Exam 14 - Health Promotion of Older Adults (Part II)

Endocrine System Age-Related Changes

• Hormone levels and tissue response to hormones change with age.
• Thyroid disturbances, like hypothyroidism and diabetes mellitus, are common in older adults.

Endocrine System Assessment

• Monitor laboratory results for abnormal calcium, glucose, or thyroid hormone levels.

Diabetes Mellitus

• There are two types of diabetes mellitus: type 1 and type 2.
• Type 2 is more prevalent, affecting 85-90% of adults with diabetes.
• Older adults with type 2 may not exhibit classic symptoms like thirst, increased appetite, or frequent urination.
• Initial signs and symptoms could include:
  • Repeated infections
  • Slow healing
  • Blurred vision
  • Weight gain or loss

Type 2 Diabetes Mellitus Interventions

• Focus on achieving and maintaining stable metabolic control through diet management, weight control, and exercise.
• Diabetic education should cover topics like:
  • Medication
  • Disease process
  • Blood glucose monitoring
  • Signs and symptoms of hyperglycemia and hypoglycemia
  • Sick-day management
  • Foot care
  • Eye care
  • Complications
• Active involvement from patients and families promotes information retention and compliance.
• Encourage personalized diets that meet recommendations while accommodating personal preferences.
• Aim to achieve and maintain a healthy BMI and weight.
• Weight reduction decreases insulin resistance.
• Advise individuals to balance intake with recommended protein, carbohydrates, fats, vitamins, and minerals.
• Encourage limiting refined sugar and opting for a high-fiber diet.

Foot Problems in Older Adults with Diabetes

• Older adults with diabetes are at greater risk for foot problems due to changes in peripheral nerves and blood vessels.
• Inadequate blood flow to the feet and nerve damage can lead to ulcers and infections.
• High blood glucose levels (200 mg/100 mL or higher) are associated with altered immune system responses.
• Peripheral neuropathy presents as abnormal sensations, numbness, and burning in the extremities.
• Neuropathy increases with age, especially in individuals with diabetes.
• Decreased pain awareness, temperature sensitivity, and circulation create a high risk for injury.
• Untreated injuries can easily become infected and potentially require amputation.
• Activities that promote good circulation include:
  • Avoiding smoking
  • Avoiding constricting footwear
  • Keeping legs uncrossed

Foot Care for Older Adults with Diabetes

• Recommend daily foot cleansing with non-drying agents.
• Encourage daily foot inspection for blisters, cuts, or infections using a mirror.
• Cut or file nails straight across to prevent skin injury.
• Suggest regular visits to a podiatrist or healthcare provider for foot inspections.
• Individuals with neuropathy, hyperglycemia, or a history of foot infections should seek immediate medical attention for any sign of injury or infection.

Hypothyroidism

• Aging affects thyroid gland function.
• Over time, thyroid function may become impaired.
• Neoplasms, hypothyroidism, and hyperthyroidism are more likely with aging.
• Clinical symptoms of hypothyroidism and hyperthyroidism are subtler in older adults.
• Approximately 20% of people over 65 years old experience thyroid problems, with hypothyroidism being the most frequent.
• Decreased thyroid function often presents subclinically and is identified through routine serum testing.
• Most cases are inconspicuous and develop slowly towards thyroid failure.
• Common signs of hypothyroidism in older adults include:
  • Unexplained elevated triglycerides or plasma cholesterol
  • Nonspecific cognitive impairment
  • Slow metabolism
  • Chest pain or atrial fibrillation
  • Constipation
  • Macrocytic anemia
  • Vague arthritic complaints
  • Cold intolerance
  • Depression with apathy and withdrawal
• Treatment aims to stabilize thyroid levels using medication (levothyroxine).
• The practitioner monitors response to therapy by measuring thyroid-stimulating hormone (TSH) levels.
• Nursing interventions focus on:
  • Patient and family education about disease signs, symptoms, and medication therapy
  • Careful medication management

