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semi final clinfo " Geriatric Notes "

semi final clinfo " Geriatric Notes "

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01/14/2013

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GERIATRICS

“Grow old with me/ the best is yet to be. /The last of life, for which the first was made.” By: Robert Browning Late Adulthood can be divided into 4 subgroups:  65 to 74 yrs. Of age – Young old  75 to 84 yrs. Of age – Middle age  85 to 99 yrs. Of age – Old old  100 yrs. Or more – Elite old DEFINITION OF TERMS: • GERONTOLOGY – the science & study of aging process • GERONTOLOGIC NURSING – the care & attention to individuals undergoing the aging process with the emphasis on the developmental stages of aging • GERIATRICS – the science & study of the physiologic & pathologic problems of individuals in their later maturity; a medical specialty that addresses the diagnosis and treatment of physical problems of the elderly • GERIATRIC NURSING – care of the elderly individual regardless of whether they are diseased or not • SENESCENCE – the normal aging process • SENILITY – aging process characterized by severe mental deterioration • AGING – physiologic, behavioral & social changes that occur with increasing chronological age I. A.COMMON BIOLOGIC THEORIES OF AGING

THEORY TYPE HYPOTHESIS 1. WEAR & TEAR -Proposes that humans like automobiles have different parts that THEORY run down with time, leading to aging & death -proposes that the faster an organism lives, the quicker it dies -proposes that cell wear out through exposure to internal & external stressors (trauma, chemicals, build up of natural wastes) 2. ENDOCRINE -proposes that events that occurring in the hypothalamus & THEORY pituitary are responsible for changes in hormone production & response that result in the organism’s decline 3. FREE – RADICAL -proposes that unstable free-radicals (groups of atoms) result THEORY from the oxidation of organic materials such carbohydrates, & proteins. These radicals cause biochemical changes in the cells & the cells cannot regenerate themselves. 4. GENETIC THEORY / -proposes that organism is genetically programmed for a MUTATION THEORY predetermined number of cell divisions, after which the cells/organism dies -proposes that when damage to the protein synthesis occurs, faulty proteins will be synthesized & will gradually accumulates, causing a progressive decline in the organism 5. CROSS – LINKING -proposes that the irreversible aging of proteins such as collagen THEORY / COLLAGEN is responsible for the ultimate failures of tissues & organs THEORY -proposes that cells age, chemical reactions create strong bonds, or cross- linkages between proteins. These bonds cause loss of elasticity, stiffness, & eventual loss of function 6. AUTOIMMUNE -proposes that the immune system becomes less effective with THEORY / age, & viruses that have incubated in the body become able to IMMUNOLOGIC damage body organs THEORY -proposes that a decrease in immune function may result in an increase in an autoimmune responses causing the body to produce antibodies that itself I. B. PSYCHOSOCIAL THEORIES • Described the aging individual in terms of his / her social group / culture. 1. DISENGAGEMENT -the basis of this theory arises from the fact that human beings THEORY are mortal & must eventually leave their place & role in society. Therefore, it is their responsibility to look for suitable replacement 2. ACTIVITY THEORY -assumes that the same norms exists for all mature individuals. The degree to which the individual “acts like” or “looks like” a middle – aged is the determinant of the aging process 1

