Exam 14 - Health and Wellness of Older Adults (part I)

Older Adulthood Defined

• Older adulthood is divided into four subgroups: young-old (65-74 years), middle-old (75-84 years), old-old (85-99 years), and elite-old (100 years and older).
• Individuals older than 75 years of age with health concerns are referred to as frail elderly.
• Centenarians are those over 100 years of age.
• Chronic age might not accurately predict health or behavior.

Demographics

• In 2015, 47.9 million people were 65 years of age and older in the US, representing more than 14.9% of the population.
• The US Census Bureau estimates that by 2050, there will be 83.7 million people over the age of 65 living in the US, more than double the number today.
• In 2015, the life expectancy in the United States was 79.3 years.
• Life expectancy for Americans has increased by almost 10 years in the past 50 years.
• The population of older adults (ages 65 and older) has grown twice as quickly as the rest of the population in the past two decades.

Wellness, Health Promotion, and Disease Prevention

• Wellness is more than just the absence of disease.
• It involves a balance among the individual’s emotional, spiritual, social, cultural, and physical states.
• Health promotion takes a positive approach to health and emphasizes the strengths, resources, and abilities of an individual.
• Primary prevention includes exercise, a well-balanced diet, and recommended vaccinations.
• Secondary prevention focuses on early detection and treatment of disease, including screening for hypertension, cancer, and polypharmacy.

Healthy Aging

• Most myths about aging are generalizations that focus on the negative aspects.
• Research has proved many of these myths inaccurate.
• Biologic theories attempt to explain why the body ages, while psychosocial theories try to explain the responses and interactions older adults have with society during late adulthood.
• Ageism is prejudice against older adults.

Legislation that Affects Older Adults

• The Social Security Act of 1935 aimed to provide financial security for older adults.
• The Older Americans Act (OAA) of 1965 was established to preserve the rights and dignity of older citizens.
• The National Family Caregiver Support Program provides resources to address the growing needs of caregivers.
• The Patient Protection and Affordable Care Act (ACA) of 2010 encourages payment for preventive services to Medicare recipients and provides a drug discount for eligible seniors.

Psychosocial Concerns of the Older Adult

• Caregivers are at high risk for stress-related problems, including depression, anxiety, and increased vulnerability to physical health problems.
• The "sandwich generation" are caregivers to both their parents and their children.
• Older adults experience significant psychosocial changes related to role changes, retirement, and the loss of significant others.
• Short-term or long-term depression may result from grief from real and perceived losses.
• Nurses who work with older adults assist the entire health care team to meet the physical, spiritual, and psychosocial needs of dying patients or residents.

Aging Body

• Physiologic changes affect a person’s biologic, psychological, social, and environmental status.
• Inactivity is the most important contributor to declining physical mobility and function.
• Positive lifestyle modifications, including physical activity and proper nutrition, help optimize physical abilities and promote healthier aging.

Integumentary System

• Age-related changes in the integumentary system include dry and thin skin, loss of tone and elasticity, age spots, graying and thinning hair, thicker and more brittle nails, and changes in touch sensation.
• Susceptibility to infection, ecchymosis, and tearing increases with aging.
• Wounds heal more slowly than those in a younger adult.

Skin Assessment

• Examine skin for color changes, moisture, temperature, lesions, and turgor
• Note the presence, location, and amount of exudate
• Examine lesions for changes in size, color, or shape
• Lesions that are irregularly shaped, raised, crusted or pitting, or bleed easily should be examined by a dermatologist
• Observe hair for excessive loss, dryness, or oiliness
• Observe the nails for color, length, shape, symmetry, and cleanliness
• Nursing interventions are indicated to manage cleanliness, excessive length, sharp edges, brittleness, increased thickening, and color changes

Pruritus

• Older people may report dryness and itching (pruritus) of the skin
• This is more common in cold, dry weather because of reduced glandular secretions and moisture
• Soap tends to be drying, older adults should use soap sparingly and rinse the residue completely away
• Antibacterial soap is very drying and usually is not a good option
• Skilled nursing facilities may have schedules for showering and shampooing
• On nonshower days a partial bath is provided, which includes the washing of face, hands, axillary region, and perineal area
• Less frequent bathing is recommended for sedentary older adults because of a decrease in body oils and perspiration
• Water-based or light oil-based lotions, rather than alcohol-based lotions, are best to use
• Application of water-based lotions to dry areas, especially after bathing, usually increases most individuals’ comfort and avoids the feeling of oil residue that some people find uncomfortable

Moles

• Most moles are benign
• Sun-related skin changes, including precancerous actinic keratosis, basal cell or squamous cell carcinoma, and malignant melanoma, sometimes develop on sun-exposed areas
• Ask a dermatologist to examine any suspicious-looking lesions

Nail Abnormalities

• Bilateral clubbing of fingers indicates possible pulmonary or cardiac disease
• Yellowed nails indicate possible fungal infection
• Splintered nails indicate possible malnutrition, and pitting sometimes signals peripheral vascular disease, psoriasis, diabetes mellitus, or syphilis
• Brittle nails are often associated with fluctuations in hormones that occur during menopause

