MS 3 PRINCIPLES OF GERONTOLOGY ` Health promotion, health protection, disease prevention and treatment of disease with emphasis on evidence-based best

practices and current clinical practice guidelines. Aging is an inevitable and steadily progressive process begins at the moment of conception and continues throughout the remainder of life. The final stage of life consisting of old age, can be the best or worst time of life ` `

known today as the developing world. The term feminization of later life describes how women predominate at older ages and how the proportions increase with advancing age The gender differences in life expectancy may be explained by the complex interactions between biological, social, and behavioral factors.

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Greater male exposure to risk factors (tobacco, alcohol, and occupational hazards) might negatively affect male life expectancy. LIFE AFTER 65 ` ` Women 65 + 19 years; Men 65 can expect to live another 16.

requires work and planning throughout all of the previous stages to be a successful and enjoyable period. a. DEMOGRAPHICS AND AGING ` ` ` Countries all over the world are facing demographic aging. All nations are soon will be faced with important issues regarding the provision of healthcare to older persons. In 1997 -10% (561 million) of the world s population was age 60 and older

` life expectancy - attributed to improved healthcare - increased use of preventive services - healthier lifestyles ` SENESCENCE refers to the progressive deterioration of body systems that can increase the risk of mortality as an individual gets older.

c. THEORIES OF AGING Theories of aging fall into several groups, including biological, psychological, and sociological theories. 1. BIOLOGICAL AGING THEORIES ` ` A. PROGRAMMED THEORIES hypothesize that the body s genetic codes contain instructions for the regulation of cellular reproduction and death. ` A1. Programmed Longevity aging is the result of the sequential switching on and off of certain genes- with

projected to increase to 15% by 2025. b. LONGEVITY AND THE SEX DIFFERENTIAL ` ` Prior to 1950 - the male population outnumbered the female population.

` In 1950, this trend reversed. Women comprise the majority of the older population (55%) in all nations and the majority of these women (58%) live in developing countries. ` By 2025, nearly three quarters of the world s older women are expected to reside in what is

aging, associated functional deficits are manifested. A2. Endocrine Theory Biological clocks act through hormones to control the pace of aging. Proponents of this theory ascribe to the use of various natural and synthetic hormones, such as human growth hormone, to slow the aging process ` A3. Immunological Theory A programmed decline in immune system functions leads to an increased vulnerability to infectious disease, aging and eventual death. B. ERROR THEORIES environmental assaults and the body s constant need to manufacture energy and to fuel metabolic activities cause toxic by-products may eventually impair normal body function and cellular repair. ` B1.Wear and Tear Theory Cells and organs have vital parts that wear out after years of use.

- Once the binding occurs, the CHON cannot perform normally and may result in visual problems like cataracts or wrinkling and skin aging. B3.Free Radical Theory accumulated damage caused by oxygen radicals causes cells and eventually organs, to lose function and organ reserve. - The use of antioxidants and vitamins is believed to slow this damage. B4. Somatic DNA Damage Theory Genetic mutations occur and accumulate with increasing age - cells deteriorate and malfunction. 2. PSYCHOLOGICAL AGING THEORIES A. JUNG S THEORY OF INDIVIDUALISM ` the shift of focus is away from the external world (extroversion) toward the inner experience (introversion). search for answers to many of life s riddles and try to find the essence of the true self . To age successfully, the older person will accept past accomplishments and failures. According to Erickson, there are 8 stages of life with developmental tasks to be accomplished at each stage. ego integrity versus despair the older adult will become preoccupied with acceptance of eventual death without becoming morbid or obsessed with these thoughts. Older persons who have not achieved ego integrity may look back in their lives with dissatisfaction and feel unhappy, depressed, or angry

B. ERICKSON S DEVELOPMENTAL THEORY `

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- master clock controls all organs - cellular function slows down with time - less efficient at repairing body malfunctions that are caused by environmental assaults.

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B2.Cross Link Theory an accumulation of cross-linked proteins resulting from the binding of glucose (simple sugars) to protein causes various problems.

over what they have done or failed to do. 3. SOCIOLOGICAL AGING THEORIES A. DISENGAGEMENT THEORY Introduced by Cummings and Henry ` the appropriate pattern of behavior in later life is for the older person to engage in a mutual and reciprocal withdrawal. Thus, when death occurs, neither the older individual nor the society is disadvantaged and social equilibrium is maintained B. ACTIVITY THEORY ` contradicts the disengagement theory; older adults should stay active and engaged if they are to age successfully. When retirement occurs, replacement activities must be found. ` C. CONTINUITY THEORY ` successful aging involves maintaining or continuing previous values, habits, preferences, family ties, and all other linkages that have formed the basic underlying structure of adult life. Older age is not viewed as a time that should trigger major life readjustment, but rather just a time to continue being the same person. `

those needs, and evaluate the effectiveness of such care. The nurse s primary challenge is to identify and use the strengths of older adults and assist them in maximizing their independence. Nurses actively involve older adults and family members as much as possible in the decision-making process, which has an impact on the quality of their clients everyday life.

ADVANCED GERONTOLOGICAL NURSING  Advanced Practice Gerontological Nurse (APRN) - an RN who holds a master s, doctorate, or higher degree - demonstrates advanced knowledge and clinical expertise in the care of the older adults ` APRNs consist of Clinical Nurse Specialists (CNSs) and Nurse Practitioners (NPs) Gerontological Nurse Practitioners (GNPs) deliver primary care to older clients and have considerable autonomy addressing healthcare problems, often with prescriptive authority. Focuses more attention on the direct provision and evaluation of care.

