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Chapter 11 The Older Patient Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 1 Learning Objectives • Describe the roles of the gerontological nurse. • Determine the extent to which selected myths and stereotypes about older adults are factual. • Describe the biologic and physiologic factors associated with aging. • Explain the psychosocial factors associated with aging. • Describe modifications needed for activities of daily living. • Explain why drug dosage adjustments may be needed for older persons. Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 2 Definitions of Old Age • Most definitions = having lived a long time • Aged: defined as old or advanced in years • Aging: process of growing older or more mature • We all age, but not all of us are old in years, roles, behaviors, health, or physical limitations • Aging is an ongoing developmental process that begins at conception and ends in death Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 3 Gerontology • The study of aging Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 4 Geriatrics • The biomedical science of old age and the application of knowledge related to the biologic, biomedical, behavioral, and social aspects of aging to the prevention, diagnosis, treatment, and care of older persons Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 5 Roles of the Gerontologic Nurse • Formal preparation for care of older adults occurs at the master’s degree level • Also nursing personnel who have demonstrated competencies as a result of onthe-job training • Employment settings for licensed vocational or practical nurses have shifted from traditional hospital-bound positions to a range of community-based long-term care facilities and home health care positions Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 6 Gerontologic Nurse • Professional nurses and advanced-level practitioners, clinical specialists, and nurses holding national certification • Incorporates basic nursing methods and specialized knowledge about the aged • Increase healthy behaviors in the aged • Minimize and compensate for health-related losses and impairments of aging • Provide comfort through the distressing and debilitating events of aging, including dying and death • Diagnose, care, and treat disease in the aged Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 7 Ageism • Systematic stereotyping and discrimination against people because of their age, most often directed toward older adults • Allows for separation and denial of the older person’s humanness • Allows those who practice ageism to distance themselves from their own aging • Influences the behavior of its victims Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 8 Biologic and Physiologic Factors in Aging • Despite intense interest in longevity by so many cultures, scientists do not agree on precisely why or how humans age • Knowledge of the underlying mechanisms of aging is critical to develop a system that considers the special needs and health conditions of an aging population Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 9 Theories of Aging • Theories of aging ranged from the concept of purely genetic control of aging to environmental assaults that result in death • Most experts now believe that aging is not explainable by a single theory but represents many processes working simultaneously Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 10 Error Theories • Based on the belief that the rate of aging is directly related to the organism’s rate of living and that external events cause damage to the organism’s cells • The damage from all causes accumulates over time, resulting in cellular, molecular, and organ malfunction or errors Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 11 Programming Theories • Based on belief that aging is programmed into cells and is internal to the organism • These theories postulate that aging, like prenatal development and menopause, is the natural and expected result of a purposeful sequence of events written internally into gene structure Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 12 Physiologic Changes in Body Systems Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 13 Nervous System • Essential to know that in the absence of disease, most aged people remain alert, with functional intellectual capability, sound judgment, creativity • Only modest impairments in memory and learning after age 70 in most people who are relatively free from major disease • Changes may result in a progressive slowing of responses, problems with short-term memory, and altered learning Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 14 Nervous System • Short-term memory loss frequently a concern of the aged; long-term memory may remain intact • Stimulus input into the neurons; dependent on adequate tissue oxygenation • May not remember planned daily events but easily recall young adulthood experiences • Mild cognitive impairment (MCI) • Persistent memory problems with otherwise normal cognitive function • 40% will develop Alzheimer’s disease within 3 years; others do not progress to more serious impairment Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 15 Nervous System • Strategies to cope with memory problems • Mnemonics • Stringing