Pressure Injury

• More than 2.5 million US residents develop pressure injury every year
• Pressure injury is a significant risk for older adults and patients with chronic disease
• Thin skin and lack of subcutaneous fat predispose older adults to pressure injury development when their fragile skin is compressed between bony prominences of the body and other objects
• Damage to the skin at these pressure points is best prevented by repositioning the patient at least every 2 hours
• Many pressure-reducing pads and aids are available, but only those that do not restrict circulation or create pressure on surrounding areas should be used
• Fragile skin bruises and tears easily
• Measures should be instituted to prevent pressure, friction, shearing forces, and moisture
• Friction occurs when fragile skin rubs against the bed sheets
• Gentle handling during turning and transfer is necessary
• Additional assistance or equipment may be needed to lift and move a resident to avoid friction burns and tearing of the skin during repositioning in bed
• The use of tape on the skin of older adults should be kept to a minimum, because fragile skin can easily tear in the process of removing tape
• Urine, drainage, or fecal material left in contact with the skin even for a short time potentially causes the skin to become impaired
• Urine and stool tend to accelerate the formation of pressure injury at pressure points such as the coccyx or hip
• Urine, drainage, and fecal material must be removed, and the skin washed, rinsed with clear water, and patted dry
• Prevention and healing of any pressure ulcer depend on good nutritional status and adequate hydration
• A well-balanced diet with attention to protein, vitamins, and minerals plays an important role in maintaining skin integrity in the older adult

Patient problems and interventions for a resident with pressure injury:

• Patient Problem: Potential for Compromised Skin Integrity, related to fragile skin associated with aging
  • Nursing Interventions:
    • Perform daily skin inspection
    • Reduce frequency of bathing
    • Use mild, nonirritating soaps, and rinse thoroughly
    • Use emollients and lotions to maintain skin moisture
    • Turn and reposition frequently
    • Move and transfer carefully
    • Reduce sources of pressure
    • Keep linens clean, dry, and free from foreign objects
• Patient Problem: Compromised Skin Integrity, related to inadequate nutritional intake
• Patient Problem: Potential for Infection, related to impaired skin integrity
  • Nursing Interventions:
    • Assess nutritional intake
    • Explain importance of nutrition
    • Provide adequate protein, vitamins, minerals, and fluids
    • Assess wounds daily, including size, location, and depth
    • Obtain wound cultures if appropriate
    • Follow strict aseptic technique when performing wound care per the health care provider’s orders
    • Use photographs to document healing or changes in pressure injury

Gastrointestinal System

• A balanced diet provides fuel for the body
• Good nutrition is essential to health, function, and quality of life, regardless of age
• An inadequate or imbalanced diet can be tied to numerous chronic conditions, including obesity, hypertension, diabetes, cancer, and cardiovascular disease
• Older adults may experience a reduction in the sense of taste and smell
• Medications may alter the taste of foods or result in a decrease in saliva production
• Older adults living alone may report a lack of interest in preparing solo meals or may have limited financial resources to obtain nutritional foods
• These occurrences contribute to undernutrition
• Inactivity, boredom, and mental health concerns may result in excessive food consumption
• This may result in overnutrition
• Assess the patient’s nutritional status
• Interventions for nutritional issues can help the older adult attain higher self-esteem, improved physical well-being, and a better quality of life

Age-Related Changes

• Older adults have decreased secretion of saliva and a diminished gag response, which increases the chances of choking and aspiration
• Many medications taken by older adults may compound the problem by further reducing saliva production
• The stomach of the older adult has decreased gastric motility as well as decreased production of bicarbonate and gastric mucus
• Aging also can cause decreased production or lack of production of the intrinsic factor causing the body to become unable to use ingested vitamin B12, leading to pernicious anemia
• Enzymes in the intestinal tract also are altered
• The abdominal wall becomes less firm, and abdominal muscles weaken
• Decreased tone of the intestine occurs, and it is common for peristalsis to become slower, leading to increased constipation
• The normal changes of aging often are intensified by medications commonly prescribed for other conditions, lack of fluids or dietary roughage or fiber, and lack of exercise or activity
• Liver function often decreases, making drug metabolism less efficient

Assessment

• Assess oral cavity for presence of lesions; dental caries; loose, broken, or missing teeth; dentures that do not fit well; edematous gums; and halitosis
• Assess ability to chew and swallow
• Assess for reports of heartburn and nausea
• Assess dietary intake, especially of high-fiber foods, fat, and sodium
• Note amount and type of food and fluid intake
• Assess appetite
• Assess weight
• Compare with norms, and monitor for significant changes
• Assess frequency, amount, odor, and consistency of bowel elimination
• Assess abdomen for tenderness, distention, and active or diminished bowel sounds
• Ask about intestinal cramping
• Assess individual’s ability to control defecation
• Assess bowel elimination routines and use of laxatives
• An annual fecal occult blood test is recommended for adults more than 50 years of age for detection of colorectal cancer
• A stool DNA test may be completed for detection of colorectal cancer

