geriatric nurse

["Physiologic Changes\u2003 CHAPTER 3\t 33 ranging in color from light tan to black, are most often observed on the upper half of the body, and they may A decrease in the function of sebaceous and sweat cause discomfort and itching. Skin tags, or cutaneous gland secretion increases the likelihood of dry skin, or papilloma, are small, brown or flesh-colored projec- xerosis (Figure 3-2). Dry skin is probably the most tions of skin that are most often observed on the necks common skin-related complaint among older adults, of older adults. particularly when accompanied by pruritus (itching). This problem is often more severe on the lower extrem- Aging results in decreased elastin fibers and a ities because of diminished circulation. thinner dermal layer (Table 3-1). With the loss of elas- ticity, the skin starts to become less supple. \u201cCrow\u2019s Capillary walls become increasingly fragile with feet,\u201d or wrinkles, develop. Skin that is very dry or that age and may hemorrhage, leading to senile purpura: has had excessive exposure to sunlight or harsh chemi- red, purple, or brown areas commonly seen on the legs cals is more likely to wrinkle at a younger age. Hair and arms. By 70 years of age, the body has approxi- color tends to fade or \u201cgray\u201d because of pigment loss, mately 30% fewer cells than at age 40. The remaining and hair distribution patterns change. Color changes cells enlarge, so body mass appears approximately the and hair loss patterns tend to be hereditary. The hair same. Total body fluid decreases with age. Plasma and on the scalp, pubis, and axilla tends to thin in both men extracellular volume remain somewhat constant, but and women. Hairs in the nose and ears often become intracellular fluid decreases, increasing the risk for thicker and more noticeable. Some women experience dehydration. Tissue changes include a decrease in sub- the growth of facial hair, particularly after menopause. cutaneous tissue that is visible in the eye orbits, hollows Fingernails grow more slowly, may become thick in the supraclavicular space, and sagging of breasts and more brittle, and ridges or lines are commonly and neck tissue. observed. Toenails may become so thick that they require special equipment for trimming. Sweat gland COMMON DISORDERS SEEN WITH AGING function decreases; thus the amount of perspiration Basal Cell Carcinoma and Melanoma decreases. This results in heat intolerance, because the It is important to distinguish normally occurring body\u2019s cooling system through evaporation is less changes in the skin from lesions that may be precancer- efficient. ous or cancerous. Cases of basal cell carcinoma are commonly observed in older adults who have spent Table 3-1\u2003 Integumentary Changes Associated With Aging RESULTS Increased pallor in white skin PHYSIOLOGIC CHANGE Decreased hair color (graying) Decreased vascularity of dermis Increased dry skin; decreased perspiration Decreased amount of melanin Increased wrinkling Decreased sebaceous and sweat gland function Increased susceptibility to trauma Decreased subcutaneous fat Increased incidence of brown spots (senile lentigo) Decreased thickness of epidermis Increased purple patches (senile purpura) Increased localized pigmentation Decreased amount and thickness of hair on head and body Increased capillary fragility Increased brittleness of nails Decreased density of hair growth Increased longitudinal ridges of nails; increased thickening Decreased rate of nail growth Decreased peripheral circulation and yellowing of nails Increased facial hair in women Increased androgen\/estrogen ratio NURSING ASSESSMENTS AND CARE STRATEGIES RELATED TO INTEGUMENTARY CHANGES NURSING ASSESSMENTS CARE STRATEGIES Monitor skin temperature. Adjust room temperature and provide adequate clothing or covers to prevent chilling. Assess skin turgor over sternum or forehead, not forearm. Check Provide adequate fluid to prevent dehydration. tongue for furrows. Assess for skin breakdown or changes in color or pigmentation. Institute measures to reduce pressure over bony prominences; possible dermatology referral. Assess areas where skin surfaces touch and trap moisture (under Keep skin dry. Pad surfaces to reduce friction. Report breasts, adipose rolls, etc.) for signs of maceration or yeast abnormal observations for treatment. infection. Determine adequacy of hygiene and need for toenail trimming. Modify skin care to reduce drying. Refer to podiatrist.","34\t UNIT I\u2003 Overview of Aging FIGURE 3-2\u2003 Xerosis. (From White GM, Cox NH: Diseases of the skin: A A color atlas and text, ed 2, Philadelphia, 2006, Mosby.) B significant amounts of time in the sun. Almost half of FIGURE 3-3\u2003 Pressure ulcers. A, Early-stage pressure ulcers, or stage Americans who reach age 65 have had either basal cell or squamous cell carcinoma at least once. Older men I lesions, are commonly dismissed as minor abrasions because their are most at risk for melanoma, a potentially fatal form primary attribute is nonblanchable erythema. B, Stage II ulcer, which of skin cancer because of its ability to metastasize. The is characterized by some skin loss, may be difficult to identify risk of melanoma doubles if someone has had more accurately because of its resemblance to a blister or abrasion. (From than five sunburns at any age. In 2015 there are Ignatavicius DD, Workman ML: Medical-surgical nursing: Critical expected to be nearly 10,000 melanoma deaths. thinking for collaborative care, ed 7, St. Louis, 2013, Saunders.) The unusual appearance of moles should be sus- FIGURE 3-4\u2003 Rosacea pustules and papules. Note the bulbous red pected to be melanoma. Irregular shapes, irregular nose of rhinophyma. (From White GM, Cox NH: Diseases of the borders, changes in color, changes in size or symp- skin: A color atlas and text, ed 2, Philadelphia, 2006, Mosby.) toms, such as itchiness or bleeding, are all considered unknown, but it is most common in postmenopausal abnormal. Older men, in particular, should be taught women, people who flush easily, and individuals to screen themselves for changes in the skin. Suspicious taking vasodilating medications. Treatment of vasodi- changes should be documented and reported so that lation includes lifestyle modification, for example they can be examined promptly by a physician. Early avoidance of triggers such as stressful situations, diagnosis and treatment is effective at prolonging life. extreme heat, sun exposure, spicy foods, and alcoholic beverages. Oral and topical medications or light and Pressure Ulcers laser treatments may provide some benefits. Shrinkage in the cushion provided by subcutaneous tissue along with vascular changes places the older adult at increased risk for pressure ulcers (breakdown of the skin and tissues located over bony prominences) (Figure 3-3). This is a significant problem for immobi- lized people such as those who are bedridden or con- fined to wheelchairs. Staging of pressure ulcers and special precautions for prevention are discussed in Chapter 17. Inflammation and Infection Changes in the integumentary system increase the older adult\u2019s risk for skin inflammation and infection. Skin inflammation and infection often occur on visible body surfaces, such as the face, scalp, and arms, making the conditions distressing to older adults. Common types of inflammation include rosacea and various forms of dermatitis. Rosacea appears as redness, dilated superficial blood vessels, and small \u201cpimples\u201d on the nose and center of the face (Figure 3-4). It may spread to cover the cheeks and chin. Left untreated, it can lead to swelling and the enlargement of the nose or to conjunctivitis. The exact cause is","Physiologic Changes\u2003 CHAPTER 3\t 35 FIGURE 3-6\u2003 Seborrheic dermatitis is characterized by itching and patches of scales that exfoliate. The most common sites are on the scalp, behind the ears, and on the midface, including the eyebrows and lashes. (From White GM, Cox NH: Diseases of the skin: A color atlas and text, St. Louis, 2000, Mosby.) FIGURE 3-5\u2003 Rhus dermatitis. Linear bullae are characteristic of subcutaneous and adipose tissue. This loss of insula- an allergic contact dermatitis. (From Habif TP: Clinical Dermatology, tion is most likely to result in hypothermia if the person ed 5, 2010, Mosby.) is exposed to an environment that is too cold. Several forms of dermatitis are common in older THE MUSCULOSKELETAL SYSTEM adults, including contact, allergic, and seborrheic der- matitis. Contact and allergic dermatitis appear as The musculoskeletal system performs many func\u00ad rashes or inflammation that is either localized to certain tions. The skeletal bones provide a rigid structure that areas of the body or generalized (Figure 3-5). Clues to gives the body its shape. The red bone marrow in the the causative substance are gained from the unique cavities of spongy bones produces red blood cells pattern presented on each individual. Identification of (RBCs), platelets, and WBCs. Structures such as the the particular irritant may be difficult because of the ribs and pelvis protect easily damaged internal organs. number of chemicals, drugs, and other substances to The muscles provide a power source to move the which an individual is exposed. Treatment consists of bones. The combined functions of bones and muscles avoiding the offending substance. allow free movement and participation in the activities necessary to maintain an active life. Seborrheic dermatitis is an unsightly skin condi- BONES tion characterized by yellow, waxy crusts that can be Bone consists of protein and the minerals calcium and either dry or moist (Figure 3-6). Caused by