Professional Documents
Culture Documents
Course Outcomes:
Course outline:
A. The Aging Population
B. Theories of Aging
C. Common Aging Changes
D. The Specialty of Gerontological Nursing
E. Gerontological Nursing Practice
F. Ethics of Caring and Legal Aspects of Gerontological Nursing
G. Spirituality
H. Respiration/Circulation
I. Hydration/Nutrition
J. Elimination
K. Movement
L. Infections
M. Cancer
N. Cardiovascular Conditions
O. Respiratory Conditions
P. Dermatological Conditions
Q. Metabolic/Endocrine Conditions
R. Safe Medication Use
S. Family Caregiving
A. The Aging Population
B. Theories of Aging
There are many theories of aging, but few are widely accepted. Aging
proceeds at different rates in different species. Even within a species, aging
proceeds at different rates among individuals. A reasonable conclusion is that
aging must be genetically controlled, at least to some extent. Both within and
between species, lifestyle and exposures may alter the aging process.
Genetic Theory
Some scientists regard this as a Planned Obsolescence Theory because it
focuses upon the encoded programming within our DNA. Our DNA is the blue-
print of individual life obtained from our parents. It means we are born with a
unique code and a predetermined tendency to certain types of physical and
mental functioning that regulate the rate at which we age.
But this type of genetic clock can be greatly influenced with regard to its
rate of timing. For example, DNA is easily oxidized and this damage can be
accumulated from diet, lifestyle, toxins, pollution, radiation and other outside
influences.
Thus, we each have the ability to accelerate DNA damage or slow it down.
One of the most recent theories regarding gene damage has been the
Telomerase Theory of Aging. First discovered by scientists at the Geron
Corporation, it is now understood that telomeres (the sequences of nucleic acids
extending from the ends of chromosomes), shorten every time a cell divides. This
shortening of telomeres is believed to lead to cellular damage due to the inability
of the cell to duplicate itself correctly. Each time a cell divides it duplicates itself a
little worse than the time before, thus this eventually leads to cellular dysfunction,
aging and indeed death.
Environmental Theory
According to this theory, factors in the environment (e.g., industrial
carcinogens, sunlight, trauma, and infection) bring about changes in the aging
process. Although these factors are known to accelerate aging, the impact of the
environment is a secondary rather than a primary factor in aging. Nurses can
have a profound impact on this aspect of aging by educating all age groups
about the relationship between environmental factors and accelerated aging.
Science is only beginning to uncover the many environmental factors that affect
aging.
Immunity Theory
As the body ages, the immune system is less able to deal with foreign
organisms & increasingly make mistakes by identifying ones own tissues as
foreign (thus attacking them). These altered abilities result in increased
susceptibility to disease & to abnormalities that result form autoimmune
responses.
Neuroendocrine Theory
First proposed by Professor Vladimir Dilman and Ward Dean MD, this
theory elaborates on wear and tear by focusing on the neuroendocrine system.
This system is a complicated network of biochemicals that govern the release of
hormones which are altered by the walnut sized gland called the hypothalamus
located in the brain.
PSYCHOSOCIOLOGICAL THEORIES
These theories focus on behavior and attitude changes that accompany
advancing age, as opposed to the biological implications of anatomic
deterioration.
Disengagement Theory
Refers to an inevitable process in which many of the relationships
between a person and other members of society are severed & those remaining
are altered in quality. Withdrawal may be initiated by the aging person or by
society, and may be partial or total. It was observed that older people are less
involved with life than they were as younger adults. As people age they
experience greater distance from society & they develop new types of
relationships with society. In America there is evidence that society forces
withdrawal on older people whether or not they want it. Some suggest that this
theory does not consider the large number of older people who do not withdraw
from society. This theory is recognized as the 1 st formal theory that attempted to
explain the process of growing older.
Activity Theory
This is another theory that describes the psychosocial aging process.
Activity theory emphasizes the importance of ongoing social activity. This theory
suggests that a person's self-concept is related to the roles held by that person
i.e. retiring may not be so harmful if the person actively maintains other roles,
such as familial roles, recreational roles, volunteer & community roles. To
maintain a positive sense of self the person must substitute new roles for those
that are lost because of age. And studies show that the type of activity does
matter, just as it does with younger people.
Continuity Theory
This theory states that older adults try to preserve & maintain internal &
external structures by using strategies that maintain continuity. It means that
older people may seek to use familiar strategies in familiar areas of life. In later
life, adults tend to use continuity as an adaptive strategy to deal with changes
that occur during normal aging. Continuity theory has excellent potential for
explaining how people adapt to their own aging. Changes come about as a result
of the aging person's reflecting upon past experience & setting goals for the
future.
The most common legal and ethical issues in geriatric care involve
assessment of decisional capacity and competence, identification of decision
makers, resolution of conflicts about care, disclosure of information, termination
of treatment at the end of life, and decisions about long-term care. Although the
approach to resolution of these issues is similar for all age groups, the
physiologic, psychologic, and social reserves of the elderly place them at greater
risk of adverse outcomes. The fact that the elderly often lack the support of family
and friends makes them especially vulnerable to the automatic and sometimes
unthoughtful process of the health care system.
Capacity
A clinical determination of a patient's ability to make decisions about
treatment interventions or other health-related matters.
Elderly patients with decisional capacity have the same rights as other
adults to make choices about their care. Because many elderly patients can
make some decisions but not others, capacity is considered decision-specific.
Thus, a patient may be capable of choosing between relatively benign
alternatives that may have few serious consequences but may not be capable of
evaluating and choosing alternatives in a life-threatening circumstance.
For the elderly, who are often deprived of the opportunity to make any
decision when they are unable to make some, the notion of partial capacity is
especially important. Many elderly patients have diminished or fluctuating
capacity and can be supported in their exercise of some autonomous decision
making. For example, patients who become confused at the end of the day
(sundowning) can make health care decisions when they are lucid. These
decisions can then be recorded in the patient's medical chart. Patients with short-
term memory loss may still be able to judge the appropriateness of a suggested
intervention, especially if they have shown a long-standing pattern of stable
choices that can be corroborated. If, however, patients must retain current
information to choose among treatment options, then short-term memory loss is
relevant (eg, if memory is needed for compliance with certain rehabilitation
regimens, then it is relevant).
Competence
A legal designation that recognizes that persons beyond a certain age
generally have the cognitive ability to negotiate certain legal tasks, such as
entering into a contract or making a will.
In most states, persons are declared competent at age 18, at which time
they can vote, sign binding contracts, and otherwise make legally binding
decisions about their lives. The concept of generic competence reflects a societal
determination to include or exclude certain persons from full participation and
therefore does not reflect a focused assessment of the abilities or disabilities of
an individual.
All adult patients who are not mentally retarded or who have not been
declared incompetent by a court have the same legal rights. Elderly patients,
however, are at greater risk of having their legal rights abrogated because they
are more likely to be isolated, poor, demented or confused, or institutionalized.
They may be less able to advocate for their beliefs and desires and tend to have
a smaller support network. Health care practitioners, therefore, need to identify
and support the rights and interests of elderly patients and guard against their
being accidentally or deliberately disempowered.
Informed Consent
A decisionally capable patient's legally binding treatment decision reached
voluntarily and based on information about risks, benefits, and alternative
treatments gained from discussion with a health care practitioner.
Several legal principles form the basis for informed consent. The right of
knowledgeable self-determination and choice obligates the health care
practitioner to inform patients of the risks and benefits of alternative treatments.
The constitutional right to privacy, as well as the concept of personal liberty and
restraints on state interference with independent action and choice, allows
capacitated persons to choose individually appropriate medical care from among
available treatment options.
Self-determination (the concept that "every adult of sound mind has the
right to decide what shall be done with his own body"), or autonomy, is the
foundation of the legal and ethical doctrine of informed consent. When decision
making is preceded by discussion with a health care practitioner who provides
the patient with the information necessary for choosing among options, the
patient's consent or refusal is said to be informed and is ethically valid and legally
binding. All states require that informed consent of the capacitated patient
precede medical intervention. The patient has the legal and ethical right to make
an informed choice, ie, to consent to or refuse care, even if the likely outcome of
the refusal is death. The physician is legally and ethically obligated to promote
this right to all patients, even to those who are unsophisticated or difficult to
inform.
One way to augment the patient's voice is to allow sufficient time for
discussion of preferences. Another is to talk with the patient alone, although
many elderly patients, out of dependence or suspicion, request that a family
member be present. If the patient exercises autonomy by delegating decisional
authority, then that decision should be respected. For example, if the patient says
in response to questions, "Do whatever my daughter wants," then the physician
should consult the daughter. Even so, the physician should periodically attempt
to inform the patient and include him in discussions.
Advance Directives
Legal statements that allow persons to articulate values and establish
treatment preferences to be honored in the future when capacity has lapsed.
All states have laws permitting and governing advance directives, but
there is variability in some of the details, and some states have special rules for
certain interventions. New York, for example, requires that the patient specifically
address the issue of artificially administered food and fluid if the surrogate is to
be able to refuse this care.
Living Wills
A living will lists the interventions the patient would request, accept, or
reject in the future, usually at the end of life. Physicians often have difficulty
accepting a patient's choice to abandon aggressive care and permit death.