together known and unknown information • Rehearsal memory training • Repetition • Temperature regulation • Low tolerance for extremes in temperature • Pain perception and tactile sensation • Some researchers have found dulling of pain and tactile sensation in older persons, but these results are not consistent Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 16 Respiratory System • Forced vital capacity, vital capacity, and maximum breathing capacity thought to decrease progressively with aging • Atrophy/weakening of respiratory muscles • Increase in the anteroposterior diameter of the chest as a result of kyphosis • Vertebral loss of calcium • Calcification of costal cartilage Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 17 Respiratory System • Loss of elastic tissue surrounding alveoli and alterations in pulmonary circulation result in decreased diffusion across the alveolarcapillary membrane • Pulmonary blood flow • Decreases because of a reduction in cardiac output • Pulmonary diffusion • Thickened capillary walls, and fewer capillaries surrounding the alveoli cause impaired gas exchange Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 18 Respiratory System • Exertional dyspnea • Shortness of breath with exertion • A frequent complaint with the older adult • Ability to perform prolonged strenuous work decreases with aging • Lung disease: acute or chronic • Poses a threat to the older adult • Pulmonary secretions handled less effectively Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 19 Cardiovascular System • Resistance to blood flow in many organs increases as people age • Aging results in the development of whitish patches, fibrosis, and sclerosis in the endocardium • The heart becomes more rigid and myocardial contractility is compromised Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 20 Cardiovascular System • Coronary blood flow may be reduced by as much as 35% because of changes in the vessels • Valvular rigidity and incomplete closure of aortic and pulmonic valves may result in murmurs • Heart cells have a decreased capacity to use oxygen, which may help explain the aged person’s reduced tolerance for physical work • Pulse increases and the pulse pressure widens Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 21 Cardiovascular System • Decrease in resting cardiac output • Amount of blood pumped each minute • Between ages 25 and 65, resting cardiac output falls 30% to 40% • Reduced cardiac output reflects a decreased heart rate and decreased stroke volume • Cerebral blood flow maintained, but other body systems, such as the liver and kidneys, receive a diminished blood supply Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 22 Renal System • Kidneys decrease in renal function; decrease in cell mass, and an increase in extracellular fluid • Decreases in filtration rate, plasma flow rate, and tubular reabsorption and secretion • Blood urea nitrogen tends to increase • Ability to concentrate or dilute urine is diminished • The bladder capacity may be reduced by half Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 23 Renal System • Response to the stretch receptors in the bladder wall that signal the need to void may be delayed until the pressure is high and the bladder almost filled to capacity • Lax muscle tone may lead to incomplete emptying of the bladder • Residual volume may cause subsequent urinary tract infections Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 24 Renal System • Incontinence • May appear as a symptom of upper or lower urinary tract dysfunction • Conservative behavioral treatment is recommended as the first level of intervention • Behavioral treatments: scheduled or prompted voiding, environmental adaptation, and pelvic muscle exercises (Kegel exercises) Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 25 Integumentary System • Skin changes can be the most distressing to the older person because they are so visible • Skin changes include dryness, loss of elasticity, wrinkles, uneven pigmentation and brown spots, roughness, looseness, thinness, and the development of various skin lesions Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 26 Integumentary System • Wrinkles • Occur when the deep layer of the skin loses moisture and elasticity • Tiny creases and folds are formed • Extent and timing determined by genetics and sun exposure • Persons in certain ethnic groups with thicker, oilier skin wrinkle at a slower rate; maintain a youthful, wrinkle-free appearance longer Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 27 Integumentary System • Itching • Related to loss of oils in the skin • Suggest tepid baths, using moisturizers liberally, avoiding overuse of antiperspirants, soaps, perfumes, and hot baths • Generalized itching should be reported to the health care provider; may be sign of diabetes, cancer, kidney disease, or liver disease Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 28 Integumentary System • Hair loss, hair thinning, and color changes • Men tend to grow bald, and women experience thinning of the hair on the head and genitalia • The number of facial and nasal hairs may increase • Gray hair is caused by a slowing of the pigment production in the hair follicles • Determined by genetics and tends to be irreversible • Nails • Become