Common Concerns and Nursing Interventions

• Obesity

  • Defined as weighing at least 20% more than ideal body weight, obesity is common in older adults
  • Older adults should consume less food than they did in their earlier, more physically active years
  • Adults 75 to 90 years of age need approximately 30 calories per kilogram of body weight, compared with 40 calories per kilogram for people 20 to 37 years of age
  • This normally represents a diet of 1800 to 2400 calories daily, depending on gender and ideal weight
  • Along with fewer calories, older adults need to consume quality foods, such as grains, vegetables, and fruits, which contain vitamins, minerals, roughage, and fiber, to meet their daily needs without large amounts of sugar and fat
  • They also need foods that provide protein and are good sources of calcium
  • Some foods are not as well tolerated because of changes in the digestive tract or difficulty with chewing or swallowing
  • Individual food preferences should be respected
  • A well-balanced diet is generally accepted as adequate without vitamin supplements
  • Vitamins A, C, and E and niacin may help slow the aging process, counteract the effects of free radicals, and extend life

• Weight Loss

  • Gradual weight loss over time is a normal response to loss of body mass
  • This typically occurs with changes in body composition of fat, muscle, and fluid
  • Decreased nutrient intake in aging because of decreased appetite, lower metabolic rate, and diminished energy output also produces weight loss
  • Rapid weight loss may indicate an illness and should be reported to the health care provider
  • Unexplained weight loss totaling more than 5% of weight in 6 months to 1 year necessitates a medical evaluation

• Fluids and Dehydration

  • Fluids are necessary for the body to function and to remove the waste products of metabolism
  • An older person needs a minimum of 1500 mL of fluids daily
  • Because of arthritis or other conditions, some older adults have difficulty pouring liquids and drinking from a cup
  • Older adults sometimes decrease their fluid intake to control incontinence or because of an illness such as heart failure
  • When fluid deficit is caused by the older adult trying to control incontinence, the most appropriate interventions are to make fluids readily available and toilet facilities more easily accessible
  • Arranging the room so that access to the bathroom is unobstructed often helps
  • Sometimes the older adult needs assistance to the bathroom on a schedule, usually every 2 hours during waking hours and every 4 hours at night
  • If needed, a commode or urinal should be placed where the person can easily use it
  • Older adults who have difficulty picking up a cup or bending the neck often find that an adapted cup with a double handle or a cutout for the nose is a good solution
  • Some older adults who are disoriented likely need to be prompted to drink
  • Those with severe impairments often must be assisted to drink fluids on a scheduled basis

• Oral Hygiene

  • Loss of teeth often is assumed to be normal in old age, but this is a misconception
  • It is not part of the normal aging process
  • Many of today’s older population matured before the introduction of many modern methods of dental prophylaxis, which affects their dental health in addition to individual oral hygiene habits and the possibility of untreated periodontal disease
  • In the future, with good oral hygiene practices throughout life, many people will maintain their natural teeth for life
  • Missing teeth make chewing difficult and tiring
  • Loose-fitting dentures tend to make chewing difficult and often allow food to collect under the denture, resulting in lesions
  • Both of these problems decrease a person’s desire to eat
  • Oral hygiene is essential to eliminate debris that has the potential to interfere with taste or cause lesions
  • Recommended mouth care for older adults consists of a thorough cleansing of the entire mouth with a soft-bristled toothbrush or foam-stick applicator in the early morning and at bedtime
  • Mouth care is also important when an older adult has dentures
  • In addition to cleaning the dentures, brush the gums and the tongue, and rinse the mouth
  • If dentures are damaged, loose, or exert pressure on the oral mucous membranes, refer the person for dental services

• Loss of Appetite

  • Older adults frequently experience a loss of appetite
  • Changes as a result of decreased saliva production and a decreased number of taste buds sometimes make food unappealing
  • Gastric motility slows because of the loss of smooth muscle in the stomach, which causes a delay in emptying time, distention, and early satiety
  • Anorexia and weight loss often result
  • In addition, many medications taken by older adults can produce side effects such as dyspepsia, nausea, vomiting, anorexia, diarrhea, and constipation, which affect the appetite
  • Interventions to counteract the lack of taste buds or the lack of interest in eating may include preparing the food with color and garnishes, using attractive dishes and table settings with good lighting and bright colors, and providing foods that have more seasoning if there are no restrictions
  • Encourage the patient or caregiver to prepare homemade frozen dinners from extra portions of a favorite meal as an easy and effective way to provide a meal that will be enjoyed
  • Individuals who have impaired mobility or activity intolerance that interferes with the ability to prepare food may benefit from community-based programs such as Meals on Wheels or home-delivered meals from a senior nutrition site
  • In addition, a wide variety of fresh, canned, and frozen foods in small or single servings is available in stores
  • Older adults should check the sodium content in canned or frozen to avoid consuming excessive amounts of sodium
  • For most individuals, eating also is associated with a social setting. Dining alone may make eating less appealing
  • When an older individual has lost a spouse, or is unable to leave the house, Despair, Grief, and Social Seclusion are patient problem statements to be considered
  • Interventions that may assist the older adult in improving nutritional intake include community meal programs, church dinners, or senior citizen programs that provide transportation, meals, and opportunities to socialize