excessive phosphorus. Calcium is necessary for bone strength, sebum production, seborrheic dermatitis can occur on muscle contraction, myocardial contraction, blood the scalp, eyebrows, eyelids, ears, axilla, breasts, groin, clotting, and neuronal activity. It is normally obtained and gluteal folds. There is no known cure, but special by eating dairy products and dark-green leafy vegeta- shampoos and lotions can help. bles. Vitamin D is needed for the absorption of calcium and phosphate through the small intestine; vitamins Infectious diseases of the skin and nails commonly A and C are needed for ossification, or bone matrix seen in older adults include herpes zoster (shingles); formation. fungal, yeast, and bacterial infections; and infestation with scabies (mites). Each of these diseases has a For the long bones to remain strong, adequate unique cause, characteristic appearance, and specific dietary intake of these nutrients is important. However, treatment that are beyond the scope of this text. the dietary intake of minerals alone does not maintain bone strength. It is also necessary to apply stress to the Hypothermia long bones to keep the minerals in the bones. This The decrease in subcutaneous tissue reduces the needed stress is best provided by weight-bearing activ- older adult\u2019s ability to regulate body temperature. ities, such as standing and walking. The calcium that Very thin older adults lose the insulation provided by is needed for clotting and nerve and muscle functions is constantly being withdrawn from the bone and moved into the bloodstream to maintain consistent blood levels. Calcium is normally redeposited in the","36\t UNIT I\u2003 Overview of Aging each vertebra. The bones of the spinal column protect this nerve tissue from injury. bone at an equal rate, replacing the lost calcium. As long as this movement of calcium is in balance, the Fibrous pads, called intervertebral disks, are bone remains strong. located between the vertebrae and cushion the impact of walking and other activities. Hormones also play an important role in bone maintenance. Calcitonin, produced by the thyroid JOINTS, TENDONS, AND LIGAMENTS gland, slows the movement of calcium from the Joints are the places where bones meet. The freely bones to the blood, lowering the blood calcium level. moving synovial joints are lined with cartilage, which Parathyroid hormone (PTH) increases the movement allows free movement of the joint surfaces. Many of calcium from the bones to the blood, increasing the of these joints contain a bursa, which is a fluid sac blood calcium level. PTH also increases the absorption that provides lubrication to enhance joint mobility of calcium from the small intestine and kidneys, further (Figure 3-7). increasing the blood calcium level. Insulin and thyrox- ine aid in the protein synthesis and energy production Tendons are structures that connect the muscles to needed for bone maintenance. Estrogen and testoster- the bone, and ligaments are structures that connect one, produced by the ovaries and testes, respectively, bones to other bones. help retain calcium in the bone matrix. VERTEBRAE MUSCLES The spinal column consists of a series of small bones, There are three types of muscle tissue in the body: called vertebrae, which stack up to form a strong, flex- cardiac muscle, smooth muscle, and skeletal muscle. ible structure. The spinal column supports the head Cardiac muscle, located only in the heart, is respon- and allows for flexible movement of the back. The seg- sible for the pumping action of the heart that maintains ments of the spinal column consist of cervical, thoracic, the blood circulation. Smooth muscle is found in the lumbar, and sacral vertebrae. The muscles that move walls of hollow organs such as the blood vessels, the back connect at bony processes that protrude from stomach, intestines, and urinary bladder. Because each vertebra. The spinal cord, the nerve tissue that cardiac and smooth muscle normally cannot be stimu- extends downward from the brain, passes through the lated by conscious effort, they are called involuntary vertebral canal, which runs through an opening in muscles. Condyloid joint Saddle joint Atlantooccipital Carpometacarpal joint of thumb Ball and socket joint Pivot joint Shoulder Dens of axis rotating Hip against atlas Head of radius rotating against ulna Gliding joint Hinge joint Articular processes Elbow between vertebrae FIGURE 3-7\u2003 Types of synovial joints: condyloid\/ellipsoid joint, ball-and-socket joint, gliding\/plane joint, saddle joint, pivot joint, hinge joint. (From Fritz S: Mosby\u2019s fundamentals of therapeutic massage, ed 5, St. Louis, 2013, Mosby.)","Physiologic Changes\u2003 CHAPTER 3\t 37 Skeletal muscle accounts for the largest amount of metabolism, glucose interacts with oxygen transported muscle tissue in the body. The major function of skel- in the bloodstream by hemoglobin or oxygen stored in etal muscle is to move the bones of the skeleton. the muscle fibers as myoglobin. This reaction involves Because their actions can be controlled by conscious the production of ATP, heat, water, and carbon dioxide. effort, skeletal muscles are considered voluntary If muscle fibers do not receive enough oxygen, glucose muscles. Muscles are connected to bones by tendons. may not be oxidized completely, and a chemical inter- Contraction or relaxation of muscles causes the bones mediate, lactic acid, is produced. Elevated levels of to move. Controlled and coordinated movement of lactic acid may result in muscle fatigue and soreness. bones and muscles allows us to perform the variety of movements required for activities of daily living. EXPECTED AGE-RELATED CHANGES Special effort and practice allow us to perform special The major bone-associated change related to aging is activities such as dancing, playing sports, and playing the loss of calcium (Table 3-2). This change begins the piano. between age 30 and 40. With each successive decade, the skeletal bones become thinner and relatively The amount of muscle mass and the type of muscle weaker. Women lose approximately 8% of skeletal development differ greatly among individuals. Men mass each decade, whereas men lose approximately normally have larger muscles, or more muscle mass, 3%. Decalcification of various parts of the skeleton, than do women, particularly in the muscles of the such as the epiphyses, vertebrae, and jaw bones, can upper body. The male hormone testosterone stimulates result in increased risk for fracture, loss of height, and muscle development. In both men and women, the loss of teeth. largest and strongest skeletal muscles are found in the legs and upper arms; the smallest and weakest are The intervertebral disks shrink as the thoracic ver- located in the lower back. tebrae slowly change with aging. The result is a condi- tion called kyphosis, which gives the older adult a Muscle tissue is normally in a state of slight contrac- stooped or hunchback appearance, with the head tion. This muscle tone is necessary to support the head, dropping forward toward the chest. The combination to keep the spine erect, and to perform any controlled movement. Muscle mass is built and muscle tone is Table 3-2\u2003 Musculoskeletal Changes Associated maintained by means of exercise. There are two general With Aging types of exercise: isometric exercise, which involves muscle contraction without body movement, and iso- PHYSIOLOGIC CHANGE RESULTS tonic exercise, which involves muscle contraction with body movement. Isometric exercise helps main- Decreased bone Increased osteoporosis; tain muscle tone and strength but does little to increase calcium increased curvature of the muscle size. Isotonic exercise maintains muscle tone spine (kyphosis) and strength and increases muscle mass if it is done repetitively. Aerobic exercise is isotonic exercise Decreased fluid in Decreased height that occurs for 30 minutes or longer. Aerobic exercise strengthens the skeletal, cardiac, and respiratory intervertebral disks muscles. People who lead inactive or sedentary lifestyles suffer from the lack of isotonic exercise. Decreased blood Decreased muscle strength Regardless of age, unless people undertake an exercise supply to muscles program, they manifest poor muscle development and strength. Decreased tissue Decreased mobility and flexibility elasticity of ligaments and tendons Muscle movement is controlled by impulses from the parietal lobes of the cerebrum and is coordinated Decreased muscle Decreased strength; increased by impulses from the cerebellum. Muscle sense is a mass risk for falls term used to describe the brain\u2019s ability to recognize the position and action of the muscles without con- NURSING ASSESSMENTS AND CARE STRATEGIES scious effort. Receptor cells in the muscles, called pro- RELATED TO MUSCULOSKELETAL CHANGES prioceptors, send information to the brain that enables it to integrate all body movements. This coordinative NURSING ASSESSMENTS CARE STRATEGIES function of the brain allows us to walk, bend, or eat without consciously thinking about all of the separate Assess strength and Provide assistance as needed, movements and feeling all of the different positions. functional mobility. modify physical environment, initiate safety precautions \t Muscles need energy to function. The most abun- to decrease risk for falls, dant source of muscular energy is glycogen. Adenosine encourage range of motion triphosphate (ATP), the direct energy source for mus- (ROM) exercise, refer to cular contraction, is a product of glycogen metabolism. physical or occupational Glycogen is first broken down into glucose. During cell therapy. Assess nutritional Educate regarding importance