2. GERONTOLOGICAL NURSING ISSUES SCOPE of PRACTICE American Nurses Credentialing Center (ANCC) defines practice for the gerontological nurse as follows: ` Gerontological nurses specialize in the nursing care and the health needs of older adults. They plan, manage and implement health care to meet `

Clinical Nurse Specialist (CNSs) provide direct and indirect care to patients and their families and serve as consultants to staff on complex issues of patient care. Focuses more attention on the educator and consultative role.  Play an important role in caring for older patients by preventing, recognizing, and treating common

problems and illnesses that are major causes of morbidity and mortality ` work with nursing staff to provide palliative care to dying patients(pain and symptom control) with certification and licensure requirements, they may be authorized to prescribe medications, including controlled substances describe the necessary competencies of care for each step of the nursing process. essential foundation of the action taken by gerontological nurses when caring for their patients

individualized to the older adult. Rationale The ultimate goals of providing gerontological nursing care are to influence health outcomes and improve or maintain the aging person s health status. Outcomes often focus on maximizing the aging person s state of well-being, functional status and quality of life. ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` ` Standard IV: PLANNING. The gerontological nurse develops a plan of care that prescribes interventions to attain expected outcomes. Rationale A plan of care is used to structure and guide therapeutic interventions and achieve expected outcomes. It is developed in conjunction with the older adult, significant others, and interdisciplinary team members. Standard V: IMPLEMENTATION. The gerontological nurse implements the interventions identified in the plan of care. Rationale The gerontological nurse uses a wide range of culturally competent direct and indirect interventions designed toward health promotion, health maintenance, prevention of illness, health restoration, rehabilitation, and palliation. `

STANDARDS of GERONTOLOGICAL NURSING `

to identify and meet the professional responsibility to deliver quality patient care to older persons. ANA Standards of Clinical Gerontological Nursing Care ` Standard I: ASSESSMENT. The gerontological nurse collects patient health data. Rationale Interviewing, functional assessment, environmental assessment, physical assessment, and review of health records enhance the nurse s ability to make sound clinical judgments. Assessment is culturally and ethnically appropriate. ` Standard II: DIAGNOSIS. The gerontological nurse analyzes the assessment data in determining the diagnosis. Rationale The gerontological nurse, either independently or in collaboration with interdisciplinary care providers, evaluates health assessment data to develop comprehensive diagnoses that form the basis for care interventions. ` Standard III: OUTCOME IDENTIFICATION. The gerontological nurse identifies expected outcomes

` The gerontological nurse implements the plan of care in collaboration with the older adult and others. The gerontological nurse selects intervention according to his or her level of education and practice. ` Standard VI: EVALUATION. The gerontological nurse evaluates the older adult s progress toward attainment of expected outcomes. Rationale Nursing practice is a dynamic and evolving process. The gerontological nurse continually evaluates the older adult s responses to treatment and interventions. Collection of new data, revision of the database, alteration of nursing diagnoses, and modification of the plan of care are often essential. The effectiveness of nursing care depends on ongoing evaluation.

Adult Day Care. Adult day care is an option for frail elderly people who require daytime supervision and activities. ` Residential Care Facilities. -Called rest homes, these facilities are sometimes large private homes that have been converted to provide rooms for residents who can provide most of their own personal care, but may need help with laundry, meals and housekeeping.

Transitional Care Units. Provide subacute care, rehabilitation and palliative care health services to patients who no longer require acute care. Most of these patients are recuperating from major illnesses or surgery, have complex health monitoring needs, or require palliative care with pain and symptom control. ` ` Rehabilitation Hospitals or Facilities. Special facilities exist to provide subacute care to patients with complex health needs. These patients may be:

Role by Setting ` Gerontological nurses are employed in most healthcare settings. 60% of hospital patients 80% of homecare patients

 head-injured or on ventilators  require aggressive rehabilitation after injury or surgery  require the services and intensive treatments from specialists such as PT, OT, dietitians, and physiatrists ` Community Nursing Care. - the nurse visits the patients on a regular basis to monitor VS - provide education or counseling - administer IM injections, - change a dressing and deliver wound care - provide supervision to home health aids or homemakers.

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` 90% of nursing home patients; are over the age of 65. Sites of care include: ` Skilled Nursing Facilities. - Skilled care is delivered by nurses and others to residents. - Care may be subacute or chronic for frail elderly residents requiring help with ADLs. ` Retirement Communities. Senior citizen retirement communities range in size and scope of services.

ETHICS ` The ethical practice is guided by the Code for Nurses with Interpretive Statements (ANA, 2001)

RELEVANT CONTEXTUAL FACTORS. Age, education, life situation, family relationships, setting of care, language, culture, religion and socioeconomic factors. CAPABILITY OF THE PATIENT TO MAKE DECISIONS. Legally competent, clearly incapacitated, diminished capacity, fluctuating mental status, presence of drugs or illness to cloud capacity. PATIENT PREFERENCES. Understanding of condition, views on quality of life, values regarding treatment, and advance directives. NEEDS OF THE PATIENT AS A PERSON. Psychic suffering, interpersonal dynamics, resources and coping strategies, adequacy of the environment for care. PREFERENCES OF THE FAMILY. Competence as surrogate decision maker, judgment and evidence of knowledge of patient preferences, opinions on quality of life. COMPETING INTERESTS. Interests of family, healthcare providers, healthcare organization and futile utilization of scarce resources. ISSUES OF POWER OR CONFLICT. Between clinicians and family/patient, among family, among healthcare workers. OPPORTUNITY OF ALL INVOLVED TO SPEAK AND BE HEARD. Includes respect for opinions. When an ethical dilemma arises in a clinical practice, nurses should begin an ethical analysis and communicate with colleagues to seek a

The gerontological nurse is concerned with the following ethical issues: ` ` ` ` Obtaining informed consent for research and clinical treatment. Obtaining, clarifying, and carrying out advance directives. Appropriateness of emergency treatment Provision of palliative care, including pain and symptom control, need for selfdetermination, quality of life, and treatment termination. Elimination of the use of chemical and physical restraints Patient confidentiality including electronic records Surrogate decision-making Access to complementary treatments Fair distribution of resources

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` Economic decision-making Basic ethical principles include: ` Beneficence / Nonmaleficence. To do good and not harm patients. Justice. To be fair and distribute scarce resources equally to all in need.