-one must constantly struggle to remain functional & take on new activities to replace lost one 3. CONTINUITY -accounts for the continuous flow of phases in the life cycle & THEORY does not limit itself to change -it assumes that persons will remain the same unless there are factors that stimulate change or necessitate adaptation II. NORMAL PHYSICAL CHANGES ASSOCIATED WITH AGING PHYSICAL CHANGES RATIONALE INTEGUMENTARY -↓in sebaceous glands activity & tissue fluid  Increased skin dryness -↓vascularity of the dermis  Increased skin pallor -reduced thickness & vascularity of the  Increased skin fragility dermis; loss of subcutaneous fats  Progressive wrinkling & sagging of the -loss of skin elasticity, increased dryness, & ↓ subcutaneous fat skin -clustering of melanocytes  Brown “age spots” (lentigo senilus) on -reduced number of sweat glands exposed body parts (face, arms, hands) -progressive loss of pigment cells from hair  Decreased perspiration bulbs; decrease melanin production  Thinning & graying of scalp, pubic & -↑ calcium deposits axillary hair  Slower nail growth & increased thickening with ridges NEUROMUSCULAR  Decreased speed & power of skeletal -↓ in muscle fiber muscle contractions -diminished conduction speed of nerve fibers  Slower reaction time & ↓ muscle tone -atrophy of intervertebral disk  Loss of height (stature) -bone demineralization, loss of calcium from  Osteoporosis the bones= increase propensity to Fracture -deterioration of joint cartridge  Joint stiffness -↓muscle reaction time & coordination  Impaired balance SENSORY / PERCEPTION VISION -Degeneration leading to lens opacity  loss of visual acuity (cataract), thickening & inelasticity (presbyopia)  increased sensitivity to glare & decreased -changes in the ciliary muscle; rigid pupil ability to adjust to darkness  partial or complete glossy white circle sphincter; decrease in pupil size around the periphery of the cornea (arcus -fatty deposits senilis)  loss of color sensitivity (esp. color ---------------------------------------------------------------PURPLE) ---------------------------------------------------------------- ----------changes in the structures & nerve tissues in ---------the inner ear (presbycusis); thickening of the  progressive loss of hearing ear drum -↓ in number of taste buds in the tongue  decreased sense of taste, especially sweet because of tongue atrophy sensations @ the tip of the tongue(prefers SALTY DIET) -atrophy of the olfactory bulb at the base of  decreased sense of smell the brain (responsible to smell perception)  increase threshold for sensations of pain, touch, & temperature PULMONARY  decreased ability to expel foreign object or accumulated matter  decreased lung expansion, less effective exhalation, reduced vital capacity & increased residual volume -possible nerve conduction & neuron changes

-↓ elasticity & ciliary activity -weakened thoracic muscles; calcification of costal cartilage- making the rib more rigid; dilatation from inelasticity of alveoli 2

-diminished delivery & diffusion of oxygen to  difficult, short, heavy, rapid breathing the tissues to repay the normal oxygen debt because of exertion or changes in both (dyspnea) following intense exercise respiratory & vascular tissues CARDIOVASCULAR  reduced cardiac output & stroke volume, -↑ rigidity & thickness of the heart valves ↓filling/emptying abilities); ↓ particularly during increased activity or (hence contractile strength unusual demands; may result in shortness of breath in exertion & pooling of blood in the extremities  reduced elasticity & increased rigidity of -↑ calcium deposits in the muscular layer the arteries  increased in diastolic & systolic pressure  orthostatic hypertension -inelasticity of systemic arteries & ↑ peripheral resistance -Reduce sensitivity of the blood pressure – regulating baroreceptors

GASTROINTESTINAL  delayed swallowing time  increased tendency for ingestion  increased tendency for constipation

-alteration in swallowing mechanism -gradual decrease in digestive enzyme, reduction in gastric pH & slower absorption rate -↓ muscle tone of the intestines; ↓ peristalsis

URINARY  reduced filtering ability of the kidney & -↓ number of functioning nephrons & arteriosclerotic changes in blood flow impaired renal function -↓ tubular function  less effective concentration of urine -enlarged prostate gland in men; weakened  urinary urgency & urinary frequency muscle supporting the bladder or weakness of the urinary sphincter in women  tendency for a nocturnal frequency & -↓ bladder capacity & tone retention of residual urine GENITALS  prostate enlargement (benign) in men  multiple changes in women (shrinkage & atrophy of the vulva, cervix, uterus, fallopian tubes & ovaries; reduction in secretions; & changes in vagina flora)  reduced vaginal lubrication  increase in time for full sexual response -exact mechanism is unclear; possible endocrine changes -diminished secretion of female hormones & more alkaline vaginal pH

Erikson (1963) - developmental task = “ego integrity vs. despair” EGO INTEGRITY DESPAIR  views life with a sense of wholeness &  believes they have made poor choices derives satisfaction from past during life & wish they live life longer accomplishments  inability to accept one’s fate  views death as an acceptable  gives rise to feeling with frustration, completion of life discouragement, & a sense that one’s life  accepts one’s one and only life cycle has been worthless  bringing serenity & wisdom Peck (1968): proposed the 3 developmental task for older adults (contrast-Erikson’s) Ego Differentiation vs. work – role preoccupation Body transcendence vs. body preoccupation 3