Most patients use living wills to refuse life-sustaining care when the
prognosis for improvement or recovery is hopeless and the ability to relate to
others is severely diminished or destroyed. However, as managed care becomes
more pervasive and as patients become concerned about being denied care,
living wills that request care are becoming more common.
A durable power of attorney for health care, or health care proxy, is a legal
document that allows the patient to appoint a person, called a health care agent
or proxy, to make health care decisions should the patient become temporarily or
permanently incapacitated or be declared legally incompetent. This legal
appointment places a loving, concerned, trusted person in a dialogue with the
physician to reach an appropriate decision. The agent's decisions are guided by
specific instructions from the patient, by notions of substituted judgment (what
the patient would likely want under the circumstances), and by the concept of
best interest. The agent can discuss the patient's diagnosis, prognosis, treatment
alternatives, and likely outcomes with the physician, respond to the patient's
changing condition, and base a decision on current circumstances in light of
known patient preferences and values.
Prior discussions between patient and agent provide the agent with a
richer understanding of the patient's values and preferences, allowing more
nuanced decisions to be made later. This opportunity for dialogue generally
results in a better decision than could have been reached by following the static
directives in a living will.
Unless there is a durable power of attorney for health care, the choice of a
surrogate may be unclear. Once identified, the surrogate bases a decision on
one of three standards, in the following hierarchy:
Finally, best interest is resorted to when the patient's history, wishes, and
values are unknown. This judgment is informed by the clinical evaluations of the
health care team about prognosis and the likely outcome of treatment, some
notion of what a reasonable person in the patient's situation would want, and an
evaluation of the benefits and burdens of care in maximizing the patient's comfort
and function. Especially when making decisions based on substituted judgment
and best interest, the surrogate must not confuse the patient's perspective of
quality of life with some arbitrary judgment about the value of the patient's life to
others.
Do-Not-Resuscitate Orders
A statement in the medical record that cardiopulmonary resuscitation will
not be performed.
It is essential to clarify that DNR does not mean do not treat. Only CPR
will not be performed. Other treatments (eg, antibiotics, transfusions, dialysis,
ventilatory support) may and should still be provided if indicated. More specific
orders are required to indicate whether the person should be hospitalized,
treated in an intensive care unit, or subjected to other interventions.
Despite the family members' best efforts, they may be unable to meet the
safety or health care needs of the elderly person. Whereas the patient's decision
to consent to or refuse care is determined by patient autonomy, the decision to
accept or refuse care is governed by the notion of accommodation, ie, the rights
and interests of others may be directly affected by the patient's discharge choice.
For example, a patient wishing to live with his daughter may not be able to do so
if the daughter has other demands on her time and energy.
Even if residing with family or residing alone poses a greater risk than
living in a long-term care facility, the patient has the right to choose either.
Decisionally capacitated patients can assume the risks of discharge options.
Many elderly persons choose to return home even when health care practitioners
believe that residential treatment is medically and socially preferable. Some
patients even choose to return home when the possible result is death. If the
patient is decisionally capacitated and appreciates and accepts the
consequences, this choice can be legally and ethically supportable. A
decisionally capacitated patient cannot be placed in a residential facility over his
objection without a court order. Overriding a patient's discharge preferences may
require petitioning the court for a general or a limited guardianship.
Despite the family members' best efforts, they may be unable to meet the
safety or health care needs of the elderly person. Whereas the patient's decision
to consent to or refuse care is determined by patient autonomy, the decision to
accept or refuse care is governed by the notion of accommodation, ie, the rights
and interests of others may be directly affected by the patient's discharge choice.
For example, a patient wishing to live with his daughter may not be able to do so
if the daughter has other demands on her time and energy.
Even if residing with family or residing alone poses a greater risk than
living in a long-term care facility, the patient has the right to choose either.
Decisionally capacitated patients can assume the risks of discharge options.
Many elderly persons choose to return home even when health care practitioners
believe that residential treatment is medically and socially preferable. Some
patients even choose to return home when the possible result is death. If the
patient is decisionally capacitated and appreciates and accepts the
consequences, this choice can be legally and ethically supportable. A
decisionally capacitated patient cannot be placed in a residential facility over his
objection without a court order. Overriding a patient's discharge preferences may
require petitioning the court for a general or a limited guardianship.
G. Spirituality
With the high prevalence of physical and mental health conditions that beg
for the attention of nurses who work with older adults, spiritual needs are often
overlooked in geriatric care. Yet more than any other time in life, the relationship
between spirituality and the general state of health and well-being is greatest in
advanced years.
When the body no longer functions as it did when it was younger, when
taking medications and addressing other care needs becomes a pervasive daily
routine, and when the feeling prevails that one is viewed as a Model T in a
NASCAR society, the essence of being---the spirit---can provide a safe haven.
Even for the senior who is blessed with fine health and has been afforded and
taken advantage of opportunities to be fully engaged in society, reflection on the
purpose and value of life becomes significantly more common and acute than
was often apparent during the younger years when one’s doing often masked the
importance of one’s being.
Developmental Tasks
For some time, it has been recognized that psychological growth
continues into old age. Erik Erikson (1950) was among the earliest psychologists
to consider generational cycles and the mapping of a sequence of stages
through which individuals progress over the life cycle. The eighth and final stage
of the model he offered was Integrity vs. Despair. Erikson described ego integrity
as the acceptance of one’s life as something that had to be, inclusive of joys and
sufferings, accomplishments and failures.
When the holistic model of unified body, mind, and spirit is considered, it is
easy to see that Spirit is an integral part of each human being. A specific religion
may be selected as an expression of one’s spirituality; however, spirituality exists
with or without adherence to the doctrines and practices of a religion. Spirituality
provides the means for older adults to transcend the changes and limitations that
may be present to realize the worth, joy, and meaning of their lives. A connection
with Spirit affords people an important place in the universe as they view
themselves in relationship with other human beings, nature, and the
environment. Peace and comfort can be gained through the assurance that Spirit
enhances individuals’ own strengths to face suffering and hardship. Courage and
empowerment abound when people feel that their journey has purpose and is not
being made alone.
Major Religions :
Buddhism
Christian
Protestant
• Assemblies of God (Pentecostal)
• Baptist
• Christian Church (Disciples of Christ)
• Church of the Brethren
• Church of the Nazarene
• Episcopal (Anglican)
• Lutheran
• Mennonite
• Methodist
• Presbyterian
• Quaker (Friends)
• Salvation Army
• Seventh-Day Adventist
Roman Catholic
Eastern Orthodox
Other Christian Religions
• Christian Science
• Jehovah’s Witnesses
• Mormons (Church of Jesus Christ of Latter Day Saints)
Hinduism
Islam (Muslim)
Judaism
• Orthodox
• Conservative
• Reform
Other
• Baha’i
• Nation of Islam
• Scientology
• Shinto
• Taoism
• Unitarian Universalist
• Zoroastrianism
• Expressing gratitude
• Praising attributes of God/Spirit
• Confessing
• Petitioning
• Intercessing
• Listening for guidance, answers
Spiritual Needs
Regardless of age, people have basic spiritual needs that include love,
meaning and purpose, hope, dignity, forgiveness, gratitude, transcendence, and
the expression of faith (Eliopoulos, 2005). In fact, some of these needs may take
on greater significance for older adults in light of the growing risk and prevalence
of chronic conditions and the heightened awareness of the finiteness of life.
Love
Of all spiritual needs, the exchange of love is perhaps the most significant.
This is hardly surprising when we consider that humans are relational beings.
People normally value being cared about and valued by others, and having
others for whom they can care.
Love, from a spiritual perspective, is unconditional, reliable, and genuine.
It does not depend on what one looks like or can offer. Instead, it is a deep
feeling that rests on appreciation of the person within… a heart to heart to
connection.
In the changing world of the elder individual, multiple losses are faced:
loved ones, personal health and function, financial security, home, roles. The
exchange of love fills in the void left by losses and gives reason to face another
day. Love is healing at many levels; conversely, the lack of love can interfere with
optimal health and well being, as is profoundly witnessed in the Failure to Thrive
Syndrome.
Hope
Hope is the expectation that something will happen in the future. It is not
merely the desire for something to happen, but rather, the belief that it actually
will. That “something” can range from having ample provisions to keeping a roof
over one’s head to finding a treatment that will control a disease to having eternal
life. Hope is derived from a relationship with Spirit that is not limited by the
constraints of this world, but for whom all things are possible.
The elder with hope sees life as an unfolding of new experiences. Life is
dynamic, not static. Lost roles and relationships can be replaced by new ones. In
the presence of pain and suffering, hope for relief and a better tomorrow can
motivate a person to face a new day and continue engaging in life.
Dignity
It is natural for people to want to be valued and respected, and although
this need is not diminished with age, it can become more of a challenge. In our
society, older adults have a risk of having stereotypes applied to them on the
basis of their age. This is apparent in statements such as “most old people are in
nursing homes,” “people lose interest in sex as they grow old,” and “older
workers aren’t as productive as younger workers.” These views can result in
prejudicial treatment of elderly individuals, a process that a few decades ago was
given the label ageism (Butler, Lewis, and Sutherland, 1991). Ageism erodes the
self-worth of older adults.