Autonomy. To respect patients needs for self-determination, freedom and patient rights. Important aspects of Ethical Decision-making will include: ` ` ASSESSMENT. The older patient s condition, including medical problems, nursing diagnosis, prognosis, treatment goals and treatment recommendations.

solution. The process is a way to seek balance , address issues, and understand the needs of all involved. COMMUNICATION ` ` Important Lines of communication must be clear to develop an appropriate NCP. Nurses need to communicate effectively with older patients with a variety of physical and cognitive impairments in order to develop a therapeutic relationship with each patient.

An important part of communication involves attentive listening. Many times just the caring response and careful listening of the nurse will be a comfort to the patient. Encouraging reminiscing is usually fruitful often gives comfort and reassurance to patients that they can talk about a time in their life when circumstances are better.

a. Normal aging and nutrition Physiological changes that are common in older adults can lead to problems with nutrition. Organ function declines with age; this can affect digestion, metabolism, absorption of nutrients, and the ability to eliminate waste products via the kidneys The GI system slows with age, resulting in less efficient absorption of nutrients. Changes in the oral cavity include tooth loss or ill-fitting dentures, mouth dryness and decreased esophageal motility Delayed gastric emptying, hiatal herniation, and decreased secretion of gastric juices may cause bloating and discomfort. Changes in the pH of the GI tract malabsorption of the B vitamins Decreased hepatic and renal reserves harder to metabolize medications and alcohol; to conserve water or excrete nitrogenous wastes Thirst regulation often affected risk for dehydration

Nurses should follow these guidelines for verbal communication: ` Do not yell or speak too loudly to patients.

( Not all older people are hard of hearing. If they are wearing a hearing aid, yelling can be disturbing) ` Try to be at eye level with the patient. Try to minimize background noise as it can make it difficult for the pt to hear. Monitor the patient s reaction. Touch the patient if appropriate and acceptable. Supplement verbal instructions with written instructions as needed. Do not give long-winded speeches or complicated instructions to persons with cognitive impairment, anxiety or pain. Ask how the patient would like to be addressed. Avoid demeaning terms like sweetie, honey or dearie.

(Sit down if the pt is sitting or lying down) `

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CHANGES in BODY COMPOSITION SARCOPENIA refers to the age-related phenomena; lean muscle mass diminishes. Causes:  Lessened physical activity (related to disability or disease)  decreased anabolic hormone production (testosterone, GH)  decreased nutrition Loss of muscle mass can lead to a spiral of negative physical and functional changes:  Decrease resting energy expenditure or metabolic rate  Functional decline strength and endurance become affected  Decline in physical activity  Drop in total body water from 72% to 60%  Loss in bone mineral density ORAL and GI CHANGES DENTITION - EDENTULISM    Poor dental health missing or loose teeth ill-fitting dentures

 Insufficient retention of poorly fitting dentures ATROPHIC GASTRITIS - result from a decrease in size and number of glands and mucous membranes ACHLORHYDRIA - Lack of HCL acid production Iron and Vit. B12 require an acid medium in the stomach to begin absorption; lack of HCL can limit absorption of both nutrients

Decrease gastric production of intrinsic factor Decrease Vit B12 absorption in the ileum CONSTIPATION Contributing factors:  Slowed intestinal peristalsis  Inadequate intake of fluid and fiber  Illness  Medications  Sedentary lifestyle APETITE DYSREGULATION Increase CHOLECYSTOKININ production Causes early SATIETY - can also be due to changes in gastric emptying and central neurotransmitters responsible for feeding drive ANOREXIA of AGING diminished intake ff deliberate wt loss and refeeding THIRST DYSREGULATION - Aging blunts the thirst mechanism - angiotensin production is impaired - increasing the risk of uncompensated DHN Three main forms of DHN:

 Can affect the type of food eaten and interfere w/ proper nutrition  Fewer pairs of post teeth result in less variety of the diet & higher fat intake * Mandibular bone loss osteoporosis or periodontal disease causes structural tissue changes affects chewing XEROSTOMIA Decrease or lack of sufficient saliva production  Can affect taste perception  Hinder swallowing

1. ISOTONIC DHN loss of Na & H2O during GI illness 2. HYPERTONIC DHN water losses exceed Na losses; most common type; occur from fever or limited OFI, 3. HYPOTONIC occur with diuretic use when Na loss is higher than H2O loss. SENSORY CHANGES VISION - cataracts, macular degeneration, and general poor vision can make shopping, food preparation and even eating a burden. ** Mealtime assistance using the clock analogy w/ the dinner plate: Your carrots are at three o clock and the beef is at six o clock. HEARING - Hearing losses that occur w/ age can make a social dining a difficult experience. TASTE AND SMELL  decline or diminished olfactory and taste perceptions reduced pleasure w/ eating  Medications taste alterations ACE inhibitors, anticholinergics, antidepressants, antihistamines can cause XEROSTOMIA and diminished taste perception  DYSGEUSIA altered taste perception - complain of chalky and metallic taste SOCIAL and ECONOMIC CHANGES AFFECTING NUTRITION Retirement from a workforce sedentary lifestyle ENERGY

Decreased activity on body composition muscle loss and fat gain Social isolation, loneliness, loss of a spouse, or bereavement can introduce additional influences that can alter adequacy in the diet Changes in socio-economic status - poverty NUTRITIONAL REQUIREMENTS and AGING The older person has some unique nutritional requirements due to the physical and functional changes that occur with aging dietary requirements for some nutrients increases w/ age. Dietary Standards Dietary Reference Intakes (DRIs) Food Guide Pyramid Recommendations for older person are categorized in two age groups:

- 51 to 70 years - over 70 years NUTRIENT RECOMMENDATIONS The DRIs for the general adult population and the older adult population are the same w/ the exception of Vitamin D, B12, B6, Calcium and energy.

