PHYSIOLOGIC CHANGES IN AGING AFFECTING VARIOUS SYSTEMS

RESPIRATORY SYSTEM

Normal Changes of Aging

The following changes occur in the lung structure and function with normal aging and
can limit respiration:

● Stiffening of elastin and the collagen connective tissue supporting the lungs
● Altered alveolar shape resulting in increased alveolar diameter
● Decreased alveolar surface area available for gas exchange
● Increased chest-wall stiffness
● Stiffness of the diaphragm

Respiratory Diseases Common in Older People

Asthma - is a chronic respiratory disease characterized by unusually reversible airflow

obstruction, airway inflammation, increased mucus-secretion, and increased airway
responsiveness (contraction of airway smooth muscles) to varieties of stimuli.

Diagnostic studies - pulmonary function test, chest radiography, electrocardiography,

and a complete blood count with differential to confirm the diagnosis of asthma in the
older person.

Medications used to treat asthma in older person:

● Inhaled corticosteroids therapy

● Cromolyn sodium
● Leukotriene antagonists
● Inhaled beta2-agonist
● Methylxanthine

Chronic Obstructive Pulmonary Disease (COPD)

- is a term used for two closely related diseases of the respiratory system: Chronic
bronchitis and emphysema.
Symptoms - the earliest presenting symptoms of COPD is early-morning cough with the
production of clear sputum. The sputum will turn to yellow or green should the older
person develop a respiratory infection.

Diagnosis - Spirometry is the preferred diagnostic method for testing pulmonary

function. The three volume measures most relevant to COPD are forced vital capacity,
residual volume, and total lung capacity. Although most of the measured lung volume
changes with COPD, residual volumes usually increase dramatically resulting in the
classic “barrel chest” appearance. This increases the result of weakened airways
collapsing before all of the normal expired air can leave the lungs. The residual volume
makes breathing become more difficult because the trapped air occupies a large area and
impedes the influx of fresh air.

Treatment - quitting smoking can almost always prevent COPD progression.

Home-oxygen therapy (greater than 15 hrs/day) has been shown to increase the survival
rate of persons with advanced COPD who have hypoxemia, or low blood oxygen levels.

Medications used to treat older persons with COPD are similar to those used to treat
older adult with asthma include the following:

● Bronchodilators
● Inhaled corticosteroids
● Antibiotics
● Influenza vaccine
● Expectorants

Other Common Respiratory Disease

Tuberculosis - Mycobacterium tuberculosis is spread through the air and usually infects
the lungs, although other organs are sometimes involved.

Transmission - TB is primarily an airborne disease that is spread by droplets when an

infected person coughs, sneezes, speaks, sings, or laughs. Only people with active disease
are contagious.

Diagnosis - a positive TB skin test and old scars on chest x-ray may provide the only
evidence of past infection.
Treatment - usually several antibiotics are prescribed and given for between 6 to 12
months. Medications used to treat tuberculosis:

● Isoniazid
● Rifampin plus
● Pyrazinamide
● Rifampin

Lung cancer -lung cancer deaths are more common in the young-old than in the old-old.
Deaths from lung cancer first appear at 35 to 44 years of age, and a sharp increase occurs
between the age of 45 to 55 years. The incidence continues to increase through the age of
64 to 74 years, after which it levels off and decreases among the very old.

Types of lung cancer

● Squamous-cell carcinoma
● Adenocarcinoma
● Large-cell carcinoma
● Small-cell carcinoma

Symptoms - symptoms of lung cancer are vague and mimic the symptoms of other
pulmonary illness, making diagnosis difficult. Chronic cough, hemoptysis, chest pain,
shortness of breath, fatigue, weight loss, and frequent lung infection, such as pneumonia
and bronchitis, that do not resolve with antibiotic treatment could all be warning signs.

Diagnostic procedures include Chest x-ray, Computerized axial tomography (CAT)

scan, Positron emission tomography (PET) scan, and Magnetic resonance imaging (MRI)
scan.

Pulmonary embolism

Pulmonary embolism is an occlusion of a portion of the pulmonary vascular bed by an

embolus consisting of a thrombus, an air bubble, or fragment tissue or lipid.

Symptoms:

- Tachypnea
- Dyspnea
- Chest pain
- Hypoxia
 - Decreased cardiac output
- Systemic hypotension
- Possible shock.

Treatment - treatment consists of intravenous administration of heparin and other

anticoagulant therapy.

Respiratory infections

- infections are the major cause of respiratory illness.

● Sinusitis- inflammation of the mucosal lining of the paranasal sinuses that can
lead to mucus stasis,obstruction, and subsequent infection. It is diagnosed by the
presence of dull pain over the maxillary sinuses that is worsened by bending over.
Treatment usually involves nasal decongestants.
● Pneumonia - inflammation of the lungs is the most common type of infectious
disease of the lungs.
● Acute bronchitis - is the inflammation of the bronchi. It is usually a self-limiting
viral illness

CARDIOVASCULAR SYSTEM

The heart has two sides. The right side pumps blood to the lungs to receive oxygen
and get rid of carbon dioxide. The left side pumps oxygen-rich blood to the body.
Blood flows out of the heart, first through the aorta, then through arteries, which branch
out and get smaller and smaller as they go into the tissues. In the tissues, they become
tiny capillaries.
Capillaries are where the blood gives up oxygen and nutrients to the tissues, and
receives carbon dioxide and wastes back from the tissues. Then, the vessels begin to
collect together into larger and larger veins, which return blood into the heart.

