Module 5 - Older Adult Health

A 71-year-old patient enters the emergency department after falling down stairs in the home. The nurse is conducting a fall history with the patient and his wife. They live in a one-level ranch home. He has had diabetes for over 15 years and experiences some numbness in his feet. He wears bifocal glasses. His blood pressure is stable at 130/70. The patient does not exercise regularly and states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, and able to answer questions clearly. What are the fall risk factors for this patient? (Select all that apply.) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1. Impaired vision 4. Leg weakness 5. Exercise history

A 63-year-old patient is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years and was a dedicated employee. His wife is a homemaker. She raised their five children, babysits for her grandchildren as needed, and belongs to numerous church committees. What are the major concerns for this patient? (Select all that apply.) 1. The loss of his work role 2. The risk of social isolation 3. A determination if the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the patient chose to retire

1. The loss of his work role 4. How the wife expects household tasks to be divided in the home in retirement

A patient's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before and knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (Select all that apply.) 1. The center needs to be clean, and rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides three meals daily with a set menu and serving schedule. 5. Staff encourage family involvement in care planning and assisting with physical care.

2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 5. Staff encourage family involvement in care planning and assisting with physical care.

A nurse is caring for a patient preparing for discharge from the hospital the next day. The patient does not read. His family caregiver will be visiting before discharge. What can the nurse do to facilitate the patient's understanding of his discharge instructions? (Select all that apply.) 1. Yell so the patient can hear you. 2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 4. Send a written copy of the instructions home with him and tell him to have the family review them. 5. Include the family caregiver in the teaching session.

2. Sit facing the patient so he is able to watch your lip movements and facial expressions. 3. Present one idea or concept at a time. 5. Include the family caregiver in the teaching session.

During a home health visit a nurse talks with a patient and his family caregiver about the patient's medications. The patient has hypertension and renal disease. Which of the following findings place him at risk for an adverse drug event? (Select all that apply.) 1. Taking two medications for hypertension 2. Taking a total of eight different medications during the day 3. Having one physician who reviews all medications 4. Patient's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2. Taking a total of eight different medications during the day 4. Patient's health history of renal disease

A nurse is participating in a health and wellness event at the local community center. A woman approaches and relates that she is worried that her widowed father is becoming more functionally impaired and may need to move in with her. The nurse inquires about his ability to complete activities of daily living (ADLs). ADLs include independence with: (Select all that apply.) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2. Toileting. 3. Bathing. 5. Eating.

Sexuality is maintained throughout our lives. Which of the following answers best explains sexuality in an older adult? 1. When the sexual partner passes away, the survivor no longer feels sexual. 2. A decrease in an older adult's libido occurs. 3. Any outward expression of sexuality suggests that the older adult is having a developmental problem. 4. All older adults, whether healthy or frail, need to express sexual feelings.

4. All older adults, whether healthy or frail, need to express sexual feelings.

Age Definitions of Older Adults

"Young-old" - 65-74 years old "Middle-old" - 75-84 years old "Old-old" - 85 years old and older

The nurse is completing an admission assessment with an 80-year-old man who experienced a hip fracture following a fall. He is alert, lives alone, and has very poor hygiene. He reports a 20-pound weight loss in the last 6 months following his wife's death, as well as estrangement from his only child. He admits to falls before this most recent fall. What should the nurse suspect? 1. Dementia. 2. Elder abuse. 3. Delirium. 4. Alcohol abuse.

Alcohol abuse

A nurse is assessing an older adult brought to the emergency department following a fall and wrist fracture. She notes that the patient is very thin and unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son who accompanied her to the hospital. The nurse's next step is to: 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so she can complete her assessment. 3. Call adult protective services because you suspect elder mistreatment. 4. Assess patient's cognitive status.

Ask the son to step out of the room so she can complete her assessment.

The nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started noticing a glare in the lights at home. Her vision is blurred; and she is unable to play cards with her friends, read, or do her needlework. The nurse suspects that the woman may have: 1. Presbyopia. 2. Presbycusis 3. Cataract(s). 4. Depression.