DRI s for energy and estimated energy requirements (EERs) based on gender, age, BMI, and activity level Individuals w/ higher lean body mass or higher activity levels require more energy

EER adjusted for age to account for losses in lean muscle mass adjust calorie intake downward: MEN 7cal/decade over 30 years of age WOMEN 10 cal/decade over 30 years of age VITAMIN D Role in maintaining bone mineralization and proper serum Calcium levels Inadequate Vit. D leads to poor bone mineralization, rickets, and osteomalacia. AI (adequate intake) for Vit D triples from young adulthood to age 71. 50y/o and below 200 IU 51 70y/o 400 IU over 70y/o 600 IU Increased recommendations are aimed at reducing bone loss and fracture risk due to diminished endogenous synthesis of Vit D w/ age, limited sun exposure, and reduced absorption of Vit D. Food sources: liver, fortified milk, fish liver oils

Adults over age of 50 requires Vit B12 supplement due to decreased absorption of the vitamin associated w/ atrophic gastritis and altered gastric pH. Sx s of deficiency:  macrocytic anemia  neuro problems  peripheral neuropathy  Irritability  Depression  poor memory Food sources: animal products like: meats, fish, poultry, dairy, eggs Fortified foods like: cereals and soy products VITAMIN B6 (PYRIDOXINE) Coenzyme in metabolism of CHON, fat and other biochemical reactions DRI for B6 over 50 y/o Women = 1.5 mg per day Men = 1.7 mg per day Food sources: meat, fish, poultry, legumes and whole grain B6 deficiency found in combination w/ other B vit deficiencies chronic alcoholics; medications: INH, theophylline, penicillamine Sx s: inflamed tongue and oral mucosa GLOSSITIS and CHEILOSIS : depression, confusion VITAMIN D, B12, and CALCIUM are the only nutrients with routine consideration given to supplementation in the older person.

CALCIUM

Maintenance of bone mineral density and plasma Ca levels. AI (adequate intake) for Ca: 19 to 50y/o = 1,000 mg over 50 = 1,200 mg; may be increased to 1,500mg due to accelerated bone loss and risk of osteoporosis. VITAMIN B12 (CYANOCOBALAMIN) Required in cell division and to maintain the myelin sheaths of the CNS RDA = 2.4ug

FLUID Sufficient water intake ensures:

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- regulation of body temp - medium for biochemical reactions - elimination of waste products of metabolism and digestion. Predisposing factors to DHN:  Blunted thirst perception  Altered hormone response  Decreased total body water Daily Total Water Recommendation: (older than 51) From all foods and beverages: Men : 3.7 L Women : 2.7 L - From beverages alone: Men : 13 cups Women : 9 cups Nutritional Assessment A comprehensive evaluation of a client s nutritional status and typically includes data collection in each of the ff areas:  demographic and psychosocial data  medical Hx and dietary Hx

HEIGHT Height standing or recumbent position Recumbent measurements  Lying flat and straight in bed.  Make light pencil marks on bed linens at head and heel.  Measure w/ a cloth tape. * Bed ht measurements are 1.5 inches longer than standing ht. INDIRECT HEIGHT MEASUREMENTS - Knee-height and arm span estimation - it can be can be estimated by measuring the distance from the heel to the top of the knee (knee-height) using a broad-bladed caliper; foot at 90 degree angle to the leg Formula: (Knee Height as an estimate of stature) M = (2.02 x knee height in cm) (0.04 x age)+ 64.19 F = (1.83 x knee height in cm) (0.24 x age) + 84.88 ARM SPAN or DEMI-ARM SPAN - no special calculations - requires mobility of either one or both arms and hands extended fully Measurement: - from L hand fingertip to R hand fingertip - Demi-arm span = from fingertip to sternal notch and the value is doubled BODY MASS INDEX (BMI) Formula: BMI = weight(kg)/height(m) BODY FAT MEASUREMENT * Tricep skinfold measures SQ fat over the triceps muscle at the back of the upper arm using a caliper. * Tricep skinfold should be measured with calipers that have a known degree of accuracy.

 anthropometrics  medications and lab values  physical assessment. PARAMETERS ANTHROPOMETRICS any scientific measurement of the body Height & weight are the mainstays of A.M. WEIGHT Ideally the client is weighed in the morning while wearing light clothing; AFTER voiding unable to stand use bed or chair scales

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MUSCLE MASS MEASUREMENTS * Midarm circumference - used to derive lean body mass - should be measured at the midpoint of the distance between the tip of the acromial process of the scapula and the olecranon process of the ulna. DUAL-ENERGY X-RAY ABSORPTIOMETRY (DXA) Fast, non-invasive, and highly accurate method for assessing lean tissue and bone mass New scanning device that evaluates bone density at several sites and to evaluate body fat in a minimum amt of time (<20mins) w/ minimum radiation exposure (<5mrem)

 Affected by immune status and hydration  Levels below 3.5g/dl indicates some degree of malnutrition TRANSFERRIN  Is a carrier protein for Iron;  derived from total iron-binding capacity  Shorter half life 8 to 10 days  More rapid predictor of CHON depletion PRE-ALBUMIN Is a carrier CHON for retinolbinding protein Half-life of 2 to 3 days Sensitive to sudden demands on CHON synthesis Often used in the acute care setting TOTAL LYMPHOCYTE COUNT (TLC) Sometime used as a nutritional marker In severe or prolonged malnutrition, immune CHONs are depleted and the TLC is decreased. FOLATE and VIT B12 Particularly pertinent due to the effects of aging, disease and meds on absorption and metabolism of both vitamins.

LABORATORY VALUES PLASMA PROTEINS Albumin, prealbumin and transferrin are all used to assess visceral CHON status. Albumin does not give the most current picture in nutritional assessment.