• Gastric Reflux

  • Reflux occurs when the sphincter at the opening to the stomach becomes less efficient, which allows food and digestive enzymes to flow back into the esophagus
  • Symptoms include heartburn, sour stomach, and regurgitation of sour, bitter material
  • Reflux can be controlled by eating small meals, avoiding eating before bedtime, and elevating the head of the bed
  • Achieving and maintaining ideal body weight are also helpful

• Food Intolerance

  • Lactose, primarily found in milk, is a common source of food intolerance
  • Dairy products are an important source of calcium, which is needed to prevent osteoporosis
  • Lactose-intolerant individuals may need to replace milk with cheese and yogurt, which is processed and easier to digest

• Dysphagia

  • Difficulty swallowing (dysphagia) may arise from many possible causes, including a stroke or other neurologic dysfunction, local trauma, and obstruction with a tumor
    • Assessment should focus on whether the dysphagia is with liquids, solids, or both and on the time frame for the progression of the symptoms
  • The older adult often has more difficulty swallowing fluids or foods that contain firm foods in liquid such as soup than swallowing semisolid or solid food
  • Interventions for individuals who have difficulty swallowing include avoiding liquids, positioning, and verbal coaching
  • Thickeners can be added to liquids to improve the ability to control swallowing
  • The upright position, leaning slightly forward with the chin down, enlists the assistance of gravity to improve swallowing
  • Placing food on the unaffected side, reducing distractions in the room, and cueing the person to swallow are other ways to facilitate success

Patient problems and interventions for the older adult with gastrointestinal system changes:

• Patient Problem: Compromised Swallowing Ability, related to neurologic or vascular conditions

  • Nursing Interventions:
    • Refer to speech therapist for evaluation
    • Assess individual’s unique needs and problems
    • Verify condition of teeth or fit of dentures
    • Assist to sitting position with chin flexed toward chest
    • Allow adequate time for meals
    • Feed slowly
    • Give frequent verbal cues to swallow
    • Reduce distractions during meals
    • Keep suctioning equipment available in case of problems

• Patient Problem: Insufficient Nutrition, related to lack of interest in food

  • Nursing Interventions
    • Assess reasons for loss of interest, such as depression or grief
    • Monitor daily intake
    • Weigh weekly
    • Determine individual food preferences
    • Provide oral hygiene before meals
    • Serve meals in attractive manner; assist as needed
    • Supplement meals with nutritious snacks if permitted
    • Consult with dietitian
    • Provide for social interaction during meals

• Failure to Thrive

  • Failure to thrive in older adults is characterized by refusal to eat, loss of weight and lean body mass, and subsequent malnutrition
  • This complex situation is associated with mental disorders, such as dementia and depression, and social and economic factors

• Specialized Nutritional Support

  • A patient’s or resident’s inability to ingest, digest, or absorb nutrients is in some cases an indication for enteral tube feedings
  • Feeding tubes can be placed into the stomach or the small intestine
  • A nasogastric or nasointestinal tube is inserted through the nose
  • A gastrostomy tube or percutaneous endoscopic gastrostomy (PEG) is inserted directly through the abdominal wall
  • Another option is a jejunostomy
  • Standard enteral formulas contain whole proteins and complex carbohydrates
  • Other formulas contain modified protein (peptides) or amino acids
  • Enteral feedings sometimes are ordered short term after surgery, traumatic injury, or burns to improve nutritional intake

Feeding Tubes in Advanced Dementia

• Use of feeding tubes in cognitively impaired individuals is declining
• Use of feeding tubes is not recommended for patients with advanced dementia
• Use of feeding tubes decreased from 11.7% in 2000 to 5.7% in 2014
• Racial disparities exist in the use of feeding tubes
• 8.6% of white patients with advanced dementia had feeding tubes in 2000 compared to 37.5% of black patients
• Numbers decreased to 3.1% and 17.5% respectively in 2014

Gastrointestinal Cancer

• Follow-up and diagnostic testing is necessary with:
  • Change in bowel or bladder habits
  • Persistent oral lesions
  • Visible or occult blood
  • Indigestion or difficulty swallowing
  • Unexplained weight loss
  • Constipation
  • Persistent bloating
• Constipation is defined as infrequent or difficult passage of hard, dry feces
• Constipation can be acute or chronic
• Older adults often report deviations from perceived normal elimination
• Assessment of constipation includes fiber and fluids intake, medication usage, mechanical obstruction, activity, limitations, and depression
• Nursing interventions include adequate fluids, exercise, and a diet rich in fiber
• Bran is a good source of fiber and up to 10g per day can be included in the diet
• Example of patient problem and interventions for constipation:
  • Patient Problem: Infrequent or Difficult Bowel Elimination, related to inadequate intake of fiber and fluids
  • Nursing Interventions:
    • Assess frequency and consistency of bowel movements
    • Increase dietary fiber by encouraging cereals such as bran and fruits such as prunes
    • Determine fluid preferences
    • Keep fluids at bedside and offer frequently
    • Administer stool softeners as ordered

Fecal Incontinence

• Most common cause of fecal incontinence is fecal impaction associated with immobility, inadequate fiber and fluid intake
• Soft or liquid stool may ooze around the impaction
• Underlying diseases such as cancer, inflammatory bowel disease, colitis, and neurologic disease can also cause fecal incontinence
• Digital rectal examination might be needed to determine the cause