Normal Changes in aging

HEART

● Deposits of the "aging pigment," lipofuscin, accumulate.

 ● The valves of the heart thicken and become stiffer.
● The number of pacemaker cells decreases and fatty & fibrous tissues
increase about the SA node. These changes may result in a slightly
slower heart rate.
● A slight increase in the size of the heart, especially the left ventricle,
is common. The heart wall thickens, so the amount of blood that the
chamber can hold may actually decrease.
● Age changes make the heart less able to pump efficiently. Less
blood pumped results in lowered blood oxygen levels.
The limits of the heart to exert itself are reduced with age. Medications
processed and eliminated differently than in young adults.

BLOOD VESSELS
● Arteries lose elasticity with age making heart have to pump harder to
circulate blood, this is mainly due to:
- thickening & stiffening in the media of large arteries is
thought to be caused by collagen cross-linking.
- smaller arteries may thicken/stiffen minimally; their ability
to dilate and constrict diminishes significantly.

● In veins age-related changes are minimal and do not impede normal

functioning.

BLOOD VESSELS

Effects:
● The aorta becomes thicker, stiffer, and less flexible. This makes the
blood pressure higher resulting in LV hypertrophy.
● Increased large artery stiffness causes a fall in DBP, associated with
a continual rise in SBP. Higher SBP, left untreated, may accelerate
large artery stiffness and thus perpetuate a vicious cycle.
● Baroreceptors (stabilize BP during movement/activity) become less
sensitive with aging. This may contribute to the relatively common
finding of orthostatic hypotension.

AGING CHANGES
 ● People aged 65 and older are much more likely than younger people
to suffer a heart attack, to have a stroke, or to develop coronary
heart disease (commonly called heart disease) and heart failure.
Heart disease is also a major cause of disability, limiting the activity
and eroding the quality of life of millions of older people.

● Aging can cause changes in the heart and blood vessels. For
example, as you get older, your heart can't beat as fast during
physical activity or times of stress as it did when you were younger.
However, the number of heartbeats per minute (heart rate) at rest
does not change significantly with normal aging.

● Changes that happen with age may increase a person's risk of heart
disease. A major cause of heart disease is the buildup of fatty
deposits in the walls of arteries over many years. The good news is
there are things you can do to delay, lower, or possibly avoid or
reverse your risk.

COMMON CARDIOVASCULAR DISEASE IN OLDER ADULTS

1. HYPERTENSION
- is a major risk factor for other cardiovascular conditions. Hypertension is
blood pressure that is higher than normal. Your blood pressure changes
throughout the day based on your activities.
- diagnosed when blood pressure consistently measures >130 mmHg systolic
and >80 mmHg diastolic. Blood pressure is measured using a blood
pressure cuff, which is a non-invasive device that can detect the pressure
inside your arteries, conveying numerical values using a
sphygmomanometer or an electronic device.

Symptoms :
● Severe headaches
● Nosebleed
● Fatigue or confusion
● Vision problems
 ● Chest pain.
● Difficulty breathing
● Irregular heartbeat.
● Blood in the urine.

Treatment consists of :

-Angiotensin-converting enzyme (ACE) inhibitors

- Angiotensin II receptor blockers (ARBs)
- Diuretics
- Beta-blockers
- Calcium channel blockers
- Alpha-blockers
- Alpha-agonists
- Renin inhibitors
- Combination medications

Intervention :
● Provide calm, restful surroundings, minimize environmental activity and noise
● Maintain activity restrictions (bedrest or chair rest); schedule uninterrupted rest
periods; assist patients with self-care activities as needed.
● Provide comfort measures (back and neck massage, the elevation of head).
● Instruct in relaxation techniques, guided imagery, distractions.
● Monitor response to medications to control blood pressure.
● Administer medications

2. CORONARY ARTERY DISEASE

is the buildup of plaque in the arteries that supply oxygen-rich blood to your heart.
Plaque causes a narrowing or blockage that could result in a heart attack.
Symptoms include chest pain or discomfort and shortness of breath
Diagnostic test done through ECG and Echocardiogram

Symptoms :
● Chest pain or discomfort (angina)
 ● Weakness, light-headedness, nausea (feeling sick to your stomach), or a cold
sweat.
● Pain or discomfort in the arms or shoulder.
● Shortness of breath.

Treatment :
● Nitrates
● Beta-blockers
● Calcium channel blockers
● Fibrinolytics anticoagulant and antiplatelets
● Lipid lowering drugs

Intervention :
● Discuss pathophysiology of condition. Stress need for preventing and managing
anginal attacks
● Review significance of cholesterol levels and differentiate between LDL and HDL
factors.
● Emphasize the importance of periodic laboratory measurements.
● Encourage avoidance of situations that may precipitate anginal episode
● Review importance of weight control, cessation of smoking, dietary changes, and
exercise
● Encourage patients to follow prescribed reconditioning programs; caution to avoid
exhaustion.
● Discuss impact of illness on desired lifestyle and activities, including work,
driving, sexual activity, and hobbies. Provide information, privacy, or consultation,
as indicated
● Demonstrate how to monitor your own pulse and BP during and after activities,
and to schedule activities, avoid strain and take rest periods.
● Discuss steps to take when anginal attacks occur, (cessation of activity, keeping
“rescue” NTG on hand, administration of prn medication, use of relaxation
techniques).
● Stress the importance of checking with a physician before taking OTC drugs.
● Review symptoms to be reported to physician: increase in frequency of attacks,
changes in response to medications
● Discuss the importance of follow-up appointments.
 3. MYOCARDIAL INFARCTION
- A heart attack (myocardial infarction) happens when one or more areas of the
heart muscle don't get enough oxygen. This happens when blood flow to the heart
muscle is blocked.