Ego transcendence vs. ego preoccupation

DEVELOPMENTAL TASK OF OLDER ADULTS (HAVIGHURST – 1972 ; believes these occur lifetime) • • 65 TO 75 YEARS Adjusting to decreasing physical strength and health Adjusting to retirement and lower and fixed income Adjusting to the death of parents, spouses and friends Adjusting to new relationships with adult children Adjusting to leisure time Adjusting to slower physical and cognitive responses Keeping active and involved Making satisfying living arrangements as aging progresses 75 YEARS AND OLDER Adapting to living alone Safeguarding to physical and mental health Adjusting to the possibility of moving into a nursing home Remaining in touch with other family members Finding meaning in life Adjusting for one’s own death

FACTORS AFFECTING THE HEALTH OF OLDER PERSON Economic change Relocation – relocation stress syndrome = Assisted living – a facility that meets the needs of the older person (e.g. wide doorways, grab bars in the bathroom, a call light ) = Adult day care – a center that provides health and social services to older person = Adult foster care and group home – offers services to individuals who can care for themselves but require some form of supervision for safety purposes

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Maintaining independence and self-esteem – aging people need to recognized for the unique Individual characteristics Facing death and grieving – great bonds of affection and closeness can develop during this period of aging together and nurturing each other 4

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-When a mate dies, the remaining partner inevitably experiences feelings of loss, emptiness, and loneliness. -More women than men face bereavement and solitude because women usually live longer

COGNITIVE DEVELOPMENT Older people need additional time for learning, largely because of the problem retrieving information. Motivation is important. Lifelong mental activity, particularly verbal activity, helps the older person retain a high level of cognitive function and may help maintain long-term memory. A decline in intellectual abilities that interferes with social or occupational functions should always be regarded as abnormal.

MORAL DEVELOPMENT + Kohlberg’s Moral Development (relationships are based on MUTUAL TRUST) Pre-conventional level – an older person at this level obeys rules to avoid pain and the displeasure of others Conventional level – where most older people stay, they follow society’s rules of conduct in response to the expectation of others

PRINCIPLES IN THE CAREOF OLDER PERSON 1. Older persons should have access to adequate food, water, shelter, clothing and health care through the provision of income, family and community support and self-help. 2. Older persons should have the opportunity to work or to have access to other incomegenerating opportunities. 3. Older persons should be able to participate in determining when and at what pace withdrawal from the labour force takes place. 4. Older persons should have access to appropriate educational and training programmes. 5. Older persons should be able to live in environments that are safe and adaptable to personal preferences and changing capacities. 6. Older persons should be able to reside at home for as long as possible. o Participation: 7. Older persons should remain integrated in society, participate actively in the formulation and implementation of policies that directly affect their well-being and share their knowledge and skills with younger generations. 8. Older persons should be able to seek and develop opportunities for service to the community and to serve as volunteers in positions appropriate to their interests and capabilities. 9. Older persons should be able to form movements or associations of older persons. o Care: 10. Older persons should benefit from family and community care and protection in accordance with each society's system of cultural values. 11. Older persons should have access to health care to help them to maintain or regain the optimum level of physical, mental and emotional well- being and to prevent or delay the onset of illness. 12. Older persons should have access to social and legal services to enhance their autonomy, protection and care. 5

o Independence:

13. Older persons should be able to utilize appropriate levels of institutional care providing protection, rehabilitation and social and mental stimulation in a humane and secure environment. 14. Older persons should be able to enjoy human rights and fundamental freedoms when residing in any shelter, care or treatment facility, including full respect for their dignity, beliefs, needs and privacy and for the right to make decisions about their care and the quality of their lives.

15. Older persons should be able to pursue opportunities for the full development of their potential. 16. Older persons should have access to the educational, cultural, spiritual and recreational resources of society. Dignity 17. Older persons should be able to live in dignity and security and be free of exploitation and physical or mental abuse. 18. Older persons should be treated fairly regardless of age, gender, racial or ethnic background, disability or other status, and be valued independently of their economic contribution.

o Self-fulfillment

 HEALTH ASSESSMENT GERIATRIC ASSESSMENT – is a comprehensive evaluation designed to optimize an older person’s ability to enjoy god health, improve their overall quality of life, reduce the need for hospitalization and or institutionalization, and enable them to live independently for as long as possible.