Gastrointestinal Bleeding

• Older people are more susceptible to gastrointestinal bleeding due to less protective mucus secretion
• Assess for blood in the stool presence of dizziness, pallor, tachycardia, or hypotension
• Rectal bleeding can be a sign of hemorrhoids, rectal fissures, or cancer
• Consider guaiac-positive stool an indication of pathologic disturbance until proven otherwise
• Laxatives, iron supplements, cimetidine, anticoagulants, aspirin and NSAIDS, and red meat may yield a false-positive guaiac result

Age-Related Changes in the Genitourinary System

• Overall kidney function decreases with age
• Body has adequate reserve to support normal functions, even with a 50% decrease, unless kidney disease is present
• Bladder capacity decreases by 50% with age
• Some older adult bladders only hold 150 mL
• Incontinence can happen due to decreased bladder capacity, increased urine residual, and increased bladder contractions
• Decreased bladder tone can lead to sensation of a full bladder quickly
• Urinary tract infections can also trigger incontinence, confusion can be the first symptom
• Urinary incontinence affects more than 17% of women and 11% of men over 65
• Perineal changes as estrogen levels decline in women:
  • Intercourse may become painful as the vaginal opening constricts and vagina shortens, loses tone, and dries
  • Abnormal postmenstrual bleeding may indicate endometrial cancer
• Enlargement of the prostate gland in men obstructs the flow of urine
• Scrotum becomes more pendulous in men
• Libido does not decrease in men, but erections may develop slower and orgasms become less intense

Genitourinary System Assessment

• Assess frequency, amount, odor, color and consistency of urine
• Assess individual's ability to control urination
• Assess satisfaction with sexuality and affectionate relationships

Common Concerns and Nursing Interventions in Genitourinary System

• Nocturia:
  • At least 50% of older men and 70% of older women have to get up at night to void
  • Decrease in bladder capacity may be associated with increase in voiding at night
  • May be associated with other factors
  • Nursing interventions include limiting fluids in the evening, diuretics in the morning, and preventing fall hazards when getting up to urinate
  • History of nocturia or increase in episodes necessitates medical evaluation for possible infection
• Urinary Incontinence:
  • Several types of incontinence include stress, urge, overflow, and functional incontinence
  • These types may occur in combination
  • Stress Incontinence: involuntary loss of small amount of urine with increased abdominal pressure, common in older women after multiple vaginal births or loss of muscle tone
  • Urge Incontinence: associated with cystitis, urethritis, tumors, stones, and CNS disorders, involuntary urine loss after sudden urge
  • Overflow Incontinence: chronically full bladder, accompanied by weak urine stream, difficulty starting to pass urine, interrupted voiding, or feeling of incomplete emptying
  • Functional Incontinence: inability to get to the toilet due to physical limitations, depression, or confinement to bed
  • Never reprimand or humiliate an older adult for having to urinate or accidents
  • Careful evaluation helps identify treatable factors
  • Treatment options include pharmacology, surgery, use of urethral inserts, transvaginal or transrectal electrical nerve stimulation
  • Behavioral therapies such as pelvic floor muscle training and bladder retraining can improve UI
  • Bladder retraining encourages gradual increase in time between voidings
  • Pelvic floor muscle training, also known as Kegel exercises, is effective for stress incontinence
  • Many other therapies are available for stress incontinence
  • Ensure older adults have frequent and easy access to bathroom
  • External collection devices, panty liners, or absorbent briefs can be used
  • Never refer to an absorbent brief as a diaper
• Patient problems and interventions for urinary system changes:
  • Patient Problem: Inability to Control Urination
  • Nursing interventions:
    • Collect bladder diaries
    • Assess circumstances that precipitate incontinence
    • Assess awareness of dribbling and ability to control urination
    • Assess general health, current medications, and past medical problems
    • Assess use of incontinence products
    • Assess for other urinary symptoms
    • Assess physical and mental factors that may cause the patient to be unable to get to the bathroom on time
    • Assess caregiver's willingness to participate in a behavioral program to treat incontinence
  • Patient Problem: Inability to Control Urination, due to physical stress
  • Nursing Interventions:
    • Encourage the patient to use the toilet at appropriate intervals
    • Teach pelvic floor exercises
    • Provide toileting assistance and incontinence supplies as needed
  • Patient Problem: Inability to Control Urination, due to urgency
  • Nursing Interventions:
    • Implement bladder training to increase awareness of the need to toilet
    • Encourage use of toilet at appropriate intervals
    • Provide information on urge inhibition
    • Teach pelvic floor exercises
    • Restrict caffeine intake
  • Patient Problem: Inability to Control Urination/ Urgency Due to Overflow
  • Nursing Interventions:
    • Allow sufficient time for voiding
    • Teach Credé’s method (manual expression of urine from the bladder) and encourage double voiding
    • Notify the physician for an order for assessment of postvoid residual
  • Patient Problem: Functional Inability to Control Urination
  • Nursing Interventions:
    • Teach caregiver to implement a prompted voiding program
    • Encourage fluid intake of 1500–2000 mL per day unless contraindicated
    • Modify environment to maximize the patient's ability to get to the bathroom
    • Obtain referral for physical or occupational therapy if indicated

