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Brain:
In the chronological order of the aging process brain function which was once stable during most of
adulthood, begins to decline. The brain does not decline in a unilateral order, rather certain aspects of the
brain and their function decline at different times and declining of brain function may vary from person to
person.
o Short-term memory and the ability to learn new material tend to be affected relatively early.
o Verbal abilities, including vocabulary and word usage, begin to decline at about age 70.
o Reaction time and performance of tasks may become slower due to the slower processing of nerve
impulses by the brain.
As aging progresses, the number of neurons in the brain is usually decreased, however loss is on a
case-by-case basis, depending on the person's health. In addition the remaining nerve cells function less
effectively. To compensate for the losses of neurons the brain employs the following:
o Redundancy: The brain has more cells than it needs to function normally; which may help
compensate for the loss of nerve cells that occurs with aging and disease.
o Formation of new connections: The brain actively compensates for the age-related decrease in
nerve cells by making new connections between the remaining nerve cells.
o Production of new nerve cells: Some areas of the brain may produce new nerve cells,
especially after a slight brain injury or a stroke. Which would explain how people who have
had a brain injury or stroke can sometimes learn new skills, as occurs during occupational
therapy.
Lifestyle, like for everything else in life, plays a factoring how quickly brain function declines. For
example, a healthy lifestyle consisting of mental (such as brain teasers and puzzles) and physical (running
and yoga) exercise seems to slow the loss of nerve cells in areas of the brain involved in memory. Such
exercise also helps keep the remaining nerve cells functioning albeit at only a degree. On the other hand, an
unwholesome lifestyle, for example consuming two or more drinks of alcohol a day can speed the decline
in brain function.
• Normal Physiological Changes of the Brain due to Aging
o Blood flow to the brain may decrease by an average of 20%.
o The brain atrophies as a result of aging process.
o The brain weight decreases
o A decrease in enzymes, protein and lipids in brain tissue are also the norm.
o A shrinkage of large neurons resulting in loss of large neurons with an increase in smaller
neurons.
o Alterations in the amount of neuro-transmitters.
Spinal Cord:
During aging, the disks between vertebrae become less elastic even hard and brittle, and parts of
the vertebrae may hypertrophy. As a result, the disks lose their capacity to cushion stress on the vertebrae,
so more pressure is put on the spinal cord and on the spinal nerve roots. The increased pressure may injure
some sensitive and minute nerve fibers in the spinal cord. Such injury can result in decreased sensation and
sometimes decreased strength and balance, leading to safety issues among the elderly.
Peripheral Nerves:
As we age, peripheral nerves may conduct impulses more slowly, and consequently in decreased
sensation, slower reflexes, and often some clumsiness. Nerve conduction slows because myelin sheaths
degenerate. Degeneration occurs due to the blood flow decreasing, nearby bones overgrowing and put the
added pressure on the nerves, or both. In a non-diseased older adult, the effect may be so minute that no
change in function is noticeable; unless nerves are injured by something else a frequently culprit is
diabetes.
The peripheral nervous system's response to injury is also reduced. In comparison to a person’s youth
when damaged axons of peripheral nerves have the ability to repair itself so long as its body, in close
proximity to the spinal cord is undamaged, in older adults this regenerative process more slowly and
incompletely, increasing an older adults risk for injury and vulnerable to disease.
• Other Changes due to the Aging Neurologic System of the Older Adult:
o Clinical changes due to the above are decreased sensation of vibrations (notably in legs),
less brisk deep tendon reflexes with ankle reflex absent entirely and a decreased ability
for upward gaze.
o Functional changes include slowing of response to tasks and the increase in time to
recover from physical exertion
o Cognitive changes include memory loss, decrease in perceptual ability and decrease
in proficiency.
II. Neurological Physical Assessment of an Older Adult
Neurologic examination for elderly patients, similar to that for any adult, includes evaluation of
cranial nerves, motor function, sensory function, and mental status.
It is noted however that non-neurologic disorders that are common among elderly people may
complicate the assessment. For example, visual and hearing deficits may impede evaluation of cranial
nerves, and periarthritis (inflammation of tissues around a joint) affecting certain joints, especially
shoulders and hips, may interfere with evaluation of motor function.
Findings are taken with background knowledge of the patient's age, history, and other findings.
Symmetric findings unaccompanied by functional loss and other neurologic symptoms and signs may be
noted in elderly patients.
