AGING a normal developmental process occurring throughout the human life span causes a mild progressive decline in body

system functioning older client----- 65 years of age or older BIOLOGIC THEORIES OF AGING A. Immune system theory 1. 2 primary immune organs -thymus -bone marrow affected by the aging process contributes to a decline in T-cell production & stem cell efficiency 2. increase of infection autoimmune disease cancer B. Cross-linking theory 1. cross-linking a chemical reaction that binds glucose to protein which causes ---abnormal division of DNA ---interfering with normal cell functioning ---intracellular transport over a lifetime 2. tissue & organ failure C. Free radical theory 1. molecules that are highly reactive 2. life expectancies among family members are the same if parents died over the age of 80 the children are more likely to live to that age F. Neuroendocrine theories 1. anterior pituitary hormones contribute to the aging process 2. an imbalance of certain chemicals in the brain may contribute to altered cell division within the body E. as a result of oxygen metabolism in the body 2. causes physical decline by damaging proteins, enzymes & DNA 3. Beta-carotene & vitamins C & E naturally occurring antioxidants counteract the free radicals D. Stress theory [WEAR & TEAR] 1. the body------will eventually wear out secondary to repetitive usage, damage & stress 2. individuals react differently to stress positive negative Genetics theory 1. preprogrammed life expectancy cells can only divide a specific number of times

AGE-RELATED CHANGES

SYSTEM Special senses vision

CHANGE Presbyopia decreased ability to focus on near objects -often requiring reading Glasses Decreased lacrimal secretions chronic dry eye scratchiness Pupils smaller decreased peripheral vision & ability to adapt to the Dark increased sensitivity to Glare Lens larger, more rigid & Discolored yellow opacity decreased depth perception & ability to focus Colors distorted blue / green red / orange more pleasing Presbycusis decreased ability to hear pitch or level of sound 1st high, then low & Background Tinnitus ringing in the ear results from decreased blood supply to neurosensory receptors in ear problems distinguishing horns / sirens

NURSING INTERVENTIONS -provide increased illumination without glare -provide safe environment by orienting client to surroundings & removing potential hazards -use sunglasses outdoors -use large-print books -avoid night driving

Hearing

look directly at the client when speaking -speak clearly & slowly -low pitched voice heard best -decrease background noise

Taste / Smell

Olfactory fibers atrophy decreased sense of smell decreased appetite / ability to enjoy foods

-provide attractive meals in comfortable social setting -vary taste, textures & colors of foods -be alert for difficulty chewing or swallowing when selecting foods

Touch

Sensory nerve receptors less acute requires stronger stimuli increased pain tolerance skin tears more difficult to distinguish hot, cold, or pressure Fine discrimination abilities impaired hands & feet

protect skin from injury -lower bath water temperature to 100105 F -provide for safety around hot liquids & mealtimes

Nervous

Overall intellect remains the same Fewer neurons & reduced blood flow to brain short term memory loss learning ability slowed Myelin sheath degenerates decreased reaction time reduced deep tendon reflexes increased time to respond to Stimuli Change in sleep patterns

-promote independence in daily activities -allow ample time for completion of tasks -offer back rub or warm milk at bedtime -provide recreational & divertional activities -maintain environmental stability -minimize frequency of transfers

Integumentary

Sweat glands diminish decreased thermoregulation Collagen & Subcutaneous fat decreases subcutaneous medications absorb more slowly wrinkles poor turgor poor estimate of Hydration Hair follicles decrease / produce less melanin baldness / gray hair Vascular supply to nailbeds reduced dull, brittle nails hard to cut Delayed wound healing

provide adequate warmth -maintain adequate hydration -avoid overexposure to the sun -provide adequate heat & humidity in environment -keep skin clean, dry, lubricated & pressure free -decrease frequency of baths

Cardiovascular

Increased peripheral resistance / increased blood pressure especially systolic Baroreceptors less sensitive decreased sensitivity to change in positions orthostatic hypotension Decreased venous valve competency increased dependent edema Mitral / aortic valves thicker & more rigid more murmurs without Disease Decreased stroke volume & cardiac output Decreased pacemaker cells possible dysrhythmias Muscles weaken & atrophy, rib cage calcifies, barrel-shaped chest increased energy to expand lungs, harder to cough & deep breathe less tidal volume & increased residual volume secondary to cell fibrosis Alveoli decrease & thicken

assess symptoms & make appropriate modifications in care -teach client to change positions slowly to avoid falls -minimize edema & fatigue with rest periods & elevation of legs -teach energy conservation methods in daily activities

Respiratory

-manipulate environment to enhance ventilation -position client to promote optimum ventilation -encourage exercises & prescribed pulmonary exercises

less sensitive to hypoxia & Hypercapnia Atrophy of cilia Slowed cough reflex increased risk of infection Gastrointestinal Decreased smooth muscle tone, difficulty in swallowing [minor] & decreased peristalsis decreased esophageal motility increased heartburn constipationDecrease in digestive enzymes altered absorption of fats, protein, B12, folic acid, calcium, iron, medicationsDecreased saliva, loss of teethDecreased sphincter tone impactions incontinence