- half-life of 21 days Prealbumin and transferrin have shorter half-lives 2-3 days and 8 days respectively

- give more current information on CHON status SERUM ALBUMIN  serum protein most frequently cited in reference to malnutrition  Reflects the liver s ability to synthesize plasma CHON  Half-life of 21 days not always reflective of current nutritional status

NUTRITIONAL HISTORY DIET RECALL  24-hour dietary recall - not always indicative of normal habits  Food frequency - excellent tool to use w/ a 24 hour recall

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- simple questions about each food group can be asked to determine daily, weekly, or less often consumption of foods - ask about all food groups including fluids and supplements  Food Record - Record of food intake for up to 3 days - View of variable eating patterns

Economic Hardship - low income; less budget for food; makes it very hard to get the foods you need to stay healthy Reduced Social Contact - one-third of all older people live alone. - Being w/ people daily has a positive effect on morale, well-being and eating Multiple Medicines

NUTRITIONAL SCREENING AND ASSESSMENT NUTRITIONAL SCREENING an abbreviated assessment of nutritional risk factors to determine w/c clients are in need of a more comprehensive assessment & interventions DETERMINE Your Nutritional Health screening tool is the most widely used. The Nutritional Checklist is based on the Warning Signs. Use the word DETERMINE to remind you of the Warning Signs. DETERMINE Disease any disease, illness or chronic condition w/c causes you to change the way you eat or makes it hard for you to eat. Eating poorly eating too little and too much both lead to poor health. - Eating the same foods day after day or not eating fruits, vegetables, and milk products daily will also cause poor nutritional health. Tooth Loss / Mouth Pain - A healthy mouth, teeth and gums are needed to eat. - Missing, loose or rotten teeth or dentures w/c don t fit well; causes mouth sores making it hard to eat.

- The more medicines you take, the greater the chance of S/E such as: * dec or inc appetite * change in taste, * constipation / diarrhea * weakness * nausea Involuntary Weight Loss / Gain - Being overweight or underweight also increases your chance to poor health. Needs Assistance in Self-Care - Although most older people are able to eat, one of every five have trouble walking, shopping, buying and cooking food especially as they get older. Elder Years Above Age 80 - Most older people lead full and productive lives. - But as age increases, risk of frailty and health problems increase. * Checking your nutritional health makes good sense

COMMON NUTRITIONAL CONCERNS UNINTENTIONAL WEIGHT LOSS INSUFFICIENT INTAKE - Lack of adequate food and fluid intake occurs for multiple physical and psychosocial reasons.

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 Dehydration > lack of adequate fluid hypovolemia  Sadness and Clinical depression > depression accounts 36% wt loss > dietary inadequacy and wt loss > Meds to treat depression diminish apetite and cause xerostomia; leading to poor taste perception and difficulty swallowing  Anorexia - can be multifactorial; POLYPHARMACY associated with malnutrition  Pain - pain from arthritis or chronic disease can dull the apetite or cause nausea - pain meds may have sedative or GI effects  Chronic Diseases - CHF and COPD can contribute to anorexia - SOB can cause AEROPHAGIA while eating = results in bloating and early satiety from swallowing air  Dysphagia - result from difficulty chewing or swallowing  Dependency on others for feeding or eating-related activities is associated w/ a risk of undernutrition  Cognitive impairment diminished ability to recognize food, failure to respond to hunger cues, behavioral cues  Sensory Changes make eating less pleasurable  Improper diets long-term care may be served unfamiliar foods after a lifetime of eating culturally familiar foods  Poverty poor quality and limited quantity food intake IATROGENIC PRACTICES

 Polypharmacy and improper feeding practices  Prolonged NPO status  Reliance on clear liquid diet or routine IV fluids for nutrition NUTRIENT LOSSES - losses during absorption or metabolism HYPERMETABOLISM - warrants intake of increased energy and nutrients - needs not met = undernutrition - hypermetabolic illness: wounds, fever, infection, CP disease NUTRITIONAL INTERVENTIONS FOR UNDERNUTRITION ENHANCED EATING ENV T Improve lighting Plain dishes poor vision Play familiar music Encourage social dining Use attractive place settings IMPROVED TASTE PERCEPTION Avoid smoking Evaluate meds Add flavor enhancers INCREASE NUTRIENT-DENSE INTAKE Liberalize restrictive diets Offer juices, milk, shakes vs water as fluid Add non-fat milk powder Serve desserts made w/ eggs and milk Add sauces, gravy SALIVA STIMULATION for XEROSTOMIA Use sugar-free candy and gum

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Serve fluids w/ meals Add sauces No overly hot foods or dry foods Maintain hydration DYSPHAGIA SAFETY Appropriately thinned or thickened foods Remain upright after meals HYDRATION Offer fluids frequently Provide beverage choices Do not wait for report to thirst to offer fluid ALTERATIONS FOR CHEWING DIFFICULTY Dental consult Food alternatives (meat is hard to chew but tuna, eggs, beans, fish are easier to chew) Improve visual appeal of puree diet IMPROVED FEEDING ASSISTANCE Adequate unhurried time Proper posture: head and torso at 90-degree angle to lap Avoid mixing foods together Avoid straws if aspiration risk CULTURAL DIVERSITY AND MEDICATION SAFETY Cultural diversity and ethnic background can affect the older person s beliefs about health, illness, medications, and physiological response to medications. Examples:  Caucasian Americans intolerant to pain and expect that their disease will be quickly cured.

Hispanics, Chinese, and Asians cautious about American medicines; initiate downward dosage adjustments to avoid minor S/E.  Some cultures will engage in extensive folk remedies and herbal preparations before they initiate treatment.  Ethnic beliefs can also affect adherence to instructions to take meds as prescribed - some doubt the need for meds when sx s ease and may discontinue drugs Physiologic response to meds may also depend on the race or ethnic background of the older person. ** Asking a person s racial and ethnic background can help to assess the risk of adverse drug events. PHARMACOKINETIC ALTERATIONS in the OLDER ADULT Alterations in physiological function resulting from normal processes of aging must be carefully considered in prescribing, administering and monitoring meds  Older persons tend to have acute and chronic conditions that may alter: PHARMACOKINETICS what the body does to the drug PHARMACODYNAMICS -- what the drug does to the body Aging affects the body s ability to handle drugs. This requires consideration of the need for the dose of many meds to be less than that recommended for adults. Decrease in body water (as much as 15%) and an increase in body fat. result: increased concentration of water-soluble drugs (e.g., alcohol) and more prolonged effects of fatsoluble drugs Decreased hepatic blood flow (50% in individuals over age 65) result: increase toxicity when they take usual doses of first-

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pass effect drugs since less of these drugs would be detoxified immediately by the liver.

