessel disease, microvascular disease, peripheral neuropathy, peripheral vascular disease Oral hypoglycemics Insulin Medications which may worsen hyperglycemia: glucorticoids, diruetics (lasix, thiazides), estrogens, dilatin, lithium, sugar containing liquid medications (cough medicine) Medications which may potentiate hypoglycemia: beta blockers, insulin, alcohol, tagamet, large doses of salicylates Patient education: Hypo and hyperglycemia, importance of monitoring blood glucose levels, diet, foot care

Type I Diabetes: IDDM Abnormally high glucose levels Ketosis prone
Usually occurs in people less than 30 years old, some elderly people develop IDDM

Hypothyroidism Thyroid hormone deficiency
Primary hypothyroidism-autoimmune process. Secondary hypothyroidism-inability of the pituitary gland to secrete thyroid stimulating hormone or inadequate secretion from the hypothalamus of thyrotropin releasing hormone Incidence: 2-5% of those >65, women >men

Hypothyroidism: Signs and Symptoms
Atypical presentation in elders Arthraligia Weakness Decreased mental function Depression Constipation Cold intolerance Weight loss and anorexia Coarse dry skin and yellowish cast Dry sparse hair Mask like puffy face with periorbital edema

Hypothyroidism Diagnostic tests: ↑TSH (greater than or equal to 15)
↓or normal T4 ↓free thyroxine index Treatment Oral synthroid (start at .25mcg daily, increase by .25 mcg in two weeks and then monthly as needed) Monitor TSH level monthly Patient education

Hyperthyroidism Excessive circulating levels of T3 or T4 or both
Etiology in older adults Multinodular goiter: Makes up 50% of hyperthryroid. Mutinodular goiters may have been euthyroid for years and then change to over produce thryroid hormone. 7X more prevalent in people over age 60 Graves disease: autoimmune disorder that leads to the production of antibodies to the TSH receptors on the thyroid follicular cells. This antibody is also capable of stimulating the thyroid cell causing excess secretion of hormones.

Hyperthyroidism Signs and symptoms
Atypical: Progressive functional decline, Cardiac sx: tachycardia, atrial fibrillation Weakness and fatigue Memory loss Heat intolerance Diagnostic Tests ↓TSH ↑T3 and T4

Hyperthyroidism: Treatment
Radioactive Iodine: to obliterate thryoid gland followed by thyroid replacement therapy Anti-thyroid drugs (Propythiouracil, tapazole) Beta blockers to treat cardiac sx Surgical removal of the thyroid gland followed by thryroid replacement therapy

Musculoskeletal system
Osteoporosis Loss of bone material and matrix leading to decreased density of bone that results in decreased strength of bone and impaired skeletal function Etiology of primary osteoporosis is not know Men and women have different risk factors The most common metabolic disease Affects 50% of women at some point during their lifetime

Osteoporosis Primary osteoporosis Secondary osteoporosis
Menopausal bone loss Senescent bone loss Secondary osteoporosis Use of glucocorticoids Inadequate intake of vitamin D Hyperparathyroidism Malignancy Immobilization GI disease Renal disease Drugs that cause bone loss Menopausal bone loss: Sex hormones protect the body from bone loss. With decrease in estrogen in women and testosterone in men there is an increase in bone loss. Senescent bone loss: decrease in actual amount of bone formed during remodeling due to agingSecondary osteoporosis is less common in older adults First two on this list, the use of glucocorticoids and inadequate intake of vitamin D are the ones that most impact older adults

Risk factors for osteoporosis in women
Women have less bone mass than men, smaller, thinner bones Estrogen depletion during menopause Women live longer than men, increased risk for senescent bone loss

Risk factors for osteoporosis in men
Alcoholism Testosterone depletion Men have a slower decline of testosterone than women do of estrogen, so although men lose bone mass, they do so at a slower rate than women do.

Risk factors for osteoporosis in both sexes
Age Genetic: family history, Caucasian race Low body weight, small frame sedentary life style, bed rest low dietary intake of calcium limited exposure to sunlight smoking, alcohol, caffeine

Incidence One of the most important disorders of aging 30% of women over 60, 15% of men over 60 have clinical osteoporosis Signs and symptoms: diagnosis is by exclusion, x-rays are not diagnostic, bone density testing Loss of height, kyphosis, low back pain, hip, wrist, vertebral fractures

Prevention is the first step Diet: Calcium mg/day Adequate vitamin D Exercise: regular weight bearing Stop smoking Decrease alcohol and caffeine Estrogen replacement is controversial Vitamin D- essential for the metabolism of calcium and phosphorous

Osteoarthritis A slowly progressive disorder occurring late in life that is characterized clinically by pain, deformity, and limitation of motion and pathologically by focal erosive lesions, cartilage destruction, and cyst formation at the joint Etiology is unknown Increasing consensus that Osteoarthritis is not a single disorder but a group of disorders that result from a complex interplay of several factors Osteoarthritis is non inflammatory joint disease Most common form of arthritis, affects more than 50% of people over age 65 and is a leading cause of disability. Progressive erosion of the joint cartilege, you have the formation of new bone in the joint spaces

Incidence Signs and symptoms Most common arthritis
Found in 50% of people over age 65 Signs and symptoms Joint pain worse with movement and relieved by rest Stiffness of short duration after inactivity, or in the morning Pain described as aching, poorly localized

Assessment Decreased range of motion of affected joints
Crepitus (grating sensation) on range of motion Little or no inflammation Joints most commonly affected: hands, knee, hip, foot, spine Bony enlargement seen in distal interphalangeal (Heberden’s nodes), proximal interphalangeal (Bouchard’ nodes)

X-ray findings Laboratory findings Joint space narrowing
Marginal osteophyte formation Cyst formation Laboratory findings Erythrocyte sedimentation rate (ESR) :normal Joint involvement usually asymetrical at first. Pain is usually not associated with inflammation

Non-pharmacological treatment of Osteoarthritis
Weight reduction if arthritis is of weight bearing joints exercise physical therapy protection of joint from overuse moist heat ice Proper posture/body mechanics assistive devices splits

Pharmacological treatment for Osteoarthritis
Intra-articular steroids Aspirin Nonsteroidal anti-inflammatory drugs acetaminophen for pain if no acute inflammation

Inflammatory Joint Disease
Rheumatoid arthritis Most prevalent form of inflammatory arthritis Common in older adults Women more commonly affected Severity of disease ranges widely Major difference between rheumatoid and osteoarthritis is that rheumatoid arthritis can also have systemic manifestations, where as osteoarthritis does not.

Rheumatoid Arthritis Chronic syndrome
Symmetrical inflammation of peripheral joints Pain Swelling Morning stiffness Fatigue Weight loss Malaise Fever Cause unknown Commonly occurs in joints of hands, elbows, wrist, fingers, knees, ankles, feet Systemic manifestations: pleural involvement, vasculitis, renal involvement, cardiac involvement. Rheumatoid factor present in the synovial fluid and blood Long term exposure to the antigen (unknown bacteria or virus) causes normal antibodies to convert to autoantibodies, which are rheumatoid factor. Over time complex immune and inflammatory processes cause the development of pannus which is a neoplasm like mass in the synovium. This pannus causes joint damage.