Age-Related Changes in the Cardiovascular System

• Loss of structural elasticity
• Heart takes longer to contract and chambers fill
• Heart valves become thicker and more rigid
• Decrease in pacemaker cells, conduction is slowed or altered leading to dysrhythmias
• Resting heart rate tends to decrease
• Heart loses capacity to increase rate in response to exercise
• Arteriosclerosis develops, blood vessels become less elastic and lined with deposits leading to increased blood pressure
• Hypertension in the older adult was previously defined as systolic pressure ≤ 140 mm Hg
• In some studies, hypertension in the elderly is defined as systolic pressure of 150 mm Hg
• Patient's health care provider will determine the diagnosis of hypertension in the elderly based on individual factors
• Heart disease is the leading cause of death in the United States
• Risk factors include nonmodifiable (age, gender, family history) and modifiable (smoking, high blood pressure, high-fat diet, obesity, physical inactivity, and stress)

Cardiovascular System Disparities

• Stroke death rates have been decreasing, but the condition is a growing problem for African Americans
• More than 45% of African American men and women have cardiovascular disease
• Rate of stroke is twice that of whites
• African Americans with stroke are more likely to die

Cardiovascular system Assessment

• Assess for difficulty breathing
• Assess cough onset and duration
• Assess for signs of pallor, rubor, or cyanosis
• Assess for chest pain, including onset, duration, relationship to activity, character, location, radiating, and severity
• Assess apical and peripheral pulses
• Assess capillary refill time
• Assess for presence of vertigo, syncope, and fatigue
• Assess blood pressure in lying, sitting, and standing positions
• Assess for edema

Common Concerns and Nursing Interventions in Cardiovascular System

• Hypertension:
  • Contributes to coronary artery disease and stroke
  • Contributes to development of heart failure, renal failure, and peripheral vascular disease
  • Pharmacologic treatment for hypertension in those over 60 has decreased the incidence rate of coronary events
• Coronary Artery Disease:
  • Elevated serum cholesterol level is a risk factor
  • Total cholesterol of 130mg/dL raises cardiac disease risk
  • Decreasing saturated fat content in the diet helps reduce cholesterol levels
  • No more than 7% of calories should come from saturated fat, and no more than 200mg of cholesterol should be consumed per day
  • American Heart Association recommends 20 to 30 minutes of moderate intensity exercise three to five times per week
  • Advise older adults to begin an exercise program with a 10-to 15-minute warm-up
  • Walking is the best aerobic exercise
  • Encourage participation in cardiac rehabilitation programs
  • Cardiac rehabilitation involves several phases, from hospital to an outpatient setting

Patient Teaching for Cardiovascular Disease

• Assess knowledge and understanding of disease process
• Discuss diagnosis, symptoms, and potential complications
• Explain purpose, dosage, side effects, and special considerations of all prescribed medications
• Assess for modifiable cardiac risk factors and instruct the patient on the reduction of including:
  • Diet: Assess dietary intake, limit salt intake, limit canned or processed foods
  • Exercise: Implement an exercise as allowed by the healthcare provider. Seniors should attempt to engage in 150 minutes per week.
  • Obesity: Manage caloric intake to reduce BMI of 18.5–25.9 kg/m2
  • Smoking: Refrain from tobacco use. Avoid exposure to secondhand smoke
  • Diabetes Mellitus: Monitor blood glucose levels daily, Maintain prescribed dietary regimens, exercise as directed.
  • Psychological State: Identify sources of stress and changes that can be made to reduce stressors. Implement positive sleep hygiene habits to ensure rest.

Dysrhythmias

• Changes in heart structure, blood supply and pacemaker system can make the heart more susceptible to dysrhythmias
• Dysrhythmias cause the heart to be less effective in supplying blood to the body
• Dysrhythmias have the potential to lead to heart failure

Nursing Interventions for Patients with Dysrhythmias

• Frequent vital sign checks: This includes monitoring pulse rate, regularity, and strength.
• Accurate fluid intake and output (I&O) monitoring: This ensures proper hydration and helps identify fluid imbalances.
• Observation and reporting of older patient's medication response: This helps ensure the medication is effective and adjust dosages as needed.
• Minimizing stress on the heart: Includes monitoring the patient’s response to activity and providing appropriate rest periods.

Peripheral Vascular Disease

• Vascular changes affect arteries and veins in older adults: Conditions like spasms or atherosclerosis decrease blood circulation to tissues.
• Inadequate circulation can lead to cold feet, numbness, and intermittent claudication: This is cramping pain in the calves.
• Peripheral Vascular Disease (PVD) results from insufficient arterial blood supply to the lower extremities.
• Varicose veins are caused by weakened venous walls and valve malfunction: This leads to distention and inadequate valve closure.

Nursing Interventions for Peripheral Vascular Disease

• Techniques to promote circulation: Encourage walking to stimulate venous return, avoid prolonged standing, and don't cross legs.
• Compression stockings: These are used to support varicose veins.
• Interventions for skin ulcerations and altered sensation: Compression stockings, pneumatic compression pumps, Unna boots, foot and leg hygiene, protective footwear, and educating the patient on avoiding injury, as sensation to hot and cold is decreased.

