Assessing The Older Adult PDF

Chapter 24 Assessing the Older Adult Aging  In the United States, life expectancy for women is 81 years and for men it is 76 years.  Individuals over 65 years of age are considered older adults.  Advancing age puts a person at a higher risk for chronic illness and disability.  Older adu...

Chapter 24 Assessing the Older Adult Aging  In the United States, life expectancy for women is 81 years and for men it is 76 years.  Individuals over 65 years of age are considered older adults.  Advancing age puts a person at a higher risk for chronic illness and disability.  Older adults want to maintain their quality of life for as long as they are physically and mentally able to care for themselves.  Nurses should know the physiological changes occurring as individuals age. Older Adult  Types of disabilities seen in the older adult:  Hearing  Vision  Cognitive impairment  Ambulation/Mobility/Physical Activity  Self-care/Independent Living  Depression  Strength  Endurance  Nutrition  Sarcopenia – decrease in skeletal muscle mass  Sarcopenia obesity – decreased muscle mass with excessive body fat Geriatric Syndrome  Anorexia  Dementia  Dizziness  Falls  Frailty  Gait Instability  Impaired Cognition  Impaired hearing  Impaired vision  Malnutrition  Parkinson disease  Pressure ulcers  Sleep complaints  Vertigo Frail Elderly  Even though Frailty is associated with increasing age, aging is independent of frailty.  Frailty involves multisystem dysfunction  The most common geriatric syndromes are:  Urinary incontinence  Cognitive impairment  Pressure injury  Falls  Poly-pharmacy  Delirium  Weight loss Cultural Considerations  Cultural assessment will help to identify specific health care beliefs and practices of the older adult.  English may be a second language for older adults and the patient may have difficulty understanding.  Some cultures designate a specific family member to make all the decisions.  Collecting a Health  History This may be  Assess the reliability of the challenging both for patient. the patient and nurse.  Explain what you are doing  Older adults may have in simple terms. atypical presentations.  Ask short, simple, clear,  Older adults will often open-ended and focused share lifetime stories questions. and reminisce.  Secondary sources (family  Be respectful and or caregivers) may be needed to obtain the health acknowledge the older history. person; address them as Mr., Mrs., or MS. Or  Older adults may have another appropriate difficulty recalling title. information. General Health  Health: Appears healthy or with signs of illness or debilitation  Frailty, cachectic (wasting syndrome), tired may be a sign of acute or chronic illness.  Level of Consciousness: alert and oriented × 4 (person, place, time, situation); calm and cooperative.  Physical Appearance: (Normal)Age--patient looks stated age; Hygiene--well groomed, appropriately dressed for climate, no odors.  General Health  Mobility: Gait steady  Reliability: understands and symmetrical; no questions and can difficulty walking. answer  Use of assistive devices  Facial Expression: (e.g. walker, cane) relaxed with no signs of  Posture: stands discomfort straight; sits up straight  Speech: clear without support; range  Distress: No signs of of motion: ability to general discomfort or move all joints and pain; no signs of extremities; actively cardiac or respiratory participates in the distress. exam Preparation for Assessment  All patients should be addressed by their last name out of respect, unless the patient specifically says to call him or her by the first name  Working with older adults takes time; be patient and allow for extra time  Reduce background noise  Older adults experience feeling cold more often, only expose area being assessed  Minimize position changes  The review of systems and physical assessment for the older adult is the same as for any adult Focused Assessment  The assessment of the older adult is similar to any adult  You will need to be cognizant of geriatric considerations  Be alert to whether the patient is oriented, reliable or unreliable, and has physical or cognitive limitations  Expected Age Related Changes by Body system  Neurological  Integumentary (Skin) and Nutrition  Ear/Hearing  Eye/Seeing  Nose/Smell  Respiratory/Breathing  Cardiovascular  GI/Abdominal  GU/Urinary  Musculoskeletal(Movement)  Reproductive Neurological  The brain and spinal cord begin to lose nerve cells; nerve impulses slow down.  