Gout Deposition of crystals of monosodium urate in the joints with a resultant inflammatory response Etiology Genetic predisposition Ingestion of: Diuretics, foods high in purine, alcohol Emotional upset Minor trauma Surgery

Signs and symptoms Assessment
Acute: Sudden onset of acute inflammation of single joint of extremity (usually large toe), pain, swelling, redness, warmth Chronic: Joint pain in several joints Assessment Acute inflammation of a single joint, usually peripheral

Diagnostic evaluation
Aspirate of joint fluid: crystals seen on microscopic examination X-Ray shows characteristic lesions in chronic gout , “tophus” formation Twenty-four hour urine to evaluate uric acid production

Management/treatment Acute gout
NSAID Colchicine Rest affected joint Increase fluid intake Avoid alcohol Diet low in purine Pain medications as needed

Same treatment as acute gout addition of allopurinol
Chronic gout Same treatment as acute gout addition of allopurinol watch for bone marrow suppression hypersensitivity syndrome

Fractures Definition: A break in a bone Etiology:
Osteoporosis Unsteady gait Falls Incidence: Over 20,000 hip fractures/year in older adults

Assessment Hip Wrist Vertebral compression fracture Leg shortened
Externally rotated Pain with weight bearing Wrist Pain, swelling, bruising of wrist Vertebral compression fracture Acute back pain lasting 6-8 weeks

Falls Leading cause of accidental death in the US
7th leading cause of death in people over age 65 Cost: 20 billion dollars in 1994, anticipated to be over 34 billion in 2020 Hip fracture very common. Person over 85 is 10 times more likely to have a hip fracture than person age 65 After a hip fracture, ¼ of individuals remain in an institution for at least one year, many never return to own home. Falls are a major health problem for older adults in all settings. They are a major cause of disability and major cost All of above statistics from The National Center for Injury Prevention and Control, 2003

INTRINSIC RISK FACTORS
Age Related Physiologic Changes Chronic Medical Conditions/Pathophysiologic Changes Neurologic Disorders Musculoskeletal Disorders Cardiovascular Disorders Age Related Physiologic Changes Vision and overall sensory changes Balance and gait Baro-reflex activity Musculoskeletal changes Neurologic Disorders Dementia/Delirium Parkinson’s Disease Normal Pressure Hydrocephalus Hemiparesis Cerebellar degeneration Peripheral neuropathy Vertigo Musculoskeletal Disorders Rheumatoid arthritis/Osteoarthritis Osteoporosis Foot disorders Myopathies Cardiovascular Disorders Dysrhythmias Syncope Medication related Orthostatic and post-prandial hypotension

Extrinsic Risk Factors
Environment Assistive devices Medications

Medications Equal to or greater than 4 prescription medications increases overall risk for a fall Any medication that effects balance, cerebral perfusion or cognition increases fall risk Common Culprits Diuretics Sedative hypnotics/Long acting psychotropics Antihypertensives Oral hypoglycemic agents

CONSEQUENCES OF FALLS Physical Injury Immobility Psychosocial
Head trauma/Subdural hematoma Fractures/Dislocation Strangulation Lacerations/Abrasions Eye injury/Broken teeth/Dentures Immobility Pressure ulcers Contractures Pneumonia Pulmonary embolism/Atelectasis Sepsis Urinary retention /UTI Constipation/Fecal impaction Functional incontinence Orthostatic hypotension Psychosocial Fear of falls Anxiety with ambulation Depression Loss of self-esteem

ASSESSMENT AND EVALUATION
History Review past falls Events, activities, environmental factors involved with past falls Medication - OTC and prescription medications Alcohol or drug use Review any underlying risk factors

INTERVENTION Exercise Improves balance, strength and endurance
Produce long-term benefits improving sensory and motor function in elderly Inexpensive Goal is to improve muscle strength, increase reaction time and improve balance Increase in bone mass

HOME ASSESSMENT AND EVALUATION FOR EXTRINSIC RISK FACTORS
ENVIRONMENT scatter rugs/edges of area rugs raised door-sills stairs glare/poor lighting bath mats Are there handrails? Raised toilet seat? in bathroom electrical cords loose linoleum/tiles pets/small children Where is the telephone? personal emergency response system (PERS button)

In-Patient Environmental Assessment
Lighting Clutter: In room, hallway, bathroom Size of room and bathroom Assistive devices in bathroom: Raised toilet seat and grab bars Tubes attached to patient: Oxygen, IV, foley, etc. Accessibility of call bell Does patient have all their assistive devices from home: Cane, walker, eyeglasses, hearing aide? Does patient have safe and appropriate foot wear? Orientation to surroundings

INTERVENTION Medications are the most modifiable risk factor Education
Modification of lifestyle Exercise/Rehabilitation Changes in home environment

What is a physical restraint???
“Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely” CMS Final Rule for Hospitals on Restraints and Seclusion, December 2006

Commonly Used Physical Restraints
Vests (“poseys”) Wrist restraints “geri chair” table tops mittens Side rails

What is not considered a physical restraint?
Orthopedically prescribed devices Surgical dressings or bandages Protective helmets Any methods to involve physically holding patient for testing purposes Side rails on a cot or stretcher of OR table are not a restraint!

Physical Restraint Prevalence in the Hospital Setting
There is a wide variation in physical restraint use. One recent study found that physical restraint prevalence was approximately 50 per 1,000 patient days Varied by unit type Adult ICUs had highest prevalence Intra and interinstitutional variance was as high as 10 fold Ventilator use strongly associated with use Elderly patients over represented among the physically restrained (Minnick, Mion, Johnson, Catrambone, & Leipzig, 2007)

Restraint Reduction Address underlying fall problem
Address fall-related medication problems Promote activity Facilitate walking programs Refer to PT/OT as needed Provide comfortable seating Treat Pain Provide meaningful activities Negotiate w/resident & family reasonable risks

Immobility In absence of voluntary contraction, muscle strength decreases by 5% per day. Inactivity contributes to muscle shortening, and changes in joint structure which cause limitations in motion and contractures The most rapid changes take place in lower extremities

Bed rest during hospitalization
Little research examining frequency of ambulation and exercise in hospitalized elders Several early studies show large % patients on bed rest, have no nursing documentation of ambulation and only small % receiving PT Recent study (Callen et al., 2004) showed of patients considered able to walk in hallway (by nurses), only 3.4% walked more than twice and 72.9% did not walk at all during a three hour period

Herpes Zoster (Shingles)
An acute viral infection resulting from reactivation of the dormant varicella (chicken pox virus) The reactivation begins at the nerve root ganglia with neuralgia stemming from the involved dermatome The initial infection is followed by an outbreak of cutaneous vesicular skin lesions

Etiology Reactivation of the varicella virus causes an eruption of herpes zoster resulting in an acute infection During the lifetime of the individual the virus lies dormant in the sensory root ganglia and resurfacing of the virus can be initiated at any time Reactivation can be sparked by acute systemic illness, psychological upset, deficient immunological state, chronic fatigue and debilitation

Individuals over age 50 comprise 2/3 of all cases
Incidence: Individuals over age 50 comprise 2/3 of all cases Elderly more susceptible due to decreased immunological state At age 80, incidence > 10 per 1000 in population By age 85, individual has a 50% chance of developing herpes zoster