OPIATES analgesic effects and resp depression WARFARIN increased anticoagulation ANTICHOLINERGICS CNS, bladder and heart more sensitive to meds. RULE OF THUMB START LOW, GO SLOW. * The drug should be administered at about one half the recommended adult dose, and the healthcare should wait twice as long as recommended in the literature before increasing the dose. * This rule will help prevent toxic effects and adverse drug reactions.

FIRST-PASS EFFECT DRUGS significantly metabolized when they first flow through the liver (first pass into the liver) Decreases in serum albumin levels or binding capacity result: increase in serum levels of the free or unbound proportion of proteinbound drugs; - toxic level because more unbound drug is available Renal function generally decreases with age. Creatinine Clearance and GFR declines with age. BUN poor indicator of renal fx n in older person because of decrease in muscle mass; affected by level of hydration and dietary intake of CHON. Serum Creatinine levels less reliable; - older person have less muscle mass ( Creatinine - product of muscle breakdown) PHARMACODYNAMIC ALTERATIONS IN THE OLDER PERSON Pharmacodynamic changes, which affect how the drug affects the body, can also occur because of the aging process. Changes in pharmacodynamics in the older person may be due to: - Decreases in the number of receptors - Decreases in receptor binding; or altered cellular response to the drug-receptor interaction. An increased drug-receptor response can occur with: BENZODIAZEPINES resulting in increased sedation

ADVERSE DRUG REACTIONS (ADRs) particular problem in the older person Symptoms of many adverse drug effects may be similar to those other conditions affecting the older person; may be overlooked or not attributed to the drug therapy. Difficulties in the ADL may provide clues to the presence of ADRs in an older person. Suspect an adverse drug effect if a patient has a cognitive changes, falls, or experiences anorexia, nausea or weight loss. Older persons are likely to have ADRs because of inappropriate drug or dosing, drug-drug interactions, polypharmacy and non-compliance. occurrence of ADRs range from 3% - 69% IATROGENESIS - refers to harm from a therapeutic regimen. - Iatrogenic risks are related to age, the number of drugs taken, and complexity of pathophysiological alterations.

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SIDE-EFFECT - any effect other than the intended therapeutic effect - considered to be expected effects that need to be tolerated and treated only if they are bothersome to the patient or cause noncompliance. ADVERSE DRUG EVENTS (ADEs) ADVERSE DRUG REACTIONS (ADRs) terms that usually refer to drug side effects that are serious any response to a drug which is noxious and unintended, and that occurs at doses used in humans for prophylaxis, diagnosis, or therapy, excluding failure to accomplish the intended purpose. ADRs may manifest themselves differently in the older person. ADRs may be mistaken for common syndromes in the older person. ADRs increases with increasing numbers of meds taken:  6% risk two drugs are taken together  50% risk five drugs are taken together  100% risk eight or more drugs are taken together When multiple medications are used, there is a greater chance of drug-drug interactions, ADEs or ADRs, and errors of dosing Older women have more ADEs than men due to their use of a greater number of medications or possibly because of their smaller size PREVENTION OF ADRs OR ADEs AVOID POLYPHARMACY Drug Therapy should be used only if there is a specific diagnosis or clearly documented symptom or condition to be treated.

The use of a drug to treat S/E of another drug should be avoided. Change the offending drug or decrease the dose to decrease the S/E and avoid the need for another meds. POLYPHARMACY defined as the prescription, administration or use of more medications than are clinically indicated in a given patient. include the use of a medication that has no apparent indication continuing a medication after a condition has been resolved use of a medication to treat the S/E of another medication use of an inappropriate dose use of duplicate meds because the same drug has been prescribed by more than one prescriber patient self-medicates with OTC meds and herbal remedies to treat the same condition or to manage Sx s of an adverse drug effect. ALTERNATIVE and COMPLEMENTARY MEDICINE People of all ages are using alternative or complementary medicine such as HOMEOPATHIC and HERBAL MEDICINES in addition to their routine meds. 30% of those over the age of 65 use at least one alternative medicine modality CHIROPRACTIC 11% HERBAL MEDICINES 8% HIGH-DOSE OR MEGAVITAMINS 5% SPIRITUAL OR RELIGIOUS HEALING 4%

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 The most common conditions for which patients use alternative medicine modalities are arthritis, back pain, heart disease, allergy and diabetes. FDA does not regulate herbal medicines: - no assurance or standardization of their ingredients, purity, dosage, potency, etc. - no sufficient clinical trials to demonstrate their effectiveness or appropriate dosage - Adverse effects may result from the herb itself or from contaminants from the preparation Herbs do interact with medications  ECHINACEA Use: stimulation of Immunity Interactions: Counteracts effects of immuno-suppressive drugs (i.e., cyclosporine)  EPHEDRA (MA HUANG) Use: promotion of weight loss : increasing energy : treatment of respiratory condition Interactions: Sympathomimetic effects can cause elevated BP, stroke and death  GARLIC Use: Reducing risk of atherosclerosis by decreasing BP, thrombin formation, and lipid and cholesterol levels. Interactions: Inhibits platelet aggregation and potentiates effects of platelet inhibitor drugs (i.e., indomethacin, dipyridamole)  GINGKO Use: Enhancement of cognitive performance : Treatment of PVD; age-related macular degeneration; vertigo, tinnitus, erectile dysfunction, altitude sickness Interactions: Inhibits platelet-activating factor and can cause bleeding.  KAVA