Age-Related Changes in the Respiratory System

• Lung and bronchial tissues become less elastic and more rigid: This leads to reduced oxygen-carrying capacity and decreased vital capacity.
• Chest wall rigidity: Occurs due to rib immobility and calcification of cartilage.
• Weakened respiratory muscles: This contributes to decreased lung expansion and vital capacity.
• Decreased effectiveness of cilia: This increases difficulty in clearing secretions and the risk of respiratory infections.
• Kyphosis: An abnormal curve in the upper spine that restricts chest wall expansion.

Assessment of Respiratory System

• Assess depth, rhythm, and rate of respiration at rest and with activity:
• Inspect the chest for shape and symmetry, body position, and use of accessory muscles for respiration:
• Assess breath sounds for adventitious sounds like crackles and wheezing:
• Assess the patient's tolerance for activity:
• Evaluate breathlessness on a scale of 0 to 10:
• Assess the presence and characteristics of cough:

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is a combination of chronic bronchitis, chronic asthma, and emphysema: It is not a single disease but a progressive condition common in aging.
• Smoking history significantly increases COPD risk:
• Assessment findings: Diminished breath sounds, crackles, wheezes, and a "barrel chest" with an increased anteroposterior diameter.
• Nearly everyone has some degree of COPD by age 90:

Nursing Interventions for COPD

• Pulmonary hygiene: Encourage adequate fluid intake and teach diaphragmatic breathing and coughing techniques to improve airway clearance.
• Breathing retraining: Techniques like pursed-lip breathing to promote efficient exhalation and oxygen inhalation.
• Chest physiotherapy (CPT): Includes chest percussion, postural drainage, vibration, and rib shaking.
• Postural drainage: Positioning the patient head-down to facilitate drainage of pulmonary secretions
• Medications: Oral, metered-dose inhaler (MDI), and nebulizer administration.
• Oxygen therapy: Considered a medication, patients and families need to learn correct oxygen liter flow, usage, and equipment care.
• Lifestyle adaptations and ADLs: Encourage moderate-intensity exercise for 20-30 minutes three to five days a week, starting with very small increments.
• Additional interventions: Smoking cessation, avoiding air pollution, preventing infections, and receiving annual flu vaccines.

Pneumonia in Older Adults

• Pneumonia is a common and potentially life-threatening infection in older adults:
• Older adults may exhibit atypical signs like lethargy, disorientation, anorexia, and low-grade fever: Traditional symptoms like high fever, cough, pain, and headache may be absent or less pronounced.
• Interventions: Focus on fluid intake, prescribed medications, coughing techniques, turning, and deep breathing to improve gas exchange and prevent secretion stasis.

Lung Cancer

• Lung cancer is the leading cause of cancer deaths:
• Risk factors for lung cancer include: Tobacco or marijuana use, recurring inflammation, exposure to asbestos, talcum powder, radon, genetics, vitamin A deficiency, and air pollution.
• Small-cell lung carcinoma (SCLC) is the most common form: It can metastasize to the central nervous system, bones, and liver
• Early symptoms may be absent or attributed to other conditions: Nonspecific symptoms: cough, chest pain, and hemoptysis.
• Diagnosis: Based on clinical history and chest x-ray studies or CT scans.
• Treatment: Surgery for Stage I, and radiotherapy, chemotherapy, and laser therapy for other stages.
• Stage IV treatment is palliative:
• Nursing interventions: Pain management, emotional support, counseling, and discussion of treatment options.

Age-Related Changes in the Musculoskeletal System

• Gradual reduction in muscle fiber size and number: Leads to decreased muscle tone, mass, and strength.
• Joint stiffness and decreased flexibility: Caused by loss and calcification of cartilage.
• Imbalance between bone deposition and resorption: Results in bone loss and decreased density.
• Decreased estrogen levels: Increase bone resorption and decrease calcium deposition, exacerbating bone loss in women.
• Long bones and vertebrae are particularly vulnerable to bone loss:
• Narrowing of intervertebral spaces in the spine: Leads to height loss.
• Shift in center of gravity: Caused by changes in the lumbar curve.
• Increased fracture risk: Result of interconnected factors.
• Changes in gait: May occur due to structural and postural changes.

Assessment of the Musculoskeletal System

• Assess active and passive range of motion of each joint for stiffness and limitation of movement:
• Inspect joints for edema, erythema, pain, and crepitus: Note these findings with specific movements.
• Assess ability to perform personal care (eating, bathing, dressing, grooming, elimination) and other activities (housework, driving, climbing stairs, caring for pets):
• Assess standing and gait for balance, posture, base of support, step size, and turning ability:
• Inspect for limping, numbness, tingling, deformity, and changes in skeletal contour:
• Assess for muscle weakness, paralysis, tremors, spasms, clumsiness, muscle wasting, and muscle aches:
• Evaluate pain using a scale of 0 to 10: Note location, type, onset, aggravating factors, alleviating factors, and position of comfort.
• Obtain a history of falls, traumatic injuries, surgeries on joints or bones, and back problems:

Arthritis in Older Adults

• Rheumatoid arthritis: A systemic inflammatory disease that can affect individuals of any age.
• Osteoarthritis (degenerative joint disease): The most common type in older adults. Characterized by cartilage deterioration and new bone growth on the joint surface.
• Commonly affected joints: Hands, fingers, toes, knees, hips, and spine!