Reproductive System Age-Related Changes

• The primary reproductive system changes associated with aging involve diminished estrogen and progesterone levels in women and decreased androgen and testosterone levels in men.
• Aging diminishes sexual function, but does not eliminate it.
• Hormone deficiencies affect arousal, orgasm, post-orgasm responses, and genitalia in both sexes.
• While it takes longer for men to achieve arousal, erection, and ejaculation, they retain sexual function well into their 80s and 90s.
• Menopause in women is characterized by:
  • Decreased hormone levels
  • Inability to procreate
  • Tissue atrophy of ovaries, fallopian tubes, cervix, and vulva
  • Decreased vaginal secretions
  • More alkaline vaginal pH

Assessing Sexuality in Older Adults

• Holistic care necessitates open discussions about potentially sensitive topics, including sexuality.
• Integrate sexual assessment into routine nursing assessments.
• Begin with a general statement acknowledging the ongoing sexual needs of older adults.
• Use open-ended questions to explore the patient's sexuality.
• Examples of questions include:
  • "Tell me how you express your sexuality."
  • "What concerns do you have about fulfilling your continuing sexual needs?"
  • "In what ways has your sexual relationship with your partner changed as you have aged?"
• The PLISSIT model can be used to assess and manage adult sexuality.
• The PLISSIT model involves:
  • Obtaining permission to initiate sexual discussion.
  • Providing limited information necessary for sexual function.
  • Giving specific suggestions for sexual activity.
  • Providing intensive therapy related to sexuality issues.
• The goal of assessment is to gather information that allows individuals to express their sexuality safely and without inhibition.

Nursing and Sexuality

• Nurses and nursing students often feel uncomfortable assessing the sexual desires and functions of older patients.
• However, a sexual assessment is a crucial component of routine nursing assessments.
• Skill and comfort develop with practice.

Reproductive System Assessment

• Assess:
  • Past sexual experiences or difficulties
  • Sexually transmitted infections (STIs)
  • Signs of vaginal or penile ulceration, edema, or discharge
  • Presence of breast lumps, dimpling, or drainage

Sexual Function in Older Adults

• Misconceptions about older adults being impotent, asexual, or perverse if sexually active contribute to sexual dysfunction.
• Regular sexual activity maintains the capacity for sexual response.
• For vaginal dryness, suggest estrogen creams or water-soluble lubricants to alleviate discomfort.

Sexuality and Aging

• Research and information from various sources indicate that aging individuals can be sexual, maintain interest in sex, and are indeed sexual beings.
• The lack of a sexual partner is often the primary factor for decreased sexual activity in older adults.
• Sexuality encompasses:
  • Sexual identity as a man or woman
  • Intimacy (emotional closeness to others)
  • Touch
• Regardless of age, feeling good about oneself as a male or female and having close relationships is important.
• Sexual intimacy goes beyond intercourse and includes:
  • Caressing
  • Stroking
  • Kissing
  • Emotional companionship
• A positive correlation exists between sexuality and physical health.
• Preserving sexual activity and function contributes to health promotion.
• To better assist patients and their partners, reflect on your own feelings about sexuality and aging and familiarize yourself with age-related changes in sexual function.
• Support the sexuality of older adults by:
  • Encouraging and assisting them to look their best
  • Complimenting them when they look nice
  • Respecting and allowing their privacy
  • Allowing their expressions of affection
  • Using touch to communicate acceptance
• A pat on the arm or a hug can communicate concern and caring to most individuals.

Interventions for Impaired Sexual Expression in Older Adults:

• Patient Problem: Impaired Sexual Expression, related to lack of privacy
• Nursing Interventions:
  • Allow verbalization of concerns regarding sexual needs
  • Provide privacy for interaction between alert, consenting individuals
  • Assist individuals to maintain good physical hygiene and meet cosmetic needs
  • Provide distraction and alternative activities for disoriented individuals who masturbate; if ineffective, provide privacy.

