Chapter 12: Health Care of the Older Adult PDF

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Chapter 12: Health Care of theOlder AdultI. OVERVIEW OF AGINGDEMOGRAPHICS OF AGING● Aging - normal process of timer related change that begins at birth ● In America, the older population is becoming more diverse reflecting change in demographics ● Life Expectancy - average number of years that a per...

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Chapter 12: Health Care of the Older Adult I. OVERVIEW OF AGING

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2030, it is estimated that the white non-Hispanic population will decrease to 72% of the elderly population; 11% Hisapnic, 10% black, 5% Asian Chronic Disease - major cause of disability: heart disease, cancer, and stroke 20% of 65 years of age report a chronic disability

HEALTH STATUS OF THE OLDER ADULT DEMOGRAPHICS OF AGING

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Aging - normal process of timer related change that begins at birth In America, the older population is becoming more diverse reflecting change in demographics Life Expectancy - average number of years that a person can be expected to live By 2030 it is estimated that 20% of Americans will be 65 years of age or older This number is estimated to increase to about 20 million in 2010 (6.8% of total), to 33 million in 2030 (9.2%), and to almost 50 million in 2050

Due to improvements in the prevention and early detection and treatment of diseases, there has been a noticeable impact on the health of people 65 years of age and older Older people are more likely to maintain good health and functional independence if encouraged to do so and if appropriate community-based support services are available Nurses should promote positive lifelong health behaviors among all populations

NURSING CARE OF THE OLDER ADULT ● ● ●

Gerontology - scientific study of the aging process, is a multidisciplinary field that draws from the biologic, psychological, and sociologic sciences Geriatrics - a practice that focuses on the physiology, pathology, diagnosis, and management of diseases of older adults Gerontologic/geriatric nursing ○ Field of nursing that specializes in the care of the elderly ○ Provides acute care, skilled and assisted living,the community, and home settings.

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The goal is early intervention and to help older people maintain maximum functional level and dignity despite physical, social, and psychological losses. Functional assessment - common framework for assessing elderly people Aging is not synonymous with disease and that the effects of the aging process alone are not the primary contributors to disability and dis ease

THEORIES OF AGING ● ●

Aging - passing of time, subjectively how a person feels, and functionally, as in changes in physical or mental capabilities Functional Consequences Theory ○ Miller (2009) ○ Challenges nurses to consider the effects of normal age-related changes as well as the damage incurred through disease or environmental and behavioral risk factors when planning care ○ Nurses can alter the outcome for patients through nursing interventions that address the consequences of these changes ○ Nurse must differentiate between normal age-related changes that cannot be reversed and risk factors that can be modified

II. AGE RELATED CHANGES ●

Well-being - depends on physical, psychosocial,mental, social, economic, and environmental factors

PHYSICAL ASPECTS OF AGING ● ●

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Refer to Table 12-2 for AGE-RELATED CHANGES IN BODY SYSTEMS AND HEALTH PROMOTION STRATEGIES Intrinsic Aging ○ Within the person ○ Changes caused by the normal aging process that are genetically programmed and essentially universal within a species. Ex. Pollution and excessive exposure to sunlight Universality is the major criterion used to distinguish normal aging from pathologic changes associated with illness but is less predictive since people age differently due to different factors

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Cellular and extracellular changes ○ Cause a change in physical appearance and a decline in function ○ Body’s ability to maintain homeostasis becomes increasingly diminished and organ systems cannot function at full efficiency because of cellular and tissue deficit ○ Degradation of elastin and collagen causes connective tissue to become stiffer and less elastic Lipofuscin - when cells become less able to replace themselves and accumulate into a pigment

CARDIOVASCULAR SYSTEM ● CHANGES: ○ Decreased cardiac output; diminished ability to respond to stress; heart rate and stroke volume do not increase with maximum demand; slower heart recovery rate; increased blood pressure ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Dyspnea or neurologic symptoms ○ Mental status changes or vague symptoms such as fatigue, nausea, and syncope ○ Burning or sharp pain or discomfort in an area of the upper body ○ Digestion and breathing complaints ○ Optimal blood pressure 120/80 mm Hg ○ Prehypertension 120–139/80–89 mm Hg ○ Hypertension 140/90 mm Hg ● HEALTH PROMOTION STRATEGIES: ○ Exercise regularly; pace activities; avoid smoking; eat a low-fat, low-salt diet;participate in stress-reduction activities; check blood pressure regularly; medication compliance; weight control ● Myocardial hypertrophy ○ Abnormal enlargement, or thickening, of the heart muscle ○ Change in left ventricular strength and function ○ Fibrosis and stenosis of the valves ○ Decreased pacemaker cells ○ All of which results to reduced stroke volume, calcium and fat deposits accumulate within arterial walls, and veins become