intake. of calcium intake, administer supplements as ordered. Determine activity Encourage regular low-impact patterns. exercise.","38\t UNIT I\u2003 Overview of Aging fractures in people who have osteoporosis. Common fracture sites include the hip (usually the femoral of disk shrinkage and kyphosis results in loss of over\u00ad neck), ribs, clavicle, and wrist. Factors that increase the all height. A person can lose as much as 2 inches of risk for osteoporosis include the following: height by age 70. People who are concerned about their \u2022\t Female gender appearance find these changes disturbing because \u2022\t Caucasian or Asian race clothing no longer fits properly, and it is increasingly \u2022\t Small body frame difficult to find flattering styles. \u2022\t Family history of osteoporosis \u2022\t Poor nutrition (diet low in calcium and vitamin D) Connective tissues tend to lose elasticity, leading to \u2022\t Malabsorption disorders, such as celiac disease restriction of joint mobility. Loss of flexibility and joint \u2022\t Menopause (low estrogen levels) mobility begins as early as the teen years and is \u2022\t Chemotherapy common with aging. Regular stretching exercises can \u2022\t Lack of exercise\/immobility help slow or even reverse flexibility problems. \u2022\t Excessive alcohol consumption \u2022\t Cigarette smoking Muscle tone and mass typically decrease with aging, \u2022\t Hormonal imbalances (hyperthyroidism and hyper- and these decreases are directly related to reductions in physical activity and exercise. People of all ages who parathyroidism) exercise regularly have better muscle mass and tone. \u2022\t Long-term use of medications, including phenytoin Hormonal changes, particularly the decrease in testos- terone level, tend to reduce muscle mass in aging men. (Dilantin), heparin, and oral corticosteroids Reduced blood supply to the muscles because of aging Bone mineral density (BMD) may be assessed in or disease can lead to changes in muscle function. Less someone at risk for osteoporosis. Measurement of glycogen is stored in aging muscles, thereby decreas- bone density generally reflects its strength and ability ing the fuel available for muscle contraction. Any con- to bear weight. Osteoporosis is best prevented and dition that restricts oxygen availability (e.g., anemia or treated by lifestyle modifications and medications. respiratory problems) can lead to an excessive produc- Lifestyle modifications include a well-balanced diet tion of waste products such as lactic acid and carbon with adequate amounts of calcium and vitamin D, dioxide. This can increase the incidence of muscle regular weight-bearing exercise, smoking cessation, spasms and muscle fatigue with minimal exertion. and restriction of alcohol intake. Calcium and vitamin Decreased endurance and agility may result from a D supplements are necessary for individuals who do combination of these factors. Neuronal changes in the not consume adequate amounts of these nutrients. areas of the brain responsible for muscle control can Medications for osteoporosis generally fall into two result in alterations of muscle sense, which may be categories: (a) medications that increase bone strength observed in older adults as an unsteady gait and and density (anabolic drugs); and (b) medications that impairment of other activities that require muscular inhibit bone loss (antiresorptive medications). Newer coordination. research is suggesting improved effectiveness when these two classifications of medications are given As a person ages, muscle mass decreases, and the together. Commonly prescribed antiresorptive medi- proportion of body weight resulting from fatty, or cations include alendronate (Fosamax), risedronate adipose, tissue increases. This has important implica- (Actonel), ibandronate (Boniva), raloxifene (Evista), tions for medication administration. Intramuscular and calcitonin (Calcimar). Teriparatide, a form of para- injection sites may not be well muscled, and fatty thyroid hormone, is currently the only anabolic osteo- tissue tends to retain medication differently than does porosis medicine approved by the Food and Drug lean tissue. Absorption and metabolism of drugs Administration (FDA). Hormone therapy (HT) has can be significantly different from those in younger beneficial effects on bone density but also brings persons. increased risk for heart attack, blood clots, stroke, and breast cancer. Use of HT is controversial and requires COMMON DISORDERS SEEN WITH AGING a candid risk\/benefit analysis between the patient and Osteoporosis physician. If medications are given for osteoporosis, Excessive loss of calcium from bone combined with BMD testing may be done every 2 years to evaluate insufficient replacement results in osteoporosis. treatment. Currently, 5.3 million Americans have osteoporosis, and 34 million more have decreased bone mass (osteo- Degenerative Joint Disease penia), placing them at risk for osteoporosis. This dis- Osteoarthritis.\u2002 The incidence of osteoarthritis, the order is projected to become even more common as most common form of arthritis, increases with age. the population ages. Osteoporosis is characterized by Osteoarthritis is estimated to affect 27 million adults porous, brittle, fragile bones that are susceptible to in the United States, according to the CDC (2012a). breakage. Spontaneous fracture of the vertebrae or Fifty percent of adults will experience some degree of other bones can occur in the absence of obvious trauma. osteoarthritis during their lifetime. Although common In fact, spontaneous hip fractures may lead to a fall, rather than the fall leading to the hip fracture. Simple falls or other traumas are more likely to result in","Physiologic Changes\u2003 CHAPTER 3\t 39 with aging, osteoarthritis is not a normal part of aging. It affects men and women equally, although men are atrophy, soft tissue changes, and bone and cartilage usually affected at a younger age. The exact cause of changes. Symptoms of RA include: osteoarthritis is unknown; however, risk factors have \u2022\t Pain and stiffness, particularly after rest been identified, including age, obesity, joint injury or \u2022\t Warm, tender, painful joints overuse, genetic predisposition, and muscle weakness \u2022\t Fatigue (Arthritis Foundation, 2014). People employed in jobs \u2022\t Sense of feeling unwell that place a high amount of physical stress on certain \u2022\t Occasional fevers joints are likely to experience changes in those joints The most serious deformities and problems are typi- later in life. After years of normal joint use, the carti- cally observed when an individual has suffered from lage on the bones\u2019 articulating surfaces thins and this disease for an extended period. Affected individu- begins to wear out. Bony particles or spurs (osteo- als are best treated by a rheumatologist, a physician phytes) may form within the joint, causing pain, swell- who specializes in the disorder. ing, and restriction of joint movement. Heberden nodes, which are caused by abnormal cartilage or Treatments for RA include lifestyle changes such as bony enlargement, may be seen in the distal finger stress reduction, balanced rest and exercise, and joint joints. Pain may occur with activity or exercise of the care using splints to support joints. Early (within 2 affected joints and may worsen with emotional stress. years of onset) and aggressive treatment is being Synovial membrane of the bursa may become damaged advised for some patients to try to encourage remis- or inflamed. This is particularly true in the weight- sion and avoid joint damage (Haines, 2012). Medica\u00ad bearing joints of the spine, hips, knees, and ankles. tions from a wide variety of classifications are used to Obesity increases the stress on joints and can aggravate treat this condition, including the following: symptoms. \u2022\t NSAIDs, such as aspirin, acetaminophen, ibupro- Osteoarthritis is treated with a combination of exer- fen, and naproxen cise, weight control, joint protection, physical or occu- \u2022\t Corticosteroids, such as methylprednisone pational therapy, and medications. Medication therapy \u2022\t Disease-modifying antirheumatic drugs (DMARDs), may include nonsteroidal antiinflammatory drugs (NSAIDs) or by injecting corticosteroids into the joints. such as cyclosporine, azathioprine, sulfasalazine, Dietary supplements, such as glucosamine, chondroi- and methotrexate tin sulfate, and various vitamins, have shown benefits \u2022\t Tumor necrosis factor inhibitors, such as etanercept for some individuals and are being studied for and infliximab safety and effectiveness. Like all dietary supplements, \u2022\t Interleukin-1 inhibitor, such as anakinra however, quality and potency can vary between brands Surgical interventions, including synovectomy, tendon because the products are not FDA-regulated (Barrett, reconstruction, and joint replacement, may be per- 2014). There are also potential cautions and interac- formed to reduce pain, to improve joint function, and tions with prescription medications: chondroitin can to allow the individual to maintain the highest possi- potentiate blood thinners, and patients allergic to ble level of independent function. seafood should avoid glucosamine, because it is made from shellfish shells. Intraarticular injection of hyal- Bursitis.\u2002 Bursitis, inflammation of the bursa and the uronic acid, a joint lubricant, has received mixed surrounding fibrous tissue, can result from excessive reviews. It does provide pain relief to some people, but stress on a joint or from a localized infection. Bursitis often only temporarily. In severe cases, arthroscopic commonly results in joint stiffness and pain in the removal of bone fragments or surgical joint replace- shoulder, knee, elbow, and hip, ultimately leading to ments may be necessary. restricted or reduced mobility. Although bursitis can Rheumatoid arthritis.