Assessment: Most common in trunk region Various sizes of erythematous lesions arise and evolve into purulent, fluid filled vesicles stemming from the reddened base Is one sided, does not cross midline of body Eruption continues to appear for seven days and lasts up to 3-4 weeks Postherpetic neuralgia (chronic pain at the site for many years) common in elderly

Treatment Analgesic agents for pain (acetaminophen) Antiviral agents (acyclovir) Topical care (burow’s solution) Systemic steroids for inflammation (prednisone) Oral narcotics for severe pain Psychotropics as needed for anxiety and depression Watch for bacterial infection Patient education: Risk of infecting those who have not had chicken pox

Adult Candidiasis A fungal infection of the skin Etiology: Candida albicans Usually seen in compromised elderly patients More common in obese women, diabetics, taking systemic antibiotics Assessment: Red rash, Itching and burning, often seen in vulvar area, skin folds

Treatment Keep skin clean and dry Intertriginous candida can be treated with nystatin, miconazole, or clotrimazole b.i.d. Avoid use of cornstarch Loose cotton undergarments

Skin Cancers Abnormal condition resulting from uncontrolled growth of cells in one skin layer Aging skin especially susceptible Types of skin cancer distinguished by kinds of cells tumors resemble

Most common skin cancer in older adults More common in caucasians
Basal cell carcinoma Most common skin cancer in older adults More common in caucasians Metastasis rarely seen, but can be locally invasive Prevalent in people with chronic sun exposure, fair skin, and immunosuppression Lesions frequently originate as pearly gray papules with a waxy, raised border Nose, eyelid, cheek are most often affected, as well as neck, back of hands, trunk Penetration of skin is primarily local Nodule may have a central induration and spread outwards in a “spider like” fashion 85% of nonmelanoma skin cancers are basal cell. 5X more prevalent than squamous cell, higher incidence in men

Second most common form of skin cancer
Squamous cell Second most common form of skin cancer Has potential for metastasis if not treated Lesions are slow growing Can arise from premalignant lesions in sun exposed areas, or from areas of chronic irritation or trauma Papule or nodule appears reddened, scaly, wart-like with a wide depressed border Lesions often on neck, ears, arms, hands Squamous cell usually occurs at later age, more prevalent in women

Stems from melanocytes found in pigmented lesions
Malignant melanoma Stems from melanocytes found in pigmented lesions Third and least common type of skin cancer Highly metastatic Associated with sunlight or irritation of a mole Hands and face are primary areas in elderly Nodular lesion can be tan, black, gray, red, white, or blue and often < 1 cm. In diameter Area is flat or somewhat raised with an irregular shape and stems from a pigmented mole Malignant melanoma usually metastasizes to other parts of body. Responsible for 75% of skin cancer deaths

Treatment of skin cancer
Basal and squamous cell: Surgery (scalpel excision), or medications (cryotherapy or radiotherapy) Malignant melanomas: Deep excision of primary lesion followed by antineoplastic agents, radiotherapy, and anti-infective agents

Skin – 2 Main Layers Epidermis – outermost layer of the skin
It varies in the thickness from about 0.1mm thick on the eyelids to 1mm thick on the palms and soles. It is acidic with an average pH of It contains and regulates the production of the brown pigment called melanin. Dermis – thick, deeper layer of the skin It is composed of Collagen, Elastin, and fibers with an extra-cellular matrix. This matrix contributes to the skin’s strength and pliability.

Pressure Ulcers: Staging: Stage I
Observable pressure related alteration Skin is intact Non blanchable redness Darker pigmented skin may not have visible blanching, but the color may be different than the surrounding area Changes in one or more of: Skin temperature Tissue consistency (firm or boggy) Sensation (pain or itching) Pressure Ulcer staging is unique to pressure ulcers. No other wounds are staged in this manner!

Pressure Ulcers: Staging: Stage II
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Presents as a shiny or dry shallow ulcer without slough or bruising May also present as an intact or open/ruptured serum-filled blister.

NPUAP Pressure Ulcer Staging6
Suspected Deep Tissue Injury Stage I Stage II Stage IV Stage III Unstageable

Stage III Stage III: Full-thickness skin loss
Deep crater involving damage or necrosis of subcutaneous tissue

Stage IV Stage IV: Extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures

Suspected Deep Tissue Injury (DTI)
Purple or maroon localized area of discolored intact skin. A blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones.

Unstageable: Full thickness tissue loss
The base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable dry and intact eschar on the heels should not be removed. It serves as a protective cover.

Pressure Ulcer Staging
Important points Stage only once Stage to maximum anatomic depth after necrotic tissue is removed Don’t reverse or backstage to describe a healing pressure ulcer Eschar cannot be staged Limitations of staging system with dark pigmented skin

Differences between Acute and Long Term Care in PU Staging
MDS does not have stages of “Deep Tissue Injury” or “unstageable”, the NPUAP does MDS only has stages 1-4 The NPUAP recommends that unstageable pressure ulcers (PU with necrosis) in the LTC setting should be classified as stage 4 for MDS Deep Tissue Injury (DTI)-The NPUAP does not have a recommendation for which stage this corresponds to due to the potential variation in DTIs

Differences between Acute and Long Term Care in PU Staging
NPUAP guidelines state that you do not backstage Reason: Physiology of wound healing. The healing site is filled with granulation tissue instead of muscle or fiber that was in the wound before. MDS forces staging of the ulcer bses on the actual description of the wound at the time MDS is being completed.

Risk Assessment:Braden Scale
Sensory perception Moisture Activity Mobility Nutrition Friction and shear

Pressure Ulcer Prevention
Skin care and early treatment Inspect skin daily Bathe (avoid hot water and friction) Assess/treat incontinence Moisturizers for dry skin

Pressure Ulcer Prevention
Proper positioning/turning/transferring Dry lubricants to reduce friction Proper nutrition Improve mobility/activity Mechanical off-loading and support surfaces Pressure reducing mattress and chair cushion Heel protectors Pillow/foam wedges beneath calf Bed elevation: short term, maximum 30 degree angle

Characteristics of intact Dark Skin
Assess skin color  darker than the surrounding skin  color - purplish / bluish Importance of lighting source  use natural or halogen light  avoid fluorescent lamps Assess skin temperature  warm initially  later cool Assess for edema/fluid

Normal Age-Related Changes of the Eye
Normal age-related changes in vision occur gradually; however, over time these changes can limit the functional ability of the older adult

External changes Graying and thinning of the eyebrows and eyelashes Subcutaneous tissue atrophy  wrinkling of skin surrounding the eyes Decreased orbital fat  sunken appearance of eye + sagging of eyelids

FIGURE Normal changes of aging in the eye include a thinning of skin surrounding the eye. Source: National Eye Institute, National Institutes of Health, 2004. External changes Graying and thinning of the eyebrows and eyelashes Subcutaneous tissue atrophy  wrinkling of skin surrounding the eyes Decreased orbital fat  sunken appearance of eye + sagging of eyelids © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Internal changes Cornea and lens Less endothelial cells on cornea  reduced ocular sensitivity  decreased pain response Lipid deposits around peripheral cornea  arcus senilis Lenses thicken + harden Yellowish appearance + opacity Light to scatter  interference with color discrimination Reduced space for drainage of aqueous humor  glaucoma Impedes accommodation presbyopia (decrease in near vision) arcus senilis – GREY /YELLOW RING AROUND THE CORNEA Accommodation – ability to focus on objects at varying differences