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increasingly tortuous, increasing arterial resistance; this increases the workload of the heart Hypotension - low blood pressure ○ Intervention: rise slowly (from a lying, to a sitting, to a standing position), having five or six small meals each day, avoiding extremes in temperature, including hot showers and whirlpool baths Assessment of older people is needed because they have different symptoms than those younger patients. The absence of chest pain in an older patient is not a reliable indicator of the absence of heart disease Heart disease is the leading cause of death and hospitalization. And is a major cause of morbidity and mortality of elderly population in the U.S.

RESPIRATORY SYSTEM ● CHANGES: ○ Increase in residual lung volume; decrease in muscle strength, endurance, and vital capacity; decreased gas exchange and diffusing capacity; decreased cough efficiency ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Fatigue and breathlessness with sustained activity; decreased respiratory excursion and chest/lung expansion with less effective exhalation; difficulty coughing up secretions ○ Exhibit headache, weakness, lethargy, anorexia, dehydration, and mental status changes ● HEALTH PROMOTION STRATEGIES: ○ Exercise regularly; avoid smoking; take adequate fluids to liquefy secretions; receive yearly influenza immunization and pneumonia vaccine at 65 years of age; avoid exposure to upper respiratory tract infections or people who are ill. ○ Major focus of health promotion activities should be on smoking cessation and avoidance of environmental smoke ○ Older adults should be frequently reminded to cough and take deep breaths, particularly postoperatively, because their decreased lung capacity and decreased cough efficiency predispose them to atelectasis and respiratory infections

INTEGUMENTARY SYSTEM ● CHANGES: ○ Decreased subcutaneous fat, interstitial fluid muscle tone, glandular activity, sensory receptors resulting in decreased protection against trauma and sun exposure, and temperature extremes; diminished secretion of natural oils and perspiration; capillary fragility ○ Decrease of epidermal proliferation, and the dermis becomes thinner ○ Elastic fibers are reduced in number, and collagen becomes stiff ○ Subcutaneous fat diminishes in extremities but increase in abdomen (men) and thighs (women) ○ Decreased numbers of capillaries results to diminished blood supply ○ Hair pigmentation may change and balding can occur ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Thin, wrinkled, and dry skin; complaints of injuries, bruises, and sunburn; complaints of intolerance to heat; bone structure is prominent ● HEALTH PROMOTION STRATEGIES: ○ Limit solar exposure to 10–15 minutes daily for vitamin D (use protective clothing and sunscreen (SPF) of 15 or higher); dress appropriately for temperature; maintain a safe indoor temperature; take shower rather than hot tub bath if possible; lubricate skin with lotions that contain petroleum or mineral oil ○ Not smoking, optimal nutrition and hydration ● FUNCTIONS: ○ Protection, temperature regulation, sensation, and excretion REPRODUCTIVE SYSTEM ● CHANGES: ○ Female: Vaginal narrowing, shortening and decreased elasticity; decreased vaginal secretions, Ovarian production of estrogen and progesterone ceases with menopause.Involution (atrophy) of the uterus and ovaries and decreased pubococcygeal muscle tone, resulting in a relaxed vagina and perineum

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Male: Less firm testes and decreased sperm production at 50 yrs old. Men may still produce viable sperm at 90 yrs old. ○ Male and Female: Slower sexual response, less response to sexual stimulation. Sexual desire does not disappear. SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Female: Painful intercourse; vaginal bleeding following intercourse; vaginal itching and irritation; delayed orgasm. Women may lose their partner; the absence of a partner is often the primary factor causing lack of sexual activity. ○ Male: Delayed erection and achievement of orgasm. Decreased libido. HEALTH PROMOTION STRATEGIES: ○ May require vaginal estrogen replacement; gynecology/urology follow-up; use a lubricant with sexual intercourse

GENITOURINARY SYSTEM ● CHANGES: ○ Male: Benign prostatic hyperplasia (enlarged prostate gland) causes a gradual increase in urine retention and overflow incontinence. ○ Female: Relaxed perineal muscles, detrusor instability (urge incontinence), urethral dysfunction (stress urinary incontinence) ○ Decrease in kidney mass, primarily because of a loss of nephrons, filtration rate, diminished tubular function, slower restoration of acid–base balance in response to stress ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Male: Urinary retention; irritative voiding symptoms including frequency, feeling of incomplete bladder emptying, multiple nighttime voidings ○ Female: Urgency/frequency syndrome, decreased “warning time,” drops of urine lost with cough, laugh, position change ○ Older adults who take medications may experience serious consequences ● HEALTH PROMOTION STRATEGIES: ○ Male: Limit drinking in evening (eg, caffeinated beverages, alcohol); do not wait long periods between voiding and empty bladder all the way when passing urine.