Assessment consists of the following steps: 1. An examination of the older person’s current status in terms of: physical, mental and psychosocial health ability to function well and to independently perform the basic activities of daily living such as dressing, bathing, meal preparation, medication management. Living arrangements, their social network and their access to support services

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2. An identification of current problems or anticipated future problems in any of these areas. 3. The development of a comprehensive care plan which addresses all problems identified, suggests specific interventions or actions required and makes specific recommendation regarding resources needed to provide the necessary support services. 4. The management of a successful linkage between resources and the older person and that person’s family, so that provision of necessary services is assured. 5. An ongoing monitoring of the extent to which this linkage has or has not addressed the problems identified, and the modification of the care plan as needed.

Assessment activities include the measurement of: 1. 2. Weight Height 6

3. 4. 5. 6. 7.

Vital signs Observation of the skin for dehydration status or presence of lesion Examination of visual acuity using the Snellen’s chart Examination of hearing acuity using the Weber and Rinne tests Ask the following: a. Usual dietary pattern b. Any problem with bowel / urinary elimination c. Activity / exercise and sleep / rest pattern d. Family and social activities and interest e. Any problems with reading, writing, or problem solving f. Adjustment to retirement or loss of partner Health care Professionals should also be alert for the following: a. Symptoms of depression b. Risk factors for suicide c. Signs of abnormal bereavement d. Changes in cognitive function e. Medications that increase risk of falls f. Signs of physical abuse or neglect g. Skin lesions (malignant and peripheral) h. Tooth decay, gingivitis, loose teeth i. Peripheral arterial disease

COMMON HEALTH PROBLEMS AMONG ELDERLY Accidents Fall Hypothermia Chronic disabling illness – arthritis, osteoporosis, heart disease, COPD, hearing & visual Drug use and misuse – consider the variations in absorption, distribution, metabolism, and excretion of drugs in relation to physiologic changes associated with aging Alcoholism Dementia – is a slow, insidious process that results in progressive loss of cognitive function Alzheimer’s disease – most common type of dementia Characteristics: changes in memory, judgment, language, mathematic calculation, abstract reasoning, problem solving ability and impulsive behavior, stupor, confusion, disorientation 7

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Nursing intervention:  Spend time with the patient  Use touch to convey concern  Provide frequent reiteration of orientation data (e.g time, place)  Have clocks or calendars in the environment  Explain all actions, procedures, and routines to the patient  Address the patient by his name  Keep a routine of activities 8. Elder abuse – passive or active  TYPES OF ELDER ABUSE: a. Psychological abuse – instilling fear, threatening or making the elderly perform demanding task b. Physical abuse – hitting, slapping or burning c. Financial abuse – taking their money or forcing them to sign over their assets d. Neglect – withholding food, medication or basic care e. Infringement of personal rights – restraining for long periods of time against their will or isolating them from normal social interactions f. Sexual abuse  The perpetrator of abuse is usually the spouse or the child of the victim. Caregivers who abuse their elderly family members are often middle age or older or have emotional problems such as alcoholism or substance abuse.

9. Postural hypotension Nursing intervention  get out of bed slowly  sleep with head of bed slightly elevated  have a daily fluid intake of 2 to 3 liters per day  avoid hot showers or baths, may cause venous dilatation thereby venous pooling.  Rest for 1 hour after meals  Avoid hyperventilation – lowers BP  Exercise regimen is recommended  Use thigh – length elastic stockings to reduce venous pooling  Avoid prolong standing  Pharmacotherapy – Fludrocortisone (a mineralocorticoid that promotes retention of water and sodium)

10. Hypertension 8

Nursing intervention  Encourage stress education and relaxation  Encourage exercise such as swimming and walking  Encourage healthy diet (fresh fruit, rice vegetables)  No weightlifting  Quit smoking & alcohol  Reduce intake of saturated fats  Reduce salt intake to 1 to 6 gms per day  Take prescribed medications at regular basis