Cataract(s)

Physiological Changes of Aging: Respiratory

Decreased cough reflex; decreased cilia; increased anterior-posterior chest diameter; increased chest wall rigidity; fewer alveoli, increased airway resistance; increased risk of respiratory infections. *Powerpoint: Intrapulmonary changes- Lung elastic recoil is lost with age (less surfactant production), number of functional alveoli decreases, alveolar-capillary membrane thickens, reducing the surface area for gas exchange, decreased tidal volume due to skeletal rigidity, osteoporosis reduces usable lung space

Physiological Changes of Aging: Musculoskeletal

Decreased muscle mass and strength, decalcification of bones, degenerative joint changes, dehydration of intervertebral disks, fat tissues increases. Bone structure: Loss of bone mass leading to brittle, weak bones. Vertebrae compress leading to a decrease in height Muscle strength: Atrophy of large muscles (on total bed rest, 25% of muscle mass is lost over a 48 hr period). Arm/leg muscles become thin & flabby. Loss of flexibility & endurance with decreased activity Joints: Limited range of motion (ROM). Cartilage thins - joints become inflamed, painful, & stiff

Physiological Changes of Aging: Neurological

Degeneration of nerve cells, decrease in neurotransmitters, decrease in rate of conduction of impulses. Neurons Steady loss in brain & spinal cord Decreased in synthesis & metabolism of neurotransmitters (dopamine & serotonin) Progressive loss of brain mass (due to dehydration) Movement Kinesthetic and tactile sense is less effective Balance may become impaired Decrease in reflex/reaction time (decrease in myelin sheaths) Sleep Insomnia and increased night waking Decreased REM sleep (20 minutes until deep REM sleep)

The nurse is completing a health history with the daughter of a newly admitted patient who is confused and agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening and was hallucinating. She was unable to calm her, and her mother thought she was a stranger. On the basis of this history, the nurse suspects that the patient is experiencing: 1. Delirium. 2. Depression. 3. New-onset dementia. 4. Worsening dementia.

Delirium

Delirium

Delirium: Acute confusional state(rapid onset), it is a potentially reversible cognitive impairment that often has a physiological cause. It resolves as quickly as its onset. Confusion or forgetfulness. EX: Dehydrated - restless, combative, agitated. Start IV fluids of isotonic solution like normal saline to reverse the acute confusion. In their delirious state, to prevent patient from ripping it out, cover it with dressing or wound wrap before attempting to restrain the patient EX: Client is malnourished; interventions include increase the calorie intake by NG tube or gastrostomy tube. The client who is delirium would rip the tube out. Cover the G tube with an abdominal binder w/ a towel underneath the the tube. Or a soft physical restraint may be applied but last intervention. EX: S/S for scabies- little tracks in b/w their fingers, itchiness. May cause superinfections.

Dementia

Dementia: Generalized impairment of intellectual functioning that interferes with social and occupational functioning. A gradual, progressive onset, irreversible cerebral dysfunction. Mild to severe; moderate to severe becomes more difficult. The cause of dementia is insidious hypertension (disease that progresses gradually with inapparent symptoms), lead to TIA's, and develop to CVA. The client will lose mobility, neurogenic bladder, loss of function, aggressive. Dementia of the Alzheimer's Type (DAT) - case in which social boundaries can completely go out the window. Sundowners Syndrome: metabolism, circadian rhythm, patients begin acting out when the sun goes down. The sun setting causes shadows to be casted, darkness sets in, and so does the fear. This can cause catastrophic reactions. Primary culprit: patient cannot digest the environment. During the entire day, there is a lot of involuntary and voluntary energy is being spent, and much of the metabolism is being spent, mix in a raging infection and the brain has to struggle to digest everything. Metabolism is tapped out by the end of the day. Use structured care plans.

A nurse conducted an assessment of a new patient who came to the medical clinic. The patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Hypoglycemic reaction.