-encourage annual influenza vaccines & onetime pneumococcal vaccine

assess condition of teeth & mouth, fit & comfort of dentures & ability to chew -encourage fluids & foods high in fiber -encourage optimal activity -promote independence & privacy in the use of bathroom -keep stool record & observe for constipation assess voiding patterns -provide adequate fluids -establish a bladder program to promote continence [assist to bathroom or offer bedpan every 2-3 hours] -avoid catheterization unless comatose, skin breakdown, or bladder outlet obstruction -promote good perineal care, treat with prescribed creams [e.g. estrogen] -use vaginal lubricant as needed -provide encouragement & discuss modifications of sexual expression as necessary ; rest before & after sexual activity

Renal

Decreased GFR secondary to decreased kidney size & number of nephrons & decreased renal blood flow ability to concentrate / dilute urine decreased, decreased excretion of medicationsDecreased bladder capacity & weakened bladder & pelvis muscles frequency, urgency, nocturia, incontinence, retention, infectionsProstate enlargement / obstruction [retention], dribbling, overflow incontinence

Reproductive Female

Diminished vaginal secretions secondary to decreased estrogen painful intercourse, Infections

Male

Slower erections & ejaculations secondary to sclerosis or penile veins & arteries decrease in sexual activity

PSYCHOSOCIAL CHANGES IN THE OLDER ADULT A. Successful aging process FACTORS: -physical -psychological -social -cultural 1. some cultures have a great respect for older persons 2. in the US---much value is placed on the youth 3. be aware of ageism [discrimination against the older adult simply because of age] Developmental tasks for the older adult 1. ego integrity vs. despair [Erikson] a. with ego integrity the persons life is felt to have meaning & Accomplishment b. with despair there are feelings of worthlessness for a life not well Lived 2. other possible developmental tasks a. successfully adjusting to retirement b. making safe & satisfactory living arrangements c. adjusting to reduced income d. keeping socially active e. maintaining contact with friends & family f. making safe decisions about driving a car g. adjusting to death of spouse/ significant other h. adjusting to idea of ones own death

PSYCHOLOGIC/SOCIAL THEORIES OF AGING A. Activity theory 1. maintaining a level of active involvement in life helps the older adult stay psychologically & socially Healthy 2. as life roles or physical capacity are lost older adult will substitute new roles or intellectual activities B. Continuity or developmental theory 1. adjustment to old age is impacted by individual personality older adult will exhibit similar choices & decisions to younger years 2. this theory allows for great variation in successful aging as individual habits & preferences are unique C. Disengagement theory 1. gradual mutual withdrawal between the individual & society as the aging process continues 2. while this theory was a major milestone in aging research it is now felt to be flawed as many older adults remain engaged in psychosocial aspects of life

ASSESSMENT PATTERNS OF HEALTH & DISEASE IN THE OLDER ADULT A. Diseases that occur to varying degrees in most older adults 1. cataracts 2. arteriosclerosis 3. benign prostatic hypertrophy [males] B. Diseases with increased incidence with advancing age 1. neoplastic disease 2. diabetes mellitus 3. dementia disorders C. Diseases that have more serious consequences in the elderly & make homeostasis more difficult to maintain 1. pneumonia 2. influenza 3. trauma D. Chronic disease very common 1. seventy-nine percent of noninstitutionalized persons over age 70 have at least one chronic disease 2. most common chronic diseases: -arthritis -hypertension -heart disease 3. most hospital visits for persons over 65 are for chronic diseases E. Functional disability [inability to perform activities of daily living [ADL]] 1. thirty-two percent of persons over 65 have some limitation of Functions 2. twenty-five percent of persons over 65 require help with at least one ADL or IADL [instrumental activities of daily living -e.g. shopping, paying bills Character istic Cause Chronic Diseases Acute Diseases Health History & Gerontologic Focus A. assessment of the older adult client is complex 1. allow sufficient time to conduct a thorough health history Interview 2. depending on the clients stability the interview may take more than one session B. Presenting problem 1. assess client systematically depending upon the presenting Problem 2. typical presentations of disease may change with age e.g. client may not exhibit chest pain with a myocardial Infarction 3. the problem is likely to have multiple contributing factors & affect the clients functional abilities C. Mental status & mental health 1. it is important to obtain baseline for -orientation -memory -level of alertness -decision-making capabilities 2. assess the client for -quality of life issues -mood -affect -anxiety D. Lifestyle & function 1. often, there is little correlation between diseases & functional Abilities 2. functional assessment provides clearer picture of physical, psychological & social health 3. use the clients own baseline from previous assessments to determine any changes in function 4. have the client demonstrate function wherever possible [e.g. observe gait & balance, drinking a glass of water, dressing self] E. Medication usage 1. ask for information about all types of medications that the client is taking -prescription medications -nonprescription medications [analgesics & laxatives] -vitamin supplements -herbal medications 2. be sure the client understands the -purpose -dosage -side effects -special considerations or interactions for all medications 3. discuss the clients abilities to obtain medications [e.g. renewing prescriptions, paying of medications] 4. polypharmacy is often present average older adult takes 11 prescription medications per Day F. Nutrition & hydration 1. obtain food / fluid intake profile [either 24 hours or 3 days] 2. determine any difficulties ingesting food / fluids [chewing, salivation, swallowing, manual dexterity, tremors]

