Geriatrics Quiz: Aging and Health Care

Assessing the Older Adult

• Life expectancy in the US is 81 years for women and 76 years for men.
• Individuals over 65 are considered older adults.
• Aging increases risk for chronic illnesses and disabilities.
• Older adults want to maintain quality of life.
• Nurses need to understand physiological changes with age.

Types of Disabilities in Older Adults

• Hearing impairment
• Vision impairment
• Cognitive impairment
• Mobility/Physical Activity limitations
• Self-care/Independent Living challenges
• Depression
• Strength and Endurance declines
• Nutrition issues, including sarcopenia and sarcopenia obesity (decreased muscle mass with or without excessive body fat)

Geriatric Syndromes

• Anorexia - is a common geriatric syndrome affecting older adults, characterized by decreased appetite and unintended weight loss.
• Dementia -is a geriatric syndrome characterized by impaired cognition and memory decline.
• Dizziness
• Falls
• Frailty - is a geriatric syndrome marked by decreased strength, endurance, and increased vulnerability to adverse health outcomes, often associated with conditions like depression and nutrition issues, including sarcopenia and sarcopenic obesity.
• Gait instability
• Impaired cognition
• Impaired hearing
• Impaired vision
• Malnutrition
• Parkinson's disease
• Pressure ulcers
• Sleep complaints
• Vertigo

Frail Elderly

• Aging is not synonymous with frailty
• Frailty involves multi-system dysfunction.
• Common geriatric syndromes in frail elderly include:
  • Urinary incontinence
  • Cognitive impairment
  • Pressure injuries
  • Falls
  • Polypharmacy
  • Delirium
  • Weight loss

Cultural Considerations

• Cultural assessment is essential to understand health beliefs and practices.
• Language barriers may exist (second language or understanding difficulties).
• Some cultures designate a specific family member to make decisions.

Collecting a Health History

• Assess patient reliability.
• Explain procedures in simple terms.
• Ask short, simple, clear questions to the patient.
• Use secondary sources (family or caregivers) when necessary.
• Respect the patient; address with appropriate title (Mr., Mrs., Ms).
• Older adults may have difficulty recalling information.

General Health

• Assess health status (healthy, illness, or debilitation).
• Observe for frailty, cachexia (wasting syndrome), and tiredness (which may indicate acute or chronic illness).
• Assess level of consciousness (alert and oriented x4, calm, and cooperative).
• Observe physical appearance (normal age, hygiene, appropriate dress, and no odors).
• Assess mobility (gait steady and symmetrical, no difficulty walking, use of assistive devices like walkers or canes).
• Assess posture (stands straight, sits up straight without support, range of motion in all joints and extremities, participates in exam).
• Assess reliability, facial expressions, and speech.
• Assess for distress (no discomfort, pain, or respiratory/cardiac distress).

Preparation for Assessment

• Address patients by their last names unless they prefer to be addressed by their first names.
• Allow extra time for older adults.
• Minimize background noise.
• Be mindful older adults may feel cold more easily.
• Limit position changes.

Focused Assessment

• Older adult assessment is comparable to a standard adult assessment.
• Be cognizant of geriatric considerations.
• Note patient's orientation (person, place, time, situation), reliability, and any physical and/or cognitive limitations.

Expected Age-Related Changes by Body System

• Neurological
• Integumentary (Skin and Nutrition)
• Ear/Hearing
• Eye/Seeing
• Nose/Smell
• Respiratory/Breathing
• Cardiovascular
• GI/Abdominal
• GU/Urinary
• Musculoskeletal (Movement)
• Reproductive

Neurological Changes

• Nerve cell loss and slowing of nerve impulses.
• Decreased sensation and reflexes.
• Decline in balance.
• Observe for tremors and involuntary movements.

Mental Status

• Confusion
• Sleep difficulties
• Social and economic resources
• Living environment (isolation, barriers)
• Physical barriers or neglect
• Memory changes
• Anger, irritability, inability to control frustrations
• Loss of appetite
• Depression

Cognitive Assessment

• Mini-Cog Assessment: simple screening tool for early mental decline.
  • Three-item recall test to assess memory and a simple clock-drawing test.
  • Scoring is used to determine likelihood of dementia.
• Cognitive decline may affect short and long-term memory and cause confusion.

Cognitive Disorders

• Dementia (progressive, irreversible decline in mental function, and memory impairment).
• Alzheimer's disease (a type of dementia)
• Delirium (acute, reversible state of disorientation and confusion--medical emergency)
• Geriatric Depression (depression in elderly--15-question scale assessment survey).

Skin and Hair Changes

• Skin becomes thinner, more fragile, pale, dry (blood vessels become transparent).
• Nerve endings decrease, causing decreased sensation.
• Sweat glands function less, risking hyperthermia and hypothermia.
• Sebaceous glands produce less oil.
• Subcutaneous fat layer thins.
• Wrinkles develop.
• Hyperpigmentation spots or lesions appear.
• Skin tents when pinched.
• Hair grays.

