GERIATRIC AGE SPECIFIC Self Learning Module, Study notes of Nursing

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A Health System

GERIATRIC AGE SPECIFIC

Self Learning Module

For Clinical Staff

Revised 6/10 Anila Ladhani, RN, MSN, CNS

Geriatric Age Specific

Self Learning Module

Instructions:

• Review the objectives
• Read the module content
• After reading the module, please go to Mosby’s Skills and complete the Self Learning Geriatric Age Specific Post Test.

Course Objectives:

At the completion of this self learning module the user will be able to:

1. List age-related changes for the normal elderly person.
2. Describe changes in the elderly as they relate to medication usage.
3. Differentiate between delirium and dementia.

NEUROLOGICAL CHANGES

Age related changes in the nervous system can be difficult to accurately predict because of how systems interact. For example, cardiovascular problems can decrease cerebral blood flow and could be responsible for cerebral dysfunction.

Changes in the nervous system could progress so slowly that it goes unnoticed and is non-specific in nature.

Nerve cells are lost with age and there is a decrease in conduction velocity. Most reflexes are slowed, but the deep tendon reflexes remain intact.

Sleep stages 3 and 4 become less prominent and sleep is more frequently interrupted. However, the amount of sleep loss is minimal.

Alterations in proprioception (sense of physical position) can lead to problems with balance and spatial orientation.

IMPLICATIONS FOR NURSING: Assure safety and assess for balance and gait. If necessary provide assistive devices for ambulation.

Delirium/Acute Confusional State

Delirium is an acute confusional state, characterized by:

• Disorganized thinking
• Disturbances in attention
• Disorientation
• Changes in Short Term Memory
• Changes in psychomotor activities
• Sleep deprivation

Possible Causes:

• Psychological conflicts, depression
• Drugs, substance abuse
• Emotional trauma
• Environmental changes (relocation, hospitalization)
• Head injuries, brain injuries
• Metabolic disturbances
• Nutritional deficiencies
• Infections
• Changes in oxygenation

Once these are corrected, the delirium will clear.

Dementia A general irreversible, progressive, deterioration of mental function caused by organic factors.

• Alzheimer’s disease

Causative/Contributing factors:

• Multiinfarct dementia
• Alcoholism
• Parkinson’s disease
• Huntington’s disease
• HIV- related dementia
• Trauma
• Heavy metal toxicity
• Hydrocephalus

Sundowner’s Syndrome Agitation, disorientation, wandering, and general worsening of behaviors as evening approaches.

Not fully understood, but occurs most frequently in those with a cognitive impairment; contributing factors include recent admission to a health care facility, relocation within the facility, dehydration, sensory overload or deprivation, use of restraints or interruption of sleep.

Causes:

• Turn lights on before dark to reduce transition from light to dark.

Interventions:

• Place familiar objects around the patient.
• Provide afternoon activities.
• Offer toileting assistance.

Here are several actions, which may assist you in collecting data when sensory deficits exist:

• Face the patient
• Eliminate background noise and limit distractions
• Speak slowly and clearly
• Keep questions brief
• Provide privacy

CARDIOVASCULAR CHANGES

Usually the size of the heart does not change with aging. Therefore, enlargements in the elderly are associated with cardiac disease. In addition, marked inactivity can lead to cardiac atrophy.

The valves become thick and stiff due to sclerosis and fibrosis. As a compensatory mechanism for the decrease in oxygen utilization efficiency, the aortic volume and systolic blood pressure increases.

Decreased efficiency of the heart decreases cardiac output by approximately 1% per year through adulthood. The stroke volume also decreases by 0.7% each year.

• Most can adapt quite easily taking the elevator instead of the stairs, driving rather that walking great distances and they learn to pace themselves. However, when elders are faced with added demands, it is quite evident.

The resting heart rate is not significantly affected in the elderly. Even so, the heart rate may not reach the levels of a younger person. After a stressful event, however, it takes the heart longer to return to normal

The Baroreceptors decreased sensitivity to blood pressure, leading to increased problems with orthostatic blood pressure.

Question patients on how they feel when going from a lying to a sitting position before letting them stand. If they are dizzy, allow time for the blood pressure to equilibrate.

• Calcium deposits

There is increased peripheral resistance caused by:

• Cross linkage of collagen
• Reduction in elastin
• Decreases the effective exchange of nutrients

Capillary walls are thicker:

• Promotes capillary fragility

GASTROINTESTINAL CHANGES

The GI system has age related effects at every part.