11. Osteoporosis Nursing intervention  Have adequate calcium in the diet milk or dairy products fish beans orange juice cereal or bread that have added calcium take calcium supplements

 get regular exercise  Avoid alcohol, quit smoking. Alcohol and smoking reduce bone mass.  Avoid large amount of proteins – rich or salty and caffeinated foods. It cause loss of calcium from the body  Make the home safe to avoid accidents  Practice good posture  Use body mechanics when lifting objects  Do back exercises to improve posture  Wear rubber soled, low heeled shoes that grip well

CHANGES IN THE OLDER PERSON & THEIR IMPLICATION TO CARE Communication considerations demonstrate respect by remembering names and calling the person by the name he/she prefers being addressed (instead of “grandma or grandpa”) 9

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face the person when speaking speak distinctly and clearly do not shout, increased frequency of voice pitch makes hearing difficult increase frequency consonants (f, s, th, ch, sh, b, t, p) provide written instruction/repetition of instructions – memory & attention span have diminished

Promoting independence and self- esteem place equipment conveniently and encourage the use of self – help device

encourage them to do as much as possible for themselves, provided that safety is maintained acknowledge the elderly client’s ability to think, reason and make decisions assist with personal care as necessary

Hygienic practices and skin care daily bath is not necessary = dry skin use mild, super fatted soap use bath oils, lanolin or body lotion (no alcohol content) use pressure mattresses, floatation pads/mattresses alternately change position frequently massage bony prominences and weight bearing areas every 2 hours assist in ambulation as much as possible foot care – soak feet in warm water before cutting nails (usually hard and scaly)

Visual aids and dental care keep eyeglasses clean and always available keep night lights to prevent accidents clean dentures following each meal prevent loss of dentures

Exercise and body alignment regular exercises of feet and legs to prevent PVD (peripheral vascular disorders) encourage correct posture and deep breathing use supportive pillows and firm mattress Temperature less than 37.0 ⁰C temperature of 99 ⁰F indicates infection (bladder/respiratory) Sleep patterns and mental status 10

usually sleep lightly, intermittently with frequent walking (low bed/night light/adequate supervision when getting up) Nutritional needs increase fiber and fluid intake to prevent constipation vitamin & mineral supplements dry skim milk (rich in protein and calcium) decrease in calories, increase in CHON diet

Urinary elimination frequency voiding is common (decreased muscle tone of the bladder emptying capacity, increased residual urine infection) increase fluid intake to dilute urine and decreases its irritating properties (limit fluids during night to prevent nocturia) Sexuality still capable of sexual arousal and orgasm

Emotional needs needs someone to talk(plan time to visit; allow visit to clergyman) comforted by touch (conveys feelings of concern, interest and acceptance) maintain family contact provide diversional activities (books/magazine with large prints, radio or tv) allow to verbalize about feelings on death (do not avoid the topic)

THE AGING FAMILY
planning for care & understanding the older person must be accomplished within the context of the family FAMILY – important source of support for older people SPOUSE – assumes the role of primary caregiver if dependency needs occur ADULT CHILD – usually assumes the caregiver responsibility & help in providing care & support in the absence of surviving spouse in times of sickness, if community resources or older children are unable to provide care, the elderly are at high risk for institutionalization

 HEALTH PROMOTION Health test and screening -as for middle age adults

Safety

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-home safety measures to prevent falls, fire, burns, scalds and electrocution -motor vehicle safety reinforcement, especially when driving at night -precautions to prevent pedestrian accidents

Nutrition and Exercise -importance of well balance diet with fewer calories to accommodate lower metabolic rate and decrease physical activity -importance of sufficient amounts of vitamin D and Calcium to prevent osteoporosis -nutritional and exercise factors may lead to cardiovascular disease (obesity, cholesterol, lack of exercise) -a regular program of moderate exercise to maintain joint mobility, muscle tone and bone calcification

Elimination -importance of adequate roughage in the diet, adequate exercises and at least 8 ounce glasses of fluid daily to prevent constipation

Social Interaction -encouraging intellectual and educational pursuit -encouraging personal relationships that promote discussion of feelings, concerns and fears -availability of social community centers and programs for seniors

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