Geriatric Care

dr Putra Hendra SpPD

MYTHS
Elderly people are incompetent and incapable of making decisions or handling their own affairs. Most elderly live in nursing homes All elderly people live in poverty

 Older people are lonely and unhappy Elderly do not want to work

Old Age begins a 65

Retirement ends your active life

General Pathophysiology, Assessment, and Management

Pathophysiology
The body becomes less efficient with age. The elderly often suffer from more than one illness or disease at a time. The existence of multiple chronic diseases in the elderly often leads to the use of multiple medications.

 Factors such as disease can increase the speed and degree of the changes. Lifestyle, nutrition, economic status, and social environment can also have effects. If an individual can recognize the changes as a/an normal part of aging, the individual can usually learn to adapt to & cope with change

Integumentary System Changes

Production of new skin cells decreases Oil and Sweat glands become less active Circulation decreases

Hair losses color, and hair loss occurs Skin becomes less elastic & dry Itching is common Dark yellow or brown colored spots appear
Senile lentigines (liver spots)

Fatty tissue layer of skin diminishes Lines and wrinkles appear Nails become thick, tough, and brittle Increased sensitivity to temperature

Care of Skin
Use mild soap Bath oils or lanolin lotion Bath or Shower once or twice a week Brush Hair daily

 Shampoo as often as needed for cleanliness and comfort Care for sore or injuries immediately Socks, sweaters, lap blankets, and layers of clothing will help alleviate the feeling of coldness

 Because of the need for oxygen and nutrients the elderly may experience:
Weakness Dizziness Numbness in hands & feet Rapid heart beat

Cardiovascular Disorders
Angina pectoris Myocardial infarction Heart failure Dysrhythmias Aortic dissection/aneurysm Hypertension Syncope

Circulatory System Care

With circulatory changes:
Avoid strenuous exercise or over exertion Periods of rest Moderate exercise, according to individuals tolerance

 Prevent the formation of a blood clot (thrombus)

Support stockings, anti-embolism hose DO NOT wear garters or tight bands around legs\ If confined to bed
ROM

 High Blood Pressure =

Diet low in salt Decrease fat intake Exercise as recommended by physician

Respiratory Changes
Respiratory muscles become weaker Rib cage more rigid Alveoli thinner & less elastic which decreases exchange of gases - emphysema

 Bronchioles lose elasticity Changes in larynx lead to higher pitched & weaker voice Chronic diseases may decrease the efficiency of the respiratory system even more severely

Respiratory Disorders
Pneumonia COPD Pulmonary embolism Pulmonary edema Lung cancer

 Changes may cause the elderly to experience:

Dyspnea
Breathing increases in rate Difficulty coughing up secretions Increases susceptibility to infections such as a cold or pneumonia

Respiratory and cardiac problems can cause dyspnea.

Respiratory Care
Alternate activity with periods of rest Proper body alignment & positioning Sleep in semi-fowlers position
Use 2 or 3 pillows

 Avoid polluted air Breath deeply & cough frequently May need continuous oxygen therapy

Nervous System Changes

Blood flow to brain decreases & there is a progressive loss of brain cells - - Interferes with
Thinking Interpreting - Reacting - Remembering

 Senses of taste, smell, vision, & hearing are diminished Nerve endings less sensitive
Decreased ability to respond to pain and other stimuli

Decrease in taste& smell frequently affects appetite

 Changes in vision
Problems reading small print Seeing objects at a distance Decrease in peripheral vision Decrease in night vision Increased sensitivity to glare Cataracts Glaucoma

Cataracts diminish eyesight

 Blindness
Position where patient might be able to see you. Explain procedures before doing them. If patient has glasses make sure they are wearing them. Never pull blind patient. Walk at their side and hold their arm. Let them know about obstacles.
28

 Changes in hearing
Hearing loss usually gradual Person may speak louder than usual Ask for words to be repeated Not hear high frequency sounds May not hear well in crowded places

 Deafness

Never assume the patient is deaf. If patient is wearing a hearing aid, make sure it is on. Determine if the patient can lip-read. Note writing.
30

Speak into a stethoscope with the hearing-impaired.

 Decreased sensation to pain & other stimuli = more susceptible

Burns Frostbite Cuts Fractures Muscle strain and other injuries

Digestive Changes
Fewer digestive juices and enzymes produced Muscle action becomes slower & peristalsis decreases Teeth are lost Liver function decreases

 Dysphagia

is frequent complaint

Less saliva Slower gag reflex Loss of teeth Poor fitting dentures

Slower digestion of food

indigestion

 Decrease peristalsis
Increase flatulence (gas) Constipation

Decrease sensation of taste

Poor appetite Poor diet

 Constipation common. Smooth muscle contraction diminished. Deterioration of structures in mouth common. Decline in efficiency of liver. Reduced ability to aid in digestion and metabolism of certain drugs Impaired swallowing. Stomach sphincter valve loss.
Increase in heartburn

Malnutrition due to deterioration of small intestine. Decrease in nutrient absorption.