Depression

Depression

Depression: NOT a normal part of aging; due to a disease process or medication induced. Subjective Data: "No one cares, I don't matter, This is sad, I wish I was dead. Looking down, avoiding eye-contact. Withdrawing. No one listens to me" Three Major Types: (1) Organic: Injury to the organ (brain). Functions of the brain become depressed. Organism is affected- the brain. Injury to the brain due to trauma, TIA's, Parkinson's, CNS. (2) Clinical: Mental health issue/disorder. EX: Bipolar, OCD. Diagnosed by a psych. person. (3) Emotional: Comes and goes, depends on the situation.

Physiological Changes in Aging: Sensory

Eyes: (text) Decreased accommodation to near/far vision (presbyopia), difficulty adjusting to changes from light to dark, yellowing of the lens, altered color perception, increased sensitivity to glare, smaller pupils - Ability to focus on close objects diminished - Increased thickness of lens & opacity (cataracs) - Decreased tear production (due to dehydration) - Decreased pupillary responses (degradation in neuroprocesses) - Decreased night vision Taste: Ability to perceive bitter, salt, & sour tastes diminish (sweet sensory is still intact) Smell: often diminished Hearing: decreased ability to hear high-frequency tones, cerumen becomes hardened & causes impaction (presbycusis) Touch: decreased ability to feel light touch, pain, or temp (dysfunction of dermatomes) Proprioception: decreased awareness of body positioning in space

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch and be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Physical changes usually do not affect sexual functioning. 4. Frequency and opportunities for sexual activity may decline.

Frequency and opportunities for sexual activity may decline.

Function Incontinence

Functional incontinence is a form of urinary incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons they are unable to get to a bathroom.

Physiological Changes of Aging: Endocrine

General—alterations in hormone production with decreased ability to respond to stress Thyroid—diminished secretions Cortisol, glucocorticoids—increased anti-inflammatory hormone Pancreas—increased fibrosis, decreased secretion of enzymes and hormones, decreased sensitivity to insulin

Erikon's Stages of Older Adults

Generativity vs. Stagnation (40-65 yrs) - Generativity: Some adults want to give, they would volunteer at community services or grandchildren. - Stagnation: They don't care about anything. Integrity vs. Despair (50+ old age) - Integrity: Fully accepting oneself and coming to terms with the death. Accepting responsibility for your life and being able to undo the past and achieve satisfaction with self is essential. - Despair: Feel that their life has been wasted and will experience many regrets. The individual will be left with feelings of bitterness and despair.

Physiological Changes of Aging: Genitourinary

Genitourinary: Fewer nephrons, 50% decrease in renal blood flow by age 80, decreased bladder capacity Male—enlargement of prostate Female—reduced sphincter tone Renal (Kidney) function: Decreased renal blood flow d/t decreased cardiac output & reduced glomerular filtration rate (GFR) Ability to concentrate urine impaired Bladder: Incomplete emptying d/t loss of muscle tone Capacity decreased Micturition (peeing and pooping) F increased frequency d/t decreased muscle strength of pelvic floor muscles M increased frequency d/t prostatitis

Physiological Changes of Aging: Integumentary

Loss of skin elasticity with fat loss in extremities; pigmentation changes; glandular atrophy (oil, moisture, sweat glands); thinning hair, with hair turning gray-white (facial hair: decreased in med, increased in woman); slower nail growth, atrophy of epidermal arterioles. Skin: Loss of elasticity leading to wrinkles/folds Thinning decreased protection of blood vessels. Age spots form as melanocytes cluster, lentigo senilis Hair: Thinning of hair d/t decreased activity of hair follicles Graying d/t decreased production of melanin Tragal hair: F-chin/upper lip; M-ears/nares Nails: Become thick, dull, hard, brittle, ridged d/t decreased blood flow, slower growth Sweat glands: Fewer occur in addition to function, causes problems in thermoregulation