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Female: Wear easily manipulated clothing; drink adequate fluids; avoid bladder irritants (eg, caffeinated beverages, alcohol, artificial sweeteners); pelvic floor muscle exercises, preferably learned via biofeedback; consider urologic workup Unfortunately, this condition is often mistakenly viewed as a normal consequence of aging. This is reversible and can be treated

GASTROINTESTINAL SYSTEM ● CHANGES: ○ Decreased sense of thirst, smell (smoking, medications, and vitaminB12 deficiency) and taste; decreased salivation; difficulty swallowing food; delayed esophageal and gastric emptying/motility; reduced gastrointestinal motility (reduces the absorption of iron, calcium, and vitamin B1) ○ Digestion of food is less influenced by age-related changes than by the risk of poor nutrition ○ Difficulties with chewing and swallowing are generally associated with disease ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Risk of dehydration, electrolyte imbalances, and poor nutritional intake; complaints of dry mouth; complaints of fullness, heartburn, and indigestion; constipation, flatulence, and abdominal discomfort ○ Difficulty in swallowing, or dysphagia ○ Aspiration Of food or fluid is the most serious complication and can occur in the absence of coughing or choking. ○ Mild constipation - abdominal discomfort and flatulence, and more serious constipation leads to fecal impaction ○ ● HEALTH PROMOTION STRATEGIES: ○ Use ice chips, mouthwash; brush, floss, and massage gums daily; receive regular dental care; eat small, frequent meals; sit up and avoid heavy activity after eating; limit antacids; eat a high-fiber, low-fat diet; limit laxatives; toilet regularly; drink adequate fluid

NUTRITIONAL SYSTEM ● CHANGES: ○ Eldery require fewer calories and more nutrients due to sedentary lifestyle; reducing fat intake while consuming sufficient protein,vitamins, minerals, and dietary fiber for health and disease prevention. ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Decrease in taste and smell; maintain a taste for sweetness but require more sugar to achieve a sweet flavor; lose the ability to differentiate sour, salty, and bitter tastes. ○ Apathy, immobility, depression, loneliness, poverty, inadequate knowledge, and poor oral health also contribute to suboptimal nutrient intake. ● HEALTH PROMOTION STRATEGIES: ○ Encouraging a varied diet that is low in sodium and saturated fats and high in vegetables, fruits, and fish ○ No more than 30% of dietary calories should be consumed as fat ○ Increase protein intake or adequate nitrogen equilibrium ○ Carbohydrates, source of energy, supply 55% to 60% of the daily calories; Simple sugars should be avoided, and complex carbohydrates should be encouraged; Potatoes, whole grains, brown rice, and fruit are sources of minerals, vitamins, and fiber and should be encouraged. ○ 8 to 10 eight-ounce glasses of water per day ○ Multivitamin each day helps meet daily nutritional need ○ At 50 years of age should have a daily calcium intake to 1200 g, and 600 IU of vitamin D to maintain bone health SLEEP ● CHANGES: ○ Longer to fall asleep, awaken easily and frequently, and less time in deep sleep ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Sleep disturbances affect more than 50% of adults 65 years of age; lack of quality sleep at night often creates the need for napping during the day

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Sleep apnea - (a sleep disorder characterIzed by brief periods in which respirations are absent) inCreases with age ○ Insomnia - sleep related disorder (snoring, choking, or pauses in breathing) is associated with significantly impaired daytime functioning and longer psychomotor reaction HEALTH PROMOTION STRATEGIES: ○ Observe problems and recommend sleep hygiene behaviors such as avoiding use of the bed for activities other than sleeping (or sex), maintaining a consistent bedtime routine, avoiding or limiting daytime napping, limiting alcohol intake to one or two drinks a day, and avoiding caffeine and nicotine after noon