A relationship with Spirit offers a means to preserve dignity in light of
societal ageism. God and many other higher powers value the intrinsic worth of
every human being regardless of age or other characteristic.
Forgiveness
Humans are imperfect beings and will err. With the volume of interactions
that people typically experience by the time they reach old age, being the
perpetrator and recipient of wrongs is hardly uncommon. Carrying resentment
and grudges for these wrongs is a significant burden that can deplete emotional
resources. Forgiveness is crucial to peace of mind and healing. This implies not
only forgiveness of others, but also, forgiveness of self.
Gratitude
It tends to be common for people to take the blessings in their lives for
granted. Many people forget to appreciate the profound gifts of good health,
shelter, independence, freedom, and opportunities. Instead, there is the
temptation to be resentful for what one doesn’t have. Good health is ignored as
people complain of having wrinkles and fat thighs. A comfortable home is
minimized by resentment that there isn’t a pool in the backyard. The good
fortunate at having a child who is healthy and happy is overlooked by criticisms
that the child didn’t make straight A’s. An attitude of thankfulness nourishes the
spirit and, in turn, heightens spiritual awareness so that gratitude can be felt for
the ordinary.
Transcendence
Some of the mystery of life can be accepted when people feel there is a
reality beyond their own physical beings. The connection to Spirit offers a source
of strength that is unable to be realized independently. Difficult and confusing
circumstances can be understood as serving a purpose in a larger plan, guided
by the hands of a higher, wiser power.
Expression of Faith
It is important for people of faith to express that faith in the manner they
desire. For many people, this encompasses prayer, which can take many forms
(Display 2). Prayer can be individual or communal, silent or spoken, at specific
times or whenever the mood strikes, conversational with Spirit or a recitation of
scripture verse.
Some people may quietly kneel or sit with head bowed, while others may
walk or sing.
In addition to prayer, faith is expressed through worship, scripture reading,
celebration of specific holy days, and the practice of rituals (e.g., lighting candles,
fasting).
Assessing Spiritual Needs
The complexity, diversity, and individual meaning of spirituality limit the
usefulness of objective assessment tools in identifying spiritual needs. Open-
ended questions, life review, and intentionality are beneficial approaches for
exploring spiritual needs.
Spiritual needs can be revealed with the use of questions that open the
door for sharing and discussion.
With a keen ear for what is implied and omitted, the nurse needs to use
responses to these questions as guides for additional inquiry.
In gerontological nursing, the value of life review has been recognized and
discussed for some time (Butler and Lewis, 1982; Webster and Haight, 2002).
This therapeutic reflection on one’s life aids the elder in interpreting and refining
past experiences as they relate to self-concept and life purpose. Life review can
be facilitated through a variety of strategies, including:
The nurse may be able to identify certain themes or feelings that arise
during the life review. For example, the elder may share the multiple burdens he
faced throughout life and his ability to carry them. This could open a discussion
of what the person believes helped him get through those times. Current
challenges, losses, and impending death can be better tolerated when put in
perspective of one’s total life. Intentionality is clear, focused thinking that exceeds
merely feeling kindly toward another person. The nurse makes a planned effort to
connect with the person in a healing relationship. The difference between a nurse
assessing with intentionality versus collecting data for an assessment tool is
similar to a friend listening to your story verses a bank manager asking you the
questions on a loan application. It entails attentive listening and encouraging
sharing of stories. Often, it requires the nurse to silently be with the person---
perhaps massaging shoulders, holding a hand, or sitting alongside---as those
individual journeys through the labyrinth of feelings and memories. The important
work of unfolding one’s soul cannot be rushed.
Preparing self
Perhaps it is possible to effectively administer a medication or change a
dressing without connecting to all facets of the person---body, mind, and spirit---
however, spiritual care demands heart to heart connections that rest on the nurse
entering the dance of the person’s life. And just as the graceful dancer prepares
before taking a partner’s hand, the nurse prepares prior to engaging with the
person.
The availability to connect with another person’s heart and spirit begins
before physical contact is made by the nurse shifting focus to the individual.
Before entering the person’s room, the nurse can take a deep breath and think
about the individual. Affirmations such as I am here to serve this person and this
person will have my undivided attention can be useful. Associating deep
breathing and focusing shifts to the act of hand washing between clients can help
to make physical, mental, and spiritual preparation for the next care encounter a
routine.
Nurses should assure that a person’s desire for a special diet, prayer
times, dress style, and restrictions to activities are incorporated into the care plan
and respected. The person’s desire for visits from clergy or other members of his
or her faith community should be facilitated.
Noise, interruptions, clutter, and odors are among the features in many
hospital and long-term care facility rooms that can affect a person’s ability to
engage in spiritual practices. Nurses can assist a person in creating a “sacred
space” within these settings by establishing a personal private time for the
person and assuring that during that period the room is fresh, Bibles or other
desired materials are available, and privacy is afforded. Appropriate music and
aromatherapy with relaxing scents can assist in creating the right atmosphere.
H. Respiration/Circulation
The lungs have two primary functions: to acquire oxygen from the air,
which is required for life, and to remove carbon dioxide from the body. Carbon
dioxide is a byproduct of many of the chemical reactions that sustain life.
During breathing, air enters and exits the lungs. It flows in through
increasingly smaller airways, finally filling tiny sacs called alveoli. Blood circulates
around the alveoli through capillaries (tiny blood vessels). Where the capillaries
and alveoli meet, oxygen crosses into the bloodstream. At the same time, carbon
dioxide crosses from the bloodstream into the alveoli to be exhaled.
The lungs are continuously being exposed to particles in the air, including
smoke, pollen, dust, and microorganisms. Some of these inhaled substances can
cause lung disease if enough is inhaled or if the body is particularly sensitive to
them.
AGING CHANGES
People normally make new alveoli until about age 20. After that, the lungs
begin to lose some of their tissue. The number of alveoli decreases, and there is
a corresponding decrease in lung capillaries. The lungs also become less elastic
(able to expand and contract) due to various factors including the loss of a tissue
protein called elastin.
Changes in the bones and muscles increase the front-to-back size of the
chest. Loss of bone mass in the ribs and spine bones (vertabrae), and mineral
deposits in the rib cartilage, change the curve of the spine. There may be front-
to-back curvature (kyphosis or lordosis) or side-to-side curvature (scoliosis).
The maximal force you can generate when breathing in (inspiration) or
when breathing out (expiration) decreases with age, as the diaphragm and
muscles between the ribs (intercostals) become weaker. The chest is less able to
stretch to breathe, and the pattern of breathing may change slightly to
compensate for this decreased ability to expand the chest.
EFFECT OF CHANGES
Maximum lung function decreases with age. The amount of oxygen
diffusing from the air sacs into the blood decreases. The rate of air flow through
the airways slowly declines after age 30. And the maximal force you can
generate on inspiration and expiration decreases. However, even elderly people
should have adequate lung function to carry out daily activities, because we have
"extra" lung function in our youth. This is why normal people can tolerate surgical
removal of an entire lung and still breathe reasonably well.
An important change for many older people is that the airways close more
readily. The airways tend to collapse when an older person breathes shallowly or
when they're in bed for a prolonged time. Breathing shallowly because of pain,
illness, or surgery causes an increased risk for pneumonia or other lung
problems. As a result, it is important for older people to be out of bed as much as
possible, even when ill or after surgery. When this is not possible, it is helpful to
do "incentive spirometry." This involves blowing into a small device to help keep
the airways open and clear of mucus.
Normally, breathing is controlled by the brain. It receives information from
various parts of the body telling it how much oxygen and carbon dioxide are in
the blood. Low oxygen levels or high carbon dioxide levels trigger an increased
rate and depth of breathing. It is normal for even healthy older people to have a
reduced response to both decreased oxygen and increased carbon dioxide
levels.
The voice box (larynx) also changes with aging. This causes the pitch,
loudness, and quality of the voice to change. The voice may become quieter and
slightly hoarse. The pitch may be decreased (becoming lower) in women and
increased (becoming higher) in men. The voice may sound "weaker," but most
people remain quite capable of effective communication.
I. Hydration/Nutrition
By recognizing a potential problem early, you may save an elder adult
from a debilitating complication. Here's what you need to know.
You can classify patients at highest risk for dehydration into groups based
on underlying cause:
• mechanical impairments, such as mechanical ventilation, which
prevent patients from drinking
• functional impairments, such as coma or paralysis. Also at risk are
patients who are kept N.PO. for tests, especially if the tests are rescheduled
several times.
• physiologic factors, such as medications that increase fluid loss
(diuretics and laxatives) or that inhibit the thirst response or another
mechanism that helps maintain fluid balance. Some enteral and total
parenteral nutrition alter the fluid balance of the intracellular and intravascular
spaces. Draining wounds or fistulas also increase fluid output, raising the
patient's risk of dehydration.
• psychological factors, such as depression, which can cause a loss of
appetite and fluid intake. Elderly patients also may purposefully decrease
their fluid intake to eliminate frequent trips to the bathroom or to control
incontinence.
Monitor fluid intake and output, weigh the patient daily, and watch for
ominous trends: decreasing intake, increasing output, changes in lab results, and
changes in emotional or mental status. If you suspect dehydration, review her
care plan for anything that may be contributing to a fluid imbalance, such as
N.P.O. status, fluid restrictions, or diuretic use. When, for whatever reason, a
patient can't reach for and hold a glass of water, include ways to encourage fluid
intake in the care plan. For example, set up a schedule for offering fluids.
