Gerontology: Eye, Skin, Metabolic, and Hearing Issues

• Study notes for gerontology midterm 2 cover eye issues, hearing issues, metabolic disorders, chronic illness, and skin issues in older adults.

Eye Issues in Older Adults

• The highest risk for eye disease development is due to aging, hypertension, and family history of glaucoma/cataracts.

Cataracts

• Opacification or cloudiness in the lens makes it less transparent and scatters light due to protein and fiber breakdown.
• A common symptom of cataracts is blurred vision.
• Glare and halos around lights and faded colors are symptoms.
• Poor night vision is another symptom.
• Treatment involves surgical removal of the lens and replacement with a plastic intraocular lens.
• Surgery occurs one eye at a time
• Redness, scratchiness, clear discharge, and black spots or floaters are normal post-surgery.
• Blurred vision can persist for weeks afterward
• Heavy lifting, straining, or bending should be avoided to prevent increased IOP and damage to the new lens.

Open Angle Glaucoma

• This is the most common type of glaucoma.
• It encompasses diseases that damage the optic nerve, with the damage being irreversible.
• Diabetes can be a cause.
• Diagnosis is often delayed because individuals are unaware or have no initial symptoms.
• Symptoms include headaches, glare sensitivities, fatigue, and poor vision in dim lighting.
• Fixed and dilated pupils and needing changes to corrective lenses are symptoms.
• Experiencing poor peripheral vision is also a symptom.
• Treatment involves drugs to decrease IOP, either oral or topical eye drops.
• Beta-blockers can be used to reduce IOP by decreasing aqueous fluid production and improving flow.

Angle Closure Glaucoma

• This is a medical emergency involving aqueous humor obstruction and a rapid increase in IOP.
• Pain and redness around the eye, severe headache, nausea, vomiting, and blurred vision are symptoms.
• Untreated, it can lead to blindness.
• Treatment involves surgery to relieve IOP and allow aqueous humor to flow.

Diabetic Retinopathy

• Hyperglycemia damages retinal vessels, causing blood and lipids to leak and macular edema behind the eye.
• Microvascular hemorrhages from new vessels form in advanced disease.
• This often progresses unnoticed until vision is affected.
• Hallmark symptoms include floating spots.
• Laser photocoagulation treatment can halt the progression but not cure the disease.
• Annual dilated fundoscopic exams are necessary.
• exams should start 5 years after a type 1 diabetes diagnosis and immediately after a type 2 diabetes diagnosis.
• Strict blood pressure and glucose control are implemented.
• Cholesterol level control with screening at least once a year is required.

Diabetic Macular Edema

• Fluid(blood and lipids) build up in the macula.
• Symptoms include blurred vision, loss of contrast and patches of vision loss (black dots or lines).
• Treatment involves steroids, anti-vascular endothelial growth factor injection therapy or laser therapy to cauterize leaky vessels and reduce accumulated fluid.

Detached Retina

• This is a medical emergency
• A common occurrence after trauma or recent surgery.
• The hallmark symptom is a curtain coming down over vision and/or an increase in floaters/flashers.
• Surgery is needed immediately

Macular Degeneration

• Central vision is affected while peripheral vision remains intact.
• It is associated with aging changes to circulation, metabolism, and tissue atrophy.
• Objects may appear less bright.
• A blurred area in CENTRAL vision that grows over time while the periphery is intact will form, and blank spots are apparent.
• The Amsler grid is used for screening age-related macular degeneration.
• Perception of wavy lines indicates macular degeneration.
• Patients should screen themselves daily at home to monitor progression.

Charles Bonnet Syndrome

• This involves visual hallucinations secondary to vision loss, similar to phantom limb syndrome.
• It isn't attributed to cognitive impairment or mental illness.
• Pharmacological treatment of the hallucinations is not recommended due to significant side effects.
• The syndrome often resolves over time as the body adjusts to the loss.

Dry Eyes

• Normal age-related changes should be ruled out as well as Sjogren syndrome.
• It is caused by the reduction of goblet cells.
• Artificial tears, saline, or surgery in extreme cases act as treatment.
• Moist air in the home, avoiding hair dryers, and vitamin A ointments serve as nursing care.

Overall Nursing Interventions for Vision

• Prioritize safety by labeling patient doors and modifying the home.
• Ensure annual dilated eye examinations.
• Encourage the use of glasses and corrective devices, and remove contact lenses daily
• Use text-to-speech devices when patients cannot see well.
• Provide ophthalmology referrals and community support.

Hearing Issues in Older Adults

• These include sensorineural hearing loss and conductive hearing loss.

Sensorineural Hearing Loss

• It involves damage to the inner ear or neural pathway to the brain.
• Presbycusis or age-related hearing loss is the most common form.
• Noise-induced hearing loss is also a factor.
• The hallmark symptom is difficulty separating normal speech from background noise.
• Treatment involves hearing aids or cochlear implants.

Conductive Hearing Loss

• This occurs due to obstruction that stops sound transmission to the ear caused by abnormalities of the external and middle ear.
• Common causes are otosclerosis, infection, eardrum perforation, fluid, and cerumen.
• Treatment is to fix the obstruction like mineral oil ear drops to remove earwax by pulling the tragus up and back.