Decrease in sensations and reflexes  Decline in balance  Observe for tremors and involuntary movements Mental Status  Confusion  Sleep difficulties  Social and economic resources  Current living environment; isolation  Physical barriers or neglect  Changes in memory  Anger, irritability, inability to control frustrations  Loss of appetite  Depression Cognitive Assessment  Cognitive decline can cause changes in:  Short-term memory  Long-term memory  Changes in mentation such as confusion  Mini-Cog Assessment is a simple screening tool to identify early mental decline.  Uses a three-item recall test to assess memory and a simple scored clock- drawing test that takes about 3 minutes to administer.  Less affected by the older adult's ethnicity, language, and education Cognitive Disorders  Dementia  Alzheimer’s disease  Delirium  Depression  Geriatric depression scale is a 15-question assessment survey The Three D’s  Dementia: progressive, irreversible, decline in mental function; memory impairment.  Delirium: acute. Reversible state of disorientation and confusion; true medical emergency.  Depression: mood disorder marked by a loss of interest /pleasure in living. Common in older adults, but difficult to recognize because of less obvious symptoms. Skin and Hair  Skin changes are the most visible signs of aging  Epidermal layer becomes thinner and more fragile , blood vessels in the dermal layer become more fragile; transparent, pale, dry skin  Number of nerve endings in the skin decreases, causing decreased sensation  Decreased function of sweat glands; risk of hyperthermia/hypothermia  Sebaceous glands produce less oil, skin dry and pale  Subcutaneous fat layer thins, less insulation  Wrinkling of the skin  Aging hyperpigmented spots or lesions  Skin may wrinkle and tent when pinched; not an accurate test of skin turgor in older adults  Loss of pigmentation causes graying of hair Inspecting and Palpating the Skin  Hygiene, including body odor  Skin color  Cyanosis of lips, oral mucosa, and tongue  Pallor of lips, fingernails, and mucus membranes  Jaundice of lips, sclera of eyes, and rest of body  Temperature of skin, comparing sides  Skin turgor  Skin moisture  Lesions, rashes, scars, and masses Normal Findings: Skin  Solar lentigo (lentigines) are hyperpigmented macular lesions commonly seen on the sun-exposed body surface areas  Normal Findings: Skin  Cherry hemangiomas are small bright cherry red round spots seen on the trunk and extremities Normal Findings: Skin  Seborrheic keratosis is a non- cancerous pigmented waxy lesion; color ranges are from light tan, brown, or black Normal Findings: Skin  Cutaneous horn is caused by an overgrowth of keratin. Normal Findings: Skin  Senile purpura are areas of ruptured fragile capillaries and bruising of the skin. Abnormal Findings: Skin  Actinic keratosis is a rough, scaly patch that most often develop on chronically sun- exposed areas.  Shingles is caused by the varicella-zoster virus  Older individuals are at greater risk because their immune response decreases with age.  Tenting of skin commonly seen in the abdomen in older adults may indicate dehydration or weight loss.  May be more likely to be at risk for skin breakdown due to decreased cognition and chronic illness. Increased Risk for Skin Breakdown  Aging  Bony Prominences  Dehydration  Dry skin  Frailty  Reduced mobility/Immobility  Incontinence  Malnutrition  Reduced peripheral sensation  Weight loss  Cognitive impairment  Depression Inspecting the Mouth  Considerations that affect eating and can lead to weight loss  Decrease sense of taste  Slight decrease in saliva production causing dry mouth  Teeth wear down or fall out  Malocclusion of teeth  Poorly fitted or loss of dentures d/t resorption of gum ridge  Gums recede and trap food which can cause decay and periodontal disease which is linked to stroke and coronary artery disease  Buccal Mucosa  Hard and soft palate, pharynx, and tonsils  Tongue Assessing Swallowing  Older adults are at an increased risk for dysphagia (difficulty swallowing)  Sluggish gag reflex  Signs of dysphagia  Coughing  Drooling  Throat Clearing  Pocketing fluids on the side of the mouth  A speech therapist evaluates patients for dysphagia  Diet may consist of pureed or soft food and thickened liquids Nutritional Assessment  Older adults are vulnerable to  Malnutrition  Inadequate micronutrient intake  Sarcopenia – decreased muscle mass d/t decreased activity and decreased protein intake  Assess  