Arcus senilis

Internal changes Pupil Decreased dilation and constriction Delayed response  difficulty responding to changes in light Diameter is decreased  decreased light reaching diameter (need more light to see) Iris Loses color eyes appear gray or light blue

Visual acuity Diminishes gradually after age 50 Decreases rapidly after age 70 Light sensitivity declines with age Brightness contrast Dark adaptation Recovery from glare Glare-excessive light reflected back into the eye – night vision Brightness contrast – ability to discriminate between objects in varying degrees of light- can’t see objects in shadows

Visual Impairment Linked with four causes
Cataracts Macular degeneration Glaucoma Diabetic retinopahy Visual impairment = visual acuity 20/40 or worse by Snellen chart at 20 feet Increases with age Legal blindness = visual acuity 20/200 by Snellen chart at 20 feet Peaks at 85 years

Visual Impairment Personal cost for older person with visual impairment Loss of independence Social isolation Depression Decreased quality of life

Visual Impairment Signs of difficulty with vision
Squinting or tilting head to see Changes in ability to drive, read, watch television, or write Holding objects closer to the face Difficulty with color discrimination and walking up or down stairs Hesitation in reaching for objects Not being able to find something (American Society on Aging, 2003)

MACULA: specialized for central vision and high acuity vision
The macula is made up of densely packed light-sensitive cells called cones and rods. These cells, particularly the cones, are essential for central vision. The cones are responsible for color vision, and the rods enable you to see shades of gray. The choroid is an underlying layer of blood vessels that nourishes the cones and rods of the retina. A layer of tissue forming the outermost surface of the retina is called the retinal pigment epithelium (RPE). The RPE is a critical passageway for nutrients from the choroid to the retina and helps remove waste products from the retina to the choroid. As you age, the RPE may deteriorate, lose its pigment and become thin (a process known as atrophy), which sets off a chain of events. The nutritional and waste-removing cycles between the retina and the choroid are interrupted. Waste deposits begin to form. Lacking nutrients, the light-sensitive cells of the macula become damaged. The damaged cells can no longer send normal signals through the optic nerve to your brain, and your vision becomes blurred. This is often the first symptom of macular degeneration.

Age-Related Macular Degeneration (ARMD)
Two types Dry (atrophic form) Atrophy Retinal pigment degeneration (lack of nutrients between chorion and rods/cones) Drusen accumulations Require more light for reading Other Symptoms: blurring (trouble with street signs and fine newsprint, recognizing faces, haziness), colors aren’t as bright, “grey” spot in center of visual field (scotoma) Slow progression of visual loss

Age-Related Macular Degeneration (ARMD)
Wet (Neovascular exudates) Blood or serum leak from newly formed blood vessels beneath retina scar formation + visual problems Other symptoms More light required for reading Blurred vision Central scotomas (blind spots) Metamorphopsia- objects look smaller or larger than they actually are Straight lines appear crooked or wavy Less prevalent but more severe vision loss than dry

Risk Factors for ARMD Age (above the age of 50) Cigarette smoking
Family history of ARMD Increased exposure to ultraviolet light Caucasian race and light colored eyes Hypertension or cardiovascular disease Lack of dietary intake of antioxidants and zinc (Uphold, 2003; Fine, 2000) Treatment: laser tx for wet ARMD

ARMD Preventive Measures
Nurses should encourage Wearing ultraviolet protective lenses in sun Smoking cessation Exercising routinely Eating a healthy diet consisting of fruits and vegetables Taking vitamins in divided doses twice a day to delay progression Zinc oxide 80 mgm Cupric oxide 2 mg Beta carotene 15 mgm Vitamin C 500 mgm Vitamin E 400 IU

FIGURE A. Amsler grid as it appears to a person with normal vision. Source: National Eye Institute, National Institutes of Health, 2004. A © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

FIGURE 14-3 (continued) B. Amsler grid as it appears to a person with macular degeneration. Source: National Eye Institute, National Institutes of Health, 2004. OTHER diagnostic: angiography (to evaluate the extent of damage) and tomography imaging B © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

FIGURE 14-4 (continued) B. Normal vision
FIGURE 14-4 (continued) B. Normal vision. Source: National Eye Institute, National Institutes of Health, 2004. B © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

FIGURE 14-4 A. Simulation of vision with macular degeneration
FIGURE A. Simulation of vision with macular degeneration. Source: National Eye Institute, National Institutes of Health, 2004. A © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Cataracts Lens clouding  decreased light to retina  limited vision
Development is slow and painless Leading cause of blindness in the world > 50% of adults > 65 years have cataracts  visual problems

Cataract Eye without a cataract Eye with a cataract

Cataracts Risk factors Increased age Smoking and alcohol
Diabetes, hyperlipidemia Trauma to the eye Exposure to the sun and UVB rays Corticosteroid medications

FIGURE 14-5 A. Simulation of vision with cataracts
FIGURE A. Simulation of vision with cataracts. Source: National Eye Institute, National Institutes of Health, 2004. A © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Education for Older Persons with Cataracts
Explanation about cataracts and their causes Symptoms Treatment options Surgery Patients should avoid Lifting any heavy objects Straining at stool Bending at the waist

Complications of Cataract Surgery
Infection Wound dehiscence Hemorrhage Severe pain Uncontrolled, elevated intraocular pressure Special concerns Patients with cognitive impairments  careful supervision for at least 24 hours after surgery

Education Regarding Cataract Prevention
Wearing hats and sunglasses when in the sun Smoking cessation Eat a low-fat diet Avoid ocular injury Education regarding eye drop administration

Glaucoma Increase in intraocular pressure (IOP)  optic nerve damage  vision loss Open angle Slowed flow of aqueous humor through trabecular meshwork  build up increased IOP  damage to optic nerve fiber  loss of vision Painless vision loss Midperipheral visual field loss aqueous humor nourishes tissues produced in anterior chamber and drains out via the trabecular network. If obstructed

Glaucoma Open angle “normal-tension”
Normal IOP but still damaged optic nerve  visual changes (result of ischemia or inadequate blood flow) Symptoms Enlargement of the optic cup Nicking of the neuroretinal rim Small hemorrhages near the optic disc Exam for open angle: small hemorrhages near optic disc

Glaucoma Angle-closure
Angle of the iris obstructs drainage of aqueous humor through trabecular meshwork  increased IOP  visual changes Symptoms Unilateral headache Visual blurring Nausea and vomiting Photophobia Requires emergency intervention (meds to decrease IOP and laser therapy to increase flow of aqueous humor)

Risk Factors for Glaucoma
Increased intraocular pressure Older than 60 years of age Family history of glaucoma Personal history of myopia, diabetes, hypertension, or migraines African American ancestry

FIGURE 14-6 A. Simulated glaucoma vision
FIGURE A. Simulated glaucoma vision. Source: National Eye Institute, National Institutes of Health, 2004. A © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Diabetic Retinopathy Microvascular disease of the eye  damage to the ocular microvascular system  impairing transportation of oxygen and nutrients to the eye in diabetics Two forms