Nursing Interventions for Arthritis

• Joint protection and energy conservation: Combine rest and exercise for optimal management.
• Reduce morning stiffness: Warm baths or showers.
• Maintain muscle strength and joint motion: Encourage range-of-motion and other forms of mild exercise.
• Pain management: Heat or cold therapy, gentle massage, NSAIDs, nonopioid analgesics, and steroid injections into joints.
• Assistive devices: Splints, walkers, adapted utensils, and clothes with Velcro fasteners.
• Surgical options: Joint arthroplasty (replacement), joint fusion.

Hip Fractures in Older Adults

• CDC data (2016): One in five falls results in serious injuries (broken bones, head injury).
• Hip fractures are common in older adults: Other common fractures: vertebral and clavicular.
• Fractures classified as open or closed: This depends on location and type.
• History of trauma: Commonly precedes fracture development.
• Signs and symptoms of a fracture: Tenderness, edema, muscle spasm, deformity, bleeding, loss of function.
• Weakening of the femur from osteoporosis can lead to a hip fracture: This can even occur without a fall.
• Hip fractures are highly disabling for older adults: A significant number of affected individuals die within a year of the injury.
• Classifications of hip fractures:
  • Intracapsular (subcapital): Occur within the hip capsule.
  • Extracapsular: Occur below the capsule (intertrochanteric and subtrochanteric).
• Signs of a hip fracture: External rotation and shortening of the affected extremity, with tenderness and severe pain at the fracture site.
• Treatment: Immobilization and surgical repair (ORIF, prosthetic replacement) depending on the location and type of fracture.

Nursing Interventions Following Hip Fracture Surgery

• Vital sign monitoring and I&O monitoring:
• Respiratory interventions: Frequent turning, deep breathing, coughing, and incentive spirometer.
• Monitor the operative site for signs of infection and bleeding:
• Assess movement, circulation, and sensation of the extremity: Identify impaired circulation quickly.
• Monitor mental status: Be vigilant for postoperative delirium.
• Use opioids cautiously: Lower doses to prevent adverse effects like mental status changes, respiratory depression, and oversedation.
• Maintain extremity alignment: Use pillows between the knees or an abduction splint to minimize pain.
• Prevent hip dislocation: Avoid movements like crossing legs, adducting the legs, and activities that pose a risk of dislocation until healing and joint stabilization (6 weeks or more).
• Comprehensive rehabilitation: Focus on returning the patient to their previous level of function.

Rehabilitation After Injury or Illness

• Focus on gait and transfer training, muscle strengthening, and assistive devices
• Prevent depression by promoting independence and positive reinforcement

Osteoporosis

• Common condition in older women, characterized by low bone mass and deterioration of bone tissue
• Increased risk of fractures from routine activities like bending, lifting, or coughing
• Can cause loss of height and a C-shaped curvature in the spine ("dowager's hump")
• Begins in younger women and prevention starts in childhood with calcium and vitamin D-rich diets and weight-bearing exercise
• Bone density testing identifies individuals at risk and allows for preventive measures
• Avoid smoking, excessive alcohol, and limit caffeine intake
• Additional information available at www.nof.org

Osteoporosis Prevention in Women

• Hormone replacement therapy (HRT) can reduce estrogen deficiency during perimenopause, but has controversial side effects
• HRT may increase the risk of endometrial cancer, breast cancer, cardiovascular disease, and stroke

Osteoporosis Treatment

• Daily calcium intake of 1200-2000 mg and vitamin D intake of 600-800 IU recommended
• Deficiency in vitamin D is common in patients with hip fractures
• Bisphosphonates like alendronate, risedronate, zoledronic acid, and ibandronate are commonly prescribed to improve bone density

Patient Problems and Interventions for Older Adults with Musculoskeletal System Changes

• Patient Problem: Self-care deficit, related to weakness

  • Interventions:
    • Assess ability to perform self-care activities
    • Develop a plan to maximize function
    • Provide adequate time for activities
    • Utilize assistive devices as needed
    • Consult with physical and occupational therapy
    • Modify environment to facilitate self-care

• Patient Problem: Potential for Falling, related to age-related changes

  • Interventions:
    • Assess balance, gait, strength, medications, sensory issues, and mobility
    • Encourage regular, enjoyable weight-bearing exercise
    • Ensure good lighting and provide assistive devices like walkers or canes
    • Remove environmental hazards, clutter, uneven surfaces, and scatter rugs
    • Encourage slow transitions from lying to standing to minimize orthostatic hypotension (sudden blood pressure drop upon standing)

Test your knowledge on health, wellness, and demographic trends among older adults. This quiz covers various aspects such as life expectancy, care complexities, and misconceptions about aging. Challenge your understanding of the unique factors affecting the older population.