Use: Anxiolytic and sedative Interactions: Causes excessive sedation when used with other CNS depressants  ST. JOHN S WORT Use: Treatment of mild to moderate depression Interactions: May cause excess levels of serotonin if taken with selective serotonin reuptake inhibitors (SSRIs). : Can increase the metabolism of many drugs, resulting in reduced effectiveness  VALERIAN Use: sedative, hypnotic Interactions: Withdrawal from valerian mimics acute benzodiazepine withdrawal syndrome. : Potentiates sedative effects of barbiturates and anesthetics and anesthetic adjuvants OVER-THE-COUNTER MEDICATIONS Increased risk of drug interactions with prescribed medications overdosage by the use of an OTC drug similar or identical to a prescribed drug self-medication with OTC drugs may delay the timely medical diagnosis and prescription of more appropriate and effective therapy PROMOTING ADHERENCE AND COMPLIANCE INTELLIGENT NONCOMPLIANCE - reducing medications or discontinuing a drug when the person experienced S/E that were bothersome. o NONCOMPLIANCE - objectionable to some patients and clinicians since it implies a patient must surrender to the orders of the clinician; some prefer the term ADHERENCE

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Various levels of cognitive and physical skills are needed by the older person to safely take medications as prescribed. The nurse should assess the following factors:   Ability to read and comprehend main label (prescription) Ability to read and comprehend the auxiliary labels (e.g., warnings) Manual dexterity (open vials, remove correct number of tablets, recap medication)

Assessing Older Patients Appropriate Use of Medications GUIDELINES: 1.Review the patient s medical conditions and allergies. 2. Review each drug; whether prescribed or OTC, including vitamins and herbal medicines. - Has it been prescribed? - Is the drug considered to be inappropriate for use in older persons? - Is the patient taking it as prescribed? Is the medication producing the intended effect? - Is the medication outdated? - Does the pt understand what condition the drug is treating and the S/Sx that should be reported immediately? - Does the pt have any cognitive or physical condition affecting the ability to safely administer the medication? - Does the pt have any cultural or ethnic beliefs or practices that might impact compliance? Review each drug for: - Interactions with other drugs - Interactions with herbal medicines - Interactions with vitamins or foods - Allergies - Duplicate therapy Medication Management The nurse has a major role in promoting the safe and effective management of medications. The nurse is also responsible for promoting the intended therapeutic effect or reducing or eliminating the need for the medication. Document indications that the therapeutic effect is or is not being achieved Monitoring for adverse drug effects.

Strategies for enhancing compliance ENABLING STRATEGIES: - To prepare patient to be compliant. Examples:  Counseling  Patient education  Simplifying regimens  Increasing access to medical care and to prescriptions  Prescription of less costly therapies CONSEQUENCE STRATEGIES To reinforce compliant behavior Example:  Teaching patients to maintain records of medication taking and rewards for compliance STIMULANT STRATEGIES To prompt pill taking Examples:  Tailoring doses to daily rituals  Use of reminder cards in prominent places in home  Home visits to reinforce compliance  Use of special drug package to help organize and prompt patient to take medications  Medication reminder systems (e.g., phone calls, email reminders)

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 Monitoring laboratory tests Prevention of ADEs involves checking the pt s history of allergies and using knowledge of drug pharmacology to detect potential or actual interactions or contraindications Identification of patients by ID bracelets is important; especially in older person who may have hearing or cognitive deficits Unsafe Medication Practices Sharing Other s Medications take only medications prescribed for them. Using imported medications medications imported from or obtained in another country is controversial and illegal Using outdated medications risky - the meds may not only be ineffective but can actually cause injury to the heart, liver, or kidneys. SLEEP a natural, periodically recurring, physiologic state of rest for the body and mind. -- a state of inactivity or repose that is required to remain active. y normal sleep physiology is composed of 4 distinct stages when measured by EEG y Sleep ranges from stage 1-4 (light sleep to deep sleep) y Classified either REM sleep or NREM sleep y During NREM sleep, growth hormone, prolactin, and TSH are released . y Deep sleep appears to stimulate physical restoration through release of growth hormone while decreasing blood pressure and respiratory function. y Regulation of sleep and wakefulness occurs primarily in the hypothalamus, which contains both a y

sleep center and a wakefulness center. The thalamus, limbic system and reticular activating system are controlled by the hypothalamus

Stages of sleep NREM SLEEP (Stage 1-4) y Stage 1 (Light Sleep)  person feels as if they are drifting in and out of sleep  can be accompanied by a feeling of falling with sudden muscle contraction  easily awakened y Stage 2 (Medium Sleep)  Slowed brain waves and eye movements  easily awakened y Stage 3 (Medium Deep Sleep)  Char. by slowing brain waves and sleep spindles, which are bursts of electrical activity  Relaxed muscles, slowed pulse, decresed body temp  Awakened with moderate stimuli y Stage 4 (Deep sleep)  The brain produces mostly delta waves char. by large, slow patterns of brain activity.  Muscle tone, pulse, RR and BP are reduced  Awakened with vigorous stimuli. stage 1 and 2 - persons are easily aroused from sleep stage 3 and 4 - more difficult to arouse REM SLEEP - Active Sleep  Rapid eye movements  Intense brain activity resulting in small, brief muscle contractions.  Increased or fluctuating pulse, BP, and respirations  Breathing is irregular and shallow  Eyes dart quickly from side to side  Limbs become temporarily paralyzed  DREAMING occurs (referred as DREAM SLEEP)  Necessary for learning, memory consolidation and day time concentration.