Tooth loss is not a normal part of aging, but with years of poor dental hygiene, diet and environmental influences, most of today’s elderly have lost their teeth. Many rely on dentures, which may be ill fitting or uncomfortable.

Taste sensation decreases because taste buds atrophy. Chronic irritations with smoking can also cause decreased taste sensation. Excessive use of seasonings to combat diminished taste could lead to health problems.

The amount of saliva produced is decreased by two thirds. Salivary ptyalin is also decreased, so digestion of starches is less efficient.

Esophageal motility is decreased and the esophagus tends to become slightly dilated. It empties more slowly which can lead to discomfort from food remaining for longer periods of time. There is also slower stomach motility.

The lining of the stomach is thinner, the production of digestive juices (HCL, pepsin, and pancreatic enzymes) is decreased and fats are not tolerated well.

Both the small and large intestines atrophy. The elderly are predisposed to constipation due to decreased motility of the colon and dulled sensation for defecation.

Assure adequate fluids, a high fiber diet, physical activity and laxatives and/or enemas if necessary. Monitor bowel status.

The mass of the liver decreases in weight and storage capacity. The incidence of gallstones increases because of less efficient cholesterol metabolism. The fat content of the pancreas increases.

The chance for aspiration is increased due to the changes in motility. Encourage the patients to sit up in their chairs for meals. If they are unable to get out of bed, make sure the head of the bed is elevated. Have patients sit up Have patients sit up a MINIMUM of 30 minutes after each meal. These precautions are also important for patients receiving NG tube or G-tube feedings.

GENITOURINARY CHANGES

The renal mass becomes smaller with age. There is approximately a 50% decrease in renal blood flow and glomerular filtration rate. Tubular function decreases leading to

• Decreased ability to concentrate urine

• Decrease in the re-absorption of glucose
• Urinary frequency, urgency and nocturia are associated with bladder changes in the elderly. Emptying becomes more difficult leading to large residual volumes. Bladder muscle and volume decreases. The micturition reflex is delayed.
• Incontinence is not
• In women stress incontinence may occur due to a weakened pelvic diaphragm.

a normal outcome of aging.

• Prostate enlargement occurs in most elderly men. Three-fourths of men 65 years old and older have some degree of prostate disease, which causes urinary difficulties. Although most are benign, there is a risk of malignancy, so evaluation is essential.
•  Decreased testosterone production

Male reproductive changes include:

 Reduced sperm count  Smaller testes  A need for more direct physical stimulation to achieve an erection

•  Decreased estrogen production

Female reproductive changes include:

 Reduction in breast tissue  Vaginal secretions are more alkaline, therefore increasing possible vaginitis  Vaginal canal is drier, requiring longer foreplay or the use of lubricant to facilitate penile penetration

• There is no change in libido of either sex. Sexual activity patterns and preference tend to be consistent over the lifespan.

Changes in the kidney’s function with aging alter the renal excretion of drugs. Drugs are likely to be excreted more slowly.

Drug dosages such as digitalis, aminoglycosides, and other antibiotics should be calculated using creatinine clearance. A decrease in clearance time means an increase in the drug’s half life. Drugs excreted by the kidneys stay longer in the body.

Assure safety at night. If patient gets up to void during the night, keep path free from furniture (tray table, chairs, etc.). Keep a light on. Encourage patient to call for assistance anytime, especially if there is any incontinence.

INTEGUMENTARY CHANGES

The skin becomes less elastic, drier and more fragile. Advancing age is evidenced by wrinkles and sagging.

The risk of skin breakdown is increased.

The clustering of melanocytes causes “age spots” of “liver spots” in areas that have had excessive exposure to the sun.

Scalp, pubic and axilla hair thins and loses color. But nose and ear hair thickens. Women may develop some facial hair.

Fingernail growth slows and they become thicker and more brittle.

There is a loss of tissue, with the exception of fat tissue.

Increased proportion of adipose tissue is a consideration during:

• nutritional assessment
• drug therapy since certain medications are stored there

Doses may need to be adjusted.

• deepening of the hollows of intercostal and supraclavicular spaces, orbits, axilla and sagging breast.

The loss in subcutaneous tissue is evidenced by:

• less insulation

Reduced subcutaneous tissue leads to:

• more severe response to temperature changes.

IMMUNE SYSTEM CHANGES

There is a depression in the immune system in the elderly, leading to an increased risk of infection.

Natural antibodies decrease in number.