yellow and thicker Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 29 Gastrointestinal System • Oral cavity • Deterioration in the teeth and a decrease in the functional taste buds • Decrease in saliva secretion • Related to medications, inadequate hydration, and illness states rather than normal aging change • Saliva tends to become more alkaline as the salivary glands secrete less ptyalin and amylase Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 30 Gastrointestinal System • Muscles associated with chewing weaken, peristalsis is slower, and the risk of formation of intestinal diverticula increases • Gastric emptying is slower • Gastric glands decrease the volume and concentration of hydrochloric acid, intrinsic factor, and pepsin • Less amount of calcium absorbed Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 31 Gastrointestinal System • Constipation • Frequent gastrointestinal complaint • From decreased intestinal motility, altered bacteria flora, a diet low in bulk and roughage, medications, lack of physical activity • Educate about diet, activity, increased fluid intake, and avoidance of laxative abuse Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 32 Musculoskeletal System • Arthritis • The most prevalent chronic disease in men • More severe in women • Leading cause of disability • Osteoarthritis • Most common form of arthritis • Caused by damage to the inside surface of the joint • Age, heredity, and obesity contribute to development • Large weight-bearing joints (knees, hips, spine) are most affected Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 33 Musculoskeletal System • Kyphosis • Curvature of the thoracic spine that gives rise to the bent-over appearance of some older adults • Teach benefits of weight-bearing exercises • Walking, bicycling, and stair climbing help maintain bone and muscle mass • Assistive devices for walking and preventing falls • Avoid too much bed rest because of the detrimental effects of immobility Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 34 Figure 11-1 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 35 Sensory System • Presbycusis • Hearing loss associated with age • 25% of adults older than age 69, and half of adults older than age 85 are hearing impaired • Conduction deafness • Blockage of the ear canal caused by excessive wax buildup, abnormal structures, or infection • Sensorineural deafness • Damage to nerve tissue as a result of exposure to loud noises, disease, and certain drugs Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 36 Sensory System • Macular degeneration • Affects the macula, the part of the eye responsible for sharp central vision • Cataract • Clouding or opacity of the normal transparent lens within the eye • Surgical removal of the clouded lens Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 37 Sensory System • Presbyopia • Affects the shape of the lens • Reading and other close work become difficult • Glaucoma • Atrophy of the optic nerve usually associated with elevated pressure of the fluid in the eye • Optic nerve carries visual impulses from the eye to the brain Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 38 Sensory System • Chemosensory disorders • Involves taste and smell • Causes: nasal obstruction, allergies, certain drugs • Some scientists believe that the decline in smell is due to a decrease in olfactory nerve fibers • Major changes in ability to taste most often caused by diseases or side effects of certain drugs • Dentures, hormonal changes, medications, and changes in chemicals needed to transmit taste are causes of older person’s diminished sense of taste Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 39 Psychosocial Factors Associated with Aging • Older adults show cumulative developmental effects that produce unique personality styles, coping mechanisms, challenges, and growth • That a person has survived to old age is one marker of successful adaptation • Effective adaptation: meeting environmental and functional needs; attaining sense of well-being • Maturity: optimal psychological, social, and biologic adaptation achieved during midlife years, arbitrarily set between 45 and 65 years of age Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 40 Figure 11-2 Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 41 Psychosocial Factors Associated with Aging • Movement toward Erikson’s ego integrity is facilitated when the older person • Recognizes and accepts changes in physical and mental capabilities • Gives up some roles and develops new ones • Develops new activities that can be carried out successfully with aging • Develops a different self-concept • Revises life goals • Adapts to new lifestyles Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 42 Coping and Adaptation • Old age has been described as the season of losses • Roles, statuses, physical abilities, and deep personal losses through the deaths of friends and the disruption of family networks • Real, threatened, or imaginary loss a stressor; requires adaptation, flexibility, and resiliency to cope successfully Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 43 Coping and Adaptation • The older person may cope with these losses with positive or negative adaptation • Positive adaptation • Include rational action, perseverance, positive thinking, intellectual denial, restraint, drawing strength from adversity, and humor • Negative adaptation • Lose sense of personal identity and fulfillment and suffer from deterioration in self-esteem, an altered self-concept, and a loss of meaningfulness in life Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 44 Coping and Adaptation: Family • Most older adults in the U.S. occupy a variety of family roles; come from multigenerational units • Marital relations and the relationships between parent and child seem to be most important • Although family responsibility appears to be an internalized value for most people, it is important to know that more than half of the states have legal statutes that can require children to provide financial support for needy parents Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 45 Coping and Adaptation: Family • The combination of personal limitations, competing roles, and stresses generated by the care recipient’s behavior and the physical demands created by various levels of emotional, physical, financial, and family strain places enormous stress on informal caregivers • Caregivers frequently report symptoms of depression, anxiety, helplessness, low morale, and emotional exhaustion Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 46 Coping and Adaptation: Family • In part because of caregiver stress, more than 1 million older adults are abused physically and psychologically or are neglected each year by their caregivers • Education for learning and positive adaptive behaviors can assist caregivers and recipients • Families must be part of the holistic approach in the assessment and care of the aged Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 47 Functional Assessment • Activities of daily living; environmental, financial, family, economic, and community resources • Data useful during times of health, at the onset of illness, at the beginning of treatment, and following therapeutic interventions • Knowing what activities an individual performs alone, what activities require assistance, and what activities the person is totally unable to perform or to perform safely is essential to define care needs Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 48 Functional Assessment • The older person’s database should describe both basic and instrumental activities of daily living • Basic • Grooming, bathing, dressing, eating, elimination, and mobility • Instrumental • Prepare a meal, shop for groceries, use the telephone, negotiate transportation, take medications, housekeeping and laundry tasks Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 49 Drug Therapy and Older Adults • 88% of older adults who reside in the community use 1 or more medications • In long-term care facilities, more than 75% receive 4 or more medications and 33% receive 7 to 10 medications • Age- and disease-related changes slow the clearance of drugs, which increases the risk of adverse effects Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 50 Drug Therapy and Older Adults • Reduction in body size, decrease in lean body mass and water content (extracellular volume), and increase in fat • Serum albumin concentration is lower; tends to make more free drug available to tissues or to permit more rapid elimination of the drug • A gradual decrease in blood flow to the internal organs in the abdomen reduces drug clearance through the liver or kidney Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 51 Drug Therapy and Older Adults • The liver prepares drugs for elimination in the urine or in feces • Age-related changes that have an impact on the inactivation of drugs by the liver include decreased liver size, reduced hepatic blood flow, and reduced liver enzyme activity on drugs • These changes increase drug concentrations in the blood and possibly increase the amount of time it takes the body to get rid of the drug Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 52 Drug Therapy and Older Adults • Older adults tend to respond more vigorously to drugs that act on the central nervous system because of a greater tissue sensitivity and altered physiologic changes • Adverse effects: postural imbalance, staggering, uncoordinated movements, respiratory depression, and changes in mental alertness Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 53 Drug Therapy and Older Adults • Risk factors for adverse drug reactions • Age, sex, race (more frequent in older white females), number of drugs consumed, dosage, duration of treatment, severity of illness, and patient cooperation • Symptoms and signs • Restlessness, falls, depression, confusion, loss of memory, constipation, and urinary incontinence Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 54 Drug Therapy and Older Adults • Baseline and continual assessments • The amount, frequency, and purpose of all medications taken • Ability and willingness to take recommended medications • Potential for drug interactions and adverse drug reactions Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 55 Drug Therapy and Older Adults • Effectiveness of the medication over time • Whether any of the drugs taken can be discontinued or decreased in dose • Assessment of drug effects and adverse reactions must be documented Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 56