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 If reduced, an individual may have diff of concentration, irritability and anxiety the next day.  occurs cyclically every 90-120 mins throughout the night. NORMAL SLEEP AND AGING y Changes by chemical, structural and functional levels and result in a disorganization of sleep and disruption of the circadian rhythms. y Neurotransmitters such as serotonin and norepinephrine keep some parts of the brain on alert during sleep. y Declines in the cerebral metabolic rate and cerebral blood flow, reductions of neuronal cell counts and structural changes such as neuronal degeneration and atrophy can all occur with aging. Age-related Changes in Sleep y increased sleep latency y reduced sleep efficiency y increased nocturnal awakenings y increased early morning awakenings y increased daytime sleepiness ABNORMAL SLEEP BEHAVIORS: 1. Myoclonus or sudden contractions of muscles and tingling feelings in the legs RESTLESS LEG SYNDROME 2. Sleepwalking or sleep terrors 3. Sleep-related epileptic seizures y Because of these sleep problems older adult will experience daytime sleepiness as a result of poor quality and insufficient quantity of sleep. y requires evaluation from neurologist/sleep specialist y usually treated with anti-anxiety agents (benzodiazepines) y healthy older people require 6-10 hours of sleep nightly HEALTH PROBLEMS AND SLEEP DISRUPTION 1) Pulmonary dse, heart dse, arthritis, dementia associated with Alzheimer s can cause sleep disruption 2) Pain or physical discomfort can be a major deterrent for sleep increased number of nighttime awakenings.

Can cause tension and muscle spasms. 3) Psychosocial problems life stresses combined with emotional factors Factors affecting sleep y Environment; noise, lighting, temperature y pain and discomfort y lifestyle changes;retirement, loss of spouse, relocation, having a roommate y dietary influences DEMENTIA y increased confusion and agitation. y nocturnal wandering SNORING y people consider snoring a minor annoyance but it can signal a potentially serious condition known as SLEEP APNEA , a temporary interruption of breathing during sleep, each lasting about 10 secs, these interruptions in breathing can occur as often as 20-30times per hour 2 Major Types of Sleep Apnea 1. CENTRAL SLEEP APNEA there is cessation of respiratory efforts, both diaphragatic and intercostal Seen with insomnia, mild or intermittent snoring and depression. Causes: 1) Decreased responsiveness to central chemoreceptors (as in COPD) 2) Increased responsiveness of chemoreceptors (as at a high altitude) 3) Delayed transit of information (stroke or heart failure) ** TREATMENT - medication 2. OBSTRUCTIVE SLEEP APNEA More common in older adults Air flow ceases because of airway obstruction, while respiratory efforts continue Factors: y Obesity BMI >30 y Short neck or neck circumference <43cm

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Jaw deformities; large tonsils, large tongue or uvula y Narrow airway and deviated septum TREATMENT: weight loss; body positioning during sleep to prevent lying supine. ** CPAP the pressure keeps the airway open, preventing its collapse and allowing the pt to breathe more normally. (5-20cm) y Symptoms of sleep apnea heavy snoring usually on inspiration choking sounds or struggling to breathe during sleep delays in breathing during sleep (with reduction in blood-oxygen saturation) excessive daytime sleepiness morning headaches difficulty with concentration and staying awake during driving * Repetitive hypoxemic events may be more prone to sudden death, stroke, angina and worsening hypertension RESULT: y problems with central nervous system and the brain y cause partial obstruction of the airway when the muscles in the throat, soft palate, and tongue relax during sleep lead to partial or complete collapse of the airway If sleep apnea is suspected, the older person should be referred to a sleep center for an overnight sleep study. POLYSOMNOGRAPHY y a specialized method of sleep testing that measures brain and body activity during sleep. This includes: y EEG- to monitor brain waves and identify sleep stages y Electro-oculograms - to measure eye movement so that REM sleep can be distinguished from NREM sleep. y Facial and leg electomyograms - to measure muscle tone and movement y ECG - to monitor cardiac activity y Measurement of chest movement and oxygen saturation URINARY PROBLEMS

Common age related alterations in Urinary Tract function are: - Urinary frequency, nocturia, incontinence. y BPH- urinary retention of more than 50cc of urine shld be referred for cystoscopy y UTI- urgency, frequency, burning on urination, foul odor, cloudy urine ALCOHOL AND CAFFEINE y alcohol is a potent disrupter of REM sleep due to its sedative effect on the CNS y many medications have serious interactions with alcohol (cardiac meds, diuretics, sedative-hypnotics, painkillers) - can reach toxic levels when combined with alcohol y alcohol, caffeine and nicotine are typically used in conjunction with one another, the sedating and arousal effects frequently interact, creating multiple sleep disturbances. SLEEPING MEDICATIONS  Hypnotic medications - generally recommended for short term use (about 2wks or less) - long term use will blunt the effect  OTC sleep aids - antihistamines (Benadryl) has a number of side effects; daytime sleepiness,dizziness, blurred vision, risk for fall and injury  Sedating antidepressants - used to treat mood disorders can affect sleep. y taken in the evening : Amitryptyline (Elavil), Doxepin (Sinequan), Nortriptyline (Pamelor) y taken in the morning: Desipramine (Norpramin), Sertraline Hcl (Zoloft), Paroxetine Hcl (Paxil) y Benzodiazepines should be used with caution because they can exacerbate sleep apnea, suppress deep sleep, increase likelihood of falling and caused increased confusion y some carry a high risk of addiction like Diazepam (Valium) and Alprozam (Xanax) y

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Rule in discontinuing sleep medication: If the med has been used at least 5 nights a week for >2weeks, a taper and withdrawal schedule should be followed. Using a gradual withdrawal schedule: - One-half the dose for 1 week prior to discontinuation to lessen rebound insomnia and withdrawal sx s. NURSING INTERVENTIONS y Sleep hygiene should be encouraged emphasize sleep requirements and on changes in nature and quality of sleep y Environmental problems should be corrected if possible air conditioners or heaters maybe appropriate y Earplugs may ease night time noise y The timing of the medications should be examined for appropriateness y Dietary and lifestyle changes should be recommended harmful effects of alcohol, caffeine and nicotine on sleep. y Activities, hobbies, and special interests should be pursued y Multiple long naps should be avoided excessive daytime sleep and boredom may interfere w/ nightime sleep y Appropriate exercise like walking and stretching should be recommended but not before bedtime y

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