\u2002 Rheumatoid arthritis (RA) is a occur at any age, age-related changes in the musculo- collagen disease that results from an autoimmune skeletal system make it more common in older indi- process, affecting more women than men. This disease viduals. Treatment includes resting the joint and causes inflammation of the synovium, damage to the administering NSAIDs. Corticosteroid preparations cartilage and bone of joints, and instability of liga- are occasionally injected into the painful areas to ments and tendons that support the joints. The onset reduce inflammation. Mild range-of-motion exercise is is usually between ages 30 and 50, although a signifi- encouraged to prevent permanent reduction or the loss cant number of individuals develop the disease after of joint function. age 60. RA is characterized by periods of exacerbation (sometimes called flares), during which the symptoms Gouty arthritis.\u2002 Gouty arthritis is caused by an inborn are severe and cause further damage, and remission, error of metabolism that results in elevated levels of during which the progress of the disease\u2014and the uric acid in the body. Crystals of these acids deposit damage it causes\u2014halts. RA can result in muscle within the joints and other tissues, causing episodes of severe, painful joint swelling. Some joints, such as those of the great toe, are more commonly affected. Chills and fever may accompany a severe attack. Attacks of gout become more frequent with age.","40\t UNIT I\u2003 Overview of Aging air sac, which is surrounded by pulmonary capillaries to allow the efficient exchange of gases by diffusion. It Untreated, this disease can result in joint destruction. is here that oxygen enters the bloodstream for trans- It is observed more often in men but is also common port to body tissue and carbon dioxide from the body in postmenopausal women. Recommendations may leaves the bloodstream. This gaseous exchange is include reduction of body weight and decreased intake essential for normal cell function and for the mainte- of alcohol and foods rich in purines, such as liver or nance of acid-base balance. dried beans or peas. Because the alveoli have a moist lining, their sur- THE RESPIRATORY SYSTEM faces could adhere if they touched when the alveoli were empty. This is prevented by a special protein The respiratory system provides the body with the substance called surfactant. oxygen needed for life. Without oxygen, cells quickly die. The brain cells are the most sensitive cells in the AIR EXCHANGE (RESPIRATION) body; they will die if deprived of oxygen for as little The movement of air into and out of the alveoli is as 4 minutes. Breathing, the process of inhaling to take called ventilation. Ventilation requires the action of in oxygen and exhaling to release carbon dioxide, muscles, primarily the diaphragm and the intercostal occurs at a rate of 12 to 20 times per minute for our muscles. During inhalation, the diaphragm contracts entire lives. The respiratory system is typically divided and moves downward although the intercostal muscles into two parts: the upper respiratory tract and the pull the ribs upward and outward. These combined lower respiratory tract. The entire respiratory tract is activities increase the size of the chest cavity until the lined with mucous membranes. air pressure inside the lungs is lower than the atmo- UPPER RESPIRATORY TRACT spheric pressure and air is drawn into the lungs. This On its way to the lungs, air passes through the upper process is known as inhalation or inspiration. When respiratory tract, which includes the air passages of the air pressure inside the lungs equals or exceeds the nose, mouth, and throat, all of which are located atmospheric pressure, air ceases to enter the lungs. above the chest cavity. Mucous membranes line the When the diaphragm and intercostal muscles relax, the nasal passages and warm and humidify the air that diaphragm moves upward and the ribs move inward, passes through the nose. Cilia and mucus in the nasal making the chest cavity smaller. As the chest cavity passages trap particulate matter (bacteria and debris) becomes smaller, the pressure in the lungs becomes and sweep it toward the pharynx, where it is routinely greater than the atmospheric pressure. Air is forced out swallowed and destroyed by gastric acid. The cough of the lungs until the pressure in the lungs equals the and sneeze reflexes also help prevent debris and atmospheric pressure. This action is known as exhala- foreign objects from entering the respiratory tract. The tion or expiration. Regulation of respiration is both pharynx, which is located at the back of the oral cavity, neurologic and chemical. The respiratory centers in the has three segments: the oropharynx, nasopharynx, and medulla and pons of the brainstem continuously laryngopharynx. monitor and control the rate and depth of involuntary respiration. Most breathing is unconscious and invol- The nasopharynx is connected to the middle ear by untary. If we had to think about inhaling and exhaling the Eustachian tubes, which help maintain proper air every breath, we would have little time to do anything pressure in the middle ear. The larynx, or voice box, is else. However, breathing can be conscious and volun- composed of cartilage rings and folds of tissue, called tary. When swimming, singing, or engaging in other vocal folds. The epiglottis, which is the uppermost activities that require breath control, we can temporar- cartilage ring, prevents food from entering the airway. ily alter our breathing patterns. During inhalation, the vocal folds move to the sides of the larynx to allow air to pass freely. During exhala- EXPECTED AGE-RELATED CHANGES tion, we can speak and sing by controlling the distance With aging, changes are seen throughout the respira- between these folds, which vibrate when air is forced tory tract (Table 3-3; Box 3-1). Years of exposure to air through them and produce sound. pollution, cigarette smoke, and other hazardous chem- LOWER RESPIRATORY TRACT icals can damage the air passageways and lung tissue. The lower respiratory tract includes the lower trachea, Decrease in elastic recoil of the lungs leads to dimin- bronchial passages, and alveoli, all of which lie within ished air exchange. Mucous membranes in the nose the chest cavity. The trachea is a cartilaginous passage- become drier as the fluid content of body tissue way connecting the larynx to the bronchial passages. decreases; thus, incoming air is not humidified as The trachea branches into two major bronchi; these effectively. The number of cilia decreases, diminishing further divide like the branches of a tree into smaller their ability to trap and remove debris. Decreased and smaller bronchioles. At the ends of the bronchi- vocal cord elasticity leads to changes in voice pitch and oles are the alveoli, or air sacs, which are the functional quality, and the voice develops a more tremulous units of respiration. A thin layer of fluid lines each tiny character.","Physiologic Changes\u2003 CHAPTER 3\t 41 Table 3-3\u2003 Respiratory Changes Associated Several factors increase the possibility of inadequate With Aging oxygenation and the risk for respiratory tract infec- tions in older adults. The cilia movement inside the PHYSIOLOGIC CHANGE RESULTS lungs decreases. The airways and alveoli are less Decreased body fluids elastic, and there is a decrease in the number of capil- Decreased ability to humidify laries surrounding the alveoli, interfering with gas air resulting in drier mucous exchange. The lung tissue itself has decreased physical membranes mobility and elasticity, which can lead to increased pooling of secretions, especially in the lower lobes. Decreased number of Decreased ability to trap cilia debris COMMON DISORDERS SEEN WITH AGING Chronic Obstructive Pulmonary Disease Decreased number of Increased risk for respiratory Chronic obstructive pulmonary disease (COPD) is an macrophages infection umbrella term for the commonly occurring respiratory disorders of emphysema and chronic bronchitis. Decreased tissue Decreased gas exchange; Although they may appear independently, these dis- elasticity in the alveoli increased pooling of orders often occur together and may coexist with and lower lung lobes secretions asthma. COPD is common in people who have a history of smoking or who have had a high level of Decreased muscle Decreased ability to breathe exposure to environmental pollutants. In asthma, the strength and deeply; diminished strength trachea and bronchioles are extremely sensitive to a endurance of cough variety of physical stimuli and emotional stress that cause constriction of the bronchial passages and Decreased number of Decreased gas exchange increase mucus production within the airways. This capillaries narrows the airways and restricts airflow. Asthma used to be considered part of COPD, but is now Increased calcification Increased rigidity of rib cage; thought of as a related, but different, disorder. Asthma of cartilage decreased lung capacity is typically reversible; COPD is not (Yawn, 2009). Older adults with asthma may be less aware of bron- NURSING ASSESSMENTS AND CARE STRATEGIES chospasms and be slower to seek emergency care. RELATED TO RESPIRATORY CHANGES This can result in poor outcomes. Emphysema is char- acterized by changes in alveolar structure. The alveoli NURSING ASSESSMENTS CARE STRATEGIES lose elasticity, become overinflated, and are