Diabetic Retinopathy Nonproliferative
Endothelial layers of blood vessels in eye are damaged + development of microaneurysms  leakage  edema near macula  impaired vision

Diabetic Retinopathy Proliferative
Damaged blood vessels  retinal ischemia  decreased blood supply + nutrient supply to retina  neovascularization  fragile blood vessels + RBC leakage  hemorrhage + vision obscured If tension exerted on retinal surface + vitreous body  retinal detachment + further damage to surrounding blood vessels  hemorrhage If neovascularization of the iris impaired drainage of the aqueous humor  Neovascular glaucoma

Diabetic Retinopathy Symptoms Gradual vision loss Generalized blurring
Areas of focal vision loss Treatment: laser therapy Manage hypertension and hyperlipidemia

FIGURE 14-8 A. Simulated diabetic retinopathy vision
FIGURE A. Simulated diabetic retinopathy vision. Source: National Eye Institute, National Institutes of Health, 2004. A © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Prevention of Diabetic Retinopathy
Tight glycemic control Average postparandial 80 to 120 mgm/dL Average bedtime capillary blood glucose 100 to 140 mgm/dL HbA1c < 7 Manage hypertension Manage hyperlipidemia

Medications with Side Effects of Visual Disturbance
Hydroxychloroquine (Plaquenil)—retinopathy, blurred vision, and difficulty focusing Tamoxifen (Nolvadex)—decreased visual acuity and blurred vision Thioridazine (Mellaril)—blurred vision, impaired night vision, and color discrimination problems Levadopa—blurred vision Propranolol—dry eyes, visual disturbances

Ophthalmic Solutions with Potential Adverse Effects
Beta-blockers (Betagan, Timoptic, Ocupress) (blue or yellow bottle caps)—bradycardia, congestive heart failure, syncope, bronchospasm, depression, confusion, sexual dysfunction ** lower the intraocular pressure by decreasing the rate at which fluid flows into the eye Adrenergics (Lopidine, Alphagan, Epinal) (purple bottle caps)—palpitation, hypertension, tremor, sweating ** reducing the production of fluid and increasing the amount of fluid drainage. (Alpha agonists do this also (Alphagan and Lopidine) Mitotics/cholinesterase inhibitors (pilocarpine, Humorsol) (green bottle caps)—Bronchospasm, salivation, nausea, vomiting, diarrhea, abdominal pain, lacrimation **increase the rate of fluid drainage from the eye

Ophthalmic Solutions with Potential Adverse Effects
Carbonic anhydrase inhibitors (Trusopt, Azopt) (orange bottle caps)—fatigue, renal failure, hypokalemia, diarrhea, depression, COPD exacerbation **reduce fluid flow into the eye Prostaglandin analogues (Xalatan, Lumigan) —changes in eye color and periorbital tissues, itching **increase the outward flow of fluid from the eye

FIGURE 14-9 Structure of the ear.
External ear Auricle wrinkles and sags Increased cerumen production Dry canal  pruritis Hard cerumen Decreased apocrine gland activity accumulation Inner ear Atrophy of organ of Corti and cochlear neurons Loss of sensory hair cells Degeneration of the stria vascularis © 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458

Hearing Loss > 30% aged 65 to 76 years 50% >75 years
Older men > older women Caucasian men and women > African American men and women

Hearing Loss Risk Factors Long-term exposure to excessive noise
Impacted cerumen (ear wax) Ototoxic medications Tumors Diseases that affect sensorineural hearing Smoking History of middle ear infection Chemical exposure (e.g., long duration of exposure to trichloroethylene)

Hearing Loss Temporary threshold shift (TTS)
Sounds < 75 dB(A)  temporary hearing loss Sounds > 85 dB(A) for 8hrs/day + many years  permanent loss

Conductive Hearing Loss
Sound unable to be transmitted to inner ear  poor reception + amplification Site of problem External or middle ear

Conductive Hearing Loss
Cause Otitis externa Impacted cerumen Most common and reversible- symptoms include feeling of fullness, itching, tinnitus, vertigo Otitis media- red bulging membrane and absent distorted light reflex Benign tumors Tympanic membrane perforation Foreign bodies Otosclerosis

Sensorineural Hearing Loss problems with the inner ear
Problems with cochlea + auditory nerve  sound distortion Causes Presbycusis Hearing impairment as a result of aging Bilateral Impaired ability to hear high pitches Rare, severe hearing loss or deafness Damage as a result of excessive noise exposure Meniere’s disease- abnormality of fluid (vertigo, tinnitus, fullness) Tumors Infection

Common Hearing Problems in Older Persons
Tinnitus Objective—pulsatile sounds with turbulent blood flow through the ear Hypertension Anemia Hyperthyroidism Subjective—perception of sound without sound stimulus Medications Infections Neurological conditions Disorders related to hearing loss

Drugs with Risk of Hearing Changes
Aminoglycoside antibiotics (gentamycin)—ototoxic Antineoplastics (cisplatinum)—ototoxic Loop diuretics (Furosemide)—ototoxic Baclofen—tinnitus Propranolol (Inderal)—tinnitus and hearing loss

Cerumen Impaction Hygiene
Cerumen removal (Contra-indications: tumors, perforated TM, ear trauma) Currette- by APN Lavage or irrigation-with bulb syringe Contra-indications: otitis externa, ear surgery

FIGURE 14-10 The tip of a bulb irrigation syringe is placed into the external canal.
© 2006 Pearson Education, Inc. Pearson Prentice Hall Upper Saddle River, NJ 07458 Gerontological Nursing By Patricia Tabloski

Hearing Aids Documentation on admission Type Model number
Serial number

Hearing Aids Assessment
Integrity of the ear mold: Are there cracks or rough areas? Is there a good fit? Battery: Use a battery tester if you have one. Are the contacts clean? Inserted correctly with + on battery matched to + in compartment? Dials: Are they clean? Easily rotated? Does the patient report variation of volume when the volume dial is moved? Switches: Do they easily turn on and off? Is there excessive static or feedback? Tubing for behind the ear aids: Are there cracks? Is there good connection to the earpiece?

Hearing Aids Care of hearing aids Remove and clean at bedtime
Warm water or saline NO alcohol or harsh soaps Use cotton pad Carefully remove cerumen Disengage battery Store in safe place

Hearing Aids Other devices Cochlear implants
Assistive listening devices Amplifiers in theaters Telecommunications device for the deaf (TDD)-use of a keyboard

Taste Normal changes associated with aging
Diminished sense of taste- hypogeusia Thresholds are ~2.5 to 5 times higher in older adults Protein Salt Sweetness What are the implications of taste alterations?