1. Cranial nerves:
a. Elderly people often have small pupils; their pupillary light reflex may be sluggish,
and their pupillary mitotic response to near vision may be diminished.
b. Upward gaze and, to a lesser extent, downward gaze are slightly limited.
e. In many elderly people, sense of smell is diminished because they have fewer
olfactory neurons, have had numerous upper respiratory infections, or have chronic
rhinitis. However, asymmetric loss (loss of smell in one nostril) is abnormal.
f. Taste may be altered because the sense of smell is diminished or because patients
take drugs that decrease salivation.
g. Visual and hearing deficits may result from abnormalities in the eyes and ears rather
than in nerve pathways.
a. Elderly people, particularly those who do not do resistance training regularly, may
appear weak during routine testing. For example, during the physical examination,
the nurse may easily straighten a patient's elbow despite the patient's effort to sustain
a contraction. If weakness is symmetric, does not bother the patient, and has not
changed the patient's function or activity level, it is likely to be clinically
insignificant.
b. Increased muscle tone, measured by flexing and extending the elbow or knee, is a
normal finding in elderly people; however, jerky movements during examination and
cogwheel rigidity are abnormal.
c. Tremors are examined during handshaking and other simple activities. If tremor is
detected, amplitude, rhythm, distribution, frequency, and time of occurrence (at rest,
with action, or with intention) are noted.
e. Weak extensor muscles of the wrist, fingers, and thumb are common among patients
who use wheelchairs because compression of the upper arm against the armrest
injures the radial nerve. Having the patient pick up an eating utensil or touch the
back of the head with both hands can test arm function.
f. Motor reaction time and motor coordination are tested. Reaction time often decreases
with aging, partly because conduction of signals along peripheral nerves slows.
h. The deep tendon reflexes are checked. Aging usually has little effect on them.
However, eliciting the Achilles tendon reflex may require special techniques (eg,
testing while the patient kneels with the feet over the edge of a bed and with the
hands clasped). A diminished or absent reflex, present in nearly ½ of elderly patients,
may be normal. It occurs because tendon elasticity decreases and nerve conduction in
the tendon's long reflex arc slows. Asymmetric Achilles tendon reflexes may indicate
sciatica.
i. Overall postural control is evaluated using the Romberg test (patients stand with feet
together and eyes closed). With aging, postural control is often impaired, and
postural sway (movement in the anteroposterior plane when the patient remains
stationary and upright) may increase.
3. Sensation: Evaluation of sensation includes touch (using a skin prick test), cortical sensory
function, temperature sense, proprioception , and vibration sense testing. Aging has limited
effects on sensation.
a. Many elderly patients report numbness, especially in the feet. It may result from a
decrease in size of fibers in the peripheral nerves, particularly the large fibers.
Nonetheless, patients with numbness should be checked for peripheral neuropathies.
In many patients, no cause of numbness can be identified.
b. Many elderly people lose vibratory sensation below the knees. This loss occurs
because small vessels in the posterior column of the spinal cord change. However,
proprioception, which is thought to use a similar pathway, is unaffected.
4. Mental status: A mental status examination is a key component of evaluation. A patient who
is disturbed by such a test should be reassured that it is routine. The examiner must make sure
that the patient can hear; hearing deficits that prevent a patient from hearing and
understanding questions may be mistaken for cognitive dysfunction. Evaluating the mental
status of a patient who has a speech or language disorder (eg, mutism, dysarthria, speech
apraxia, aphasia) can be difficult.
01. Parkinson’s Disease: A chronic (long term) progressive degenerative neurological disorder affecting
the brain centers that are responsible for control and regulation of movement
Pathophysiology
o Coordination problems
o Degeneration of substanita nigra (pigmented neurons) leads to depletion of Dopamine
causing decreased and slowed voluntary movements, rigidity and tremors
o With the Decrease in Dopamine(Inhibits excitability) you have an increase in
Acytlcholyene(h excitability). That’s why you have the tremors, rigidity, and slow
movements
Incidence
o Begins most often in 5th decade of life
o Affects men and women equally – whites more than blacks
o Not a familial disease
Etiology
o May Follow
a. Acute encephalitis (viral infection ) – RARE
b. Carbon monoxide, metallic or other poisoning
c. Sometimes associated with arteriosclerosis
o Cause is unknown
Diagnosis
o Clinical Manifestations form history
o Must have 2 of the 3 cardinal symptoms
o No Conclusive lab work
o Handwriting changes may be first clue
o May take a while to diagnose
Prognosis
o Symptoms come on rapid in first year and then level off
o Advance of symptoms most often extended over several decades
Clinical Manifestations
o Resting tremors - Pill-rolling tremors
a. Disappears with purposeful movement
o Intentional Tremor – Piggyback – hold hand
o Muscle rigidity (cogwheel rigidity) – prevents from doing normal activity
a. Jerky PROM
o Akinesia / Bradykinesia
a. Absence of movement / Slow movement
o Mask-like facial expression
a. Have a stare and eyes may not blink
o Moist oily skin
o Monotonous, low pitched, slow poorly articulated speech
o Drooling
a. Due to problems swallowing secondary to muscle problems R/F
Aspiration
o Heat intolerance
o Intellect is not affected – Do not treat them as if it is affected
o Characteristic Propulsion Gait
a. Forward stoop, with a tendency to get going too fast where they
are unable to stop
b. Shuffling gait, walk on toes, take tiny steps, and do not have
normal movement with hands and arms = potential safety problems
HRF Injury
o Appetite increased but can’t eat much because of drooling and difficulty swallowing
resulting in weight loss.
o Impaired handwriting
a. First sign although not a cardinal symptom
b. Handwriting gets small and shaky looking
o Deficits in judgment and emotional instability
o Intention tremors
a. When attempting to do something like pick up a glass
o Depression – Common
o Decreased cerebral blood flow = dementia
o All signs and symptoms increase with fatigue, excitement, and frustrations
a. As a nurse you would: Not let them get too tired, excited, or
frustrated
o Complications form immobility (Pneumonia, UTI) and the consequences of falls and
accidents are major causes of death
Medical Management
o There is no known treatment
Drug therapy
o Anticholinergic drugs – Causes constipation in elderly
o These drugs are either used to hDopamine supply or i Achytocholine response
a. Congentin – Control tremor and rigidity
b. Artaine – Same as Congentin
c. Levadopa – Replaces or converts to Dopamine in basal ganglia;
usually given with Sinemet to allow increased levels of Dopamine
d. Symmetrel – Antiviral – rigidity, tremors, and bradykenisa
e. Sinemet – 3 main symptoms
Surgical Treatment
o Destroy part of brain tissue in thalamus - Thalamectomy
o Effective for younger people
o Surgery not used often on elderly, usually use the meds instead – Levadopa
Nursing Management
o Physical Therapy / Gait training
o Teach to use wide gait and look ahead which forces them to keep the head up
o Teach patient to exercise for posture and prevent deformities
o Keep neck straight and prevent contractures
o Can lead to respiratory problems
o No pillows under the neck causes flexion of the neck
o Weigh periodically – Intake problems
o Rest and eating appropriately
o Speech Exercises – May need voice amplifier
o Constipation problems – possibly due to drooling
o Weakness of the muscles needed to defecate
o Do oral care and protect skin around the mouth – drooling
o May have problem eating – getting food to mouth and chewing – have suction
available
o Lassitude (exhaustion)
o Tremor control – Hold on to chair or hold one hand in the other
o General health measures
o Patient and/or family education
o Medications – SE
o Exercise and walking
o Well-balanced diet – Usually regular diet
o Small frequent feedings
o Warming plate for food
o Over the counter meds must be Ok’d by MD
o Cannot have Vitamin B6: Fortified breads and cereals may have Vitamin B6
Parkinson’s Crisis
o Medical Emergency- See sudden severe exacerbation of classic symptoms – call for
immediate attention – not able to swallow, walk, sweating, tachycardia, etc.
o Results form sudden withdrawal of anti-parkinsonian medications or some severe
emotional trauma
o Can die from this – quiet environment may give sedative-hypnotic, anticonvulsants
and antiparkinson’s meds IV
o First calm patient and be sure patient is breathing
o Provide respiratory and cardiac support
o May be given an injection of Phenobarbital
02. Dementia
Alzheimer’s type is a specific degenerative process occurring primarily in the cells located at the
base of the forebrain that send information to the cerebral cortex and hippocampus. It is the most common
form of dementia and is characterized by a steady and global decline.
Vascular dementia reflects a pattern of intermittent deterioration related to multiple infarcts to
various areas of the brain. Although the etiologies differ, these two forms of dementia share a common
symptom presentation and therapeutic intervention.
Signs and Symptoms
Early dementia
04. Cerebrovascular Accident (CVA, Stroke) Definition: decreased blood supply to the brain Risk
factors
o hypertension, uncontrolled
o smoking
o obesity
o increased blood cholesterol and triglycerides
o chronic atrial fibrillation
Diagnostics
Types of CVA
Management - to prevent or minimize the damaging effects of stroke; dependent on the type of CVA
Expected outcomes:
o Occlusive stroke
a. pharmacologic
o thrombolytics
o anticoagulant therapy: heparin, coumadin
o antiplatelet therapy: aspirin, dipyridamole
1. platelet aggregation inhibitor: clopidogrel (plavix),
ticlopidine HCL (ticlid)
o steroids: dexamethasone
b. surgery - bypass
o Hemorrhagic stroke
a. pharmacologic
o antihypertensive agents
o systemic steroids: dexamethasone (decadron)
o osmotic diuretics: mannitol
o antifibrinolytic agents: aminocaproic acid (amicar)
o vasodilators
o alpha-blockers and beta-blockers
o anticonvulsants
Nursing interventions