Sensory Perception Age-Related Changes

• Sensory systems provide a link with the environment by receiving and interpreting various stimuli, including vision, hearing, taste, and smell.
• Visual and hearing impairments can interfere with communication, social interactions, and mobility, leading to social isolation.
• Modern sensory classifications acknowledge more than the five traditional senses (sight, hearing, taste, smell, and touch).
• Two major sensory categories:
  • General senses: touch, pressure, pain, temperature, vibration, and proprioception
  • Special senses: sight, hearing, taste, smell, and balance
• Sensation, or perception, refers to the conscious awareness and interpretation of sensory stimuli by sensory receptors.

Vision Age-Related Changes

• Visual changes increase with aging, particularly after 65 years.
• Changes include:
  • Pupil reduction in size
  • Difficulty adjusting to changes in room lighting
  • Decreased effectiveness of eye muscles, leading to changes in visual acuity
  • Reduced ability to distinguish colors of similar hues
  • Decrease in tear production
  • Visual impairments can lead to injury from falls
  • The four leading causes of visual impairment are: cataracts, glaucoma, macular degeneration, and diabetic retinopathy.
  • Undiagnosed visual disorders are increasingly common in older adults, especially ethnic and cultural minorities.
• Age-related vision changes include:
  • Presbyopia (farsightedness due to lens elasticity loss)
  • Narrowing of peripheral field of vision
  • Decreased ability to focus on near objects
  • Decreased visual acuity as the pupil shrinks and becomes less responsive to light
  • Lenticular clouding
  • Yellowing of the lens
  • Changes in color perception, making it difficult to differentiate shades of green, blue, and violet.
  • Distorted depth perception
  • Difficulty with vision in dim light
• General vision screening for those wearing glasses or contact lenses involves observing them reading print from a newspaper.
• Note the distance at which they hold the newspaper and verify their ability to see print clearly.
• Poor vision requires a more detailed eye examination.
• While age-related changes decrease visual capabilities, blindness is not a normal consequence of aging.

Glaucoma

• Glaucoma, the second leading cause of blindness in the United States, is caused by blocked drainage of fluid in the anterior chamber of the eye, leading to increased intraocular pressure.
• This pressure affects the optic nerve, potentially causing damage or blindness.
• Primary open-angle glaucoma, the most common type (90% of cases), can gradually reduce vision without pain, leading to undetected damage to the optic nerve.
• Visual loss begins with deteriorating peripheral vision.
• Early diagnosis allows for control and prevention of serious visual impairment.

Acute Angle-Closure Glaucoma

• Acute angle-closure glaucoma occurs suddenly due to a complete blockage in the aqueous humor pathway.
• Signs and symptoms include:
  • Severe eye pain
  • Erythema (redness)
  • Clouded or blurred vision
  • Nausea and vomiting
  • Rainbow halos around lights
  • Pupil dilation
  • A steamy appearance of the cornea
• Severe problems arise when intraocular pressure rises above 50 mm Hg (normal range is 10-22 mm Hg).
• Without emergency medical attention, severe vision loss occurs within 2 days, potentially leading to blindness.
• An iridectomy is a viable option to reduce intraocular pressure.

Managing Glaucoma

• Medical follow-up and eye medication are required lifelong.
• Eye drops are crucial even in the absence of symptoms.
• After administering eye drops, apply pressure to the lacrimal duct for 1 minute to prevent rapid systemic absorption.
• Use a medical alert bracelet or card to identify glaucoma and the prescribed eye drop solution.

Cataracts

• Cataracts are the most common disorder in aging eyes.
• An estimated 50% of individuals have cataracts or have undergone corrective surgery by age 80.
• A cataract is a clouding of the normally clear and transparent lens of the eye.
• Degenerative changes in lens proteins and fatty deposits (lipofuscin) are contributing factors.
• The lens focuses light on the retina to produce a sharp image.
• Cataracts can make the lens opaque, blocking light transmission to the retina.
• The size and location of a cataract determine the degree of interference with vision.
• Symptoms include:
  • Dimmed, blurred, or misty vision
  • Need for brighter light to read
  • Sensitivity to glare and light

Cataract Management and Treatment

• Treatment is conservative until visual impairment affects daily activities like reading and driving.
• Surgical options include:
  • Ultrasound to break the lens into small fragments for removal through a tiny incision
  • Placement of a permanent, plastic intraocular lens to restore vision
• Cataract surgery is highly successful

Hearing and Balance

• The organs of hearing and balance can be divided into three parts:
  • External ear
  • Middle ear
  • Inner ear
• The inner ear is involved in both hearing and balance.
• Hearing loss is not a normal part of aging and requires evaluation.