Taste Contributing factors to taste alterations Oral condition
Olfactory function Medications- antibiotics, antidepressants, anticonvulsants Diseases- Head trauma, MS, DM, Hypothyroidism, cancer, liver disease, CRF, AIDS, HTN Surgical interventions Environmental exposure Medical conditions

Taste Oral status can affect gustatory function
Poor dentition  improper chewing  less flavor release Improperly fitting dentures  obstruction of palate  decreased taste perception Oral infections  release of acidic substances  altered taste + impaired salivary stimulations  decreased ability for food to dissolve  diminished flavor

Taste Focused assessment for taste disturbances
Head and neck- r/o injury, deformity, obstruction, or infection, also dental caries or gum disease Mucous membranes- dryness, ulceration, thrush Interview with focus on past dietary habits

Taste Education Implications of inability to distinguished between salt and sugar Use of seasonings and additives Eat different foods on the plate Decreased taste  lack of motivation to prepare + eat  malnutrition

Xerostomia Cause Implications Systemic diseases (DM, HTN, Alzheimer’s)
Radiation Medications (anti-cholinergics) Sjogren’s syndrome (found in RA, SLE, Scleroderma) Implications Altered taste Difficulty swallowing  Risk for aspiration pneumonia Periodontal disease Speech difficulties  embarrassment  social isolation Dry lips + dry mucosa  increased infection + dental caries Halitosis Sleeping problems

Smell What are the implications of smell alterations?
Thresholds for common odors ~11 times higher for older people Structural alterations contribute to loss of sense of smell (hyposmia) Upper airway Olfactory tract and bulb Hippocampus Amygdaloid complex Hypothalamus What are the implications of smell alterations?

Olfactory Dysfunction
Statistics Males > females Causes Nasal and sinus disease Upper respiratory infection Head trauma Secondary Chemotherapy or other medications Radiation Current or past use of cocaine or tobacco Poor dentition

Olfactory Dysfunction
Special concerns Safety related to smoke and fire Malnourishment Sense of smell fails to be detected because it is not adequately tested Use three familiar smells Repeat with both nostrils, in different orders

Bacteremia Most frequently results from undiagnosed or inadequately treated infections Urinary tract is most common then respiratory Clinical signs: confusion, agitation, altered mental status, low grade fever, positive blood cultures Complication: septic shock

HIV/AIDS in the older adult
Infection with HIV can occur at any age Assessment for risk behaviors including drug use and sexual behaviors is often overlooked due to age of patient Decline in immune function as a normal part of aging increases the risk for HIV infection after exposure in elders In older women, changes in vaginal tissue as a result of aging may increase susceptibility to infection after exposure to sexually transmitted HIV infection.

HIV Infection in the older adult
Modes of acquiring HIV infection the same as in younger adult population Testing often delayed, many patients undergo extensive medical evaluations to rule out malignancies, due to stereotypical views of elders Disease staging the same as in younger population, retroviral therapy treatment the same. Studies show that age >60 associated with shorter survival rates than younger adult Patient Education Dealing with stigma of HIV/AIDS

Tuberculosis Highest > age 65 Mycobacterium tuberculosis exposure
Atypical signs and symptoms Confusion and altered mental status Pleural effusion Dissemination to lymph nodes, bones and kidneys, GI tact, kidneys may cause delay in dx. Two-step Mantoux method

Tuberculosis Transmission via airborne droplets
Repeated exposure with active TB 50% chance if one spends 8 hrs/day for 6 months OR 24 hrs/day for 2 months with person diagnosed with active TB Odds increase with risk factors

Risk Factors for TB in Older Populations
Living in an institution Diabetes mellitus Use of immunosuppressive drugs! Malignancy Malnutrition Renal failure

TB Greatest risk first year after Infection Symptoms Weight loss
Night sweats Loss of appetite An active case of tuberculosis requires isolation with controlled ventilation and reverse airflow until the client has been treated for 2 weeks with recommended antibiotic therapy.

TB Diagnosis Skin test should be used for
Those who spend time with someone with active TB Those with HIV or malignancy Those who think they may have the disease Those from countries where TB is common (Latin American, the Caribbean, Africa, Asia, Eastern Europe, and Russia) Those who use IV drugs and alcohol to excess Those living in institutions where TB is common Homeless shelters Migrant farm camps Prison Nursing homes Chest x-ray

Interpretation of the PPD
“Two-step” approach for older adult Older person’s immune system may be sluggish and not respond to first test Administer an injection of 5-TU intradermally and measure the induration in 72 hours; if the test is negative, repeat the test within 1 to 2 weeks and measure the induration in 72 hours. Persons with positive skin tests have been exposed to the infection and have sustained an immune response to the exposure. They usually are given an antibiotic prophylactically.

Treatment Isoniazid (INH) antibiotics for 6 to 12 months
Teach patients with TB to take their medications at the same time daily to prevent the development of resistant Mycobacterium.

Dementia Delirium Depression
The Three “D’s”

Dementia A long-term, usually irreversible condition involving degeneration in brain function The brain function affected depends on the type of dementia Many dementias involve multiple areas of brain function

Dementia: Causes Due to both treatable and nontreatable conditions
Two most common causes Neurodegenerative disorders Vascular disorders

Dementia: Causes (cont.)
Neurodegenerative Disorders Alzheimer’s Disease (AD) Lewy Body Disease Frontotemporal Dementia Account for 60-80% of all dementias Advanced age and family history are important risk factors Alzheimer’s disease: Presence of two abnormal structures: neuritic plaques and neurofilbrillary tangles. Beta amyloid protein is found in the plaques and a tau protein is found in the tangles. Definitive diagnosis is by histopathological confirmation upon autopsy, clinical diagnosis is done from history, physical and neuropsychological testing. Lewy body disease: autopsy shows lewy bodies, round structures throughout the brainstem and basal ganglia. Lewy bodies also seen in Parkinson’s disease, but then only in the subcortical areas of the brain. Frontotemporal dementia, includes Pick’s disease. See personality changes and atrophy of frontal brain in CT or MRI.

Dementia: Causes (cont.)
Vascular Dementia The loss of cognitive function resulting from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions The result of decreased blood supply from narrowing and blocking of arteries that supply the brain A history of cardiac arrhythmias, hypertension, hypercholesterolemia, DM, CAD predispose individual to vascular dementia

Other Causes of Dementia
Parkinson’s disease Chronic subdural hematoma AIDS Neurosyphilis Liver Disease Huntington’s disease Brain Tumors

Other Causes of Cognitive Changes
Potentially reversible Hypothyroidism Alcoholism Medications Narcotics, hypnotics, antiparkinsonian drugs, antihistamines, Vitamin deficiencies: VitaminB1, Vitamin B12, Folate

Clinical Manifestations of Dementia
Chronic progressive irreversible course Increased dependency

Alzheimer’s Disease Chronic, progressive, and degenerative
Most common form of dementia, accounts for 60-80% of all dementias 4 million Americans National costs: $100 billion dollars annually

Etiology of AD Exact etiology is not known Age Genetics Gender Race
Head injury Environmental exposure Genetics: mutations in genes on specific chromosomes known to cause AD, but account for only small percentage of cases. Further research ongoing. ? Genetic testing

Pathophysiology of AD Presence of abnormal clumps (neuritic plaques), and tangled bundles of fibers (neurofibrillary tangles) in the brain. Cholinergic defect involving synthesis, activity, breakdown of acetylcholine Immune and inflammatory autodestruction Tau proteins interfere with nerve cell functioning

4 A’s of Alzheimer’s Disease
Amnesia Aphasia Agnosia Apraxia Aphasia: partial of total loss of ability to speak and understand language Agnosia: Inability to recognize common things and persons Apraxia: Inability to carry out simple tasks

Treatment of AD Disease slowing
Affect the disease process to slow progression Palliative Affect the disease process to alter symptoms