Symptoms :
● shortness of breath
● sweating,
● nausea,
● vomiting,
● abnormal heart beating
● anxiety,
● fatigue,
● weakness,
● stress,
● depression

Treatment:
Clopidogrel and ticagrelor are recommended for conservative medical management
of MI in combination with aspirin (162 to 325 mg per day) for up to 12 months. Early
administration of beta blockers is recommended during hospitalization after an MI.

Intervention:
● Assess for chest pain not relieved by rest or medications.
● Monitor vital signs, especially the blood pressure and pulse rate.
● Assess for presence of shortness of breath, dyspnea, tachypnea, and crackles.
● Assess for nausea and vomiting.
● Assess for decreased urinary output.
● Assess for the history of illnesses.
● Perform a precise and complete physical assessment to detect complications and
changes in the patient’s status.
● Assess IV sites frequently

4. ARRHYTHMIA
- is an irregular or abnormal heartbeat
Symptoms:
● Fatigue or weakness.
● Dizziness or lightheadedness.
● Fainting or near-fainting spells.
● Rapid heartbeat or pounding in the chest.
● Shortness of breath and anxiety.
● Chest pain or pressure.
● In extreme cases, collapse and sudden cardiac arrest.

Treatment :
● amiodarone (Cordarone, Pacerone)
● flecainide (Tambocor)
● ibutilide (Corvert), which can only be given through IV.
● lidocaine (Xylocaine), which can only be given through IV.
● procainamide (Procan, Procanbid)
● propafenone (Rythmol)
● quinidine (many brand names)
● tocainide (Tonocarid)

Intervention :
● Palpate pulses noting rate, regularity, amplitude and symmetry. Document
presence of pulsus alternans, bigeminal pulse, or pulse deficit.
● Auscultate heart sounds, noting rate, rhythm, presence of extra heartbeats, dropped
beats.
● Monitor vital signs
● Provide a quiet and calm environment.
● Demonstrate and encourage use of stress management behaviors,: relaxation
techniques, guided imagery, slow/deep breathing.
● Investigate reports of chest pain,
● Be prepared to initiate cardio-pulmonary resuscitation (CPR) as indicated.
● Administer supplemental oxygen as indicated.

5. ORTHOSTATIC HYPOTENSION
- is a sudden drop in blood pressure when you stand from a seated or prone
(lying down) position. You may feel dizzy or even faint.
 - Orthostatic means an upright posture. Hypotension is low blood pressure.
The condition is also called postural hypotension.
Symptoms :
● Blurred vision.
● Chest pain, shoulder pain or neck pain.
● Difficulty concentrating.
● Fatigue or weakness.
● Headaches.
● Heart palpitations.
● Nausea or feeling hot and sweaty.
● Shortness of breath (dyspnea).
Treatment :

● Droxidopa (Northera®).
● Erythropoiesis-stimulating agents (ESAs).
● Fludrocortisone (Florinef®).
● Midodrine hydrochloride (ProAmatine®).
● Pyridostigmine.

Intervention :
● recommend increasing fluid intake,
● changing body position slowly,
● avoiding alcohol,
● using compression stockings,
● avoiding standing for a long time.

6. SYNCOPE WITH CARDIAC CAUSES ( Cardiovascular syncope )

-is caused by various heart conditions, such as bradycardia, tachycardia or certain
types of hypotension. It can increase the risk of sudden cardiac death. People
suspected of having cardiac syncope but who don't have serious medical
conditions may be managed as outpatients.

Symptoms :
● Blacking out
● Feeling lightheaded
● Falling for no reason
 ● Feeling dizzy
● Feeling drowsy or groggy
● Fainting, especially after eating or exercising
● Feeling unsteady or weak when standing
● Changes in vision, such as seeing spots or having tunnel vision
● Headaches

Diagnostic test :
1. Laboratory testing
2. ECG and Echocardiogram
3. Exercise stress test
4. Ambulatory monitor
5. Hemodynamic testing
6. Head up tilt test
7. Blood volume determination

Intervention :
● Prevent injury
● Educate the patient to change positions slowly
● Reevaluate medications, review any that may cause syncope with MD
● Monitor for changes in the level of consciousness.
● Promote adequate fluid intake

7. VALVULAR DISEASE
- when any valve in the heart has damage or is diseased.

Symptoms:
● Shortness of breath
● Chest pain
● Fatigue
● Dizziness or fainting
● Fever
● Rapid weight gain.
● Irregular heartbeat.