ineffec- tive in gas exchange. Chronic bronchitis involves Assess breathing Position to facilitate ease of inflammation of the trachea and bronchioles. Chronic depth and effort. respiration. Encourage irritation leads to excessive mucus secretion and a pro- incentive spirometer or ductive cough. nebulizer as ordered. Individuals with COPD manifest symptoms such as Assess cough and Encourage adequate fluid productive cough, wheezing, cyanosis, and dyspnea sputum production. intake. Encourage smoking on exertion. They are at higher risk for developing cessation and avoidance of respiratory tract infections; in severe cases, respiratory environmental pollutants. failure can occur. Assess for signs and Teach avoidance of individuals Influenza symptoms of with active infection. Teach Influenza, often referred to as the flu, is a highly con- respiratory infection. careful hand washing and tagious respiratory infection caused by a variety of disposal of contaminated influenza viruses. Many different strains of influenza secretions. Encourage have been identified, and new forms are being identi- annual influenza vaccination. fied continually. The various forms of influenza, such as the Hong Kong or Beijing flu, are often named for Box 3-1\u2003 Pulmonary Function Changes Commonly the area where they are first recognized. Epidemics Observed With Aging occur at regular intervals and are seen most often in the winter months. The virus is usually spread through \u2022\t Diminished breath sounds airborne droplets and moves quickly through groups \u2022\t Lower maximum expiratory volume of people who live or work in close contact with one \u2022\t Increased residual volume another. The incubation period is brief, often only 1 to \u2022\t Reduced vital capacity 3 days from the time of exposure. The onset of symp- toms is sudden; symptoms include chills, fever, cough, Musculoskeletal system changes that occur with aging alter the size and shape of the chest cavity. Kyphosis contributes to a barrel-chested appearance. Costal cartilage at the ends of the ribs calcifies and becomes more rigid, thus reducing rib cage mobility. Intercostal muscles atrophy, and the diaphragm flat- tens and becomes less elastic. All of these changes reduce lung capacity and interfere with respiratory function, resulting in a decreased ability to inhale and exhale deeply.","42\t UNIT I\u2003 Overview of Aging documented. The type of microorganism involved can be determined by Gram stain and sputum culture. sore throat, and general malaise and may be dramatic Bacterial pneumonia is treated with bacteria-specific and leave the victim feeling severely ill. antibiotics and supportive medical and nursing care. Older adults are at higher risk for serious complica- Aspiration pneumonia is an inflammatory process tions of influenza than are younger people. More than of the bronchi and lungs caused by inhalation of 90% of deaths resulting from influenza occur in the foreign substances, such as food or acidic gastric con- older-than-65 population. Influenza presents a special tents. The risk for aspiration is highest in older adults danger for older adults with a history of respiratory with a poor gag reflex, decreased mental status, and in disease or other debilitating conditions. Yearly flu those who must remain supine, because these indi- shots are recommended for all persons older than 65 viduals can easily inhale or regurgitate food during years of age to reduce the chance of contracting influ- oral or tube feeding. Aspiration of highly acidic gastric enza. Immunizations should be given in the fall so that secretions can lead to cell membrane damage with the level of immunity is high before the risk for expo- exudation and, ultimately, to respiratory distress. sure occurs. Immunization should be obtained yearly, Aspiration of large amounts of feeding solution is because the vaccine is different from the previous year. likely to trigger coughing or choking episodes and Each year, the vaccine is customized to protect against dyspnea. If these fluids are not removed immediately the particular strain of the virus that is anticipated to by suction, respiratory distress and death may be the be prevalent in the country. result. Aspiration of small amounts of liquid can result in continued and progressive inflammation of the Some people refuse or are hesitant to take the lungs. The person suffering from aspiration pneumo- vaccine because of the mild symptoms that may be nia typically has a rapid pulse and respiratory rate. experienced after inoculation. It is important to explain Sputum is frothy but free of bacteria; however, a super- to older adults that these symptoms are mild and imposed bacterial infection may develop. will protect them from more severe problems later. Individuals who are allergic to eggs should not receive Tuberculosis the vaccine. Influenza vaccine is cultured in egg protein Tuberculosis is an infectious disease caused by the and can cause a serious allergic reaction in allergic bacillus Mycobacterium tuberculosis, which spreads by individuals. Given properly, these vaccines are 70% to means of airborne droplets. An infected person coughs 80% effective in preventing illness. or sneezes, releasing contaminated droplets into the air. When these droplets are inhaled by other people, Pneumonia the bacillus lodges in their lungs, and the disease Pneumonia is acute inflammation of the lungs caused spreads. Malnutrition, weakened immune system, by bacterial, viral, fungal, chemical, or mechanical crowded living conditions, poor sanitation, and the agents. In response to the agent, the alveoli and bron- presence of systemic diseases, such as diabetes and chioles become clogged with a thick, fibrous substance cancer, increase the older adult\u2019s risk for contracting that decreases the ability of the lung to exchange gases. tuberculosis. Pneumonia can progress to a state in which the exudate fills the lung lobes, which then become consolidated The symptoms of tuberculosis include cough, night or firm. Pneumonia can be detected by radiologic sweats, fever, dyspnea, chest pain, anorexia, and examination. Breath sounds exhibit characteristic weight loss. The cough may be nonproductive or pro- changes. ductive. Sputum may be green or yellow; with hemop- tysis, the presence of blood may impart a rusty color. The symptoms of pneumonia differ with the caus- ative organism. Viral pneumonia, sometimes called Because skin tests for tuberculosis are not reliable in walking pneumonia, is most commonly seen following older adults, diagnosis is based on chest radiography influenza or another viral disease. Symptoms include or sputum cultures of acid-fast bacilli. A TB blood test headache, fever, aching muscles, and cough with might be needed for someone who was raised outside mucopurulent sputum. Treatment for viral pneumonia the United States and received the BCG vaccine for TB, varies according to the symptoms. as they may present with a false positive skin test. (CDC, 2014). Early detection is important to prevent Bacterial pneumonia can be caused by a number of further spread of the disease. organisms, most commonly Staphylococcus, Strepto\u00ad coccus, Klebsiella, and Legionella. The symptoms of bac- Treatment today consists of drug therapy using a terial pneumonia are abrupt and dramatic in onset. variety of antimicrobial agents, such as isoniazid, Chills, fever up to 105\u00b0 F, elevated WBC count (leuko- rifampin, ethambutol, and streptomycin. A combina- cytosis), tachycardia, and tachypnea are common, as tion of these drugs is usually administered and contin- is pain with respiration, or dyspnea. Because of age- ued for many months. Many of these drugs are related changes in immunity, the older adult may not associated with numerous adverse effects, particularly have the dramatic fever or leukocytosis that would be in older adults. Nursing care of the older adult with expected. The associated cough may be dry and unpro- tuberculosis focuses on maintaining good nutrition, ductive or purulent and productive. The color of the sputum is significant and should be observed and","Physiologic Changes\u2003 CHAPTER 3\t 43 monitoring adherence with the medication adminis- cavity; it contains a small amount of serous fluid that tration schedule, and detecting side effects. prevents the membrane surfaces from rubbing together during cardiac activity. Lung Cancer Lung cancer, or bronchogenic cancer, is one of the The heart, which is composed of cardiac muscle most deadly forms of cancer in the United States. The (called myocardium), is a hollow organ with four dis- age range at which lung cancer diagnosis peaks is 55 tinct chambers. The right side of the heart consists of to 65 years. Excluding skin cancer, lung cancer is the the right atrium and right ventricle, which are sepa- second most common type of cancer in both men and rated by the tricuspid valve. The right side of the heart women; second to prostate cancer in men and to breast is a low-pressure pump that moves deoxygenated cancer in women. Although lung cancer is slightly blood through the pulmonary valve and pulmonary more common in men, it is by far the leading cause of artery and out to the lungs. After the blood is oxygen- death in both men and women, with death rates ated, it returns to the left side of the heart through the exceeding that of colon, prostate, and breast cancers pulmonary veins. Because less effort is required to combined (American Cancer Society, 2014a). The sur- move blood the short distance through the lungs of a vival rate after diagnosis of lung cancer is poor, with healthy individual, the muscle wall of the right side of a five-year survival rate ranging