MUSCULOSKELETAL SYSTEM ● CHANGES: ○ Loss of bone density; loss of muscle strength and size; degenerated joint cartilage; deterioration of muscle fibers and cell membrane ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Height loss; prone to fractures; kyphosis; back pain; loss of strength, flexibility, and endurance; joint pain ● HEALTH PROMOTION STRATEGIES: ○ Exercise regularly “use it or lose it”; eat a high-calcium diet; limit phosphorus intake; take calcium and vitamin D supplements as prescribed ○ Osteoporosis is preventable. ● FUNCTIONS: ○ Maintenance of safe mobility, performance of activities of daily living (ADLs) (basic personal care activities), and instrumental activities of daily living (IADLs) (activities that are essential for independent living) NERVOUS SYSTEM ● CHANGES: ○ Reduced speed in nerve conduction (neurotransmitters); increased confusion with physical illness and loss of environmental cues; reduced cerebral circulation/blood flow

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(becomes faint, loses balance); The loss of nerve cells contributes to a progressive loss of brain mass. SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Slower to respond and react; learning takes longer; becomes confused with hospital admission; faintness; frequent falls (postural hypotension of ANS); affect gait and balance ○ Sudden onset of confusion may be the first symptom of an infection or change in physical condition (eg,pneumonia, urinary tract infection, medication interactions, and dehydration) HEALTH PROMOTION STRATEGIES: ○ Pace teaching; with hospitalization, encourage visitors; enhance sensory stimulation; with sudden confusion, look for cause; encourage slow rising from a resting position

SENSORY SYSTEM ● CHANGES: ○ Vision: Diminished ability to focus on close objects; inability to tolerate glare; difficult adjusting to changes of light intensity; decreased ability to distinguish colors; ■ older central cell accumulate and become yellow, rigid, dense, and cloudy, leaving only the outer portion of the lens elastic enough to change shape (accommodate) and focus at near and far distances ○ Hearing: Decreased ability to hear high frequency sounds (Presbycusis - irreversible inner ear changes.); tympanic membrane thinning and loss of resiliency ○ Taste and smell: Decreased ability to taste and smell ● SUBJECTIVE AND OBJECTIVE FINDINGS: ○ Vision: Holds objects far away from face (presbyopia);complains of glare; poor night vision; confuses colors (discern blue from green decreases) ■ Macular degeneration - does not cause blindness but affects central vision, color perception, and fine detail, reading, driving, and seeing faces ○ Hearing: Gives inappropriate responses; asks people to repeat words; strains forward to hear; cannot follow conversation

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because tones of high-frequency consonants (the sounds f, s, th, ch, sh, b, t, p) ○ Taste and smell: Uses excessive sugar (sweet tastes are particularly dulled among 4 senses) and salt (experience blunted taste) HEALTH PROMOTION STRATEGIES: ○ Vision: Wear eyeglasses, use sunglasses outdoors; avoid abrupt changes from dark to light; use adequate indoor lighting with area lights and nightlights; use large-print books; use magnifier for reading; avoid night driving; use contrasting colors for color coding; avoid glare of shiny surfaces and direct sunlight; Cognitively impaired people tend to respond well to touch and to familiar music ■ Macular degeneration aided through photodynamic therapy ○ Hearing: Recommend a hearing examination; reduce background noise; face person; enunciate clearly; speak with a low-pitched voice; use nonverbal cues ○ Taste and smell: Encourage use of lemon, spices, herbs Recommend smoking cessation TERMS: ○ Sensory loss - compensated for by assistive devices such as glasses and hearing aids ○ Sensory deprivation - absence of stimuli in the environment or the inability to interpret existing stimuli (perhaps as a result of a sensory loss) lead to boredom, confusion, irritability, disorientation, and anxiety

PSYCHOSOCIAL ASPECTS OF AGING ● ● ● ●

The ability of older people to adapt to physical, social, and emotional, losses and to achieve life satisfaction Older people need resilience and coping skills when confronting stresses and change Positive self-image enhances risk taking and parTicipation in new, untested roles Ageism - prejudice or disCrimination against older people

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Fear of aging and the inability of many to confront their own aging process may trigger ageist beliefs; Retirement and perceived non productively are also responsible for negative feelings; elderly themselves often believe and perpetuate ageism

STRESS AND COPING IN THE OLDER ADULT ● Ability to adapt to stress develop over the course of a lifetime and remain consistent; success in young adulthood helps a person develop a positive self-image that remains solid through old age. ● Common stress: impair physical function, activities, and appearance; disabilities from injury or chronic illness; social and environmental losses related to loss of income and decreased ability to perform previous roles and activities; and the deaths of significant others. LIVING ARRANGEMENTS ● Function best in their own environment ● Marital status: women have a longer life expectancy than men; women tend to marry older men; and women tend to remain widowed, whereas men often remarry ● Older people tend to relocate in response to changes in their lives such as retirement or widowhood; increasing disability and illness, elderly people may move to retirement facilities or assisted li...