Loss of/decreased appetite  Teeth or denture issues  Dysphagia  Sense of taste  Fluid intake  24-hour food diary Mini Nutrition Assessment  The Mini Nutrition Assessment (MNA®) is the most validated nutritional screening and assessment tool that can identify geriatric patients aged 65 and above who are malnourished or at risk of malnutrition  Consists of only six questions  Available in several languages Question  You are assessing a 92 year-old patient with dementia. You note that he has lost 10 lbs. in one month. What lab work would you expect the health care provider to order? (Select all that apply.) A. Fasting blood sugar B. Complete metabolic profile C. Lipid panel D. Albumin and protein E. Vitamin B-12 level Answer  Correct answer: B and D  Complete metabolic panel to assess electrolytes and kidney functioning  Albumin and protein levels to assess nutritional stores  Fasting blood sugar, lipid panel, and vitamin B-12 level are not routinely ordered to assess weight loss. Hearing in the Older Adult  Hearing loss affects approximately one third of adults 61 to 70 years of age and greater than 80 percent of those older than 85  Hearing loss declines because cells within the organ of Corti are not replaced resulting in gradual hearing loss as a person ages  Degeneration of hair cells of inner ear  Cerumen production decreases, leads to dryness and accumulation  Tympanic membrane dull gray and less flexible  Conduct the Whispered Voice Test to assess for impairment or loss  Presbycusis  Difficulty hearing with background noise and when other people are talking at once Question  The most common cause of hearing loss in older adults is: A. Tympanic membrane becomes more flexible. B. The malleus, incus, and stapes does not vibrate. C. Cells within the Organ of Corti are not replaced. D. Increased production of ear cerumen Answer  Correct answer: C  Hearing begins to decline because the cells within the organ of Corti are not replaced. Vision in the Older Adult  Difficulty adapting to darkness; creating an increased risk of stumbling or falling  Seeing in dim light becomes more difficult, need for brighter light to see  Sight begins to decline  Slower pupillary reflex  Loss of color discrimination  Decreased tear production leads to dry eyes  Difficulty reading small print and locating objects; impaired near vision  Ptosis - drooping of the eyelid  Cloudy/grayish ring around the iris is normal for aged  Cataracts - opacity and clouding of the lens  Glaucoma – loss of peripheral vision  Macular Degeneration – loss of central vision Assessing Vision in the Older Adult  Snellen Chart  Same eye assessment as adult  Amsler Grid – assessing central vision  Wear reading glasses  Hold chart at normal reading distance  Cover left eye  Focus on the dark spot in the center of the grid  Ask if any lines are broken, distorted, or blurred  Ask if there are any dark or missing areas in the grid  Ask if can see all corners and sides of the grid  Cover right eye and repeat the test  Mark on the grid the areas that the patient isn’t seeing correctly Amsler Grid- used to assess Macular degeneration  Respiratory System  Older adults are susceptible to respiratory diseases.  Decreased lung expansion  Vital capacity of the lung decreases  Decrease elasticity of the alveoli results in decreased perfusion  Less recoil and elasticity of the lungs  Decreased cough reflex  Decreased thirst leads to thickened mucus  Lungs have less ability to fight off infection  Overall musculoskeletal, mobility, and cardiovascular changes result in pulmonary function changes Cardiovascular  Heart & Blood Vessels  Predisposed to dysrhythmias d/t accumulation of fats, collagen, lipofuscin, amyloid in the pacemaker cells of the heart and a loss of pacemaker cells.  Blood pressure increases as elasticity in arteries decreases  Peripheral pulses of lower extremities may be diminished or non-palpable, likely d/t arterial insufficiency  Hair loss on lower extremities with aging not always an indicator of arterial insufficiency  Prominent bulging veins and spider veins are common  Abdomen (GI/GU)  Older adults may suffer from chronic constipation d/t decreased motility, activity, fluid intake, fiber, and medications; ask your patient about diet, exercise, medications, and remedies to relieve constipation.  Increased risk for gallstones related to biliary sludge build up.  Older adults may have a decline in kidney functioning which puts them at risk for urinary incontinence.  