Tinnitus

• The cause of this condition is unknown, but exposure to loud noises is the biggest risk factor.
• Other causes are ototoxic medications, head/neck trauma, tumors, cerumen, CVD, and jaw issues.
• Hearing aids are used in some cases to amplify environmental sounds.
• Holistic treatments include hypnosis, CBT, chiropractor, acupuncture, and naturopath.

Overall Nursing Intervention for Hearing

• Involves caring for hearing aids due to high costs.
• Involves using assistive listening and adaptive devices.
• Assessing non-verbal cues and providing screening due to low rates.

Metabolic Disorders: Thyroid General Considerations

• Blood tests like TSH, T3, and T4 determine the levels needed for diagnosis.
• Older adults often use lower doses of levothyroxine
• Hypothyroidism symptoms (feeling cold, dry skin, hair loss, decreased metabolic rate) can be masked by normal aging changes.

Hypothyroidism

• Occurs when the thyroid gland fails to produce an adequate amount of thyroxine.
• Causes include autoimmune Hashimoto's disease and radioiodine therapy.
• Symptoms include heart palpitations, slowed thinking, and gait changes.
• Treatment includes thyroidectomy, medications, and addressing pituitary or hypothalamic problems.

Hyperthyroidism

• Occurs when the thyroid produces excess thyroxine.
• Causes include autoimmune Grave's disease, iodine ingestion or amiodarone use.
• Symptoms include unexplained AFIB, angina, signs of heart failure, constipation, anorexia, and muscle weakness.
• Apathetic thyrotoxicosis leads to slowed movements and depressed affect.
• Treatment, indicated for younger adults, is typically not performed in older adults due to operative risks.
• Cardiac issues should be considered such as increases in myocardial O2 consumption, angina and Afib.

Older Adult Considerations With Diabetes

• Glucose takes longer to break down.
• Therefore, the glucose tolerance test is rarely used.
• Diagnosis requires physical assessment, HGA1C, fasting sugars, and results from 2-3 tests on different days.
• T2D later in life is often insidious, potentially with organ damage already.
• Older adults may tolerate hypoglycemia and hyperglycemia better and are more likely to have changes in functional abilities.
• Early signs will involve dehydration, delirium, and confusion.
• Incontinence is also common with hyperglycemia.
• Every diabetic should wear a medical bracelet.
• A1C target is 8-8.5% in older adults.
• Blood pressure in patients should be screened every 3 years.
• Sulfonylurea is inappropriate due to the risk of hypoglycemia.
• Metformin use requires monitoring renal function and avoiding in patients over 80y or with CKD.
• It is best practice is to use long-acting insulins, while sliding scales are inappropriate.

Emerging Evidence in Metabolic Disorders

• HBA1C is not a true measurement in some ethnicities like African, Mediterranean, and Asian.
• Also not always reliable with kidney or liver failure.

Chronic Illness Trajectory

• Denotes the time between diagnosis and death.
• Proposes holistic interventions based on this.
• It takes the perspective of a life course rather than an isolated event. Functional status indicates the level of an older adult's functional status over time.

Sudden Death

• Level of functional ability remains stable until an acute change occurs.

Terminal Illness

• Functional ability slowly declines.

Organ Failure

• A chronic illness that leads to period of remission and exacerbation cycle.

Frailty

• A low functional ability continues to decline until death.

Chronic Illness: Intro

• The prevalence of seniors living with chronic illness is increasing rapidly.
• Onset is insidious, and progression is slow.
• This involves cycles of exacerbations and remission.
• Often deaths are preventable with proper management.
• Diminished quality of life can range from minor inconvenience to severe disability.

Treatment of Chronic Illness

• It is viewed as a life course perspective.
• It is seen as an integrated area rather than an isolated event.
• Encompasses elements of wellness and illness, sometimes simultaneously.
• Nurses educate on disease management.
• Chronic illness can be prolonged with treatment, but is not curative.
• Nurses need to respond promptly to acute events.
• Education on modifiable risk factors is extremely important.
• Patients need to be seen as more than their disease.

Assessments That Are Often Missed

• Sexual function, oral health, geriatric syndromes, depression, environmental safety, alcohol and drugs use.
• Driving, hearing, and vision loss screening, and genetic assessments should also be noted.

Cardiovascular and Respiratory Assessment

• Carotid arteries may appear enlarged, even when they are actually not, due to diminished subcutaneous tissue.
• Kyphosis will alter lung auscultation and faint S4 is common.

Peripheral Vascular and Abdominal

• Lower extremity edema makes palpation of pedal pulses difficult and requires a doppler.
• Assess for other indications of vascular integrity.
• Disposition of fat around the abdomen can make auscultation of bowel sounds hard.

Neurological

• Diminished Achilles tendon reflex and decreased vibratory sense in lower extremities are normal.
• Muscle strength may decrease with age, but it should remain bilateral and miosis should be expected.

FANCAPES Assessments

• Fluids: Assess hydration and capacity to consume and maintain optimal fluid health. Note reduced thirst.
• Also look at mechanical issues with swallowing and ensure good excretion.