Diagnostic test :
● Echocardiography
 ● ECG
● Chest X-Ray
● Cardiac MRI
● Exercise test
● Cardiac Catheterization
Treatment :
● Antibiotics
● Diuretics
● Antiarrhythmic
● ACE inhibitors
● Beta- blockers
● Anti- coagulant

Intervention :
● Assess mental status (Restlessness, severe anxiety, and confusion).
● Check vital signs (heart rate and blood pressure).
● Assess heart sounds, noting gallops, S3, S4.
● Assess manually peripheral pulses (with weak rate, rhythm indicated low cardiac
output).
● Assess lung sounds and determine any occurrence of Paroxysmal Nocturnal
Dyspnea (PND) or orthopnea.
● Monitor central venous, right arterial pressure [RAP], pulmonary arterial
pressure(PAP)
● Routinely Assess skin color and temperature (Cold, clammy skin is secondary to a
compensatory increase in sympathetic nervous system stimulation and low cardiac
output and desaturation).
● Carefully maintain intake output and daily check weight.
● Administer medication as prescribed, noting response, and watching for side
effects and toxicity.
● Administer stool softeners as needed(straining for a bowel movement further
impairs cardiac output).
● Explain the drug regimen, purpose, dose, and side effects.
● Maintain adequate ventilation and perfusion (Place the patient in semi- to
high-Fowler’s position or supine position).
● Administer O2 as ordered.
● Assess response to increased activity and help the patient in daily activities.
 ● Maintain physical and emotional rest (restrict activity and provide a quiet and
relaxed environment).
● Monitor sleep patterns; administer a sedative.
● If invasive adjunct therapies are indicated (e.g., intra-aortic balloon pump,
pacemaker), maintain within the prescribed protocol, and prepare the patient.
● Explain diet restrictions (fluid, sodium).

HEMATOPOIETIC AND LYMPHATIC SYSTEM

Hematopoietic System

Body fluids distribute essential protective factors, nutrients, oxygen, and

electrolytes throughout the body. The two major fluids of the body are blood and lymph.
These fluids flow through the body within two parallel circulatory systems.
 ● Blood - The general functions of blood include transportation of nutrients, waste
products, blood gases, and hormones; regulation of fluid-electrolyte balance,
acid-base balance, and body temperature; protection against pathogenic attack by
the WBCs and against excessive blood loss through clotting mechanisms.
a. Erythrocytes
b. Leukocytes
c. Platelets
● Lymph system - The lymph and circulatory systems are parallel and
interdependent. It is responsible for returning fluids from the tissues to the
circulation.
a. Lymph Vessels, Fluid, and Nodes - are located in most tissue spaces.
These permeable vessels absorb fluid and proteins from the tissues. Lymph
nodes and nodules also produce lymphocytes and monocytes and
phagocytize pathogens
b. Spleen and Thymus - The spleen is responsible for producing
lymphocytes and monocytes, which enter the bloodstream. It also contains
fixed plasma cells, which produce antibodies to foreign antigens, and fixed
macrophages, which phagocytize pathogens and other foreign substances in
the blood. The thymus shrinks with age, but once the T cells are
established in the spleen and lymph nodes, they are self-perpetuating.
c. Lymphocytes and Immunity - B lymphocytes, or B cells, are also
produced in the embryonic bone marrow. These cells are responsible for the
recognition of antigens located on a foreign cell and for humoral immunity.
In humoral immunity, T cells and B cells often cooperate: Sensitized
helper T cells detect antigens and induce the B cells to produce antibodies,
which are then found in the globulin portion of plasma.

EXPECTED AGE-RELATED CHANGES

The characteristics of blood change somewhat as a person ages. Plasma

viscosity increases slightly and is most often related to a general decrease in total
body fluid. The number of T cells in the body does not appear to decrease with
aging, but more of the cells are immature.

Changes in the immune response may modify the usual signs and
symptoms of infection. Such changes may be difficult to recognize in older adults:
 body temperature may not become significantly elevated until the infection is
severe, and pain may not be present to indicate infection.

COMMON HEMATOPOIETIC AND LYMPHATIC DISORDERS IN OLDER

ADULTS

Unexplained anemia in elders

Investigation of the cause of anemia in an elderly patient is frequently negative,

leading some physicians to propose various physiological explanations to account for this
finding. Others advocate an elusive underlying systemic disease or a pathological
disruption in the hematopoietic pathway.

A. Anemia
- defined as reduction in RBC mass, decreased quantity of hemoglobin, and
decreased hematocrit.
- May be caused by a decrease in red cell production, an increase in red cell
destruction , or a loss of blood.
- According to the WHO, hemoglobin in women (<12 g/dL) and in men (<13 g/dL).
- More than 20% of older adults over the age of 85 have anemia.
- Insidious in nature and an incidental finding on hematological studies.
- Increased hospitalizations, morbidity, and mortality.

Common causes of anemia in older adults:

1. Iron deficiency anemia (15% - 23%)
2. Anemia of chronic disease (15% - 35%)
3. Anemia related to Chronic Kidney Disease (8%)

Other causes:
1. Vitamin B12 or Iron Folate deficiency (14%)
2. Myelodysplastic syndromes (5%)
3. Unexplained (45%)

Symptoms:
- Fatigue and weakness
- Pallor
- Headaches
 - Dyspnea on exertion
- Palpitations
- Poor concentration
- Dizziness

Nursing interventions:
1. Focus on dietary management.
a. The patient and the family should be instructed about appropriate food
selection and meal preparations.
b. Provide a list of foods high in iron, folic acid, and vitamin B12.
c. The health care provider may order supplemental iron preparations.
d. Ensure that the older patient has an adequate income to purchase necessary
foods.
e. The nurse should be alert to the presence of other variables that may
adversely affect the older’s ability to eat.
2. Balance of rest and activity to support functional ability.
a. Identify peak energy periods during waking hours and carry out desired or
important activities.
3. Health education about the condition.