from 1% to 49% for the heart is relatively thin. The left side of the heart nonsmall cell lung cancer, depending on the disease\u2019s also has two chambers, the left atrium and left ven- stage upon diagnosis. tricle, which are separated by the mitral valve. The pressure within the left side of the heart is higher than Lung cancer results from exposure to carcinogenic, that in the right side, because the left side is respon- or cancer-causing agents, particularly tobacco smoke, sible for blood distribution to the entire body. To air pollution, asbestos, and other hazardous industrial provide the necessary force, the left ventricle has a substances. Cough, chest pain, and blood-tinged thicker muscle wall than the right ventricle. When sputum are typical symptoms, which can easily be blood leaves the left ventricle, it proceeds through the missed because they resemble those of pneumonia and aortic valve into the aorta and its branches and out to other common respiratory conditions of older adults. the rest of the body. The treatment of choice is surgical resection of the The heart chambers and valves are lined with endo- lungs. This procedure is associated with a high mortal- cardial tissue. Endothelial tissue continues out from ity rate in older adults. Radiation and chemotherapy the heart and lines all of the blood vessels. This smooth are used in some patients, with varying amounts of layer allows the blood to flow freely and reduces the success. risk for clot formation. THE CARDIOVASCULAR SYSTEM BLOOD VESSELS The arteries are blood vessels that carry blood away The cardiovascular system moves blood through\u00ad from the heart. With the exception of the pulmonary out the body. This continuous, closed system is artery, arteries carry oxygenated blood. The aorta, the responsible for the transportation of blood with oxygen largest artery in the body, leaves the heart and branches and nutrients to all body tissues. It also transports into a series of progressively smaller arteries and capil- waste products to the organs that remove them from laries. These vessels run through the entire body and the body. Through its action, the cardiovascular system reach all organs and tissues. Arteries are designed for helps the body maintain homeostasis. The heart pumps high pressure, high flow situations. the blood, and the blood vessels dilate or constrict to aid in the maintenance of blood pressure and exchange Arterial walls are composed of three layers of tissue. of materials between the blood and body tissues. The innermost layer is the endothelium, or tunica HEART intima. This layer is a continuation of the endocardial The heart is a muscular organ located centrally in the tissue that lines the inside of the heart. The middle thoracic cavity between the lungs. The sternum, or layer, or tunica media, is composed of smooth muscle breastbone, protects its anterior surface. The heart\u2019s and connective tissue. This smooth muscle is con- tip, or apex, projects toward the left side of the body trolled by the autonomic nervous system and dilates and extends directly above the diaphragm. or constricts the artery to maintain the blood pressure. The outermost layer, or tunica externa, is composed of Three pericardial membranes form a sac around strong fibrous tissue that protects the vessels from the heart. The innermost membrane is on the surface bursting or rupturing under high pressure. The rela- of the heart and is called the epicardium or visceral tive thickness of the tunica media and externa enables pericardium. The middle membrane is the parietal the arteries to perform properly. pericardium, and the outermost membrane is the fibrous pericardium. The space between the epicar- The veins are vessels that carry blood toward the dium and the parietal pericardium is the pericardial heart. With the exception of the four pulmonary veins (two from each lung), veins carry deoxygenated blood. Venules, the smallest veins, are connected to the","44\t UNIT I\u2003 Overview of Aging Table 3-4\u2003 Cardiovascular Changes Associated With Aging smallest capillaries. Veins and venules are composed of the same three layers of tissue seen in arteries. The PHYSIOLOGIC CHANGE RESULTS veins use a system of valves, which are created by endothelial tissue folds, to aid in the return of blood to Decreased cardiac Decreased tissue oxygenation the heart. The valves prevent backflow of blood, which muscle tone related to decreased could be a problem when the blood is moving toward cardiac output and reserve the heart against the force of gravity. Increased heart size, \t Compensation for decreased The smooth muscle layer of the veins is much left ventricular muscle tone thinner than that of the arteries, because the veins are enlargement not as important in the regulation of blood pressure. The outer fibrous layer is also thinner, because blood Decreased cardiac Increased chance of heart pressure in the veins is much lower than that in the output failure; decreased peripheral arteries. Veins are designed for low pressure, low flow circulation situations. Decreased elasticity of Decreased venous return; A special set of blood vessels, the coronary arteries heart muscle and increased dependent and veins, supplies the heart with blood enriched with blood vessels edema; increased incidence oxygen and nutrients. These arteries are the first of orthostatic hypotension; branches of the ascending aorta. Because the heart increased varicosities and muscle works continuously, it has high oxygen hemorrhoids demands. Any condition that obstructs the normal supply of blood to the heart can damage the myocar- Decreased pacemaker Heart rate 40 to 100 beats per dium. If it is severely deprived of oxygen and nutri- cells minute; increased incidence ents, the heart muscle will die. Too much damaged or of ectopic or premature destroyed tissue results in cardiovascular system beats; increased risk for failure and death. conduction abnormalities CONDUCTION SYSTEM To function effectively, the cardiovascular system must Decreased baroreceptor Decreased adaptation to work in a controlled, organized, and rhythmic manner. The heart\u2019s rhythm is established by specialized cells sensitivity changes in blood pressure within the heart muscle that make up the electrical system of the heart. The body\u2019s natural pacemaker, the Increased incidence of Increased risk for heart sinoatrial node, is a group of specialized cells in the valvular sclerosis murmurs right atrium. Impulses generated in the sinoatrial node travel across the atria to the atrioventricular node in Increased Increased blood pressure, the lower interatrial septum. From there, they are con- atherosclerosis weaker peripheral pulses ducted through the bundle of His, through the right and left bundle branches, through the Purkinje fibers, NURSING ASSESSMENTS AND CARE STRATEGIES and, finally, to the ventricular myocardium. When the RELATED TO CARDIOVASCULAR CHANGES cells of the heart\u2019s electrical system depolarize, the myocardium depolarizes and the heart contracts NURSING ASSESSMENTS CARE STRATEGIES (systole), following which the special cells and the myocardium repolarize as the heart relaxes (diastole). Assess apical and Observe closely for abnormal This process alternately empties and fills the cham- peripheral pulses. sounds and irregularity of bers, which pump blood through the circulatory rhythm; determine presence system. and strength of peripheral EXPECTED AGE-RELATED CHANGES pulses comparing both sides The heart does not atrophy with aging as other muscles of the body. When assessing do. In fact, the heart muscle mass increases slightly lower extremities, start distally with age, and the thickness of the left ventricular wall and move toward trunk. also increases slightly. The increase in muscle mass may occur to offset some loss of tone. The aging heart Assess blood Hypotension is likely to occur may function less effectively even when no pathologic pressure lying, while changing position; changes are present (Table 3-4). Loss of tone typically sitting, and encourage patient to change leads to the decrease in maximal cardiac output seen standing. positions slowly and to seek in older adults. The normal conduction system, SA assistance if dizzy. node, AV node, the bundle of His, and its branches all Assess ability to Instruct patient to rest if short tolerate activity. of breath or fatigued. lose cells starting fairly early in life (in the twenties). Cardiac response to autonomic stimulation shows decreased response to adrenergic stimulation caused by changes in the receptors. Older persons enhance cardiac output by increasing stroke volume, whereas younger persons increase output by increasing heart rate (Cardiac output = stroke volume \u00d7 heart rate). The heart valves show some degree of thickening and calcification with aging, resulting in mild degrees","Physiologic Changes\u2003 CHAPTER 3\t 45 of mitral valve regurgitation. The endocardium and Box 3-2\u2003 Signs and Symptoms of Myocardial endothelium lose elasticity with aging. When these Infarction in Older Adults tissues become increasingly fibrous and sclerotic, venous return from the peripheral areas of the body 1.\t Sudden-onset dyspnea decreases. Orthostatic hypotension occurs because the 2.\t Chest tightness or heaviness (usually not crushing circulation does not respond quickly to postural changes. Less effective heart muscle pumping com- pain) bined with sclerotic changes in the veins can lead to 3.\t Anxiety and confusion dependent edema and to the appearance of varicosi- 4.\t Syncope ties in the lower extremities. Weakness of the valves in 5.\t Back pain the rectal veins can lead to hemorrhoids. 6.