Multiple causes; often related to lifestyle Slow, insidious

Specific etiologies

Onset

Rapid

Duration

Indeterminate; remissions & exacerbations Often difficult because of indeterminate course, remissions, & exacerbations Somewhat predictable but often debilitating & associated with long periods of illness Management of condition Lifestyle changes required Individual with disease must assume control of disease

Short

Understan ding of disease

Simpler because symptoms more overt

Outcomes

Symptoms resolve with cure of disease Outcomes usually favorable; cures Health care provider directs care & cure

3. any foods the client is unable to eat [dairy products, sodium, sugar] or foods the client should eat [potassium- or calcium-rich foods / fluids] 4. taking in adequate amounts of water daily to stay hydrated 5. ability to afford / purchase / prepare food G. Past medical history 1. inquire about all chronic diseases & conditions be aware that the client may not even consider certain conditions treatable & therefore does not mention them -urinary incontinence -or pain from arthritis 2. obtain information about -previous illnesses -hospitalizations -surgeries Physical Examination A. assess body systems as indicated B. note physical changes in the older adult Laboratory / Diagnostic Tests Laboratory tests as indicated according to symptoms of individual client Interpret lab test results with aging changes in mind

INTERVENTIONS Pharmacotherapy in the Older Adult A. General information 1. decreased body weight Dehydration Alterations in fat to muscle ratio Slowed organ functioning may cause accumulation of a drug in the body due to higher concentrations in the tissues & slowed metabolism & excretion of the drug 2. multiple chronic diseases affecting older adults may cause changes in the metabolism & excretion of Medications 3. medication errors among older community-dwelling adults are estimated to be 25-50% 4. drug-drug interactions are increased secondary to older adults often having more than one prescribing health care provider B. Nursing Care 1. conduct a brown bag evaluation to assess all prescription, Over-the counter, & herbal medications the client may be Taking 2. assess the clients understanding of the reasons for the drug Therapy 3. assess the clients vision, memory, judgment, reading level & motivation to determine ability to self-medicate 4. provide instructions in large-print, pre-measured syringes, memory aids & daily dose containers to enhance self-medicating abilities 5. check with the pharmacist for any drug-drug interactions if Unsure 6. before beginning a medication obtain baseline vital signs -mental status -vision -bowel / bladder function 7. drug-induced side effects may present as -confusion -incontinence -falls -immobility 8. assess the clients ability to pay for the prescriptions 9. if the client requires assistance in taking medications teach family members Proper techniques for administering oral medications include position head forward neck slightly flexed to facilitate swallowing & avoid risk of aspiration 10. if client has swallowing difficulties obtain liquid forms of oral medications wherever possible 11. assess client for effectiveness of medications & any adverse Reactions EVALUATION client performs self-care activities or caregiver provides assistance as needed client is continent of bowel & bladder voids in adequate amounts & has regular bowel movements client is able to successfully communicate needs & concerns client makes positive statements about self client/caregiver modifies environment to support safety client is alert, calm, & oriented if possible skin is intact without pressure ulcers client eats a nutritionally balanced diet & maintains a stable weight client maintains friends, social interactions & sexual function client describes & adheres to treatment plan

ANALYSIS A. B. C. D. E. F. G. H. I. J. K. L. M. N. O. P. Q. R. S. T. U. V. W. X. Y. Z. AA. Nursing diagnoses for older adult clients may include: activity intolerance bowel incontinence, constipation, diarrhea acute or chronic pain anxiety or death anxiety deficient fluid volume risk for infection impaired memory impaired physical mobility impaired oral mucous membrane imbalanced nutrition: less or more than body requirements ineffective airway clearance or breathing pattern or impaired gas exchange self-care deficits: feeding, bathing/hygiene, dressing/grooming, toileting disturbed body image or ineffective role performance disturbed sensory perception sexual dysfunction impaired skin integrity disturbed sleep pattern disturbed thought processes ineffective tissue perfusion impaired urinary elimination deficient diversional activity wandering impaired social interaction Risk for other directed violence Risk for falls or injury Relocation stress syndrome Impaired home maintenance

PLANNING AND IMPLEMENTATION Goals Client will maintain: Maximum functional independence Normal bowel & bladder elimination patterns Sufficient communication skills Positive self-concept Freedom from injury & infection Optimal cognitive functioning Adequate nutritional status & fluid balance A restful sleep pattern Social contacts & interpersonal needs Treatment regimens as prescribed