B. Leukemia
- Leukemia is the result of excessive production of immature WBCs.
- There are both acute and chronic varieties, and leukemia is also classified
by the type of abnormal cells present.
- Other blood disorders (e.g., anemia) and hemorrhage (related to a decrease
in the number or function of platelets) are commonly seen with leukemia.
- Chronic lymphocytic leukemia is the form most often seen in older adults.
The average age at diagnosis is 72 years.
- Depending on the stage of the disease and the patient’s overall health, life
expectancy may vary from a few to as many as 20 years after diagnosis.
Symptoms:

- unexplained weight loss

- swollen lymph nodes
- feelings of fatigue or weakness
- easy bruising or bleeding
 - shortness of breath
- fever or night sweats

Nursing interventions:

- Support adaptation and independence.

- Promote comfort.
- Maintain optimal physiological functioning.
- Prevent complications.
- Provide information about disease process, condition, prognosis, and treatment
needs

GASTROINTESTINAL SYSTEM
Normal Aging of the Gastrointestinal Tract

Common Nutritional Disorders

1. Anorexia - Appetite regulation in some older adults is altered. Studies

suggest that impaired fundal accommodation with a meal contributes to a
sense, fullness and therefore results in reduced intake.

a. Cholecystokinin - causes grans appetite suppression in older adults

 b. Leptin - a hormone released from any, tissue that functions to decrease
appetite, is found elevated in older men

2. Malnutrition

● Undernutrition is associated with vitamin and mineral deficiencies

● Protein-calorie malnutrition is defined as weight loss and low serum
albumin levels suggesting an inadequate intake of protein.

3. Obesity – The condition of being overweight places the older adult at

increased risk for such chronic conditions as hypertension, coronary artery
disease, diabetes, and stroke. In addition, it places additional strain on
weakened joints and limits mobility and independence.

4. Dehydration Inadequate fluid intake secondary to a decline in thirst

sensation is the most common cause of dehydration in the older adult.

Clinical Manifestations

● · Malnutrition
● Vitamin and mineral deficiencies
● Obesity
● Dehydration

Disorders of the upper gastrointestinal system

1. Periodontal Disease

Periodontal disease (gingivitis and periodontitis) is inflammation of the structures that

support the teeth, with resultant bone destruction.

Signs and symptoms of gingivitis:

● Reddened, swollen gums that bleed with brushing.

● Bad breath (halitosis), a foul taste in the mouth, or presence of a
purulent exudate around the gum line.

Assessment and Nursing care:

 ● Assessment of the oral cavity should be done by a dentist at least once a year
● Screen oral cavity as part of routine oral care
● Screen patients who are taking medications, such as phenytoin and calcium
channel blocking agents that can worsen gingivitis
● Management:
● Regular tooth brushing and flossing and regular dental check-ups for plaque and
calculus removal at least twice yearly
● Dentures should be checked periodically to ensure snug fit and to prevent oral
irritation.
● Dentures should be soaked several times weekly in an antimicrobial solution.

2. Dysphagia or difficulty with swallowing

a) Oropharyngeal dysphagia is difficulty initiating swallowing and transfer

of food past the upper esophageal sphincter

b) Esophageal dysphagia is a result of disordered peristaltic activity of the

esophagus or obstruction of the lower esophageal sphincter. It occurs
after swallowing has been initiated and is followed by coughing and
choking

Signs and symptoms:

● difficulty swallowing
● frequent choking episodes
● changes in voice
● recurrent pneumonia heartburn
● drooling, and halitosis
● muscle weakness or masses in the neck and throat region
● abnormal breath sounds secondary to pneumonia or pneumonitis
● abnormal vascular sound (bruits)

Assessment:

● Observe the client at mealtime and note how he or she manages

liquids and foods of different consistencies
● Ability to produce saliva should be assessed
● Observe weight loss or signs of dehydration.
 ● Speech pattern and tone abnormalities may be noticed. A paralyzed
palate and oropharynx can result in a hypernasal tone. Hoarseness
may be caused by partial paralysis of the cranial nerve.

Management:

● Encourage to consume small, frequent portions of food

● Increase fluid intake during meals
● Avoid lying down after meals to avoid reflux
● Monitor for side effects from certain medications (nonsteroidal
anti-inflammatory drugs and certain antibiotics)
● Instruct to take all medicine in a full glass of water
● Assist the client to position his/her tongue on the palate by practicing
maneuver with him/her in front of the mirror.
● Massage the tonsillar arch with the moistened cotton swab
● Position client with the neck flex slightly forward
● Dietician can suggest high-calorie foods that are easy to swallow

1. Gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) – is the backflow of gastric contents into the
esophagus. Erosive esophagitis and esophageal spasms are caused by the gastric acids on
the mucosa of the esophagus and are responsible for the presenting signs and symptoms.