Autoantibodies increase causing a greater risk of autoimmune disorders.

Antibody response to antigens declines.

Temperature may not be elevated; Confusion is often the first indication of an infection.

ENDOCRINE

The pituitary gland loses weight and vascularity and contains more connective tissue. The follicle stimulating hormone (FSH) increases in women.

The thyroid gland experiences fibrosis, cellular infiltration and modularity. There is a decrease in T3 and a lower basal metabolism rate.

Insulin release by the beta cell is delayed. There is some reduced peripheral sensitivity to circulating insulin. Increased blood glucose levels are not uncommon and necessitate the use of age related gradients for interpreting glucose tolerance tests.

Ovarian produced estrogen ceases after menopause. Progesterone production and excretion are decreased. Testosterone production and metabolic clearance rate decline.

LEARNING

The ability to learn is not significantly changed with age; however other factors, such as motivation, attention span, delayed transmission to the brain, peripheral deficits and illness can be affected.

• May display less readiness to learn.
• May depend upon previous experiences for solutions rather than problem solving with new ideals.

Nursing Implications for Teaching the Elderly:

• Identify learning needs with them and include in discharge planning process.
• Assess knowledge and literacy level; identify sensory deficits which may affect learning and/or teaching plan.
• Be aware of cultural influence.
• Present material that is relevant and meets need.
• Relate to previous learning experiences.
• Use informal, quiet teaching atmosphere.
• Allow time for return demonstration.

COGNITIVE CHANGES

Psychological changes in aging cannot be separated from simultaneous physical and social changes. Sensory impairments can decrease interactions with the environment and others.

Personality

• Normally does not change in aging. A kind old man was probably a kind young man; a nasty grumpy old man was probably a nasty, grumpy young man.
• Change in personality traits may be related to events that altered one’s attitude to oneself, like retirement, loss of independence, or loss of a spouse.

Memory

• May be altered with age.
• Long term memory undergoes little change.
• Short term memory declines.
• Memory problems are more common in the presence of illness.

Intelligence

• Basic intelligence is maintained.
• Crystallized intelligence, which enables a person to rely on past learning and experiences for problem solving, is maintained and continues to grow throughout life.
• Fluid intelligence, which controls emotion, retention of non-intelligent information, and creative capacity shows decline later in life.

With increasing age, there is more time needed for problem solving.

Significant changes are associated with physical or mental problems.

People cannot be compared. Sick old people cannot be compared to healthy old people. A person skilled in test taking cannot be compared to those with sensory deficits or who may have never taken a test.

SPECIAL CONSIDERATIONS – MEDICATIONS

Older adults take a large volume of drugs.

Even though the elderly represent 12% of the population, they consume nearly one third of all the prescribed drugs. A majority of older persons take at least one drug daily, with many taking several.

Drugs behave differently in the elderly.

Advanced age causes differences in the pharmacokinetics (absorption, distribution, metabolism, and excretion of medications) and pharmacodynamics (biologic and therapeutic effects of drugs at the site of action or target organ).

Older adults use drugs with serious side effects.

• Cardiovascular agents

Here is a list of the most common drug types used by the elderly.

• Antihypertensives
• Analgesics
• Antiarthritic agents
• Sedatives
• Tranquilizers
• Laxatives
• Antacids

These drugs carry risks that can threaten the health and well being of the elderly. Some of the side effects are altered mental status, lightheadedness, dizziness, and fluid and electrolyte imbalance.

It is important that the nurse become familiar with the side effects associated with medications to attempt to safeguard older patients.

REFERENCES:

Christ, M.A., Hohloch, F., Gerontologic Nursing, Springhouse, 1993, Springhouse Corporation.

Eliopoulos, C., Gerontologic Nursing, Philadelphia, 2009, Lippincott.

Gallo, J. J., Fulmer, T., Paveza, G., Reichel, W., Geriatric Assessment. Massachusetts, 2003, Jones & Bartlett.

Matteson, M.A., McConnell, E.S., Gerontological Nursing, Philadelphia, 1988, W. B. Saunders Company.

McCaffery, M., Beebe, A., Pain, Clinical Manual for Nursing Practice, St. Louis, 1989, Mosby.

Murray, R., Zentner, J., Nursing Assessment and Health Promotion Through the Life Span, Englewood Cliffs, 1975, Prentice Hall, Inc.

Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., Semela, T. P., Geriatrics at Your Fingertips. 2010, New York, The American Geriatric Society.