Types of Incontinence: Stress Urgency Functional Overflow Urinary Incontinence  Stress – leaking small amounts with intraabdominal pressure; coughing, sneezing, exercising  Urge – sudden urge to urinate  Overflow – caused by weakened bladder muscle or urethral blockage, causing an overflow of urine; incomplete emptying of the bladder  Functional – unable to control bladder before reaching the bathroom d/t limitations with mobility or cognition Question  A 72 year-old female patient with Parkinson’s disease is embarrassed to wear adult pads. She is having increased tremors, difficulty walking, and getting to the bathroom as needed. Identify the type of incontinence. A. Stress B. Functional C. Urge D. Overflow Answer  Correct answer: B  Functional incontinence occurs more often with older individuals with chronic arthritis, Parkinson’s disease, or Alzheimer’s disease. These individuals are unable to control their bladder before reaching the bathroom due to limitations in moving, thinking, or communicating. Musculoskeletal  Bones become less dense leading to an increased risk for osteoporosis. Joints lose cartilage and connective tissue, muscles degenerate/atrophy, and tendons and ligaments stiffen.  *Bone changes may be influenced by decreased intake of calcium, vitamin D, medications (e.g., steroids), smoking, and lack of weight-bearing exercises.  Height loss is related to aging changes in the bones, muscles, and joints  Decreased range of motion Common Musculoskeletal Disorders  Osteoarthritis (OA) is the most common type of joint disorder in the world affecting over the age of 65. It is a progressive disease often referred to as “wear and tear arthritis”.  Rheumatoid Arthritis is a progressive inflammatory autoimmune disorder that destroys the joints and causes deformity.  Osteoporosis is a progressive disease where the bone matrix isn’t replaced by new bone; bone mass and density decrease which can lead to an increased risk for fractures.  Kyphosis “humpback” “hunchback” exaggerated curvature of thoracic spine; problems with posture, gait, and balance Get Up and Go Test/Timed Up and Go Test  Purpose: To assess patient’s gait, balance and risk for falling  Equipment: Chair with arm rest, watch or clock with a second hand  Explain to the patient that you will be giving him or her commands to follow and that this is a timed test.  Give the patient one time to practice. Get Up and Go Test  Say “Go,” to the patient and start timing the test.  Give the command, “Stand up from the arm chair.”  Give the command, “Walk in a line for 3 meters or 10 feet.”  Give the command “Turn around.”  Give the command, “Walk back to the chair.” Get Up and Go Test  Give the command,” Sit down.”  Time the second effort while assessing:  Postural stability  Gait  Stride length  Sway  Get Up and Go Test Normal Findings Abnormal Findings  Completes task in <  Completes task in > 12 10 seconds seconds.  Low scores correlate  High scores correlate with good functional with poor functional independence. independence and higher risk of falls. Sleep Assessment  Insomnia and changes in sleep patterns are part of the normal aging process.  Assess  Sleep patterns  Difficulty falling asleep  Frequent awakenings  Feeling rested  Napping  Medications  Sleep apnea Fall Risk Assessment  Older adults are at greater risk for falls due to sensory, gait, and cognitive impairments.  Risk factors:  Advancing age  Cognitive impairment  Environmental factors  Functional limitations  Gait Instability  Incontinence  Medications  Muscle weakness and fatigue  Chronic illnesses  Previous fall history  Fall Assessment-When a fall has occurred.  Priority Assessments:  Assess airway  Assess breathing  Assess circulation  Assess whether the patient hit his head  Assess vital signs  Assess whether the fall was witnessed or unwitnessed  Mnemonic for Falls  S: Symptoms experienced at the time of the fall  P: Previous number of falls or near-falls  L: Location of falls  A: Activity engaged in or attempted at time of fall  T: Time (hour) of fall  T: Trauma (e.g., physical or psychological) associated with falls  Assessing Frailty  Frailty develops because Assess the patient for the of the age-related decline presence of three of the eight in many physiological components: systems. 