Clinical Manifestations:

● Heartburn (retrosternal burning)

● “sour stomach”
● Dysphagia
● Odynophagia (painful swallowing)

Nursing management:

● Ongoing assessment, patient teaching and monitoring of response to

therapy
● Modification of lifestyle behaviors
● Instruct measures that decrease intra-abdominal pressure and aid
digestion
a) Hiatal Hernia In hiatal hernia (diaphragmatic or esophageal hernia), a major cause of
reflux and esophagitis, part of the stomach protrudes through an opening of the
diaphragm

2. Gastritis refers to inflammation of the gastric mucosa and occurs in acute or

chronic forms. Acute gastritis causes transient inflammation, hemorrhages, and
erosion into the gastric mucosal lining.

The major symptom of gastritis is abdominal pain. Other symptoms include

indigestion, distention, decreased appetite, nausea, and vomiting. Many patients with
chronic gastritis are asymptomatic.

Stress-Induced Gastritis Stress-induced gastritis or erosion may occur in

critically ill patients such as those with burns, sepsis, multiorgan failure, major
surgery, or head injury.

Nursing management

● Acid-suppressant drugs, as ordered;

● Small, frequent, easily digested meals;
● Maintenance of a calm environment to decrease the effects of stress;
● Monitoring of fluid and electrolyte status; and teaching the older
patient about precipitating and contributory factors.
● An older patient must understand the necessity of limiting or
eliminating alcohol and tobacco use

3. Peptic Ulcer Disease PUD is an ulcerative condition caused by the erosion of the GI
mucosa resulting from the digestive action of hydrochloric acid and pepsin. Although
PUD refers to injury anywhere in the GI tract, the most common occurrence is in the
stomach and duodenum.

a) Gastric Ulcers In gastric ulcers, the level of hydrochloric acid secretion is usually
normal or reduced.

b) Duodenal Ulcers In contrast to gastric ulcers, people with DUs have a normal back
diffusion of gastric acid but an increased rate of gastric acid secretion.

DISORDERS OF THE SMALL INTESTINE

 1. Malabsorptive Disease

Malabsorption – impaired assimilation of nutrients from the small intestine.

Reduced gastric acid secretion, chronic use of antacids and drugs that reduce
motility (e.g., anticholinergics and narcotics) foster bacterial overgrowth and
cause malabsorption.

Other possible causes:

● Chronic pancreatitis
● Celiac disease or gluten enteropathy
● Mesenteric ischemia
● Small-bowel contamination by abdominal bacteria (the blind loop
syndrome)

Clinical manifestations:

● Diarrhea
● Abdominal pain
● Rectal bleeding
● Osteomalacia ( people with celiac disease)
● Appears thin and emaciated
● Pale mucous membranes and dry, scaly skin

Management:

● Ask the client about his/her normal pattern of elimination and

dietary intake
● Watch for signs and symptoms of dehydration and electrolyte
imbalance by checking daily weight, character of mucous
membranes, and postural hypotension.
● Modify the diet by eliminating gluten and lactose
● Patients should be cautioned about excessive use of antacids,
which may cause harmful overgrowth of bacteria, leading to
malabsorptive state

DISORDERS OF LARGE INTESTINE

1. Diverticular Disease – a colonic diverticulum is an outpouching or
herniation through the colonic mucosa in response to increasing
intraluminal pressure.

Diverticulitis – occurs when there is microperforation and leakage of bowel

contents into the surrounding tissue, causing inflammation

Signs and symptoms:

● Constipation
● Bloating
● Abdominal discomfort and distention
● Fever
● Lower GI bleeding

Preventions:

● Encourage older clients to have yearly fecal occult blood testing.

● Advise adequate fiber intake
● Encourage active lifestyle
● Dietary manipulation and pain management

2. Intestinal Obstruction - partial or complete stoppage of the forward

flow of intestinal contents. Obstruction can be caused by mechanical
adhesions, volvulus, intussusception, tumors, neurogenic or paralytic ileus,
or ischemic bowel disease.

Signs and symptoms:

● Crampy abdominal pain that comes and goes

● Loss of appetite
● Constipation
● Vomiting
● Inability to have a bowel movement or pass gas
● Swelling of the abdomen

Preventions:
 ● Educate clients about the warning signs of colon cancer (changes in
bowel habits or rectal bleeding) and risk factors such as family
history and poor dietary habits.
● Advise annual stool testing for occult blood and routine colonoscopy
● Fluids must be replaced slowly
● Promote bed rest
● Judicious pain management

3. Constipation - constipation is a common problem caused by lack of activity, a diet

low in fiber, and inadequate hydration. Many older adults experience constipation as a
result of impaired nerve sensations, incomplete emptying of the bowel, or failing to
attend to signals to defecate.

Assessment:

● Determine the type of constipation through a bowel history.

● Identify factors that place the patient at high risk constipation
● Isolate and modify elements that are contributing to the problem of
constipation.