Aeration

• Assess SpO2 levels - note SpO2 can be incorrect should Raynaud's be present.
• Also assess respiratory status while performing ADLs and supplemental O2 challenges.

Nutrition

• Diet, texture, fluid consistency and the presence of feeding assistance should all be noted.

Communication

• Hearing and vision assessments, assistive devices, reading comprehension levels, cognitive impairment, and speech or SLP help a lot.

Activity

• Ability to partake in enjoyable activities should be noted as well as mobility devices.

Pain

• Physical, psychological, or spiritual pain rarely occurs in only one domain.
• Assess ability to communicate the presence of pain relief of pain and post intervention .
• Incorporate cultural barriers.

Elimination

• Difficulties with bowel and bladder function are not normal part of aging and are commonly seen in the older adult population.
• Causes: Immobility, meds, and environment.
• Ensure toileting safety, and assess for incontinence and the impact on social well-being.

Social Status

• Assess function in society, and giving and receiving love.

Cognitive Ability in Older Adults

• The Minni Mental State Exam can indicate if there is cognitive impairment.
• It is not a sole diagnostic indicator for dementia diagnosis.
• It should be administered in the patient's native language for best results.
• Used to screen for mild moderate and severe impairment.
• Higher scores indicate no cognitive impairment.
• The Monteral Cognitive Assessment (MoCA) shows higher sensitivity.
• Ensures delivery in the pts native language.
• Should be used to test for mild, cognitive impairment.
• Both screen for 6 things: Orientation, short term memory, attention, calculation ability, language and visual special proficiency.

Nursing Considerations for Cognitive Assessments

• Consider speech, vision, dexterity, education level, and ability to hold pencil.

Clock Drawing Test

• The result should be used to check for apraxia, a sign of dementia, and not as a SOLE diagnostic test.
• Assesses visual spatial awareness and is used in the MoCA.
• Its use is contraindicated in those who are blind, have tremors, or CVA affecting the dominant side.
• Requires number fluency. *

Geriatric Depression Scale

• Demonstrates the interconnectedness between dementia and depression.
• De-emphasizes physical complaints that can occur due to medication side effects.
• Contraindicated for those with cognitive impairment.

Functional Ability

• Includes assessments of ADLs and IADLs which requires a higher level of thinking like with shopping.

Geratirc Syndrome Assessment

• SPICES acronym: Sleep disorders, Problems w eating/feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown

RAI/MDS Assessments

• Provides a comprehensive health, social and functional profile of a person in LTC.
• PSWs document ADLs to track patterns and baseline status.
• RN/RPN do RAI assessment often quarterly

Documentation

• Transition b/w EMR is lagging behind in LTC
• Advanced directives should be documented.
• Check for underdiagnosis or overdiagnosis if the nurse if not aware of normal age related changes.
• Must be challenging in medically complex older adults.

Pain in the Older Adult

• It was previous thought that older adults experienced less pain then younger adults
• Most common pain is chronic, nociceptive, and musculoskeletal, usually arthritic in nature.
• Older adults actually have increased sensitivity to pressure.

Mangement of Chronic Pain

• Often, fear of addiction is noted, but there is nothing wrong with narcotics when used appropriately.
• Most often, pain goes untreated or undertreated on LTC homes.
• Quarterly pain assessments are not enough.

Pain in Cognitive Impairement

• Those with mild to moderate dementia may be able to verbalize pain if prompted but will often not bring it up on their own.

Painad Assessment

• Assessment is based on breathing pattern, negative vocalizations, facial expression, and ability to console.

Relief From Pain

• Chronic pain may persist, and it may not be possible to come up with a complete 0 - need to access what an acceptable level of pain is for them to still function and do their own self care Cautious of polypharmacy's since older adults have altered drug absorption, excretion and comorbid conditions Pain diaries are encouraged

Non-Pharmalogical Treatment

• Always try FIRST - massage, acupuncture, heat or cold, distraction and relaxation/meditation

Biofeedback

• There should cognitive ability - no indicated with dementia pts,
• Physical-psychological connection is powerful.

Falls in the Older Adult

• Fractured Hips and TBI's are the most detrimental consequenses.
• Check Gait, orthopedic and foot conditions.
• Orthostatics, Cognitive, Vision and hearing.

Safety Issues

• Hypothermia & Hyperthermia.
• Driving and Dementia Ethics?-
• Wandering (Silver Alert System).

Bowel and Bladder Health

Role of the Nurse

• Staff needs to recognize how often incontinence is occuring.
• What methods are occuring for treatment.

Types of Bowel Issues

• Stress: Leaking Urine with coughing or increasing pressure.
• Urge: Needing to go right away and not being able to hold it.
• Overflowing- Not being able to feel or start.

Meds

• Increase water through
• Contradictions with what they may already take
• Ensure the drug is taken for the correct reason

Nursing Interventions

• Ensure products are readily avaliable
• Use propper language
• What actions can be combined in order to make sure they properly use the restroom/

Bowel Care

• Constipation, medications, and stool softness