Hearing Impairments in Older Adults

• Hearing impairments are frequent in older adults.
• Losses can be sudden or gradual.
• Around one-third of individuals between 65 and 74 years old have a hearing impairment.
• This number increases to nearly half the population for those over 75 years old.
• Aging causes rigidity of the ossicles, leading to elasticity loss.
• Atrophic changes in the auditory nerve and inner ear end organs affect hearing.
• Exposure to loud noises throughout life and age-related changes often lead to hearing loss in specific tones, causing certain sounds to be distorted or absent.
• Older adults frequently deny their hearing loss and require encouragement and support to explore solutions for improvement.

Cerumen Impaction

• Cerumen impaction is a reversible, often overlooked cause of conductive hearing loss.
• Assess for itching and a feeling of ear fullness.
• Removing the blockage can restore hearing acuity and alleviate symptoms.
• Removal involves:
  • Instillation of a softening agent
  • Ear irrigation using a syringe device on a low setting
  • Drainage of excess fluid from the ear

Hearing Loss Categories

• Hearing impairment falls into three categories:
  • Conductive hearing loss: sound transmission interruption through the external auditory canal and middle ear, often due to cerumen impaction, otitis media, or ossicle fixation.
  • Sensorineural hearing loss: dysfunctional inner ear, auditory nerve, brainstem, or cortical auditory pathways, resulting in misinterpretation of sound waves.
  • Mixed hearing loss: conductive hearing loss superimposed on sensorineural hearing loss.

Presbycusis

• Presbycusis is a sensorineural hearing loss and the most common form in older adults.
• It is typically bilateral, causing difficulty hearing high-pitched tones and conversational speech.
• The sounds most frequently lost first are f, s, th, ch, and sh.
• As hearing loss progresses, sounds like b, t, p, k, and s become difficult to distinguish.
• The cause is uncertain.
• Signs of hearing loss include:
  • Increasing the volume of the television or radio
  • Tilting the head towards the speaker
  • Cupping a hand around the ear
  • Trouble following conversations with multiple speakers
  • Watching the speaker's lips
  • Speaking loudly
  • Not responding when spoken to
• Diagnosis involves audiometric evaluation.
• Treatment options include:
  • Cochlear implant surgery
  • Hearing aids
  • Auditory rehabilitation to facilitate communication

Interventions for a Safe Environment

• Interventions such as removing trip hazards and providing assistive devices can improve safety and prevent falls for individuals with Parkinson's disease.
• Difficulty with communication and frustration can arise from tremors and involuntary movements.
• Providing time for an individual to respond and using nonverbal communication can help alleviate frustration.

Transient Ischemic Attacks (TIAs)

• TIAs are temporary blockages in brain blood vessels.
• Symptoms, such as vision changes, headache, and balance issues, last for varying durations.
• One in three individuals who experience a TIA has a stroke within five years.

Stroke

• Stroke is the third leading cause of death and becomes more likely after age 55.
• Risk factors include heart disease, diabetes, and physical inactivity.
• Symptoms can include hemiplegia, dysarthria, dysphagia, sensory changes, aphasia, and emotional changes.

Nursing Interventions After Stroke

• Focus on rehabilitation to regain independence and address ADLs.
• Older adults may require use of the non-dominant hand and assistive devices.
• Communication strategies for individuals with aphasia include careful listening, reducing distractions, using gestures, and speaking slowly.

Patient Problems and Interventions Related to Neurologic Issues

• Compromised Verbal Communication: Provide a calm, distraction-free environment, use gestures, touch, and familiar music to enhance communication.
• Excessive Demand on Primary Caregiver: Assess family support, establish opportunities for respite, access community resources, provide stress management strategies, and assess for signs of depression.
• Inability to Perceive or Use One Side of the Body: Position bed on the unaffected side, provide range-of-motion exercises, and adapt the environment to focus on the unaffected side.