1. Unintentional weight  Emotional loss 2. Decreased activity and  Adults at risk for becoming engagement frail are individuals with 3. Self-reported the following impairments: exhaustion  Medical 4. Low energy expenditure  Nutritional 5. Weakness  Cognitive 6. Balance and gait  Activity abnormalities 7. Cognitive impairment 8. Slow walking speed Psychosocial Assessment  Areas to assess with special gerontological considerations  Functional status  Living arrangements  Social interactions  Driving  Alcohol use  Elder abuse  Sexuality  Functional Assessment  Functional status is the patient’s ability to care for themselves and meeting essential tasks for daily life.  Barthel index of basic activities of daily living (ADL) is considered a “core” to functional assessment Residential Living  Assess  Type of living arrangement  Live alone or with someone  Feeling of being safe  Plan for help or emergency medical care Social Interactions  The National Institute on Aging (2013) recommends provisions for social support and involvement in social activities to foster positive effects on the older adult's health and longevity  Ask about  Spouse or significant other  Family involvement and interactions  Friends  Community activities  Driving Assessment  Motor vehicle  If the older adult injuries are the drives, ask about leading cause of  Reading signs injury-related deaths among 65-  Seeing street to 74-year-olds. markings, cars  and people at Be alert to “red different times flags,” that is, any of the day/night. medical condition, medications, or a  Handling symptom that can headlight glare affect driving skills. at night  AARP has  Seeing at night documented  Getting lost warning signs when while driving an older adult should stop driving.  Alcohol Use  Alcoholism is more challenging to assess and diagnose due to  Chronic illness  Polypharmacy  Cognitive disorders  Adults over age 65 who are healthy and do not take medications should not have more than:  3 drinks on a given day  7 drinks in a week  Use the CAGE questionnaire   Growing and underreported Elder problem  The older adult is particularly Abuse vulnerable to elder abuse because they are more likely to suffer acute or chronic conditions resulting in physical or mental impairments.  National Center on Elder Abuse (NCEA) identifies seven types of elder abuse.  WE ARE MANDATORY REPORTERS as NURSES!  Sexuality  Sexuality does not end, but continues in older adulthood.  Discussing sexual interest and function is a very sensitive topic to discuss with the older patient.  Ask about  Expression of sexuality  Concerns or questions about sexual needs  Has the sexual relationship changed Medication Assessment  Polypharmacy is an ongoing problem  Assess use of  Multiple medications  Prescribers  Pharmacies  Forms of medications  Reason for taking the medication  Dosing  Nonadherence to regimen  Expiration dates Pain Assessment  Older adults are able to give reliable self- reports of levels of pain.  Pay attention to cognitive status.  Some patients are reluctant to report pain.  Observe nonverbal body language. Common Problems in Older Adults  “SPICES” assessment/screening tool to alert the nurse to some of the more common nonspecific indicators of disease in older adults  Sleep disorders  Problems with eating & feeding  Incontinence  Confusion  Evidence of falls  Skin breakdown Question  You are working in a physician’s office. You are assessing a 93-year-old woman who lives alone. She is wearing two different shoes, no socks, and her shirt is on backwards. What assessment should you perform to determine her functional status? A. Mini Nutritional assessment B. Driving assessment C. Barthel Index assessment D. Alcohol assessment Answer  Correct answer: C  The Barthel index of basic activities of daily living (ADL) is considered a “core” to functional assessment. Question  You are assessing a 82-year-old hospice patient who is very weak, thin, and wheelchair bound. You know that patients that are this frail are at risk for (select all that apply): A. Falls B. Disability C. Social isolation D. Hospitalization E. Mortality Answer  Correct answer: A, B, D, E  Frailty develops as a consequence of age- related decline in many physiological systems. Frail individuals are at high risk for falls, disability, hospitalization, and mortality. Healthy People 2030  Goal: Improve the health, function, and quality of life of older adults  Handouts given to older adults should be easy to read; font may need to be larger than 12 font  Due to poor eyesight or illiteracy, some older adults cannot read; ask the patient to read a portion of the handout to you to assess ability to read and follow directions.