Inspecting and Palpating Skin

• Assess hygiene (body odor).
• Assess skin color; cyanosis (lips, oral mucosa, and tongue), pallor (lips, fingernails, mucus membranes), and jaundice (lips, sclera, rest of body).
• Temperature; asses and compare sides.
• Assess turgor.
• Assess skin moisture.
• Assess lesions, rashes, scars, and masses.

Normal Skin Findings

• Solar lentigines (lentigines) are hyperpigmented macular lesions commonly found on sun-exposed areas.
• Cherry hemangiomas: small, bright, cherry-red spots seen on the trunk and extremities.
• Seborrheic keratosis: non-cancerous, pigmented, waxy lesion; color can be light tan, brown, or black.
• Cutaneous horn: caused by overgrowth of keratin.
• Senile purpura: areas of ruptured fragile capillaries and bruising of the skin.

Abnormal Skin Findings

• Actinic keratosis: a rough, scaly patch that often develops on chronically sun-exposed areas.
• Shingles: caused by the varicella-zoster virus.
• Risk for skin breakdown increases in older adults due to decreased cognition and chronic illness. Tenting of skin is noted in dehydration or weight loss.
• Increased risk of skin breakdown in older adults:
  • Aging
  • Bony prominences
  • Dehydration
  • Dry skin
  • Frailty
  • Reduced mobility/immobility
  • Incontinence
  • Malnutrition
  • Reduced peripheral sensation
  • Weight loss
  • Cognitive impairment
  • Depression

Inspecting the Oral Cavity

• Decrease in taste.
• Slight decrease in saliva production causes dry mouth.
• Teeth wear down or fall out.
• Malocclusion of teeth.
• Poorly fitting dentures. Gum resorption.
• Gum recession, trapping food, causing decay and periodontal disease.
• The latter can lead to stroke, and coronary artery disease.
• Buccal mucosa, hard and soft palate, pharynx, and tonsils.
• Tongue.

Assessing Swallowing

• Increased risk for dysphagia (difficulty swallowing) in older adults.
• Assessment of the gag reflex.
• Assess for signs of dysphagia (coughing, drooling, throat clearing, and pocketing liquids in the side of the mouth).
• A speech therapist is often involved when swallowing difficulties are detected.
• Diet may need to consist of pureed or soft foods and thickened liquids.

Nutritional Assessment

• Older adults are vulnerable to malnutrition.
• Malnutrition can include inadequate micronutrient intake and loss of or decreased appetite.
• Sarcopenia (loss of muscle mass) may occur due to decreased activity and decreased protein intake.
• Other signs of malnutrition may include: issues with teeth/dentures, dysphagia, diminished sense of taste, decreased fluid intake, and inappropriate dietary habits.
• Assess with a 24-hour food diary.
• Mini-Nutritional Assessment (MNA®) Screening tool may be used.

Hearing in Older Adults

• Hearing loss affects about one-third of adults 61-70 years, and >80% over 85.
• Decline in hearing is caused by the loss of hair cells in the organ of Corti (resulting in gradual hearing loss as the person ages).
• Cerumen production decreases, leading to dryness and accumulation.
• Tympanic membrane becomes dull gray and less flexible.
• Presbycusis: difficulty hearing with background noise or when multiple people are talking at one time..

Vision in Older Adults

• Difficulty adapting to darkness.
• Difficulty seeing in dim light (needing brighter light).
• Slower pupillary reflex.
• Vision decline.
• Impaired near vision.
• Loss of color discrimination.
• Dry eyes.
• Ptosis (drooping eyelid).
• Cloudy/grayish ring around the iris is normal.
• Cataracts (opacity and clouding of the lens).
• Glaucoma (loss of peripheral vision).
• Macular Degeneration (loss of central vision).

Assessing Vision

• Use Snellen or Amsler Grid when assessing.
• Follow the same standards as when assessing a standard adult.
• Consider eye-related equipment, such as glasses and position of eye chart.

Respiratory System

• Susceptibility to respiratory diseases increases with age.
• Vital capacity of the lung decreases.
• Reduced elasticity of alveoli results in decreased perfusion.
• Reduced recoil/elasticity in the lungs.
• Decreased cough reflex.
• Decreased thirst reflex results in thickened mucus, making it difficult to clear lungs.
• Lungs have less ability to fight off infection.
• Overall musculoskeletal, mobility, and cardiovascular changes result in pulmonary function changes.