Physiological Changes of Aging: Gastrointestinal

Periodontal disease, decrease in saliva, gastric secretions, and pancreatic enzymes; smooth-muscle changes with decreased peristalsis and small intestinal motility; gastric atrophy; decreased production of intrinsic factor; increased stomach pH; loss of smooth muscle in the stomach; hemorrhoids, rectal prolapse; and impaired rectal sensation. Oral cavity: Reabsorption (demineralization) of jaw bones may loosen teeth, reducing the ability to chew. Dysplasia (overgrowth of gum tissue) requires frequent checks for dental fit Esophagus: Gag reflex weakens; sneezing and coughing are treatments. Smooth muscle weakens delays emptying time Stomach: Decreased gastric acid secretions may impair uptake of FeSo4, Vitamin B12, & protein. Intestines: Decreased peristalsis, sphincter muscles weaken leading to inadequate emptying of bowel

The nurse is working with an older adult after an acute hospitalization. The goal is to help this person be more in touch with time, place, and person. Which intervention will likely be most effective? 1. Reminiscence 2. Validation therapy 3. Reality orientation 4. Body image interventions

Reality orientation

Reflex Incontinence

Reflex incontinence occurs when the bladder muscle contracts and urine leaks (often in large amounts) without any warning or urge. This can happen as a result of damage to the nerves that normally warn the brain that the bladder is filling. Reflex incontinence usually appears in people with serious neurological impairment from multiple sclerosis, spinal cord injury, other injuries, or damage from surgery or radiation treatment

Physiological Changes of Aging: Reproductive

Reproductive: Male—sperm count diminished, smaller testes, erections less firm and slow to develop. Testes decrease in size. Prostate gland may enlarge due to a lack of ejaculation by intercourse or masturbation Female—decreased estrogen production, degeneration of ovaries, atrophy of vagina, uterus, breasts. Atrophy of vulva, pubic hair may fall out, decreased vaginal secretions

A nursing student is caring for a 78-year-old patient with multiple sclerosis. The patient has had an indwelling Foley catheter in for 3 days. Eight hours ago the patient's temperature was 37.1° C (98.8° F). The student reports her recent assessment to the registered nurse (RN): the patient's temperature is 37.2° C (99° F); the Foley catheter is still in place, draining dark urine; and the patient is uncertain what time of day it is. From what the RN knows about presentation of symptoms in older adults, what should he recommend first? 1. Tell the student that temporary confusion is normal and simply requires reorientation 2. Tell the student to increase the patient's fluid intake since the urine is concentrated 3. Tell the student that her assessment findings are normal for an older adult 4. Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

Tell the student that he will notify the patient's health care provider of the findings and recommend a urine culture

Physiological Changes of Aging: Cardiovascular

Thickening of blood vessel walls, narrowing of vessel lumen, loss of vessel elasticity, lower cardiac output, decreased number of heart muscle fibers, decreased elasticity and calcification of heart valves, decreased baroreceptor sensitivity, decreased efficiency of venous valves, increased pulmonary vascular tension, increased systolic BP, decreased peripheral circulation. Powerpoint: Heart: Cardiac muscle strength diminished, valves become thickened and more rigid, electrical conduction is less effective and impulses are slow. Heart rate itself slows. It takes longer for the heart to speed up in response to exercise and to stress; to return to baseline following exertion or a stressful event. Blood Vessels: Arteries become less elastic. Capillary walls thicken and slow the exchange of nutrients and waste products b/w blood/tissues. Blood: Volume is reduced d/t decline in total body water. Bone marrow activity reduced (RBCs & H/H) estrogen keeps blood vessels pliable

Physiological Changes of Aging: Immune System

Thymus decreases in size and volume T-cell function decreases Core temperature elevation is lowered

Overflow Incontinence

involuntary loss of urine associated with over-distention and overflow of the bladder

Urge Incontinence

state in which a person experiences involuntary passage of urine that occurs soon after a strong sense of urgency to void

Stress Incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing