LS CH 13 Late Adulthood PDF

7589_Ch13_195-220 29/08/17 11:59 AM Page 195 13 CHAPTER Late Adulthood Key Words Chapter Outline activity theory ageism aging antioxidants atrophy autoimmune theory cerumen clockwork theory continuity-developmental theory delirium dementia demographics disengagement theory dysphagia ego integri...

7589_Ch13_195-220 29/08/17 11:59 AM Page 195 13 CHAPTER Late Adulthood Key Words Chapter Outline activity theory ageism aging antioxidants atrophy autoimmune theory cerumen clockwork theory continuity-developmental theory delirium dementia demographics disengagement theory dysphagia ego integrity free-radical theory gerontology health care proxy homeostasis immune-system-failure theory integumentary system keratosis kyphosis lacrimal ducts life expectancy life span lipofuscin living will lumen melanocytes Theories of Aging Biological Theories Clockwork Theory Free-Radical Theory Wear-and-Tear Theory Immune-System-Failure Theory Autoimmune Theory Psychosocial Theories Disengagement Theory Activity Theory Continuity-Developmental Theory Natural Remedies Thought to Delay the Aging Process Physical Characteristics Height and Weight Musculoskeletal System Cardiovascular System Respiratory System Gastrointestinal System Dentition Integumentary System Nervous System Sensory System Genitourinary System Endocrine System Homeostasis Vital Signs Developmental Milestones Motor Development Sexual Development key terms continue on page 196 Psychosocial Development Changes in Body Image Changes in Family Roles Changes in Work and Leisure Changes in Sexuality The Inevitability of Death Cognitive Development Moral Development Nutrition Sleep and Rest Exercise and Leisure Safety Health Promotion Special Health Concerns Delirium Dementia Depression and Suicide Health Care Services Social Security Medicare and Medicaid Rights of Elderly People Summary Critical Thinking Multiple-Choice Questions Student Activity Learning Objectives A t th e e n d of th i s ch ap te r , y ou s h ou l d b e ab l e to: • • • Describe three demographic changes affecting the older population. Contrast the biological and psychosocial theories of aging. List four normal, physical, age-related changes that occur during this stage of development. objectives continue on page 196 195 7589_Ch13_195-220 29/08/17 11:59 AM Page 196 196 Journey Across the Life Span Key Words (continued) nephrons neurons old opacity peristalsis pruritus reminiscence residual volume senescence senile lentigo tinnitus very old wear-and-tear theory xerostomia young old Learning Objectives • • • • (continued) Describe two developmental milestones associated with aging. Describe Erikson’s psychosocial task for this period of development. List three dietary changes important for old age. List two health-promoting activities important for old age. “Old age,” as defined by the U.S. government and Social Security Administration, includes all people aged 65 and older. The statistical characteristics, or demographics, of the older population are constantly changing. Old age is best divided into three periods: the young old, ages 65 to 74; the old, ages 75 to 90; and the very old, ages 90 and older. As with earlier life stages, not everyone older than 65 is the same. Some 80-year-old adults lead active, productive lives, whereas others are unable to be active or independent because of illness. Chronological age is usually an unreliable indicator of mental, physical, and social well-being. Elderly people comprise the fastest-growing group in the United States today. In 2011 the number of persons 65 years and older totaled 41.4 million, and this number is projected to double to 92 million by 2060. This age group represented 13.3% of the U.S. population, or about one in every eight Americans. Since 2000 the elderly population has increased by 18%, as compared to a 9.4% increase in the population younger than 65. A dramatic shift in the ethnic composition of the elderly population is expected in the 21st century as a result of immigration patterns. Racial and ethnic minority elderly populations have increased from 5.7 million in 2000 to 8.5 million in 2011 and are projected to increase to 20.2 million by 2030. Of all of the ethnic groups, Asians have the longest life expectancy, followed by whites, Hispanics, African Americans, and Native Americans. There are several important health care implications based on these ethnic population projections. Language barriers are one of the major complications for our older, ethnically diverse population. Ethnic diversity also influences an individual’s decisions about his or her health care, course of treatments, and views on disease prevention. Many people remain living in their homes, with or without their spouses, or with their families until advanced age. In 2012 more than half (57%) of noninstitutionalized persons lived at home with their spouses. Only 28% of all noninstitutionalized older persons lived alone in the year 2012. The percentage of persons living alone increases with advanced age. In 2011 a total of about 2 million people lived in a household with a grandchild present. Of the population 65 and older in 2011, only 1.5 million (or 3.6%) lived in institutional settings. The percentage increases with age to 11% for persons 85 and older. In 2011 over half (51%) of persons 65 or older lived in 9 states: California, New York, Florida, Pennsylvania, Texas, Ohio, Illinois, Michigan, and North Carolina. Pennsylvania and Texas each have 2 million or more elderly residents, while Ohio, Illinois, Michigan, and North Carolina are each home to more than 1 million elderly adults. Older people are less likely to change their residences than are younger adults. Those who do usually move within a short distance from their present homes. 7589_Ch13_195-220 29/08/17 11:59 AM Page 197 Late Adulthood 197 Cost of health care is still another factor that influences older individuals and their health care choices. The major source of income for older couples and individuals in 2010 was Social Security followed by income from assets, then pensions, and then earnings. The median income in 2011 was $27,707 for men and $15,362 for women. In 2011, 3.6 million elderly persons (about 8.7%) were living below the poverty level. In 2011, 2.4 million elderly persons were poor or “near poor.” Of these, 18.7% were Hispanic, 17.3% were African American, 11.7% were Asian, and 6.7% were white. Life expectancy refers to the average number of years that a person is likely to live. The most accurate predictors of life expectancy are the ages of one’s biological parents. In 2011 the average life expectancy for persons up to age 65 had increased by 19.2 years (compared to previous years). This translates to an additional 20.4 years for women and 17.8 years for men. A person born in the year 2011 could expect to live 78.7 years, or about 30 years longer than an individual born in 1900. This increase in life expectancy since 1900 is largely a result of reduced death rates for children and young adults. In 1900 mortality was primarily from infectious diseases that affected infant and maternal mortality. In contrast, the leading causes of death in 2010 were cancer and heart disease, which commonly appear in older populations. Dietary practices during a person’s lifetime may also affect life expectancy. Obesity, smoking, and sedentary lifestyle practices increase the risk of early death. The goals of Healthy People 2020 are to improve the health, function, and quality of life. For the population of older adults in the United States, preventative health services are important for maintaining health care quality and patient wellness. exist with regard to the aging process. See Box 13.1 for a list of common myths about aging. The study of aging is called gerontology. No one concept completely explains the aging process or why we age. Many different theories have been developed to attempt to explain the mysteries of aging. Most provide guidelines for assessing a person’s adjustment to aging. Understanding aging helps nurses assess, implement, and evaluate care for elderly people. THEORIES OF AGING B Life span is best defined as the maximum number of years that a species is capable of surviving. Life span for humans is 120 years and has remained essentially unchanged for the past 100,000 years. The aging process begins at conception. This process leads to physiological impairment and eventual death. Aging is a normal, inevitable, progressive process that produces irreversible changes over an extended time. It is important to note that although all persons age, they do so at individualized rates. The symptoms of normal aging are referred to as senescence. Many myths and misconceptions still Common myths about aging include that most older people: Biological Theories Biological theories attempt to explain the physical changes that accompany aging. Clockwork Theory Laboratory studies have revealed marked differences in cell reproduction in different species. Cells in species known to have longer life spans reproduce more times than cells of species having shorter life spans. According to the clockwork theory, connective-tissue cells have an internal clock that is genetically programmed to stop cell reproduction after so many reproductions. This “clock” determines the length of one’s life. Free-Radical Theory The free-radical theory is based on the idea that highly unstable molecules may result from cellular metabolism or substances found in the atmosphere. These particles are very reactive and may combine with proteins, lipids, or cell organelles. Free radicals are believed to cause mutations in the chromosomes, thereby changing cellular functions. According to this theory, these free radicals then cause the breakdowns in the aging process. Antioxidants, such as vitamins C and E, are thought to prevent the formation of free radicals and are therefore considered important O 13.1 • • • • • • • • • • X Co mmo n M y ths Abo ut Ag ing Are senile Live alone, isolated from their families Are ill Are victims of crime Live in institutional settings Are set in their ways and cannot learn new skills Are unhappy Are less productive than younger workers Have no interest in sex Live at or below the poverty level 7589_Ch13_195-220 29/08/17 11:59 AM Page 198 198 Journey Across the Life Span dietary substances. The exact role that antioxidants play in the aging process remains unclear, however. Wear-and-Tear Theory The wear-and-tear theory suggests that after repeated injury, cells wear out and cease to function. According to this theory, metabolic waste products accumulate over time. These waste products deprive cells of their nutrition and cause them to malfunction. Immune-System-Failure Theory The immune system provides the body with antibodies and defenses against foreign invaders. The immune response declines with advancing age. The older body loses lymphoid tissue from specific locations in the body, including the thymus gland, spleen, lymph nodes, and bone marrow. The immune-system-failure theory hypothesizes that the decline in the immune functions causes the body to slow its response to foreign invaders, making elderly people more susceptible to both major and minor infections. Autoimmune Theory The autoimmune theory suggests that aging is related to the body’s weakening immune system, which fails to recognize its own tissues and may destroy itself. The immune system is programmed to recognize and differentiate its own proteins from foreign invaders. As an individual ages, the immune system appears to lose this ability. As a result, the body begins to attack and destroy its own cells— the autoimmune response. During old age there is an increase in the body’s autoimmune response. This is evidenced by a greater incidence of autoimmune diseases such as rheumatoid arthritis and possibly cancer. Psychosocial Theories however, believe that as older people’s levels of engagement decrease, their levels of contentment also decrease. Activity Theory The activity theory suggests that individuals achieve satisfaction from life by maintaining a high level of social activity and involvement. Supporters of the activity theory advise older individuals to find rewarding, pleasurable substitutes for earlier activities. They recommend that older adults remain active in a wide variety of pursuits. If activities must be given up because of age-related changes, replacements must be found. Failure to replace old activities or roles causes people to feel that they have no purpose or social importance. The activities that are most rewarding are those that involve close personal contact. By remaining active, an individual’s morale and personal adjustments are higher than those of people who are less active and involved, which may add to their life satisfaction (Fig. 13.1). Continuity-Developmental Theory The continuity-developmental theory views each person as a unique individual with a distinct personality. Continuity development refers to the belief that a person’s personality and pattern of coping remain unchanged with aging. The aging process is seen as a part of the life cycle, not as a separate terminal stage. Personality patterns are developed over a long time and help to determine whether the person remains active or inactive and engaged or disengaged from society. Knowledge of personality type may be helpful in predicting a person’s response to aging. The individual’s state of health will also determine how long he or she will remain active and satisfied. Illness may lead to retirement, social isolation, and decreased self-esteem. Psychosocial theories attempt to explain how aging affects socialization and life satisfaction. Disengagement Theory The disengagement theory suggests that society and the individual gradually withdraw or disengage from each other. Proponents of this theory believe that disengagement provides a means for an orderly transfer of power from the old to the young and that this process is mutually satisfying for both groups. Elderly people are relieved of their societal responsibilities and pressures, and younger people assume leadership. Critics of this theory, FIGURE 13.1 Couple relationships provide love and companionship. 7589_Ch13_195-220 29/08/17 12:00 PM Page 199 Late Adulthood 199 Natural Remedies Thought to Delay the Aging Process The following herbs and dietary supplements are used to treat or prevent diseases. Scientific studies have not yet confirmed their benefits or risks. Patients interested in using any natural remedy should check with their physician before taking any of these drugs. All of these substances should be used with caution and reserved optimism. • Ginkgo (Ginkgo biloba) is used to improve circulation and blood flow to the brain. • Saw palmetto (Serenoa repens) is used to prevent or treat prostate enlargement by helping to shrink the prostate gland. • St John’s wort (Hypericum perforatum) is recommended for relief of stress, anxiety, and depression. • Evening primose (Oenothera biennis) is recommended to treat signs and symptoms of menopause and dry skin. • Black cohosh (Cimicifuga racemosa) is used to reduce signs and symptoms of menopause. • Chondroitin sulfate and glucosamine are currently used by many people to help maintain cartilage. • Celery seed (Apium graveolens) is used to treat gout and arthritis. • Garlic (Allium sativum) is recommended to reduce blood pressure and cholesterol and to prevent blood clots. • Vitamin E is recommended to help prevent heart attacks and may prevent dementia. • Vitamin C has long been touted for its usefulness in reducing the severity of colds. PHYSICAL CHARACTERISTICS Quality of life is not determined by age but largely by a person’s ability to independently perform activities of daily living such as dressing, bathing, toileting, and eating. Health problems should not be viewed as inevitable because many can be prevented or controlled. Height and Weight Many signs of aging are evident in both the conformation and composition of the body (Fig. 13.2). Trunk length decreases as spinal curvature increases and the intervertebral disks become compact. This process actually begins much earlier: On average, adults lose 1 centimeter per decade FIGURE 13.2 Physical signs of aging vary with each person. after age 30. There is also a decrease in shoulder width in both sexes as a result of the loss of muscle mass in the deltoids. There is a slight increase in chest circumference resulting from the loss of elasticity in the lungs and in the thorax. The circumference of the head decreases, and the nose and ears lengthen. Body weight decreases slowly after age 55. Other changes include a loss of body surface area and of active cell mass. Older adults have 30% fewer cells than younger adults. There is atrophy (shrinking) of body fat, giving a bony appearance and a deepening of body areas in the axillae, rib cage, and orbital cavity surrounding the eyes. These changes in body composition are vitally important in helping to understand drug metabolism and nursing interventions for this age group. Decreased body surface area and body fat affect the dosage and rate of drug absorption. To accommodate these physiological changes, lower dosages of medication are used for older persons. Musculoskeletal System Postmenopausal women lose bone mass at a faster rate than do men, putting them at greater risk for osteoporosis. The typical person at risk for osteoporosis is the aging, thin, white, menopausal woman, although osteoporosis is now being investigated as a health risk for men also. Box 13.2 offers suggestions for reducing the risks for osteoporosis. Women 7589_Ch13_195-220 29/08/17 12:00 PM Page 200 200 B O 13.2 Journey Across the Life Span X Ri sk s f or O s t eop or os i s an d I n t e r ven t i on s Genetic factors: • Female, fair skin, small body frame, family history, early menopause Nutritional factors: • Low body weight, low calcium intake, high caffeine intake, high alcohol consumption Lifestyle factors: • Smoking, lack of exercise Interventions: • • • • • • Avoid tobacco use. Limit caffeine intake. Limit alcohol consumption. Increase calcium intake. Get regular exercise. Take hormone replacement therapy. older than age 80 have a 1 in 5 chance of sustaining a fracture of the femur. Regular active or passive exercise can minimize discomfort and loss of bone mass. Postural changes also occur, resulting in kyphosis, an exaggerated curvature of the spine, or the typical “dowager’s hump.” The resultant tilting of the head and flexion of the hips and knees cause the center of gravity to shift. In addition to a loss of bone mass, there is decreased muscle mass accompanied by decreased muscle strength and tone. These changes affect balance and further increase the risk of falls. Each year 1 out of 3 older adults falls. Falls often lead to severe disability, increased hospitalization and related costs, and an increased number of deaths. Fear of repeated falls may lead to sedentary behavior, impaired function, and lower quality of life. The attachments known as ligaments and tendons are less elastic in elderly people, resulting in muscle spasms and decreased flexibility. Pronounced stiffness and diminished range of motion are more noticeable in the morning or following periods of disuse. Complaints of muscle weakness are most frequently caused not by age-related changes but by inactivity. Cardiovascular System Normally there is no significant decrease in heart size with advancing age. Heart valves become thicker and more rigid. Lipofuscin, a pigmented metabolic waste product, has been found in greater amounts in various organs of the aged body. Loss of elasticity in blood vessels, combined with the accumulation of collagen and lipofuscin, results in narrowing of the vessel lumen (diameter), causing a subsequent increase in blood pressure. It is not unusual to have a slight increase in the systolic pressure while the diastolic pressure remains the same. Significant increase in blood pressure is more likely to be the consequence of environmental factors (diet, weight, and stress levels) rather than of age. A decrease in cardiac output of 1% per year occurs between ages 20 and 80 and is a result of the loss of cardiac muscle strength and contractility. This change may be evidenced by a slower heart rate. The older heart needs more rest between beats. Regular exercise can increase cardiac performance and prevent complications. The best type of exercise for maximizing cardiac function is walking. The older person’s veins also become more visible and tortuous. Increased pressure on weak vessel walls leads to the increased incidence of varicosities in the lower extremities and rectum. Respiratory System The respiratory system is subjected to a great deal of abuse during one’s lifetime. The age-related changes are subtle and occur gradually. Several structural changes in the chest diminish respiratory function. Calcification of the rib cage and costal cartilage makes the chest wall more rigid and less compliant. These changes in the thoracic walls make the respiratory muscles work harder. Lung tissue gradually loses elasticity. Vital capacity decreases, and more muscular work is needed to move air in and out of the lungs. Between ages 20 and 60 about 1 liter of vital capacity is lost. Lungs exhale less efficiently, causing an increase in the residual volume. The residual volume refers to the amount of air remaining in the lungs after forceful exhalation. Coughing is less effective. All of these changes make the older person more susceptible to respiratory infections. Gastrointestinal System The numerous changes in the gastrointestinal system cause discomfort but are usually not serious enough to place a person at health risk. The amount of saliva decreases, resulting in xerostomia (dry mouth) and dysphagia (difficulty swallowing). A diminished gag reflex places the older person at risk for choking while eating. To decrease the chance of choking, older persons should eat slowly and in an upright sitting position. 7589_Ch13_195-220 29/08/17 12:00 PM Page 201 Late Adulthood Because of the decrease in peristalsis, the muscle movement that propels food through the gastrointestinal system, it takes longer in older adults for the esophagus, stomach, and lower intestine to empty. In the esophagus, this slower emptying increases the risk of aspiration. For this reason, older people should not only eat in an upright position but also maintain this position for an hour after eating. In the stomach, peristalsis—together with decreased gastric secretions—may result in indigestion. The total stomach capacity is also decreased, causing diminished hunger and appetite. Changes in the intestines include decreased absorption of nutrients. Individuals who use laxatives on a regular basis may be at further risk for vitamin and nutrient deficiencies. As the liver ages, enzyme production decreases, which may adversely affect metabolism of both food and drugs. In the lower intestine, the reduction in peristalsis slows the movement of waste, often producing constipation and increased flatus. To maintain normal bowel functioning, older people need to intake adequate fluid and roughage, or fiber. Regular toileting habits and exercise will further enhance normal bowel functioning. Bowel movements may also be affected by decreased nerve sensations and a delayed signal to defecate. These changes, along with weakening of the external sphincter in the rectum, may sometimes cause bowel incontinence. Dentition Tooth loss is not a consequence of the aging process but a result of poor care leading to disease. With proper care, older persons can retain their teeth through their entire lives. As they age, teeth show natural signs of wear and tear, including loss of some enamel, lengthening of the tooth, and decreased ability to cut and chew efficiently. These changes have significant implications for both safety and digestion. Chewing ability and the condition of the mouth and teeth should be considered when preparing foods for elderly people. Soft or pureed foods can be substituted for foods of regular consistency if indicated. Integumentary System The integumentary system consists of the skin, hair, nails, and oil and sweat glands. The skin helps the body maintain a state of homeostasis (internal balance). It protects the body from changes in temperature, pressure, and moisture and from invading organisms. Normal aging may compromise the skin’s ability to maintain homeostasis. The skin loses some elasticity and becomes wrinkled. As aging progresses, 201 the skin gets thinner, drier, and more fragile. These changes make the older person more prone to skin breakdown following minor bruising or injury. Normal circulatory changes may delay wound healing. Older people lose subcutaneous adipose tissue, causing a decrease in their ability to sustain changes in temperature. Further complicating the problem is a normal decrease in the number and function of the sweat glands as a person ages. Older persons perspire less and chill easily. They commonly complain of being chilly if they are seated near a window or draft. A sweater or light cover usually helps increase comfort. Elderly people are also more apt to suffer from heat stroke as a result of reduced perspiration. In warm weather they should avoid overexertion and maintain adequate hydration. Skin, as it ages, shows irregular pigmentation— senile lentigo—as a result of an uneven distribution of melanocytes (pigmented cells). The actual number of melanocytes in the skin decreases as much as 80% between ages 27 and 65. Extensive repeated exposure to the sun and ultraviolet rays can further exaggerate the normal aging effects on the skin. Many age-related skin changes place elderly people more at risk for skin disorders, such as infections, pruritus (itching), keratosis (thickening), pressure sores, and skin cancer. Nail growth gradually slows, and nails become more brittle, appearing dull and yellow. Toenails may become thicker and should be trimmed by a podiatrist regularly. Fingernails require special attention, including frequent cleaning and trimming. In 50% of the population, hair grays by age 50. Hair loss is a common occurrence beginning in the 30s in men and after menopause in women. Hair loss is not confined to the head but occurs elsewhere, including in the axillary and pubic areas. Men show an increase in hair growth in the eyebrows, nose, and ears. Women may note some unwanted hair on the face and chin. Nervous System As people age, the number of neurons, or nerve cells, decreases: 5% to 10% of neurons atrophy by age 70; after age 70, the rate of atrophy increases. The result is a decrease in the nervous system’s capacity to transmit messages to and from the brain. Brain weight peaks at age 20, and the brain loses 100 grams, or 7% of its weight, by age 80. Cerebral blood flow decreases because of changes in the vessels of the circulatory system. However, problems with memory and learning result not from these normal changes of aging, but from specific diseases that 7589_Ch13_195-220 29/08/17 12:00 PM Page 202 202 Journey Across the Life Span affect the system’s ability to function. Other neural changes include slowed motor responses. Reaction time is as much as 30% longer in older individuals. Elderly people must be assessed individually to determine their response time and ability to drive safely. Sensory System Normal age-related changes in the sensory system may cause problems with daily functioning and general well-being. The five senses—taste, sight, hearing, touch, and smell—all become less efficient, placing the older person at greater risk for injury. The vision changes that begin in middle age continue during this stage. Presbyopia, the loss of the eye’s ability to focus, and opacity (clouding) of the lens progress. The incidence of cataracts and glaucoma increases. Peripheral vision diminishes, and sensitivity to glare increases. Color vision changes with aging: Red and yellow are seen best, whereas the ability to discriminate between green and blue colors diminishes. For safety reasons, bright colors such as yellow and orange are best used to mark curbs and steps. Blockage of the lacrimal ducts (tear ducts) may cause the eyes to water excessively. Certain medications, vitamins, and diseases can cause eye dryness. Using artificial tears helps to alleviate the discomfort and protect the cornea from drying. About one-third of persons older than age 65 have sufficient presbycusis (age-related hearing loss) to affect their everyday lives. At age 10 a person can hear frequencies as high as 20 kHz; by age 50, the maximum level is 13 kHz; and by age 60, there is little hearing over 5 kHz. It is best to address older people in low-pitched, moderately loud tones to compensate for the loss of high-frequency hearing. Small insults and injuries or certain diseases may contribute to hearing loss. Changes in the middle ear of elderly adults include thickening of the tympanic membrane and calcification of the bones. The accumulation of cerumen (ear wax) may interfere with the passage of sound vibrations through the external canal to the middle ear and inner ear. Symptoms of this type of hearing loss include fullness, itching, and tinnitus (ringing) in the ears. Conductive hearing may show marked improvement after the removal of accumulated wax. Conductive hearing loss results from the obstruction or reduction in the passage of sound in the inner ear. Other types of hearing loss may be related to nerve atrophy and circulatory changes. Box 13.3 offers suggestions for improving verbal communication with individuals who are hearing impaired. B O 13.3 X Impro v ing V erbal Co mmunicatio n fo r Ind iv id uals Who Are Hearing Impaired • • • • Speak clearly and distinctly in low tones. Rephrase words as needed. Face the listener. Use facial expressions and gestures to help clarify your message. • Communicate in well-lit areas, placing lighting behind the listener. • Minimize outside distractions. • Encourage lip reading. A loss in number of taste buds causes a resulting loss in taste discrimination, first for sweet and later for other tastes. These changes are not solely age related; environmental factors may also contribute. There is little research about age-related changes to the sense of smell. It is believed that the sense of smell declines with normal aging in part because of olfactory degeneration, but loss of smell creates a safety issue because older people living alone may not be able to detect subtle gas leaks or smoke. For this reason the use of warning detectors in the home is most important. Significant changes in tactile sensation are thought to be more related to disease than to aging. Genitourinary System After menopause the ovaries, uterus, and fallopian tubes atrophy. The vaginal walls become thinner and less elastic, and lubrication and vaginal secretions decrease. These changes may result in discomfort during intercourse. Vaginal secretions normally protect the vagina from bacterial invaders. This protective function diminishes, making older women at greater risk for vaginal infections. Approximately 2.5% of the body’s calcium may be lost in the first few years after menopause, resulting in bone loss. After this initial period, however, the rate of bone loss slows down. It is believed that estrogen has an antiatherosclerotic effect, protecting women from heart disease. As estrogen levels decline, the incidence of heart disease in postmenopausal women increases to equal that in men. Other common changes occurring after menopause include deepening of the voice, thinning of the pubic hair, and atrophy of the breast tissue. Hormone replacement therapy (HRT) may be considered (see Chapter 12). After age 50, men experience a gradual decline in testicular mass. It takes longer for older men to 7589_Ch13_195-220 29/08/17 12:00 PM Page 203 Late Adulthood achieve an erection, and less semen is released at ejaculation. Testosterone and sperm levels decrease gradually, but healthy men retain fertility well into their older years. Hypertrophy of the prostate gland may cause difficulty in voiding. The prostate gland should be checked during physical examinations. It is separated from the rectum by connective tissue, making its posterior surface easily palpable on a digital rectal examination. Normal age-related changes affecting the urinary system occur gradually. The kidneys decrease in size and lose some of their functional units, or nephrons, resulting in a one-third to two-third reduction in filtration rate. This can cause a decreased ability to filter, concentrate, or dilute urine. However, even with these age-related changes, the aging kidneys should continue to maintain homeostasis. 203 The bladder walls lose elasticity, and bladder volume decreases from 250 to 200 mL. Women with a history of multiple pregnancies are at greater risk for further weakening of the pelvic floor muscles, leading to stress incontinence. The signal indicating a need to void may be delayed, making an older person prone to accidents. Endocrine System As individuals age, secretory cells of the endocrine system are replaced with connective tissue, thereby decreasing hormone levels. All body tissues and organs are affected by these age-related changes of the endocrine system. Diabetes mellitus and thyroid dysfunction are the two main endocrine and metabolic disorders affecting elderly patients. Table 13.1 summarizes age-related changes in the older person. T A B L E 13.1 S u m mar y of A g e- R el at ed C h ang es Age-Related Changes Cardiovascular System Blood vessels narrow with the accumulation of fat and scar tissue. Skin and Hair Skin becomes thin and less elastic. Hair may gray. Teeth Gums recede and tooth enamel wears away. Eyes Changes in the lens cause poor near vision. Lens may start to cloud, forming the beginning of cataracts. Suggestions for Optimal Functioning Exercise. Control weight. Follow a diet low in saturated fat with a variety of foods from the food pyramid or MyPlate chart. Limit exposure to sunlight. Use sunblock. Examine skin frequently for damage or changes. Practice good dental hygiene. Floss and brush frequently. Schedule dental visits every 6 months. Schedule annual eye examinations and wear corrective lenses as needed. Eat a diet rich in dark-green vegetables. Ears Some nerve cells are lost, but hearing remains unchanged until age 60 and older. Avoid exposure to noise pollution. Brain and Nerves Some brain shrinkage is noted with fewer nerve cells present. Remain active and involved to stimulate thinking and memory. Muscles Muscle mass and strength decrease. Exercise daily to strengthen muscles. Continued 7589_Ch13_195-220 29/08/17 12:00 PM Page 204 204 Journey Across the Life Span T A B L E 13.1 S u m mar y of A g e- R el at ed C h an g es—co nt’ d Age-Related Changes Bones Bone density declines after age 50. Joint flexibility decreases. Lungs Lungs lose elasticity. Chest wall stiffens. Digestive Levels of enzymes and digestive juices decrease. Less mobility causes constipation. Urinary System Kidneys become less efficient, and bladder muscles weaken. Men: Prostate gland enlarges. Reproductive System Men: Desire usually remains unchanged. Women: Hormonal changes with menopause cause less elasticity and lubrication. Interest in sex varies with individual. Suggestions for Optimal Functioning Exercise after proper stretching. Maintain a healthy diet. Avoid obesity. Avoid smoking and exposure to secondhand smoke. Exercise aerobically on a regular basis. Eat foods containing fiber. Drink plenty of water. Exercise regularly. Maintain regular toileting habits. Perform pelvic exercises. Drink plenty of fluids. Men: Have yearly prostate exams. Men: Avoid alcohol and smoking. Exercise regularly. Maintain normal blood pressure and cardiovascular fitness. Women: Use hormone replacement therapy if suggested by physician. Use water-soluble lubricants. HOMEOSTASIS Homeostasis is best defined as a balance or equilibrium between the internal and external environment. As an individual ages, the common agerelated changes in the body systems make it more difficult for the individual to maintain homeostasis. Changes in thermoregulatory responses that help detect changes in temperature may lead to greater risk of developing hypothermia or hyperthermia in older persons. Normal body temperature in older persons is slightly lower than in younger persons. A temperature reading of 97°F (36°C) may be normal in the older adult. If unaware of this, health care workers may misinterpret a temperature elevation of 99°F as a normal finding in the older individual when in fact it may be a 2-degree elevation and signify the presence of a possible infection. Older individuals are also extremely sensitive to changes in room temperature. The ideal room temperature for older persons is 75°F. Older persons may experience discomfort or chilling, which can lead to hypothermia when exposed to cold temperatures. Exposure to extremely high temperatures may place the older individual at risk for hyperthermia and possible brain damage. Decreased cardiac reserve that occurs with advancing age may place the person at risk for several problems. Normally during strenuous activity, cardiac output increases to compensate for the individual’s increased needs. This is known as cardiac reserve and it is adversely affected by several aging heart conditions. Older persons are susceptible to fluid overload and have difficulty regulating body fluids. The older person’s reduced awareness of thirst only further complicates matters. Additional homeostatic responses include a decreased ability for aged eyes to accommodate to darkness. This makes it more difficult to drive at night or to adjust from light to dark environments. 7589_Ch13_195-220 29/08/17 12:00 PM Page 205 Late Adulthood VITAL SIGNS Normal age-related cardiovascular changes cause a moderate increase in systolic blood pressure. Hypertension is defined as systolic blood pressure greater than 130 mm Hg and diastolic pressure of 90 mm Hg or more. Resting heart rate usually remains unchanged or slows slightly. There is little or no change in the older person’s resting respiratory rate. However, more muscle work is needed to move air in and out of the lungs. DEVELOPMENTAL MILESTONES Motor Development Changes in both the musculoskeletal and nervous systems cause movements to slow down with advancing age. Both gross and fine motor skills may be affected by stiffened ligaments and joints. Gait speed and step height decrease. Postural and balance changes further affect mobility. Sexual Development Contrary to popular belief, elderly people are capable of enjoying satisfying sexual relationships. Affection and pleasure-seeking behaviors are important and may be expressed differently as individuals age and opportunities arise. Men need more stimulation to reach erection. Women can use estrogen creams or other lubrication to prevent discomfort caused by drying of vaginal tissues. Respect for the individual’s privacy in all settings helps promote dignity and a positive self-image. Psychosocial Development Successful resolution of the first seven stages of Erikson’s psychosocial development prepares the older person for the task of ego integrity. Ego integrity is similar to a life puzzle in which all the pieces fit nicely together. Each stage of development completes the integration of the person, adding meaning to his or her life. Those who develop a sense of ego integrity usually feel satisfied with their accomplishments. They may look back over their lives and admit to certain failures and disappointments, but generally they feel that they have been successful. Ego integrity allows them to proceed with a sense of calm toward death, confident of having left a legacy for future generations. 