Symptomatic Treatment
Goal is to manage particular symptoms rather than to reverse a pathologic process Cognitive Cholinesterase Inhibitors Four have been approved by FDA for treatment of mild to moderate AD Benefits in term of cognitive tests are small, individuals perform better on tests of memory and thinking May improve global outcomes, ADLs, behavioral and psychological symptoms Overall slow symptoms on average 6 months – 1 year Cholinesterase inhibitors slow the progression of AD. Preventing the destruction of acetylcholine by inhibiting the acetylcholinesterase enzyme that destorys acetylcholine should result in cognitive improvement Cholinesterase inhibitors seem to have a cognitive and functional benefit early on in the disease, less so in the later stages of the disease

Cholinesterase Inhibitors
Increase the concentration of acetylcholine and the duration of its action in synapses by inhibiting the degradation of acetylcholine Tacrine (cognex) 20 mg qid (1st developed, rarely used due to liver toxicity Donepezil (aricept) 5 or 10 mg od Rivastigmine (exelon) Galantamine(reminyl)- renamed razdyne

New Drug Memantine Antiglutamatergic Used in Europe
Initial clinical trials found to reduce clinical deterioration in people with severe AD Based on the hypothesis that overstimulation of the NMDA receptors by glutamate causes degeneration in neurons induced by beta-amyloid. Protects against beta amyloid induced neurotoxicity

Treatment of the Behavioral Manifestations of AD
Depression SSRIs Tricyclic antidepressants Insomnia Melantonin with a darkened room Psychosis-delusions Risperidone Olanzapine Haldol Seroquel Anxiety Benzodiazepines Lorazepam Xanax Buspirone

Assessing effectiveness of treatment
Patients often do not have enough insight to assess their own symptoms Caregiver is a knowledgeable informant and can help assess the patient’s response Goal is to arrive at a consensus of the patient’s global change

Delirium DSM-IV Criteria
Disturbance of consciousness with reduced ability to focus, sustain or shift attention Change in cognition or development of a perceptual disturbance not better accounted for by pre-existing dementia Disturbance develops over a short period and tends to fluctuate during the day Evidence from history, physical or labs that the disturbance is caused by the direct physiological consequences of a general medical condition

At least 2 out of 6 of: Reduced level of consciousness
Perceptual disturbances Disturbance of sleep-wake cycle Increased or decreased psychomotor activity Disorientation to time, person, or place Memory impairment

Occurrence of Delirium in Older Persons
Medical hospitalizations: 30% Surgical hospitalizations: %

Prodromal symptoms of delirium
Restlessness Anxiety Irritability Sleep disturbance May Progress to full-blown delirium over 1 to 3 days

Duration of delirium symptoms
Range: <1 week to >2 months Typically resolve within days In older adults, some 15% of patients experience delirium symptoms for up to 30 days

Causes of delirium Central Nervous System Metabolic Cardiopulmonary
Head trauma Metabolic Acid base imbalance Cardiopulmonary MI CHF Systemic illness Substance withdrawal Infection Sensory deprivation Temperature dysregulation Postoperative state

Drugs that cause delirium
Anesthetics Analgesics Antihistamines Antihypertensives Muscle relaxants Psychotropic medications Cardiovascular medications Corticosteroids

A Predictive Model of Delirium Inouye & Charpentier, 1996
Predisposing factors: Vulnerability Vision impairment Severe illness Cognitive impairment Precipitating factors: Insults Physical restraints >3 new medications Bladder catheter Any other iatrogenic event: UTI, prolonged bleeding, pressure ulcer

Delirium: Factors impacting care
Failure to recognize delirium or underlying physiological problems Attitudes toward care of elderly Rapid pace and technological focus of hospital care Reduction in skilled nursing staff

Delirium History: Time course of cognitive changes
Association with other events Review of symptoms

Depression Need to consider depression in an elderly individual who has a change in mental or functional status Need to differentiate if the person cannot answer correctly/perform a task/etc., or is so depressed that they just do not do it Use of antidepressants should be considered

Depression in elders Depression in later life often under diagnosed due to symptoms incorrectly being attributed to aging or medical problems More common in women Family history of depression

Etiology of Depression in Elders
Depression in later life is multifactorial involving a combination of factors Biological: Levels of norepinephrine and serotonin decrease with age The enzyme monoamine oxidase (MAO) increases with age Social: Widowed Lack of supportive social network Co-occurrence of physical conditions such as stroke, cancer, etc.

Depression signs and symptoms
Decrease/increase in appetite/weight (+or- 5 lbs) Insomnia or hypersomnia Psychomotor retardation or agitation Fatigue or lack of energy Depressed or dysphoric mood Anhedonia (inability to experience pleasure) Low self esteem Feelings of helplessness Cognitive deficits (psuedodementia) Difficulty concentrating or thinking Thoughts of death or suicide

Specific Depression Scales
Geriatric Depression Scale (Yesavage) Beck Depression Inventory Zung Self-Rating Depression Scale Does not matter which you use, but use of a standard tool GDS is commonly used, full version has 30 questions, short version which is valid and reliable has 15 questions Self report

Depression: Treatment
Antidepressant medications Indicated when symptoms are moderate to severe Choice of drug is based on side effect profiles and potential adverse reactions Significant antidepressant response takes 6-12 weeks in elderly patients Dosage is case specific, but is generally less than for younger adults. Increases are done slowly while closely monitoring the patient’s response

Electroconvulsive Therapy (ECT)
Important role in the treatment of serious depression in elders Considered when antidepressants have been ineffective or patient’s medical condition contraindicates their use Efficacy rate 80% but has high relapse rate Some evidence that age heightens post-ECT confusion, especially in very old Treatments usually given 3X/week for a total of 6-12 treatments

Psychotherapy Combination of psychotherapy and antidepressants has yielded better results than medications alone Elders often adverse to idea of psychotherapy Psychotherapy focuses on reassurance, education, reminiscence, ventilation, and validation of self worth

Suicidal Behavior Completed suicides are more common among older persons than any other age. Older adults make serious attempts to kill themselves using means that are highly lethal, not just “a cry for help”. Institutionalized elders may attempt indirect suicide by stopping eating, refusing medication, tests, examinations

Suicidal Behavior Clinical depression major factor among elderly suicides. 10th leading cause of death in over age 65, highest rate in the over age 80 group, higher in men than women, whites>non-whites

Suicidal Behavior: Management
Identify suicide potential Do not leave person alone Treat underlying depression ECT is often first line of treatment in suicidal elders Hospitalization with follow-up care and treatment Support groups for patients and families

Wandering Assess when, where, and under what circumstances a resident/patient wanders to determine precipitating factors Reasons for wandering: Lifelong patterns of walking to relieve stress, feelings of insecurity, boredom, restlessness, need for exercise, personal space has been violated, side effects of medications

Wandering Strategies to manage wandering
Accompany patient on wanderings, speaking in a conversational tone and gently direct back Engage in a regular program of physical exercise Provide secure area where can wander Provide environment cues to help wanderer who is “lost” Restrict access to undesirable/unsafe locations