Preventions:

● Modify beliefs about elimination

● Educate the client about fluids, bulk, and fiber content in the diet and
establish a suitable exercise routine that will aid healthy elimination.
● Dietary fiber with adequate fluid intake (6-8 glasses of water daily)

Nursing Management:

● Encourage to establish a goal of every-other-day elimination and to calendar or

diary as a reminder during the initial phase of behavior change
● Provide warm fluids with meal
● Help client into a comfortable upright position to aid passage of stool

Pharmacological interventions:

● Psyllium or methylcellulose – bulking agents

● Osmotic laxatives – such as milk of magnesia are useful to
soften stool
 ● Bisacodyl or phenolphthalein – stimulant laxatives should be
used only when other options have failed

4. Diarrhea

Diarrhea refers to bowel movements that are increased in frequency, more liquid, difficult
to control and possibly resulting in incontinence. Chronic diarrhea may be caused by
malabsorption, diverticular disease, inflammatory bowel disorder, or medications,
especially antacids, antibiotics, antidysrhythmics, and antihypertensive.

Signs and symptoms:

● Frequent loose, watery stools

● Abdominal cramps
● Abdominal pain
● Fever
● Bleeding
● Light-headedness or dizziness from dehydration
● Tachycardia
● Postural hypotension
● Elevated haemoglobin and haematocrit as well as changes in
the serum potassium and sodium levels

Nursing Management:

● Check for fecal impaction

● Monitor intake and output and stool count
● Assess for pain or localized areas for tenderness
● Administer free amino acid formula via an enteric feeding
tube
● Increase fluid intake

URINARY SYSTEM

The urinary system includes: KIDNEYS, URETER, BLADDER and URETHRA

Its main function is to remove wastes from the system and contributes to the regulation of
fluid and electrolyte balance, acid-base balance, blood pressure, and red blood cell
production

AGE RELATED CHANGES IN THE KIDNEY

Renal function starts to decline around the age of 30 to 40, and about two-thirds of people
will experience a gradual decline in size and efficiency in the ability to filter blood
occurring in the kidney and the remaining one-third of people will retain a relatively
stable renal function throughout their lifetime - indicating factors other than age may
affect renal function

NORMAL CHANGES OF AGING IN THE URINARY SYSTEM

• Increased night-time production of urine
• Increased renal threshold for glucose
• Decrease in blood flow to kidneys and glomerular filtration rate
• Inability to concentrate urine potentiates risk of dehydration
• Bladder capacity decreases
• Increased bladder contractility
• Potential for overflow incontinence and urinary retention in men
• Decline in renal function including filtration rate with prolonged half-life of drugs
• Decreased sensation of bladder fullness resulting in less frequent voiding
• Loss of bladder capacity by about 50%
• Increase in incontinence due to detrusor

ANTIDIURETIC HORMONE AND THE AGING PROCESS

Older adults tend to have higher to have higher basal levels of ADH than younger adults,
and the pituitary responds more vigorously to osmotic stimuli by secreting more ADH is
released as a response to hypotension and hypovolemia; however, its action is blunted in
older adults requiring the release of more hormone to achieve the desired antidiuretic
effect. In addition, the aging kidney is less responsive to circulating ADH, producing
urine that is poorly concentrated and rich in sodium. This puts older adult at increased
risk of hyponatremia, which can be magnified with the use of diuretics.
COMMON URINARY SYSTEM CONCERN OR DISEASE-RELATED
CHANGES IN RENAL FUNCTION

Renal failure – the inability to remove nitrogenous waste from the body and to regulated
fluid and electrolytes and acid-base balance, may arise from problems with blood flow to
the (prerenal), injury to the glomeruli or tubules (renal), or outflow obstruction
(postrenal). The failure may be acute, with a sudden onset or chronic, in which
irreversible damage accumulates, usually over time

Signs and Symptoms are similar to younger adults, these includes:

• Decreased glomerular filtration rate
• Hyperphosphatemia
• Hypocalcemia
• Hyperkalemia
• Metabolic acidosis
• Hypertension
• Anemia

URINARY TRACT INFECTION

It is the presence of bacteria in the urethra, bladder, or kidney. This is caused by changes
in the urinary tract of older adults making them more susceptible to urinary tract
infections.

Symptomatic bacteriuria indicating classic symptoms such as:

• Urgency
• Frequency
• Pain or burning sensation with urination

Asymptomatic bacteriuria there is an absence of symptoms but microscopic evaluation

indicates the presence of bacteria in the urine

URINARY INCONTINENCE
The involuntary loss of bladder control is a common and often embarrassing problem.
The severity ranges from occasionally leaking urine when you cough or sneeze to having
an urge to urinate that's so sudden and strong you don't get to a toilet in time.

UI is classified in 4 types:
• Stress incontinence
• Urge incontinence
• Overflow incontinence,
• Functional incontinence
• Mixed incontinence

BENIGN PROSTATIC HYPERPLASIA

The growth of the prostate is influenced by the interactions among androgens and
estrogens. A condition in which the prostate, a walnut-sized body part made of glandular
and muscular tissue, grows in size. The prostate surrounds part of the urethra, which is
the tube that carries urine and sperm out of the body.