36

GI Disorders
GI hemorrhage
Upper GI bleed Lower GI bleed

Bowel obstruction Mesenteric infarct

Digestive Care

Good oral hygiene Repair or replace damaged teeth Relaxed eating atmosphere High-fiber high-protein foods with different tastes and textures Seasoning to improve taste Increased fluid intake

Urinary Changes
Kidneys decrease in size & become less efficient Bladder becomes less efficient
May not hold as much May not empty completely

incontinence

Problems with incontinence & elimination are common in the elderly.

Urinary Care
Increase fluid intake
Decrease before bedtime

Regular trips to bathroom Easy to remove clothing Absorbent pads

Endocrine Changes
Increased production of some hormones and decreased of others Immune system less effective BMR decreases Intolerance to glucose

Metabolic & Endocrine Disorders

Diabetes mellitus Thyroid disorders

Endocrine Care
Proper exercise Adequate rest Medical care for illness Balanced diet Healthy lifestyle

Reproductive System Changes

Decrease of estrogen / progesterone in female
Thinning of vaginal wall Decrease vaginal secretions Inflammation of vagina common

 Weakness in supporting tissue:

Uterus sags downward (Uterine prolapse)

Breasts sag when fat redistributed

Decrease in Testosterone
Slow production of sperm Response to sexual stimuli slower Testes smaller less firm

 Male and Female

Sexual desire may or may not decrease

Advantages of sex in elderly

Improves muscle tone & circulation Pain from arthritis seems to decrease

Reproductive Care
Understand physical and psychological sexual needs of the elderly
Allow married couples to be in the same room Give privacy to consenting elderly

Psychocosocial Changes
Some individual cope with psychosocial changes, and others experience extreme frustration and mental distress

 Fears of a sick person:

Death Chronic illness Loss of function Pain

 Dealing with fears created by an illness:

Listening Patience Understanding Provide support

Confusion and Disorientation

Six signs:
Talking incoherently Not knowing their name Not recognizing others Wandering aimlessly Lacking awareness of time or place

Change in altered mental status can denote serious underlying problems.

Neurological Disorders
Cerebrovascular disease (stroke) Seizures Dizziness/vertigo Parkinsons disease Delirium, dementia, Alzheimers

Displaying hostile and combative behavior Hallucinating Regressing in behavior Paying less attention to personal hygiene Inability to respond to simple commands or instructions

 Causes of temporary confusion / disorientation

Stress and/or depression Use of alcohol or chemicals Kidney disease Respiratory disease Liver disease Medication

 Diseases:
CVA Arteriosclerosis Atherosclerosis
Cause TIAs ministrokes which result in temporary periods of diminished blood flow to the brain.

 Dementia
Loss of mental ability characterized by a decrease in intellectual ability, loss of memory, impaired judgement, personality change, and disorientation

 Acute dementia
When the symptoms are caused by temporary reason:
High fever, dehydration, hypoxia

Chronic dementia
When symptoms are caused by permanent, irreversible damage to brain cells

Alzheimers Disease
Form of dementia that causes progressive changes in brain cells

Early Stages:

Memory loss Mood & personality changes Depression Poor judgment Confusion regarding time & place Inability to plan and follow through with ADLs

Middle Stages:
Nigh time restlessness Mood swings increase Personal hygiene ignored Weight fluctuates Paranoia & hallucinations Full time supervision needed

Late Stages:
Total disorientation Incoherent Unable to communicate with words Loses control of bladder & bowel functions

Musculoskeletal System:
Osteoporosis common. Mineral loss. Bones become brittle. Narrowing disks causes kyphosis. Curving of the spine. Osteoarthritis common. Affects joints. Cause of falls. Immobility can lead to death.

64

Stretching and weight-bearing exercises help prevent osteoporosis.

Trauma in the Elderly

Specific Injuries

Orthopedic injuries Burns Head and spine injuries

Orthopedic InjuriesCommon Fractures in the Elderly

Hip or pelvis fractures Proximal humerus Distal radius Proximal tibia Thoracic and lumbar bodies

Subcapital femoral neck fracture

Serious head injuries sometimes denote geriatric abuse.

Many states have laws that require EMS personnel to report suspected cases of Geriatric abuse and/or neglect.

Burns
People age 60 and older are more likely to suffer death from burns than any other group except neonates and infants. Factors include:
Slower reaction time Pre-existing diseases Age-related skin changes Immunological/metabolic changes Reductions in physiological function

Toxicological Emergencies
Lidocaine Beta-blockers Antihypertensives/diuretics ACE inhibitors Digitalis (digoxin, Lanoxin) Antipsychotropics Parkinsons disease medications Analgesics Corticosteroids

Transport Considerations

Modifications in positioning, immobilization, and packaging may be necessary in the elderly patient.

Blister-packs are easier for the elderly.

Home safety for the elderly

Common age-related systemic changes

Sensory changes in the elderly

Changes in the body systems of the elderly