Verbally or Physically Aggressive Behavior
Identify precipitating factors: Reaction to a new environment by person with cognitive impairment Lack of choice about daily routines Social isolation with no opportunity to express opinions or release tension in acceptable ways Reactions to disabilities in self and others Inability to deal with too much environmental stimulation

Verbally or Physically Aggressive Behavior: Management
Avoid hurrying or rushing patient Requests should be simple and non-demanding Remember that patient’s behavior is a result of brain damage, not deliberate action Environmental modifications Consistent staff caregivers Staff need to remain calm Behavior modification program

Alteration of sleep-wake cycle
Develop a routine for physical exercise and day time activities Anticipate needs to use toilet during the night with either a bedside commode, toileting rounds, night lights to bathroom Establish bedtime routines No caffeine after 12 noon Discourage naps If patient gets up at night, permit to get out of bed, offer snack and allow to sit up until they feel sleepy

ETOH abuse in later life
10-15% elders abuse alcohol, with numbers increasing Men>women Aging does not impair alcohol metabolism, but does impair physiological tolerance to alcohol. Elders are more severely impaired immediately after drinking, and it also takes longer for them to recover from its effects Alcohol is a “hidden condition” in later life, unreported. Clinicians fail to identify ETOH abuse in many older adults because of stereotypical ideas of older adults.

ETOH Abuse Alcohol: Potentiates the depressant effects of antispychotics, antidepressants, antianxiety agents, analgesics, and anticonvulsants Causes unpredictable plasma glucose concentrations when taken with oral hypoglycemics Blocks the effectiveness of some drugs such as anticoagulants

ETOH Abuse Diagnostic criteria and screening tools are not valid or reliable with elders because they do not incorporate age related adjustments ETOH abuse is suggested by any symptoms that represent physical or psychological dependence Treatment: Detoxification Antianxiety agents to manage withdrawal Family therapy and support

Elder Mistreatment Physical abuse Sexual abuse
Emotional/psychological abuse Neglect Abandonment Financial/material exploitation Self-neglect

Elder Abuse Least addressed Most underreported Underrecognized

Elder Abuse According to the NEAIS, more than 1.5 million older adults experience abuse and/or neglect in domestic settings Half of the cases were neglect 35% were psychological abuse 30% were financial exploitation 25% were physically abused

Elder Abuse One survey of nursing home staff members revealed
36% reported having witnessed at least one incident of physical abuse by another staff member in the previous year 81% had observed at least one incident of psychological abuse

Theories of the Etiology of Elder Abuse
“Psychopathology of the abuser” Caregivers who have preexisting conditions that impair their capacity to give appropriate care “Transgenerational violence” Part of the family violence continuum “Situational theory” also known as “caregiver stress” Care burdens outweigh the caregiver’s capacity “Isolation theory” Mistreatment is prompted by a dwindling social network

Assessment Caregivers of older adults should be assessed
For caregiver stress For substance abuse For a history of psychopathology Using the Caregiver Strain Index (CSI), which may aid assessment Separate interviews should be conducted for the caregiver and the patient Inconsistencies might increase the suspicion of abuse

Potential Signs of Mistreatment
The presence of both fresh and healing injuries Laboratory findings that support the presence of dehydration and malnutrition without medical causes

Interventions Nurses should plan for educational interventions for the caregiver, including Disease management Aging changes Maximizing healthcare services Respite services Behavioral management Caregiver support groups

Interventions Plan to assist in identifying family and community supports. Consider planning to organize a family meeting to discuss health and values.

Acute Pain Acute pain occurs from A time-limited illness
A recent event such as surgery Medical procedures Trauma

Chronic Pain Continues over a prolonged period of time
Affects one in five persons over 65 Good coping mechanisms and family support can lower pain levels. Depression can exacerbate pain levels.

Chronic Pain Chronic pain can lead to Labeling
Negative images and stereotypes Long-standing psychiatric problems Futility in treatment Malingering Drug-seeking behavior Common causes: Back pain, OA, osteoporosis, peripheral neuropathies, post-stroke pain, trigeminal neuralgia, ischemic pain related to vascular problems

Untreated Pain Untreated pain can cause Hyperalgesia
Hypertension, tachycardia, and even coronary ischemia Depression, anxiety, decreased socialization Sleep disturbance Impaired ambulation Increased healthcare use and costs

The Psychological Burden of Pain
The psychological burden of pain can Decrease participation in rehabilitation and self-care activities Slow recovery from illness Lower quality of life

Conduct a Baseline Pain Assessment
Baseline vital signs Ability to walk, stand, or move about in bed Baseline agitation level Appetite and eating patterns Sleep patterns Elimination habits Cognitive function and mood Use of medications and other interventions and response

For Cognitively or Verbally Impaired Patients
Obtain baseline information from a family member Do more frequent assessments Observe for nonverbal signs of pain Grimacing Moaning Guarded movements Bracing or tense body language Sad facial expressions Fidgeting Perseverant verbalizations or verbal outbursts See PAINAD- Pain Assessment in Advanced Dementia

Pain Assessment Pain is measured
Subjectively according to the patient’s self-report Ask: Where is it?, What is it like? Does it spread? What makes it worse? What improves it? Does it come and go? Is it severe? Which drugs tried? Interval between doses? s/e’s “Aches all the time” “worse when I move” “burning, stabbing” “worse when I breathe” Through careful observation

Additional Behaviors to Assess
Wandering Fidgeting Repetitive verbalization Tearfulness Delusions Sad or frightened facial expressions Noisy breathing Tense body language Repeated nighttime awakenings Hallucinations

Pain Intensity Scales

The Goal of Ideal Pain Management
Relieves both acute and chronic pain Uses both pharmacological and nonpharmacological techniques Minimizes side effects

Opioid Analgesics Older patients are generally more sensitive to opioid analgesics Start low, go slow (Remember reduced muscle mass, decrease in serum proteins, and dcreased renal clearance) Propoxyphene is not recommended because of accumulation of toxic metabolites Also not recommended: Methadone, meperidine (demerol), levorphanol (Levo-Dromoran), pentazocine (Talwin)

Management of Pain in Terminal Conditions
Management of pain for patients with a terminal condition should include higher doses of opioids that are used regardless of the secondary effects.

Adjuvant Drugs Adjuvant drugs for pain relief are used to
Relieve discomfort Potentiate the effect of the pain medication Decrease the dosage of opioid required for adequate pain control Reduce the side effects associated with higher doses of opioids

Adjuvant Drugs Medications used as adjuvants in pain control include
Antidepressants Topical analgesics Muscle relaxants Antianxiety medications Antipruritics Diuretics Magic mouthwash

Special Pharmacological Issues
Pain medication doses can be limited by the toxic effects of salycilates or acetaminophen.

Pain Medication Administration
Chronic pain Oral dosing is the preferred route Most effective when it is administered round the clock Long-acting or sustained-release forms of medication improve control Acute pain Breakthrough pain relief should be available IV or IM is preferred route Patient-controlled analgesia (PCA) is less effective in elderly and especially those who are cognitively impaired

Nonpharmacological Methods of Pain Control
Pain education programs Socialization or recreation programs (movies, art therapy, therapeutic use of music) Behavior modification (imagery, hypnosis, relaxation) Physical therapy (massage, ultrasound, exercise, hot or cold packs) Neurostimulation (acupuncture, transcutaneous nerve stimulation)

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