Risk factors includes:

• Age over 40
• Family history of BPH

Medical conditions such as:

• Obesity
• Heart and Coronary artery disease
• Type 2 diabetes
• Sedentary lifestyle
• Erectile dysfunction

Symptoms of BPH are referred to as nuisances that affects daily living includes:

• Difficulty in starting stream of urine

• Weak stream
• Straining to urinate
• Longer time needed to urinate
• Urinary frequency
• Pain during ejaculation or during urination
• Urine with unusual color or smell
• Feeling of incomplete bladder emptying

URINARY SYSTEM MALIGNANCIES

CANCER OF THE URINARY BLADDER

Risk factors include:

• Smoking
• High levels of arsenic in drinking water
• Occupation of painter
• Occupational exposure to certain chemicals known as arylamines

Signs and Symptoms are:

• Urinary tract diseases: such as microhematuria
• Urinary frequency and urgency
• Dysuria

PROSTATE CANCER

Risk factors include:

• Older age
• African ancestry
• Family history

Signs and Symptoms are:

• BPH
• Difficulty in starting urine flow
• Nocturia
• Frequency
• Hematuria
MAJOR AGE-RELATED URINARY SYSTEM CHANGES

KIDNEY

• Decreased weight, glomeruli, glomerular filtration rate

• Decreased Concentration of urine
• Increased serum creatinine, blood urea nitrogen levels
• Increased nighttime formation of urine
• Decreased drug excretion
• Increased basal level of antidiuretic hormone

BLADDER AND URETHRA

• Decreased autonomic innervation

• Decreased capacity
• Decreased detrusor contractility
• Increased post void residual

NERVOUS SYSTEM

Aging changes in the nervous system

The brain and nervous system are your body's central control center. They control your
body's:

Movements
•Senses
•Thoughts and memories
•They also help control the organs such as your heart and bowels.

Nerves are the pathways that carry signals to and from your brain and the rest of your
body. The spinal cord is the bundle of nerves that runs from your brain down the center of
your back. Nerves extend out from the spinal cord to every part of your body.

AGING CHANGES AND THEIR EFFECTS ON THE NERVOUS SYSTEM

As you age, your brain and nervous system go through natural changes. Your brain and
spinal cord lose nerve cells and weight (atrophy). Nerve cells may begin to pass messages
more slowly than in the past. Waste products or other chemicals such as beta amyloid can
collect in the brain tissue as nerve cells break down. This can cause abnormal changes in
the brain called plaques and tangles to form. A fatty brown pigment (lipofuscin) can also
build up in nerve tissue.

Breakdown of nerves can affect your senses. You might have reduced or lost reflexes or
sensation. This leads to problems with movement and safety.

Slowing of thought, memory, and thinking is a normal part of aging. These changes are
not the same in everyone. Some people have many changes in their nerves and brain
tissue. Others have few changes. These changes are not always related to the effects on
your ability to think.

SPECIAL SENSES

The senses connect the human body to to the environment. They allow individual to be
aware of and interpret various stimuli, thus enabling interaction with the environment.
Sensory changes may have a dramatic effect on the quality of life of older adults.
The five primary sensory categories include the following: sight, hearing, taste, smell and
touch. Two additional sensory categories that are recognized are general and special.
General senses include the senses of touch, pressure, pain, temperature, vibration, and
proprioception (position sense). These senses are further classified as somatic ( those
providing sensory information about the body and the environment ) or visceral ( those
supplying information about the internal organs). Special senses are produced by highly
localized organs and specialized sensory cells. These include the senses of sight, hearing,
taste, smell, and balance.

VISION

Vision plays an integral part in a persons ability to function in the environment. Visual
acuity (the ability to see clearly) is an important part of performing of activities of daily
living; dressing, grooming, cooking, driving, and reading are all tasks that involve the use
of eyesight.

Age-Related Changes in Structure and Function

Normal age-related changes in the external and internal eye have been well-documented.
The eyelids lose tone and become lax, which may result in ptosis of the eyelids,
redundancy of the skin of the eyelids and malposition of the eyelids.
The conjunctiva is thin and yellow in appearance.
The pupil decreases in size and loses some of its ability to constrict.

Two common complaints of older adults, floaters and dry eyes.

>Floaters and Flashers
Floaters appear as dots, wiggly lines or clouds that a person may see moving in the field
of vision.
Flashers occur when the vitreous fluid inside the eye rubs or pulls on the retina and
produces the illusion of flashing lights or lightning streaks.

>Dry eyes- result as the quantity and quality of tear production diminish with aging.
Stinging, burning or a scratchy sensation are common complaints of the individual with
dry eye.

COMMON PROBLEMS AND CONDITIONS

●PRESBYOPIA- The most common complaint of adults older than age 40 is a

diminished ability to focus clearly on close objects (arm's length) such as newspaper. In
presbyopia, the lens loses its ability to focus on close objects. The ciliary muscles weaken
the lens ability to contract.

●BLEPHARITIS- is a chronic inflammation of the eyelid margins commonly found in

older adults. It may be caused by seborrheic dermatitis or infection. The symptoms
include red, swollen eyelids, matting and crasting along the base of the eyelash at the
margins; small ulcerations along the lid margins, and complaints of irritation, itching,
burning, tearing, and photophobia.

●GLAUCOMA- is a group of diseases that can result in vision loss and lead to blindness
due to damage to the optic nerve. Glaucoma results from a blockage in the drainage of
the fluid (the aqueous humor) in the anterior chamber of the eye.

Three types of Glaucoma:

-Chronic open-angle Glaucoma
-Acute angle-closure Glaucoma
-Secondary Glaucoma
●CATARACTS- are the most common disorder found in the aging adult. Cataracts can
occur in one or both eyes. In addition to aging, other risk factors for cataracts include
smoking, prolonged exposure to ultraviolet light and diabetes. The size and location of a
cataract determine the amount of interference with clear sight