Safety and Security Issues for Older Adults

Falls

• Falls are the leading cause of accidental death for individuals over 65.
• Approximately 25% of adults over 65 experience falls annually.
• Factors contributing to falls include decreased circulation to the brain, diminished coordination, decreased ability to balance, and slowed nervous system responses.

Fall Prevention Strategies

• Encourage regular exercise that focuses on strength, balance, and endurance.
• Maintain a hazard-free environment, including assistive devices like walkers and canes.
• Teach older adults to rise slowly from a seated position to avoid orthostatic hypotension.

Polypharmacy

• Polypharmacy refers to the use of five or more medications.
• The risk of adverse effects increases with each additional medication.
• Age-related changes in body function can impact medication absorption, transport, and elimination.

Nursing Interventions Related to Polypharmacy

• Assess the older adult's ability to take medications properly.
• Monitor for medication interactions and signs of toxicity.
• Teach safe medication practices to homebound older adults and their caregivers.

Elder Abuse and Neglect

• Refers to violence against individuals over 65.
• Classification includes physical, sexual, psychological, financial, medical abuse, and neglect.
• Indicators include unexplained crying and fear of a specific person.
• Mandatory reporting laws exist for elder mistreatment.

Finances

• Health care costs are a significant concern for older adults.
• Medicare and Medicaid can provide financial assistance.
• Limited income and savings can pose challenges for affording rising costs.

Housing

• Housing is a significant part of self-concept for older adults.
• Relocation can be stressful and involve adapting to more restrictive environments.
• Options include downsizing, assisted living, and moving in with family members.

Assisted Living Facilities

• Assisted-living facilities provide more assistance than independent living environments, but do not offer 24/7 skilled nursing care.
• Assisted-living facilities cost more than independent living, but less than skilled nursing homes.
• The average monthly cost of an assisted living facility exceeds $3000.
• Skilled nursing long-term care facilities have an average monthly cost of 6500to6500 to 6500to7500.

Continuum of Older Adult Care

• The aging population is increasing, leading to an increased demand for healthcare resources.
• Approximately 80% of older adults have a chronic illness, with half having at least two chronic conditions.

Hospitalization, Surgery, and Rehabilitation

• Older adults have a higher risk of complications from hospitalization and surgery due to age-related changes.
• Complications include drug reactions, falls, infections, and delayed healing.
• Older adults have less reserve to cope physically and emotionally with the impact of hospitalization and surgery.
• Postoperative recovery and convalescent periods are longer for older adults.
• Measures to prevent complications of immobility and techniques to support coping skills and independence are crucial for older adults undergoing surgery.
• Frequent turning, deep breathing, coughing, and early ambulation are important for older adults to prevent complications from immobility.
• Encourage older adults to participate in self-care activities at their own pace, with rest periods.

Discharge Planning

• Older adults need adequate knowledge, skills, and resources to manage self-care needs at home upon discharge.
• Discharge planning begins with assessing biophysical, psychosocial, educational, self-care, and environmental needs.
• Strategies depend on the individual's physical and emotional readiness to learn, their educational level, and available family and community resources.
• Written or visual guidelines should be provided to reinforce verbal instructions.
• Active engagement in the learning process enhances learning.
• Preserving autonomy is a priority.
• Consider the individual's physical strength and functional abilities before modifying the home environment.
• Patient teaching should consider alertness, fatigue, individual strengths, pain, impaired joint motion, sensory impairments, and need for adaptive devices.