\t Jaw (tooth) pain COMMON DISORDERS SEEN WITH AGING Cardiovascular disease is the leading cause of morbid- attempted. MI caused by an embolus that is detected ity and mortality in the United States, accounting for quickly can be treated using thrombolytic agents, such more than 75% of all deaths in men and women older as streptokinase or tissue plasminogen activator, but than 65 years of age. the use of these drugs may increase the risk for stroke. Coronary Artery Disease Occlusion of the coronary arteries decreases the Some degree of coronary artery disease is present in nutrient and oxygen flow to the myocardium. Total most persons over age 70. The coronary arteries supply oxygen deprivation results in myocardial tissue blood to the heart. If these vessels become narrowed necrosis, which is irreversible. The types of problems or obstructed because of atherosclerosis, the heart may experienced after an MI depend on the location and not receive adequate oxygen and nutrients. Many extent of the heart muscle damage. Mild damage older adults have seriously obstructed coronary arter- may not be associated with symptoms and may be ies, yet they remain essentially asymptomatic. Once detectable on the electrocardiogram only. This type of circulation to the heart muscle decreases significantly, infarction is often referred to as a silent heart attack. the amount of oxygen delivered to the heart decreases Moderate damage may limit a person\u2019s physical activ- and ischemia occurs. The pain that may be experi- ity. Extensive damage or damage to a critical area of enced with ischemia is referred to as angina pectoris the heart may result in death. (literally, chest pain). Although the symptoms of isch- emia do include chest pain or pain radiating down Coronary Valve Disease the left arm, such pain is not always present or recog- The heart valves become less pliable over time. In nized in older adults. Vague gastrointestinal (GI) dis- addition, calcium deposits may develop on the valves, comfort or shortness of breath may be reported, or preventing them from sealing completely. This can there may be no symptoms at all. People experiencing result in mitral valve prolapse, mitral regurgitation, an angina attack are advised to decrease their activity and, ultimately, heart failure (HF). Symptoms of mitral and rest until the episode passes. Physicians usually valve prolapse include chest pain, palpitations, fatigue, prescribe coronary vasodilators, such as nitroglycerin, and dyspnea. Calcium deposits on the valves roughen or \u03b2-adrenergic blocking agents for people with isch- the lining and increase the risk for clot formation in emic heart disease. the chambers of the heart and in the blood vessels. When one or more coronary arteries become totally Cardiac Arrhythmias obstructed by atherosclerosis or embolus, the person Cardiac arrhythmias, including ventricular arrhyth- is said to have a myocardial infarction (MI), or heart mias, atrial fibrillation, and conduction disturbances, attack. The mortality rate from MI is much higher in are increasingly common with aging. Heart block is a older adults compared with young adults. Symptoms common conduction disturbance caused by disruption of a heart attack in older adults are more variable than of the electrical conduction system of the heart. This in younger people. Some might simply think they have disruption can be caused by fibrotic tissue infiltration a case of the flu. Older adults are likely to have symp- or MI. Sinus node dysfunction, sometimes called sick toms such as sudden-onset dyspnea or chest discom- sinus syndrome, is the primary conduction disorder fort, confusion, and syncope. Diaphoresis is uncommon. seen in older adults. This condition causes a distur- Many older adults who have heart attacks die sud- bance in the rate and rhythm of heart contraction, denly (Box 3-2). resulting in symptoms such as lightheadedness, fatigue, palpitations, and syncope. When the distur- If severe atherosclerotic occlusion of the coronary bance is severe, an artificial pacemaker may be used to arteries is detected before MI, angioplasty, stent place- regulate cardiac activity. ment, or coronary bypass surgery may be performed. The age and overall health of the individual are con- Heart Failure sidered before any of these surgical procedures are HF is primarily a problem of the aging population. It is estimated that more than two million people suffer","46\t UNIT I\u2003 Overview of Aging pacemakers, left ventricle assist devices, and implanted sensors, is increasingly common. from this disorder, resulting in almost one million hos- pitalizations each year. The older term congestive heart Cardiomegaly failure was used as it described the disease process: the Although aging does not routinely affect the size of the patient\u2019s lungs are often congested, and edema appears heart, many older adults develop cardiomegaly, or because the heart\u2019s pumping action is ineffective. HF enlargement of the heart, which is often related to is not a single disease but rather a syndrome that chronic HF. As we age, the muscular wall of the left accompanies and results from many other disorders. ventricle thickens. Because arteries and veins lose elas- A variety of cardiovascular diseases can contribute to ticity with age, the heart must pump harder to move the development of HF. Coronary artery disease, MI, blood through the vessels. The muscles of the left ven- hypertension, valve disease, and cardiac infection or tricle hypertrophy in an attempt to improve the output inflammation may increase the risk for HF. Diseases of of blood from the heart to meet the body\u2019s tissue other body systems, including bronchitis, emphysema, demands for oxygenated blood. asthma, hyperthyroidism, liver disease, kidney disease, and anemia, can also lead to HF. Metabolic changes The right side of the heart may also hypertrophy. and fluid and electrolyte imbalances seen with malnu- Right-sided enlargement is a result of increased resis- trition can lead to HF. Excessive sodium intake with tance in the pulmonary circulation. When one side of fluid retention increases the risk for HF. The effects of the heart is weakened, the other side is soon affected. alcohol, digoxin, hormones, some antineoplastics, cor- ticosteroids, and NSAIDs can directly or indirectly Peripheral Vascular Disease lead to HF. Vessel changes with aging can lead to mild or severe problems. In arteriosclerosis, the walls of the arteries HF is associated with a wide range of symptoms, become less elastic and plaque forms in the lumen, depending on the type and severity of the underlying further restricting blood flow. Excessive plaque is often disease. Mild chronic HF tends to have a slow, insidi- related to lifestyle factors or to other disease condi- ous onset. Older adults who experience mild symp- tions, most commonly obesity, high cholesterol intake, toms, such as dyspnea, orthopnea, or paroxysmal cigarette smoking, and diabetes mellitus (DM). If nocturnal dyspnea, often decrease their activity spon- the lumen becomes too narrow, blood flow to periph- taneously. They may not recognize these symptoms as eral sites, particularly the lower extremities, may be serious and may attribute them to \u201cslowing down\u201d restricted. This decreased blood flow deprives the with aging. Many older adults do not seek medical tissue of oxygen and nutrients and causes ischemia. If attention until they have serious problems and are the lumen is completely obstructed, tissue death may unable to perform even minimal activities (Box 3-3). result. Acute HF can result in severe pulmonary congestion or cardiogenic shock and is often fatal in older adults. An early symptom of arterial occlusive disease is Chronic HF can become acute HF with increased phys- pain. Intermittent claudication, which manifests as a ical or emotional stress. People with HF are more sus- cramping pain in the legs during or after walking, ceptible to fluid and electrolyte imbalances, infections, is common with diminished peripheral circulation. and renal or liver failure. Severe circulatory impairment can result in tissue necrosis and may require amputation. Medical management of HF includes dietary restric- tion of sodium to decrease fluid retention, administra- Acute occlusion may occur if a thrombus or embolus tion of diuretics (e.g., furosemide) to reduce fluid obstructs the blood vessel. Sudden pain, pallor, pulse- overload, administration of cardiotonic medications lessness (the \u201c3 Ps\u201d), loss of sensation, or a change in (e.g., digoxin) to increase the pumping efficiency of the body temperature should be assessed and reported heart, and planned levels of activity designed to reduce promptly. cardiac workload. Use of medical devices, including Occlusive Peripheral Vascular Problems Box 3-3\u2003 Signs and Symptoms of Heart Failure Thrombus formation (clotting) in the lumen of a vein is a common problem, particularly in immobile older 1.\t Dyspnea (shortness of breath) with exertion adults. These clots can form quickly because of slug- 2.\t Orthopnea (dyspnea at rest when recumbent) gish blood flow within the vessels. Increasing the 3.\t Coughing or wheezing with exertion or at rest patient\u2019s activity and using antiembolism stockings 4.\t Fatigue, weakness, or generalized muscle weakness help prevent problems related to venous stasis or pooling. with minimal exertion 5.\t Peripheral edema Thrombi form most often in lower extremity veins, 6.\t Weight gain without an increase in food intake (as a where they irritate and inflame the vessel and cause thrombophlebitis. Signs of thrombophlebitis include result of fluid retention) edema, swelling, warmth over the affected area, 7.