Know your patient's medications and their potential for adverse effects and
interactions. Be alert to medications, such as diuretics, that can lead to
dehydration.
Finally, educate staff, patients, and family members on the causes and
symptoms of dehydration, what signs and symptoms to watch for, and how to
avoid problems.
Spotting malnutrition
Even if she's eating regularly, an elderly patient is also at higher risk for
malnutrition because of physiologic changes of aging. Nearly 30% of people over
age 65 have a diminished ability to produce stomach acid, which impairs
absorption of many important nutrients, such as folic acid, vitamin B12, iron, and
calcium. A diminished sense of taste and smell make food less appetizing, and
dental problems can make chewing difficult.
As the elderly patient loses weight, she also loses muscle mass and
strength, becoming more frail. Her immune system may become impaired,
opening the door for disease. Continued illness can lead to depression, causing
loss of appetite and further weight loss. Besides hampering the body's ability to
heal, reduced serum albumin levels decrease the number of binding sites
available to protein-binding medications. This puts the patient at risk for toxic
reactions to relatively low doses of some medications.
Albumin and prealbumin levels can help identify the presence and severity
of malnutrition. If the patient is also dehydrated, these values may appear
elevated. Once she's hydrated, however, plasma protein levels are usually low,
as are hemoglobin and hematocrit. Don't be fooled by normal hemoglobin and
hematocrit levels if serum osmolality indicates a fluid deficit. These values will fall
once she's hydrated.
Lack of vitamin A, though rare, can impair the patient's sense of taste and
smell. Combined with the natural decline in the sense of taste in the elderly, this
could make food taste like sawdust.
ASSESSMENT
Frequent, small meals throughout the day may be more appealing to the
patient than three larger ones. Also offer liquid supplements between meals.
If the patient can't eat enough to correct malnutrition, she may require
enteral feedings. Explain your concerns to the patient and her family; if she's
alert, she'll need to consent to enteral tube insertion and feedings. If she can eat,
schedule tube feedings at night and encourage her to eat meals during the day.
J. Elimination
Aging results in both structural and functional changes in the kidney that
effect drug metabolism and kinetics as well as predisposing the patient to fluid
and electrolyte abnormalities.
K. Mobility
Gait Disorders
A slowing of gait speed or a deviation in smoothness, symmetry, or
synchrony of body movement.
For the elderly, walking, standing up from a chair, turning, and leaning are
necessary for independent mobility. Gait speed, chair rise time, and the ability to
perform tandem stance (one foot in front of the other) are independent predictors
of the ability to perform instrumental activities of daily living (IADLs)--eg, the
ability to shop, travel, and cook. Gait speed, chair rise time, and balance are also
predictors of the risk of nursing home admission and death.
Cadence (the rhythm of walking) does not change with age. Each person
has a preferred cadence, which relates to leg length and usually represents the
most energy-efficient rhythm for individual body structure. Tall people take longer
steps at a slower cadence; short people take shorter steps at a faster cadence.
Walking posture (the body position during walking) changes only slightly
with age. Unless elderly persons have diseases such as osteoporosis with
kyphosis, they walk upright, with no forward lean. They walk with greater anterior
(downward) pelvic rotation, which results in an increase in lumbar lordosis
possibly due to a combination of increased abdominal fat, abdominal muscle
weakness, and tight hip flexor muscles. Elderly persons also walk with about a 5°
greater "toe out," possibly due to a loss of hip internal rotation or to a strategy to
increase lateral stability. Foot clearance in swing is the same in elderly as in
younger persons.
Joint motion changes with age. Ankle plantar flexion is reduced during
the late stage of stance (just before the back foot lifts off), although maximal
ankle dorsiflexion is not reduced. The overall motion of the knee is unchanged.
Hip motion is unchanged in the sagittal plane but in the frontal plane shows
greater adduction. Pelvic motion is reduced in the frontal and transverse planes,
and transverse plane rotation is reduced.
Step length is shorter in the elderly. One explanation is that calf muscles
are weak and cannot produce sufficient plantar flexion. Another is that elderly
persons are reluctant to generate plantar flexion power because of poor balance
and poor control of the center of mass during single stance.
Symmetry of motion and timing between left and right sides is often
lost, producing regular asymmetry with unilateral neurologic or musculoskeletal
disorders. Symmetric short step length usually indicates a bilateral problem.
Unpredictable or highly variable gait cadence, step lengths, and stride widths
indicate breakdown of motor control of gait due to a cerebellar or frontal lobe
syndrome.
Deviations from path are strong indicators of motor control deficits. Wide
stride width can be caused by cerebellar disease, if the width is consistent.
Variable stride width suggests poor motor control, which may be due to frontal or
subcortical gait disorders.
Diagnosis
Diagnosis is best approached in four parts:
• Discuss the patient's complaints, fears, and goals related to mobility
• Observe gait with and without an assistive device (if safe)
•Assess all components of gait
•Observe gait again with a knowledge of the patient's gait
components
Assistive devices provide stability but also affect gait. Use of walkers often
results in a flexed posture and discontinuous gait, particularly if the walker has no
wheels. If safe to do so, the health care practitioner can instruct the patient to
walk without an assistive device, while remaining close. If a patient uses a cane,
the health care practitioner can walk with the patient on the cane side or take his
arm and walk with him.
Proximal muscle strength is tested by having the patient get out of a chair
without using his arms.
Step length (the distance from one heel strike to the next) can be
measured or observed. Because shorter people take shorter steps and foot size
is directly related to height, the easiest way to gauge step length is to measure or
calculate the patient's foot length; normal step length is three foot lengths. The
following equation calculates average step length in centimeters: 10 × velocity ×
time to take 10 steps. An equivalent calculation is 0.16 × velocity × cadence
(steps/minute).
Step height can be assessed by observing the swing foot; if it touches the
floor, the patient may trip. Some patients with fear of falling or a cautious gait
syndrome will purposefully slide their feet over the floor surface.
Asymmetry or variability of gait rhythm can be detected when the health
care practitioner whispers "dum...dum...dum" to himself with each of the patient's
foot contacts. Some health care practitioners have a better ear than an eye for
rhythm.
Many patients with balance deficits benefit from balance training. Good
standing posture and static balance are taught first. Patients are then taught to
be aware of the location of pressure on their feet and how the location of
pressure moves with slow leaning. Leans forward, backward (with a wall directly
behind), and to each side are then practiced. The goal is to stand on one leg for
at least 10 seconds.
Assistive devices can help maintain the patient's mobility and quality of
life. New motor strategies must be learned. Ideally, physical therapists should
prescribe assistive devices.
Canes are particularly helpful for pain caused by knee or hip arthritis.
Canes, especially quad canes, can stabilize the patient. Canes are usually used
on the side opposite the painful or weak leg. Many store-bought canes are too
long. Although a cane can be purchased in a pharmacy, it should be adjusted to
the correct height by cutting a wooden cane or moving the pin settings on an
adjustable one. To achieve maximal support, the patient should flex his elbow 20
to 30° when holding the cane.
Walkers can reduce the force and pain at arthritic joints more than a cane,
assuming adequate arm and shoulder strength. Walkers provide good lateral
stability and moderate protection from forward falls but little or no help preventing
backward falls for patients with balance problems. When prescribing a walker,
the physical therapist should consider the sometimes competing needs of
providing stability and maximizing efficiency (energy efficiency) of walking. Four-
wheeled walkers with larger wheels and brakes maximize gait efficiency but
provide less lateral stability. These walkers have the added advantage of a small
seat to sit on if the patient is fatigued.
Chronic dizziness and postural instability most often result from the
combined effects of disorders and impairments in the multiple systems
contributing to stability and equilibrium. The sensation of equilibrium requires
input from complex networks of sensory, motor, and central integrative
neurologic systems. These systems are, in turn, influenced by cardiovascular,
respiratory, metabolic, and psychologic factors. Chronic dizziness may occur
when there is overwhelming dysfunction of one system or, probably more often,
when there is impairment or dysfunction within several systems.
The vestibular nerve, which connects the vestibular system to the central
nervous system (CNS), is particularly sensitive to hypoglycemia and drugs
(aminoglycosides, aspirin, furosemide, quinine, quinidine, and perhaps tobacco
and alcohol). Head trauma, mastoid or ear surgery, and middle ear infections
may also damage the vestibular nerve.
The CNS channels input data from the senses to the appropriate efferents
in the musculoskeletal system. Given the multiple connections and their
complexity, essentially any CNS disorder may contribute to instability or
dizziness.
Diagnosis
Diagnosis is best begun by considering, based on history and
examination, whether a single cause is likely, in which case specific diagnostic
testing is warranted. If the history and examination do not suggest a specific
cause, it is unlikely that exhaustive diagnostic testing will be helpful. The goal in
most patients, therefore, is to identify and eliminate or ameliorate as many
contributing factors as possible. This approach is based on the following
assumptions: (1) the relative importance of individual contributors to dizziness
often cannot be determined; (2) the presentation often does not permit
identification of a specific cause, thus therapeutic trials are often the best way to
determine significant contributors; and (3) ameliorating even a subset of
contributors may reduce the dizziness.