Home Care

• Hospital stays are becoming shorter for most illnesses.
• Early discharge of older adults can present challenges.
• Community-based services may be necessary to promote independence and support home return.
• Medicare home healthcare benefits require homebound status, a need for skilled, intermittent care, and a referring healthcare provider's approval.
• Home health nurses assess physical, functional, emotional, socioeconomic, and environmental well-being.
• Home health nurses provide health and self-care teaching, including medication administration, wound care, and terminal care.
• Some home health nurses provide intravenous therapy, enteral and parenteral nutrition, and chemotherapy.
• Licensed practical or vocational nurses can provide skilled nursing care under the registered nurse's established plan.
• Home health aides provide personal care such as ADLs and hygiene.
• Personal care attendants are often hired for situations requiring only a sitter, rather than personal or skilled care.

Assisted Living

• Assisted living is a rapidly growing industry in the United States.
• It offers meals, assistance with bathing and dressing, social and recreational programs, laundry and housekeeping services, transportation, emergency call systems, health checks, and medication administration.
• Many services are purchased individually as needed by the residents.

Long-Term Care Facilities

• These facilities are often referred to as nursing homes or long-term care facilities.
• They provide a variety of care, including intravenous infusions, feeding tubes, ventilator care, wound vacuum-assisted closure devices, and peritoneal dialysis.
• Each facility's level of care and patient acceptance are based on the staff skillset and available resources.

Resident Characteristics of Long-Term Care Facilities

• Residents are individuals who live in these facilities temporarily or permanently.
• Many residents require nursing care until death.
• Approximately 1.6 million individuals live in these facilities in the US.
• Projections show a significant increase in this number over the next 30 years, particularly for those over 85.
• 67% of nursing facility residents are female.
• The majority (69%) are over 75 years old.
• Long-term care residents typically need 24-hour care, which is usually not possible at home due to the scope of needs and family limitations.
• Facilities provide medical, nursing, dietary, recreational, rehabilitative, social, and spiritual care.

Care Costs of Long-Term Care Facilities

• The average cost of a long-term care facility is influenced by location.
• The average cost for a semi-private room is $83,000 annually.
• Long-term care insurance, individuals, and state/federal Medicaid programs pay the majority of costs.
• Medicare covers the cost of the first 20 days of skilled and rehabilitative care.
• Medicare supplemental insurance is needed for co-pays for continued care beyond the initial 20 days.
• Medicaid provides coverage for residents who qualify.
• Government officials are addressing concerns about the sustainability of these costs.
• Future legislation will likely focus on this issue.

Quality of Care in Long-Term Care Facilities

• Long-term care facilities are highly regulated by the Omnibus Budget Reconciliation Act (OBRA) of 1987 and subsequent revisions.
• OBRA requirements include comprehensive resident assessments, increased training for UAP, a greater number of nursing staff, availability of social workers, standards for administrators, and quality assurance activities.
• Legislation protects residents' rights, which are mandatory to be communicated to them and protected by staff.
• The Long-Term Ombudsman Program supports residents' rights and facilities.
• Residents' rights include autonomy, informed consent, withdrawal or withholding of life-sustaining treatments, and the right to choose their own healthcare providers.
• Interdisciplinary functional assessment of residents is essential in long-term care.
• The minimum data set (MDS) provides a comprehensive picture of each resident, including background information, cognition, physical function, mood, behavior, and medication use.
• The MDS information forms the basis for developing individualized care plans.

Bill of Rights for Long-Term Care Residents

• Residents have the right to voice grievances and see them resolved.
• They have the right to information about their health and participate in their care.
• They have the right to choose their healthcare providers and speak privately with them.
• They have the right to consent or refuse care and treatments.
• They have the right to manage their finances or choose a financial advisor.
• They have the right to transfer or discharge only for appropriate reasons.
• They have the right to be free from all forms of abuse.
• They have the right to be free from restraints, to the extent compatible with safety.
• They have the right to privacy and confidentiality concerning their personal information and medical information.
• They have the right to be treated with dignity and respect.
• They have the right to visitation and access for family, healthcare providers, and legal advisors.
• They have the right to reasonable visitation for others.

This quiz focuses on common misconceptions and health changes associated with aging, particularly regarding sexual dysfunction and diabetes management in older adults. It also addresses sensory perception changes and common conditions like glaucoma. Enhance your understanding of nursing interventions and dietary recommendations for elderly care.