Cardiovascular System

• Accumulation of fat, collagen, lipofuscin, and amyloid causes dysrhythmias in the pacemaker cells.
• Loss of pacemaker cells.
• Blood pressure increases as elasticity in arteries decreases.
• Diminished or non-palpable peripheral pulses likely due to arterial insufficiency.
• Hair loss does not necessarily correlate with arterial insufficiency
• Bulging and spider veins are more common.

Abdomen (GI/GU)

• Older adults may suffer from chronic constipation (reduced motility, activity, fluid intake, fiber, medications; assess any dietary habits, exercise, medications, remedies to relieve constipation).
• Increased risk for gallstones related to biliary sludge build-up.
• Older adults may have decreased kidney function, putting them at risk for urinary incontinence.
• Types of incontinence include stress, Urge, Overflow, and Functional.

Urinary Incontinence

• Stress incontinence: leaking small amounts with increased intra-abdominal pressure (e.g., coughing, sneezing, exercising).
• Urge incontinence: sudden urge to urinate.
• Overflow incontinence: weakened bladder muscle or urethral blockage; incomplete emptying of the bladder.
• Functional incontinence: inability to control bladder due to mobility, cognitive, or other functional limitations (e.g. to reach the bathroom.)

Assessing Frailty

• Assess the patient for the presence of three or more of the following:
  • Unintentional weight loss.
  • Decreased activity and engagement.
  • Self-reported exhaustion.
  • Low energy expenditure.
  • Weakness.
  • Balance and gait abnormalities.
  • Cognitive impairment.
  • Slow walking speed.
• Assess other medical, emotional, and psychosocial factors in a geriatric patient as these may lead to frailty. Assess the patient for several medical conditions and how they impact the frail elderly patient.

Psychosocial Assessment

• Assess with special considerations for older adults;
  • Functional status, living arrangements, social interactions, driving, alcohol use, elder abuse, and sexuality.

Functional Assessment

• Assess the patient's ability to care for themselves and meet essential tasks of daily life (Basic Activities of Daily Living (ADL)).
• The Barthel index is a core tool in functional assessment.
• The Barthel index scores functional ability and consists of 10 areas to score (score each item and then add to get a total score).

Residential Living

• Type of living arrangement.
• Safety assessments.
• Planning for assistance, emergency care, and support needs.

Social Interactions

• Recommendations for provisions for social support and involvement for older adults from the National Institute on Aging (2013).
• Social involvement fosters positive health and longevity and should be assessed; include considerations of the patient's spouse/significant other, family involvement, friends, and community activities.

Driving Assessment

• Older adults may be at risk for motor vehicle injuries based on reduced eyesight, physical limitations or mental state).
• Assess for driving abilities and changes that may make driving unsafe or less reliable (assess ability to see signs, markings, cars, and people at different times of the day/night. Assess for handling headlight glare, night driving, and any signs of getting lost.)
• AARP documented warning signs for when an older adult should stop driving.

Alcohol Use

• Alcoholism is harder to assess and diagnose in older adults due to chronic illnesses, polypharmacy, cognitive disorders.
• Older adults should only consume up to 3 drinks on a given day and 7 drinks a week.
• Use the CAGE questionnaire when assessing alcohol use.

Elder Abuse

• Elder abuse is a growing and underreported problem in older adults.
• Older adults are frequently vulnerable to abuse because they are more likely to have acute or chronic conditions affecting their physical/mental abilities.
• Physical abuse, mental abuse, sexual abuse, among others, may occur.
• Assess for any signs of physical abuse (dehydration, weight loss, missing aids, and those associated with malnutrition).

Sexuality

• Sexuality does not end with aging; assess sexual interest and function. This is a sensitive topic;
• Assess sexuality concerns or questions about the patient's sexual needs.
• Assess if the sexual relationship has changed for the patient.

Medication Assessment

• Polypharmacy (multiple medications) is a common issue in older adults.
• Assessing multiple medications as part of the evaluation.
• Assess prescribed medication, prescriber(s), pharmacies, forms of medication, reason(s) for taking the medication(s), dosage, non-adherence to regimen, and expiry dates are all components.

Pain Assessment

• Older adults are more likely to give reliable self-reports of pain levels (pay attention to cognitive status).
• Some patients are reluctant to report pain.
• Observe nonverbal body language.

Common Problems in Older Adults

• SPICES includes an assessment and screening tool to alert nurses to some of the common nonspecific disease indicators in older adults.
• SPICES includes sleep disorders, problems with eating/feeding, incontinence, confusion, evidence of falls, and skin breakdowns.

Question and Answer Sets

• Include a variety of questions and answers regarding the assessment of various components in an older adult patient (e.g., loss of weight, dementia, frailty, and incontinence).
• Identify relevant tests and measures to use and apply findings from previous assessments.

Test your knowledge about geriatric health care and aging. This quiz covers life expectancy, common syndromes in older adults, and changes in physical health associated with aging. Assess your understanding of cultural assessments and challenges in geriatric care.