L. Infections
This link with specific diseases may explain why the presence of
autoantibodies in the elderly is associated with reduced life expectancy.
Conversely, the lack of organ-specific autoantibodies (ie, the absence of
autoreactivity) after age 80 may represent a survival advantage.
M. Cancer
Drugs may also reduce the risk of some cancers. Tamoxifen has recently
been approved for breast cancer prevention. Aspirin and other nonsteroidal anti-
inflammatory drugs (NSAIDs) appear to reduce the risk of colon cancer.
Retinoids may be helpful in reducing the risk of new primary squamous cell
cancers in persons with previous such cancers related to tobacco use. The role
of antioxidants in preventing cancers remains unclear. Inhibiting the conversion
of testosterone to 5- -dihydroxytestosterone may prevent prostate cancer.
Screening
Because cancer is more common in the elderly than in younger
populations, screening is more likely to detect cancer in older populations.
Cancers for which screening has proved beneficial in reducing mortality include
breast, cervical, and colon cancer. It is unclear whether immune surveillance of
early cancers is effective. Most cancers are poorly immunogenic and are unlikely
to raise an immune response with low tumor volumes. With prostate-specific
antigen (PSA) testing, prostate cancer is detected at an earlier stage, but most
studies have not shown that screening with PSA reduces mortality. Screening for
ovarian cancer, even in high-risk women, has proved disappointing.
Treatment
Research that focuses on cancer in younger populations may not be
applicable to the elderly, the segment of the population at highest risk for cancer,
leaving us with a paucity of knowledge on how best to manage cancer in the age
group that experiences it most.
Chemotherapy
A variety of older chemotherapeutic drugs remain effective and useful. In
addition, newer antineoplastics are becoming more commonly used in the
treatment of cancer in the elderly. Chemotherapy may be less well tolerated by
elderly patients because of kinetic and dynamic changes that occur with age,
decreased organ reserve, and poorer wound healing. Comorbid conditions such
as diabetic neuropathies, renal insufficiency, heart failure, and decubitus ulcers
may contraindicate specific treatments. However, nausea and vomiting from
chemotherapy tend to be less intense in the elderly.
Age-related decreases in liver size, blood flow, and metabolic reserve and
use of drugs that inhibit cytochromes may inhibit drug metabolism. The
neurotoxicity of drugs such as vincristine, cisplatin, and paclitaxel is especially
troublesome in the elderly, and severe neuropathies or constipation may result.
Hematopoietic toxicity of most drugs and of radiation therapy is increased to
some degree. Gastrointestinal toxicities of 5-fluorouracil and doxorubicin may be
increased, and frail patients are less able to tolerate short episodes of diarrhea or
decreased oral intake from mucositis. Reduced cardiac reserve makes it more
difficult for the elderly to tolerate anthracyclines, and decreased renal reserve
decreases tolerance to platinum drugs and methotrexate, requiring adjustments
in dose or choice of drug. With curable malignancies, great care must be taken
not to reduce doses without documented need.
Radiation therapy
This modality has become more tolerable and safer with newer
technologies and improved techniques, such as high-energy linear accelerators,
better control of target areas, three-dimensional CT planning, and improved
dosimetry. Patients who have conditions such as arthritis, kyphoscoliosis,
parkinsonism, or dementia may require special positioning or immobilization. The
elderly appear to be at increased risk of radiation lung damage, coronary artery
injury, esophagitis, and enteritis, necessitating precise planning and dosimetry.
Mucositis, esophagitis, or enteritis may lead to more rapid dehydration in the
elderly. Despite these problems, some seemingly frail elderly patients can
tolerate radiation therapy.
Pain control
Pain control is especially important in the care of elderly cancer patients.
Although pain control is often considered part of end-of-life care, persons with
cancer may have chronic pain or intermittently painful complications of cancer
during any stage of their disease and it may continue over the course of many
years. The goal is to achieve an acceptable level of pain control with tolerable
adverse effects. Comfort must be emphasized and the patient reassured that
pain will be aggressively managed. Treating the source of pain is important.
Radiation therapy to painful bony or other lesions should be considered.
Chemotherapy may be of palliative benefit.
Opioids are used to treat severe pain not relieved by NSAIDs. Addiction
should not be an issue for prescribers, and patients should be reassured that fear
of addiction should not affect their use of the drug. Timed-release morphine and
oxycodone as well as transdermal fentanyl relieve baseline pain. Fast-acting
drugs, such as hydrocodone, oxycodone, morphine, hydromorphone, and
transmucosal fentanyl lollipops, relieve intermittent or breakthrough pain.
Fentanyl clearance is decreased in the elderly. Methadone, meperidine,
pentazocine, and propoxyphene should not be used in the elderly. Stimulant
laxatives are essential for an elderly patient receiving opioid therapy.
Elderly patients may become somnolent while being treated with opioids.
Methylphenidate, taken periodically at a dose of 5 to 10 mg, is often useful,
especially for those patients desiring more social interaction when taking opioids.
Nursing Issues
Many social issues arise in the care of elderly cancer patients. These
issues often become complex and require the expertise of a social worker or an
interdisciplinary team. Services may have to be coordinated to help with home
care, travel, meal preparation, and drug adherence. Counseling may be
warranted to help patients and their families cope with the seriousness of the
illness. Efforts to overcome these difficulties frequently require alterations in
treatment plans and interdisciplinary approaches.
End-of-Life Issues
It must not be forgotten that cancer is often fatal. Sometimes treatment
becomes futile, exposing an elderly patient to suffering that outweighs any
potential benefit. Even at the time of initial diagnosis, treatment is not always
warranted. An honest discussion of what is likely to be gained and what the side
effects of treatment are likely to be is the best course of action. Most patients
understand when it is time to make a transition to more palliative goals of care
(palliative care is defined by the World Health Organization as the active total
care of patients whose disease is not responsive to treatment). This
understanding can be fostered by direct and forthright discussions regarding
prognosis and benefits and risks of therapy and is enhanced by a trusting
physician-patient relationship.
Rhythm
Heart Rate
Resting heart rate is not generally affected by aging; however, decreased
heart rate in response to exercise and stress (esp. beta-adrenergically mediated)
is characteristic of healthy aging. The clinical consequence of this is that maximal
heart rate on treadmill is decreased (220-age) and the heart rate response to
fever, hypovolemia, and postural stress is also decreased with healthy aging.
The response to beta-adrenergic blockade (as well as stimulation) is also
reduced with healthy aging. Daytime bradycardia with heart rates < 40 bpm and
sinus pauses of over 3 seconds are not seen with healthy aging.
Atrioventricular Conduction
The time for conduction through the atrioventricular (AV) node is
increased with healthy aging. Therefore, the P-R interval on the ECG increases
with age and the upper limit of normal for people >65 is 210-220 milliseconds
(not 200 ms). Second and third degree AV block are not normal consequences of
aging. Right bundle branch block is seen more frequently in older compared to
younger populations but has not been shown to identify increased risk for further
conduction abnormalities. A gradual leftward shift of the QRS axis is observed
with aging and left anterior hemiblock is seen with increasing frequency in older
populations. Isolated left anterior hemiblock is not an independent predictor of
cardiovascular morbidity or mortality in otherwise healthy elderly. Combined right
bundle branch block and left anterior fascicular block is associated with
cardiovascular disease in 75% of older patients and only 25% with this finding
have otherwise normal hearts. Left bundle branch block is not associated with
normal aging and is associated with cardiovascular disease and risks for cardiac
events.
Arrhythmias
Atrial premature contractions increase with age and are frequent in up to
95% of older healthy volunteers at rest and during exercise in the absence of
detectable cardiac disease. Atrial fibrillation is usually associated with coronary,
hypertensive, valvular, sinus node disease or thyrotoxicosis but may occur in
older patients with no other detectable diseases (1/5 of older men and 1/20 of
older women with atrial fibrillation). Similarly, isolated and even multiform
ventricular ectopy has been reported in up to 80 % of older men and women
without detectable cardiac disease.
Systolic Function
Resting left ventricular systolic function (ejection fraction and/or stroke
volume) is not altered by aging in most studies of subjects rigorously screened to
exclude coronary artery disease; however, a few studies report declines of stroke
volume with sedentary older populations. Cardiac output is equal to stroke
volume x heart rate. So, resting cardiac output and left ventricular ejection
fraction do not usually decrease with normal aging. Contractile responses to
beta-adrenergic responses are decreased with aging. Therefore, exercise
cardiac output may be reduced due to both the decrease in maximal heart rate
and a limit to the ability to increase contractility (stroke volume) in response to
beta-adrenergic blockade in the elderly. The age-associated decline in maximal
cardiac output and cardiovascular reserve capacity may not limit usual ability in
otherwise healthy elderly because the vast majority of daily activiies are
performed at low and submaximal workloads. In addition, the age-related decline
in exercise capacity can be attenuated by physical conditioning.
Diastolic Function
The time for cardiac relaxation and for ventricular filling are prolonged with
aging leading to altered early diastolic filling times on echocardiography and
nuclear studies. The etiology of the prolonged time for relaxation may be
multifactorial--increased ventricular mass, collagen infiltration, or altered
myocardial calcium handling. Prolonged filling times may limit cardiac output with
increased heart rates. While altered diastolic function accompanies aging,
congestive heart failure is not a normal consequence of the prolonged times
required for cardiac relaxation or diastolic filling.
Valvular Changes
Degenerative calcification (leading to sclerosis) and myxomatous
degeneration (which can lead to regurgitation) affect the aortic and mitral valves
with aging. These changes are considered "secondary" to aging and differ from
the primary changes due to rheumatic heart disease or congenital valve
abnormalities. These changes can progress to impair the function of the valve;
then the changes are considered pathologic and no longer "normal aging".
Table 1
Age-Related Changes vs. Cardiovascular Disease
Decreased Heart Rate Sinus Pauses
Response
Longer P-R Intervals Second and Third Degree AV Block
Right Bundle Branch Left Bundle Branch Block
Block
Increased Atrial Ectopy Atrial Fibrillation
Increased Ventricular Sustained Ventricular Tachycardia
Ectopy
Altered Diastolic Decreased Systolic Function (Ejection Fraction)
Function
Aortic Sclerosis Aortic Stenosis, Aortic Regurgitation
Annular Mitral Mitral Regurgitation, Stenosis Systolic Hypertension
Calcification Diastolic Hypertension
Atrial Fibrillation
The prevalence of chronic atrial fibrillation rises from <1 per 1000 people
at 25-35 years of age to about 40 per 100 at ages 80-90 (Framingham data,
Baltimore Longitudinal Study, Cardiovascular Health Study). Chronic atrial
fibrillation has been shown to be an important risk factor for cerebrovascular
accidents (strokes) and control of rate is associated with better exercise
tolerance. The goals of therapy in an individual patient may vary and include rate
control, prevention of stroke, or restoration of sinus rhythm.
Rate control
Immediate or long-term rate control can be achieved with the use of
digoxin, beta-blockers, calcium antagonists (verapamil or diltiazem), or
amiodarone in refractory cases. There is less experience with the use of new
Class III agents (ibutelide). The adequacy of rate control must be assessed with
activity--more active patients are less likely to have adequate rate control with
digoxin alone. Drug doses should be adjusted for age and disease state and one
must remember that adequate rate control may be lost during acute illnesses
such as pneumonia, but will be regained with treatment of the acute illness.
Prevention of stroke
With acceptable risk benefit ratios can be achieved with anticoagulation
with coumadin. However, the optimal therapy to prevent stroke for the older
patient with atrial fibrillation has not been found. This author favors
anticoagulation with coumadin to a target INR of 2-2.5 with close monitoring in
elderly patients without contraindications to anticoagulation, esp. in patients with
additional risk factors for stroke (hypertension, vascular disease, prior CVA).
Aspirin alone is not a reasonable choice in the latter group.
Hypertension
Treatment begins with diet (weight reduction if obese; low sodium for all,
and < 1 oz of alcohol/day) and exercise. The long-term benefits of
antihypertensive therapy in the elderly have been demonstrated for thiazide
diuretics (chlorthalidone 12.5-25 mg/day, hydrochlorothiazide 25 mg/day) alone
or in combination with beta-blockers (atenolol 50 mg/day, metoprolol 50 mg/day).
Thiazide diuretics and/or beta blockers are recommended as first-line
pharmacologic therapy for the older patient with hypertension (and no other
diseases) because of demonstrated longevity benefit and lower cost. Alpha-
methyl-dopamine and reserpine have also shown mortality benefits but are less
widely used secondary to side effects. Calcium channel blockers, angiotensin
converting enzyme (ACE) inhibitors, alpha-blockers, and angiotensinogen II
inhibitors are highly effective in lowering blood pressure in older patients and
may have advantages in hypertensive patients with multiple diseases (i.e.,
calcium channel blockers for coronary artery disease, cerebrovascular disease,
diabetes, chronic obstructive pulmonary disease, diabetes with renal disease;
ACE inhibitor for congestive heart failure, diabetic with renal failure, etc.; alpha
blocker for prostate disease). Similarly, beta-blockers have an advantage in the
post-myocardial infarction patient. No adverse effects on quality of life or mood
have been demonstrated with the use of beta-blockers in the elderly in
randomized clinical trials. All drug dosages should be adjusted for age and
disease-related changes.
It has long been recognized that the prevalence of coronary artery disease
rises with increasing age and that multi-vessel disease in older patients with
coronary artery disease is more common. The age-related increase in coronary
artery disease occurs in women as well as men but begins at a later age in
women. The same risk factors that predict atherosclerosis in younger adults (lipid
abnormalities, smoking, hypertension, diabetes) are predictive in older individuals
as well. Modification of these risk factors is effective in reducing the risk of
atherosclerosis in older patients. Therefore, preventive strategies for the older
patient include stopping smoking, blood pressure control, control of lipid
abnormalities, and treatment of diabetes.
Myocardial infarction
The older patient with myocardial infarction also benefits from the same
therapies as the younger patient and age >75 alone should not be a
contraindication to thrombolytic therapy. Beta blockers and aspirin should be
administered post-infarction. ACE inhibitors are also of probable benefit if given
in lower doses and not during the immediate acute MI period. However, goals of
the post-MI period may differ for the older patient vs. the younger patient. All
physiologic processes related to healing and stress appear to be attenuated with
aging, so timing for diagnostic testing after the acute event may need to be
slightly later in older patients. In addition, the probability of post-MI ischemia is
greater in the older patient because of the higher incidence of multivessel
disease. No studies of predominantly older patients have been performed to
identify the best post-MI strategy for further risk stratification and to guide in
clinical decision making regarding medical vs. revascularization strategies.
Therapy should therefore be individualized and it is not appropriate to consider
the older patient, esp. in the presence of multiple diseases, as a "routine" post-MI
pathway patient.
Systolic
The therapy of congestive heart failure due to systolic dysfunction does
not differ in the older patient. The mainstays of therapy are digoxin, diuretics, and
esp. angiotensin converting enzyme inhibitor drugs. Renal function and
potassium may need to be monitored more closely in the older patient because
of the likely concomitant administration or ingestion of nonsteroidal anti-
inflammatory drugs (high incidence of arthritis in the older population) and the
additive effects of NSAID's to lower renal perfusion and potassium excretion. The
role of beta blockers in the management of patients with congestive heart failure
is just emerging and there are no data regarding the older patient.
Diastolic
Congestive heart failure with preserved left ventricular systolic function is termed
"diastolic heart failure" and is more prevalent in the older population, may
account for one half of the older population with congestive heart failure, and
may be more common in women than men. The prognosis of patients with CHF
due to diastolic dysfunction is less ominous than in patients with systolic
dysfunction yet the morbidity can be high with frequent treatment failures and
hospital readmissions. No long-term studies of drug therapies for diastolic
congestive heart failure have been performed. Drugs which selectively affect
diastolic filling and relaxation (calcium channel antagonists or beta-adrenergic
blockers) can alter these parameters after short-term administration and might
provide a specific therapy. However, one of the more surprising findings from a
recent trial was the lower incidence of recurrent hospitalizations and death in
patients with congestive heart failure who received digoxin (vs. placebo) in
combination with diuretics and ACE inhibitors. This was true for CHF patients
with both decreased and preserved systolic function. Thus, optimal management
of the older patient with diastolic congestive heart failure is evolving. Control of
hypertension, prevention of myocardial ischemia, treatment of congestive heart
failure symptoms, and maintenance of normal sinus rhythm have received
emphasis. It appears that digoxin and diuretics do play a role and that beta
blockers and/or calcium blockers may also play a role. Treatment of acute
exacerbation of congestive heart failure or pulmonary edema in the setting of
diastolic heart failure focuses on diuretics and, if needed, positive inotropes on a
short-term basis. The role of ACE inhibitors is unclear unless used for the
treatment of hypertension or to attempt regression of hypertrophy.
Valvular Diseases
Aortic Stenosis
The frequency of aortic stenosis increases with age and it is the most
clinically significant valvular lesion in the elderly. Progressive degenerative
calcification is now the most common cause, as opposed to rheumatic disease.
The calcification occurs along the margins of the valve leaflet (vs. commisural
fusion in rheumatic fever) and thus does not affect valve opening or closing
during the early stages but will produce a murmur. Because of the stiffened
peripheral arteries in the older patient, the carotid pulse may feel normal to
palpation even in the presence of significant aortic stenosis. Other physical
findings associated with critical aortic stenosis due to rheumatic heart disease
are often absent with calcific aortic stenosis (decreased S1 and S2). The
intensity of the murmur does not correlate with the severity of stenosis.
Progression to critical aortic stenosis is often gradual but is unpredictable.
Aortic Regurgitation
The most common cause of aortic regurgitation in the elderly is aortic root
dilation secondary to the age-related rise in blood pressure and increased
peripheral resistance. With the advent of widespread echocardiography, mild
degrees of aortic regurgitation are diagnosed frequently and are usually not of
clinical significance. Aortic regurgitation due to rheumatic valvular disease or
associated with disease of a bicuspid valve is more likely to progress to clinically
significant disease. When significant aortic regurgitation is present, therapy is
aimed at afterload reduction and clinical symptom relief with monitoring for
definitive surgical intervention prior to left ventricular failure.
This may preclude the need for anticoagulation with mechanical valves,
which could potentially be of clinical advantage in the older patient since surgical
mitral valve replacement (whether it is a tissue or mechanical valve) requires
lifelong high intensity anticoagulation. The management of the less common
mitral stenosis in the elderly also targets control of heart rate and symptoms
(digoxin and diuretics), anticoagulation to prevent emboli, and antibiotic
prophylaxis to prevent infections. Surgical therapy is the only definitive therapy.
Valvuloplasty is seldom of long- term benefit.
Summary
O. Respiratory Conditions
Elderly people are at increased risk for lung infections. The body has
many ways to protect against lung infections. With aging, these defenses may
weaken.
The cough reflex may not trigger as readily, and the cough may be less
forceful. The hairlike projections that line the airway (cilia) are less able to move
mucus up and out of the airway. In addition, the nose and breathing passages
secrete less of a substance called IgA (an antibody that protects against viruses).
Thus, the elderly are more susceptible to pneumonia and other types of lung
infections.
PREVENTION
Avoiding smoking is the most important way to minimize the effect of
aging on the lungs. Exercise and good overall fitness improve breathing capacity.
Exercise tolerance can be affected by changes in the heart, blood vessels,
muscles, and skeleton, as well as in the lungs. However, studies have shown
that exercise and training can improve the reserve capacity of the lungs, even in
elderly people.
Second, more than any other group the elderly need to be aware of the
need to be up and about and should consciously try to increase deep breathing
during illness or after surgery.
P. Dermatological Conditions
Geriatric Essentials
• The overall result of age-related structural changes is an increase in skin
dryness, roughness, wrinkling, and laxity, and a decrease in skin elasticity.
• The overall result of age-related functional changes is a decline in skin
barrier function, mechanical protection, sensory perception, wound
healing, immunologic responsiveness, thermoregulation, and vitamin D
production.
Aging leads to many changes in the skin, hair, and nails. These changes
can be broadly categorized as either age-related or photoaging. Age-related
changes are presumed to be due to age alone, whereas photoaging is due to
chronic exposure to ultraviolet (UV) radiation superimposed on aging itself.
Popular notions of "old skin" often correspond more closely to photoaging than to
aging itself, and dramatic differences between aged skin protected from UV light
and younger unprotected skin are evident to patients and clinicians alike. Other
factors that affect the skin include smoking, which accelerates wrinkle
development, and disease, most notably connective tissue disorders.
Epidermis: The epidermis gives rise to the outer barrier layer of dead
cells, the stratum corneum, through terminal differentiation of keratinocytes, the
predominant cell type. The epidermis recognizes invading pathogens and other
foreign substances and generates abundant cytokines. Melanocytes reside in the
epidermal basal layer, producing and distributing photoprotective melanin to the
keratinocytes.
Elderly skin often appears dry and flaky, especially over the lower
extremities, at least partly due to a dramatic age-associated decrease in
epidermal filaggrin, a protein required for the binding of keratin filaments into
macrofibrils.
Dermis: The dermis contains the blood vessels, lymphatics, nerves, and
deeper portions of the hair follicles and glands that arise from the epidermis. It is
composed largely of extracellular matrix and gives skin its strength and elasticity.
Dermal thickness decreases by about 20% in the elderly and often even
more in photodamaged areas. UV damage produces hyperplastic changes
initially, followed by atrophic changes, particularly in fair-skinned people. These
opposing changes probably explain observed variations in the effects of
photodamage.
Even when elderly skin has been consistently protected against the sun,
within the dermis there is about a 50% decrease in mast cells and a 30%
decrease in venular cross-sectional area. Basal and peak levels of cutaneous
blood flow are reduced by about 60%. As a result of these decreases, there is a
decrease in release of histamine (a mast cell product) and other measures of
inflammatory response after exposure to UV radiation or immune challenge.
Vascular responsiveness during injury or infection is also compromised. The
striking involution of vertical capillary loops in dermal papillae is thought to
account for the pallor, decreased temperature, and impaired thermoregulation
found in elderly skin. As well, the decline in vascular supply to hair bulbs and to
the eccrine, apocrine, and sebaceous glands may contribute to their senescence.
Lamellar dystrophy manifests as brittle nails with split ends or layering and
commonly occurs in elderly people, though it may also occur in middle-aged
women.
Nerves and glands: The density of cutaneous sensory end organs
decreases progressively between the ages of 10 and 90 by about 1/3. The result
is an age-related reduction in sensations of light touch, vibration, corneal
sensitivity, 2-point discrimination, and spatial acuity. The cutaneous pain
threshold increases by about 20%.
The size and number of sebaceous glands do not appear to decrease with
aging. However, sebum production decreases by about 23% per decade,
beginning in early adulthood, probably due to the concomitant decrease in
production of gonadal or adrenal androgens, to which sebaceous glands are
exquisitely sensitive.
Q. Metabolic/Endocrine Conditions
THYROID DISORDERS
Hypothyroidism
Most prevalence estimates of hypothyroidism in older adults range from
0.5% to 5% for overt disease, and from 5% to 10% for subclinical
hypothyroidism, depending on the population studied. As in younger people,
most cases of hypothyroidism in elderly people are due to chronic autoimmune
thyroiditis.
Hypercalcemia
Primary hyperparathyroidism and malignancy-associated hypercalcemia
are the most common causes of hypercalcemia in older adults. The annual
incidence of primary hyperparathyroidism is approximately 1 per 1000, and the
disease is threefold more prevalent in women than in men. Most patients with
primary hyperparathyroidism are asymptomatic, and the diagnosis is made after
an incidental finding of hypercalcemia. When the disease is symptomatic, older
persons are more likely than younger adults to present with neuropsychiatric
symptoms such as depression and cognitive impairment, neuromuscular
symptoms such as proximal muscle weakness, or osteoporosis. In addition to
hypercalcemia, laboratory findings of primary hyperparathyroidism may include
low to low-normal phosphate, elevated alkaline phosphatase levels, and
hypercalciuria. The diagnosis is confirmed with an elevated or high normal PTH
level by the use of an assay for intact PTH, in the presence of hypercalcemia.
Surgery is the treatment of choice for primary hyperparathyroidism with serum
calcium levels > 12 mg/dL, 24-hour urine calcium levels > 400 mg, and overt
manifestations including markedly decreased cortical bone density or
nephrolithiasis. Patients with serum calcium levels < 12 mg/dL who are
asymptomatic and managed conservatively should avoid thiazide diuretics,
dehydration, and immobilization; serum calcium, 24-hour urine calcium,
creatinine clearance, and bone densitometry should be monitored. In addition,
these patients should be followed clinically for the development of nephrolithiasis,
minimal trauma fractures, and neuropsychiatric or neuromuscular symptoms.
Medical management options for hyperparathyroidism also include β-blocking
agents, estrogens in women, oral phosphate in patients with low serum
phosphate levels and good renal function, and possibly bisphosphonates.
Basal serum cortisol levels do not change with aging, because decreased
cortisol secretion is balanced by a decrease in clearance. Adrenocorticotropic
hormone (ACTH) stimulation of cortisol production is unchanged, and cortisol
and ACTH responses to stress and secretagogues are unimpaired with aging.
Clinically, acute cortisol responses to stress may be higher and more prolonged
in elderly than in younger adults. Accordingly, unless it is emergent, adrenal
function testing should be deferred at least 48 hours after major stressors, such
as surgery or trauma. In older patients with a normal ACTH stimulation test in
whom adrenal insufficiency is suspected, endocrinology consultation is
recommended to assist with further testing.
Hypoadrenocorticoidism
Chronic glucocorticoid therapy is also the most common cause of adrenal
failure in older adults, because of chronic suppression of adrenal function.
Recovery of adrenal axis function is variable and may take several months to
occur. Autoimmune-mediated adrenal failure is less common in older than in
younger adults, but tuberculosis, adrenal metastases, and adrenal hemorrhage in
anticoagulated patients are more common causes of adrenal insufficiency in
older persons. Older patients with chronic adrenal insufficiency may present with
nonspecific symptoms such as anorexia, weight loss, or impaired functional
status, and hyperkalemia may not be present initially. Accordingly, a high index
of suspicion is required to make the diagnosis. When adrenocortical insufficiency
is suspected, the ACTH stimulation test should be performed and therapy
initiated. In older people who are stopping chronic glucocorticoid therapy, the
replacement regimen should be tapered gradually, and stress dose coverage
should be given for major surgery and other acute physiologic stresses until
adrenocortical function has normalized.
Hyperadrenocorticoidism
Exogenous glucocorticoids are the most common cause of Cushing’s
syndrome in older adults, often causing adverse effects, including psychiatric and
cognitive symptoms, osteoporosis, myopathy, and glucose intolerance. For
patients beginning long-term glucocorticoid therapy, baseline and follow-up bone
densitometry measurements are indicated, and calcium, vitamin D, and
antiresorptive treatments such as bisphosphonates should be initiated.
Adrenal Androgens
In contrast to cortisol, circulating levels of the principal adrenal androgen,
dehydroepiandrosterone (DHEA), decline progressively with aging and are only
10% to 20% of young adult levels in octogenarians. Low DHEA levels are
associated with poor health, whereas DHEA levels are positively correlated with
some measures of longevity and functional status. Given these associations,
there is considerable interest in the potential therapeutic effects of DHEA
administration in older adults.
TESTOSTERONE
Despite former controversy, there is now general agreement that total and
free testosterone levels and testosterone secretion are lower in healthy older
men than in younger men. Many healthy older men exhibit moderate primary
testicular failure, with decreased sperm production, testosterone levels, and
testosterone secretory responses to gonadotropin administration. In addition,
many of these men have inappropriately normal (ie, not increased) gonadotropin
levels in the presence of low testosterone levels, suggesting secondary
(hypothalamic or pituitary) testicular failure. Overt testicular failure is common in
chronically ill and debilitated older men, manifested by total testosterone levels
well below the normal range and symptoms suggesting androgen deficiency,
including decreased libido and potency, gynecomastia, and hot flashes.
Testosterone replacement therapy is generally warranted in these patients, as in
hypogonadal young men. However, it is more common to encounter older men
with low-normal or mildly decreased serum testosterone levels and nonspecific
manifestations, such as decreased libido, weakness, decreased muscle mass,
osteopenia, and memory loss. In most cases, these manifestations have multiple
causes, but it has been hypothesized that declining testosterone levels with
aging contribute to their development, and that testosterone supplementation
may help to prevent or treat these disorders.
GROWTH HORMONE
Growth hormone secretion declines with aging, and by 70 to 80 years of
age, about half of adults have no significant growth hormone secretion over 24
hours. A corresponding decline occurs in levels of insulin-like growth factor 1,
which mediates most of the effects of growth hormone and falls to levels
comparable to growth hormone–deficient children in 40% of adults 70 to 80 years
of age.
MELATONIN
Melatonin is a hormone secreted by the pineal gland that is thought to be
involved in the regulation of circadian and seasonal biorhythms. Melatonin
secretion is inhibited by exposure to light, resulting in a marked circadian
variation in circulating melatonin levels, and its sedative effects suggest a role in
sleep induction. Production of melatonin gradually decreases throughout life after
early childhood, but the physiologic significance of this decline in melatonin
secretion is unclear. Numerous claims have been made in the lay press
regarding the “anti-aging” benefits of melatonin supplementation for various
conditions, including insomnia, immune deficiency, cancer, and the aging
process itself. Although melatonin may have sleep-inducing properties in older
people with insomnia, the long-term risks and benefits of melatonin
supplementation have not been established for insomnia or any other indication.
DIABETES MELLITUS
Diabetes mellitus is a group of metabolic diseases characterized by
hyperglycemia due to abnormalities in insulin secretion, insulin action, or both. It
is one of the most common chronic diseases affecting older persons. Estimates
of the prevalence among persons aged 65 years and over range between 15%
and 20%, with the higher rates associated with persons over age 75. Because
the disease may be asymptomatic for many years, it is estimated that one third of
older adults with diabetes mellitus are unaware of their condition. Despite the
early asymptomatic period, diabetes mellitus is a serious condition associated
with significant morbidity and a shortened survival. Older persons with diabetes
can expect a 10-year reduction in life expectancy and a mortality rate nearly
twice that of persons without this disease. When the diabetes is poorly controlled,
hyperglycemia alone can be the cause of insidious decline in an older patient,
characterized by fatigue, weight loss, muscle weakness, and functional
impairments. Complications of this disease over the longer term include loss of
vision, renal insufficiency, atherosclerosis, and neuropathies. The rates of
myocardial infarction, stroke, and renal failure are increased approximately
twofold, and the risk of blindness is increased approximately 40% in older
persons with diabetes.
Management
The principles of managing diabetes mellitus are similar to those of
managing many other chronic illnesses. As the evidence of benefit among older,
particularly frail persons is less compelling than among Type 1 and younger Type
II diabetics, attention to tradeoffs between risk and benefit is particularly
important. It is important that the patient understands the mechanisms of the
metabolic derangements and their management, becomes fully involved in
monitoring and treating the disease and its complications, and, in conjunction
with the treating physician, sets realistic goals. These goals may vary, depending
on the patient’s preferences, level of commitment, and life expectancy, the
number and severity of coexisting health problems, and the availability of
supportive services. Other health professionals such as diabetes educators,
nurses, dietitians, pharmacists, and social workers may play an important role in
formulating a comprehensive treatment plan and in providing education and
support.
Diet and physical activity remain cornerstones of the initial and ongoing
management of patients with diabetes. The specific dietary recommendations
must be tailored for each individual, but there are guidelines that are widely
applicable. Moderate caloric restriction of 250 to 500 kcal less than usual daily
intake is a reasonable goal, unless the patient is significantly undernourished. A
low-fat diet in which calories from fat are limited to 25% to 30% of total calories is
advisable. It is often recommended that meals, especially carbohydrate intake,
be spaced throughout the day to avoid large caloric loads. Physical activity
programs should also be individualized; however, at a minimum, it is reasonable
to follow the recommendations of the Surgeon General’s Report on Physical
Activity and Health that a person accumulate at least 30 minutes of moderate
physical activity on most days.
There are many options for drug therapy in older persons with type 2
diabetes and no clearly preferred algorithm. Regimens can consist of any of the
classes of drugs, used alone or in combination. It is common to adjust the
regimen over the course of the illness as goals change, the disease progresses,
or complications develop. Sulfonylurea preparations have a long record of safety
and effectiveness. Hypoglycemia is an important side effect, and these drugs
must be used cautiously in patients with significant renal and hepatic
insufficiency, since the liver is the primary site of metabolism and they are
excreted by the kidneys. α-Glucosidase inhibitors impair the breakdown of
carbohydrates in the gut and limit absorption. The residual carbohydrates in the
intestinal lumen are responsible for diarrhea in about 25% of patients who use
this drug. The biguanide preparations also have gastrointestinal side effects and
can cause lactic acidosis in patients with renal insufficiency. It is recommended
that metformin not be prescribed to patients with a serum creatinine of 1.5 mg/dL
or greater. The thiazolidinedimes are generally well tolerated, but there is a risk
of idiosyncratic hepatic toxicity. Finally, insulin can be used effectively in patients
with type 2 diabetes. It is often possible to achieve good glycemic control with
one or two injections a day of an intermediate-acting insulin preparation. The
greatest risk of insulin therapy is hypoglycemia, which can be managed with
either oral glucose solutions or injectable glucagon.
One of the primary reasons for treating diabetes is to avoid the long-term
complications of the metabolic abnormalities. Patients with diabetes can be
asymptomatic for many years, making it difficult to date the onset of the
condition. For this reason, as soon as the diagnosis of diabetes has been
established, it is appropriate to examine the patient for early signs of
complications. Hypertension should be aggressively controlled; the Sixth Report
of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure recommends maintaining the blood pressure
below 130/85. A referral to ophthalmology is recommended to monitor the patient
for retinopathy due to diabetes, an important cause of blindness. Because
diabetes is an important risk factor for atherosclerosis, a careful examination of
the heart and peripheral blood vessels, with special attention to the feet, is very
important. Symptoms and signs of neuropathy should be explored, again, with
special attention to early sensory changes in the feet, such as loss of light touch
sensation or proprioception. Genitourinary complaints, such as recurrent cystitis,
urinary incontinence, and sexual dysfunction, can be related to diabetes. Since
the kidney is an organ commonly affected by diabetes, it is important to screen
for early glomerulopathy by measuring albumin secretion. Glomerular disease
should be suspected if more than 30 mg of albumin are measured in a 24-hour
collection of urine. It is also possible to calculate the albumin-to-creatinine ratio in
a random urine specimen. A ratio exceeding 30 μg of albumin per mg of
creatinine is considered consistent with nephropathy. If microalbuminuria is
confirmed by a second measurement within 3 to 6 months, an angiotensin-
converting enzyme inhibitor should be started in an effort to slow the progression
of renal disease. Serum lipids should also be measured to complete the detailed
evaluation of cardiovascular risk factors in patients with diabetes. According to
the National Cholesterol Education Program, among patients with diabetes, the
target low-density lipoprotein cholesterol concentration is less than 100 mg/dL.
In the United States, diabetes mellitus is a very common chronic disease among
older adults. There may be a prolonged asymptomatic period before the illness is
detected. Once it is recognized, careful attention to glycemic control and
managing the related comorbid conditions will offer the best opportunity for
minimizing the complications and extending the years of high-quality life for
patients with this disease.
S. Family Caregiving
In the past two decades, the role of informal caregivers in providing care
to older persons and the relationship of informal caregivers to nurses and other
health care providers have undergone changes as a result of sociopolitical
trends. Shifting demographic patterns have resulted in a growing number of
elders who require acute and long-term care. The change in the Medicare
system from a retrospective cost-reimbursed system to a prospective fixed
payment system has shifted the responsibility for care during recuperation,
rehabilitation, and long-term disability from institutions to individuals and families
in the community. Because of these changes, the long-term care system would
not be able to meet the needs of older persons without the services provided by
family and other lay caregivers. Consequently, informal caregivers have come to
be viewed legitimately as nurse-extenders. Informal caregivers provide most of
the nursing care to elderly in long-term care; improving the quality of that care
requires an empirically-based understanding of the structures, processes, and
outcomes of family and informal caregiving as well as the ways in which nurses
can work with informal caregivers and effect change within the caregiving
relationship.
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