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Chapter 11
The Older Patient
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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.
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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
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Gerontology
• The study of aging
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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
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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
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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
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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
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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
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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
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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
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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
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Physiologic Changes in Body
Systems
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Figure 11-1
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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
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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
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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
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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
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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
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Figure 11-2
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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