205 Wisdom acquired throughout a life of experience is a common characteristic associated with a sense of ego integrity. The process of reminiscence, or life review, reassures older people about their accomplishments and worth. Reminiscing allows an elderly person to weave his or her life together, giving events and memories meaning and order. It facilitates an understanding of the past, puts the past in context, and allows the person to make peace with disappointments and face the future with optimism. People who feel that their lives have no meaning or that they have made the wrong decisions develop despair. This produces helplessness and lack of control over their lives. Despair is also associated with fear of death and anxiety about the future. As with Erikson’s other tasks, developing ego integrity is also affected by one’s family and other socialization experiences. All of these experiences combine to help shape one’s attitude toward aging. If old age is seen as a time of decline and nonproductiveness, these negative expectations are more likely to be fulfilled. Ageism, or prejudice against older people, contributes to negative perceptions of the aging process. Educational programs help combat ageism and foster positive attitudes toward older individuals. Furthermore, if young children have good role models, they are more likely to have positive attitudes toward aging throughout their lives and thus be helped to establish ego integrity themselves. Achieving ego integrity also involves adjusting to changes in body image, family roles, work and leisure, and sexuality, and facing the inevitability of death. Changes in Body Image How we view aging will ultimately affect how we cope with our changing bodies. Physical appearance has a strong impact on a person’s self-concept. Most of the visible changes of aging occur gradually, giving older persons time to adjust to their new images (Fig. 13.3). An individual whose identity is based solely on physical attractiveness continues to see life from that perspective and may become depressed. Changes in Family Roles As couples grow old together, they must make several adjustments. Physical or emotional illness of either spouse may frequently cause role changes in older marriages. One spouse may become the nurse or caregiver. This may cause anger, resentment, and depression in either the giver or receiver of care. Patterns of dominance may shift from the man to the 7589_Ch13_195-220 29/08/17 12:00 PM Page 206 206 Journey Across the Life Span FIGURE 13.3 Older people need to accept their change in body image. woman or vice versa. Roles may also change with retirement, placing new limitations and stresses on both parties. Husbands may spend more time at home than ever before, causing conflicts if they try to assume the in-charge role in the home. Other men may find that their roles have changed to that of homemakers while their wives continue to work. Any one of these role changes requires a period of adjustment. Death of a spouse produces a role change and adds stress to the remaining individual and other family members. The loss of a spouse is a highly significant life event. Studies indicate that married elderly individuals are generally healthier than unmarried persons. Married persons have a lower incidence of chronic diseases and institutionalization than single, widowed, and divorced individuals. In addition, studies indicate that mortality rates are higher among recently widowed men (6 months) and women (2 years). Married women older than age 65 are more likely to be the surviving spouses than are married men in the same age group. Two problems common to widowhood are loneliness and decline in income. Frequently, a widow finds that she is unprepared to be the decision maker and financial overseer. Former relationships and activities may disappear, forcing her to pursue new activities. Given time and support, many women lead independent, well-adjusted lives after the death of their spouse. Many elders seek new relationships for companionship. Past marital experiences, good health, adequate income, and the attitudes of grown children are factors important to successful relationships. Some widowed or divorced elders seek remarriage as an option. For a long time elders were forced to give up their former spouse’s Social Security benefits when they remarried, but Congress has since passed legislation that allows the surviving spouse to choose between the benefits of a former spouse and those of a new spouse, whichever are greater. Older people may lose friends because of death or relocation. Some older individuals on fixed incomes find it necessary to move to new communities, giving up old friends and neighbors. The divorce rate of older persons has been increasing as individuals live longer. Debilitating illnesses, disabilities, and marital distress are the main reasons cited for divorce in this age group. Anger and guilt both have an adverse effect on widowed and divorced individuals. Divorce also places individuals at risk for economic difficulties. A nursing assessment of the emotional and social support systems of those who are widowed or divorced can help identify their risk factors and specific needs. Once these factors are known, referrals and counseling may be offered. Elderly people fear loss of independence more than any other loss, commonly expressing the feeling that they do not want to become a burden to their families. Illness or disability may result in loss of independence. If this happens, every effort should be made to help the affected individual maximize his or her capabilities and independence for as long as possible. This enhances self-esteem and increases feelings of usefulness. One role that helps decrease feelings of isolation for many individuals is grandparenting (Fig. 13.4). Most elders have regular, frequent contact with their grandchildren. Most children have strong feelings of affection for their grandparents. Age and state of health will help to determine the amount of interaction and style of grandparenting they share. Many individuals live long enough to assume the role of great-grandparent. Changes in Work and Leisure Work gives many people identity and self-esteem in addition to financial rewards. Many older people continue to work after age 65. In 2012, 26.8% of older persons were in the workforce. The projected number of people ages 65 to 74 in the workforce