\t Nausea, vomiting, or anorexia aching, and cyanosis or pallor. Medical management 8.\t Paroxysmal nocturnal dyspnea (extreme orthopnea during sleep)","Physiologic Changes\u2003 CHAPTER 3\t 47 of thrombophlebitis typically includes rest, elevation Hypertension is categorized as essential (primary) or of the affected leg, application of elastic stockings secondary. Essential hypertension, the more common or wraps, administration of analgesics, anticoagulant form, has no known cause. Many factors, including therapy, and sometimes application of heat. heredity, diet, obesity, stress, smoking, increased serum cholesterol levels, and abnormal sodium transport, If a thrombus breaks loose from the vein and travels are known to contribute to essential hypertension. in the circulatory system, it is referred to as an embolus. Secondary hypertension occurs as a result of a coexist- Emboli can be life-threatening. They are particularly ing disease process or other known cause. Renal, vas- dangerous if they reach small blood vessels in the cular, and endocrine pathologic conditions are among lungs or brain, where they can occlude the blood the most common causes of secondary hypertension. supply to vital tissues. Essential hypertension tends to have a gradual Varicose Veins onset and is often asymptomatic until complications Varicose veins are seen when blood pools in the veins arise. Most often, hypertension is discovered during and dilates or stretches them. The decrease in vascular a routine physical examination. It is diagnosed based muscle tone that occurs with aging increases the risk on two elevated blood pressure determinations on for this. Varicosities are most often seen as a twisting three separate days. A reading of 140\/90\u202fmm\u202fHg discoloration in the superficial veins of the lower is considered the upper limit of normal in adults. extremities. Older adults who are obese, are inactive, (James et\u202fal, 2014). or spend a great deal of time standing are more likely to have varicosities. The risk for inflamed varicosities Essential hypertension cannot be cured, but it can increases with age. be treated. Treatment includes nonpharmacologic approaches, such as rest, smoking cessation, use of Varicosities can result in leg cramps or a dull, aching stress-reduction techniques, weight loss, and dietary pain in the legs. Patients can reduce or prevent related sodium restriction. Pharmacologic approaches typi- problems by avoiding constricting garments, such as cally include administration of a thiazide diuretic, a garters or rolled stockings, by refraining from sitting calcium channel blocker, and either an angiotensin- with crossed legs, by increasing activity, by resting converting enzyme inhibitor, or angiotensin receptor with the legs elevated, and by wearing elastic stock- blocker (but not both) (James et\u202fal, 2014). The person ings that promote venous return. experiencing hypertension must be monitored con- tinuously to determine the effectiveness of therapy. Aneurysm Treatment of secondary hypertension is directed at the Aneurysm, the pouching or ballooning of arteries, is underlying pathologic condition. common in older adults who suffer from arterioscle- rotic blood vessel changes. Older adults with a history THE HEMATOPOIETIC AND LYMPHATIC SYSTEMS of angina, MI, or HF are at increased risk for develop- ing aneurysms. As parts of the muscular walls of the Body fluids distribute essential protective factors, arteries develop plaque and become rigid, other areas nutrients, oxygen, and electrolytes throughout the of the vessels stretch, dilate, and weaken. The walls of body. The two major fluids of the body are blood and the dilated areas become thin and prone to rupture. lymph. These fluids flow through the body within two parallel circulatory systems. Aneurysms of the abdominal aorta are most common in older adults. These are sometimes observed BLOOD as a pulsating mass near the umbilicus, or navel. Blood flows within the heart and vessels of the cardio- Patients may have abdominal pain and GI complaints. vascular system. The general functions of blood include Aneurysms in the thoracic aorta are higher up the transportation of nutrients, waste products, blood aorta and can present as back pain, cough, or hoarse- gases, and hormones; regulation of fluid-electrolyte ness. Thoracic aneurysms are less common than balance, acid-base balance, and body temperature; abdominal aortic aneurysms. Aneurysms can also and protection against pathogenic attack by the WBCs develop in peripheral and cerebral blood vessels. and against excessive blood loss through clotting Thrombi can form in aneurysms and block the flow of mechanisms. blood. Rupture of an aneurysm results in massive, life- threatening hemorrhage. Early detection and surgical Blood is 91% to 92% liquid; the remaining 8% to 9% repair of the damaged area provide the best chance for is solid. The liquid of the blood is called plasma. As a survival. liquid, plasma is a substance in which many other substances can dissolve and be transported, including Hypertensive Disease nutrients (e.g., glucose, amino acids, and lipids), Hypertension is prevalent in the older-adult popula- electrolytes (e.g., sodium, potassium, calcium, and tion. More than 60% of persons older than 65 years chloride), hormones, vitamins, antibodies, and waste of age have hypertension, increasing to more than products. Carbon dioxide is carried in the plasma as 70% at age 75 (American Heart Association, 2013). bicarbonate ion. Plasma contains a variety of proteins.","48\t UNIT I\u2003 Overview of Aging sometimes considered part of the circulatory system because it is responsible for returning fluids from the Albumin, the most abundant plasma protein, is impor- tissues to the circulation. The major components of the tant in the maintenance of osmotic pressure needed immune system\u2014lymphocytes and antibodies\u2014are to regulate blood pressure and volume. In the fibrino- formed by the lymph system to protect the body from gen component are prothrombin, fibrinogen itself, pathogenic microorganisms, malignant cells, and and other clotting factors that circulate until they are foreign proteins. The lymph system consists of the required by the body. Globulins function as transport lymph vessels, fluid, nodes, and nodules; the spleen; agents for lipids and fat-soluble vitamins; the \u03b3-globulin and the thymus gland. fraction is composed of antibodies that provide immu- nity from pathogens. The solid portion of the blood is Lymph Vessels, Fluid, and Nodes composed of three types of blood cells: red blood cells Lymph vessels are located in most tissue spaces. These (RBCs), WBCs, and platelets. permeable vessels absorb fluid and proteins from the tissues. Muscular compression on the vessels moves Erythrocytes this fluid through a series of lymph nodes and nodules Erythrocytes, or RBCs, live for approximately 120 that trap and phagocytize foreign materials before the days; therefore, the body produces new RBCs through- fluid enters the circulatory system at the subclavian out life. They are formed in the red bone marrow by veins. Lymph nodes and nodules also produce lym- stem cells, which undergo mitosis. For mitosis to phocytes and monocytes and phagocytize pathogens. occur, and thus for RBCs to form, vitamin B12 and folic acid are necessary for DNA synthesis. For maturation, Spleen and Thymus the RBCs need adequate amounts of protein and iron. The spleen is responsible for producing lymphocytes and monocytes, which enter the bloodstream. It also When RBCs become old and fragile, they are contains fixed plasma cells, which produce antibodies removed from the circulation by the reticuloendothe- to foreign antigens, and fixed macrophages, which lial cells of the spleen, liver, and red bone marrow. phagocytize pathogens and other foreign substances Their iron is reused in new RBCs formed by the red in the blood. Although people can survive without a marrow. Excess iron is stored in the liver for later use. spleen, they may be more susceptible to certain bacte- The heme portion of the RBC is converted to bilirubin rial infections, including pneumonia. in the reticuloendothelial system and is then processed by the liver. The liver secretes the bilirubin, or bile The thymus, which is located behind the thyroid pigment, with the other components of bile, into the gland, is large in fetuses and infants. The embryonic duodenum for use in digestion. This bile pigment bone marrow and the spleen produce the initial T lym- helps give stool its characteristic brown color. If exces- phocytes, or T cells, which are responsible for recogni- sive numbers of RBCs are destroyed or if the liver tion of foreign antigens and for cell-mediated immunity. does not function adequately, excessive amounts of The thymus shrinks with age, but once the T cells are bilirubin remain in the circulation. High bilirubin established in the spleen and lymph nodes, they are levels result in jaundice, a yellow discoloration of the self-perpetuating. sclera of the eyes and of the skin of light-skinned individuals. Lymphocytes and Immunity B lymphocytes, or B cells, are also produced in the Leukocytes embryonic bone marrow. These cells are responsible Leukocytes, or WBCs, have protective functions: they for the recognition of antigens located on a foreign destroy dead or damaged tissue, detoxify foreign pro- cell and for humoral immunity. In humoral immunity, teins, protect from infectious disease, and function in T cells and B cells often cooperate: Sensitized helper the immune response. WBCs are produced in the lym- T cells detect antigens and induce the B cells to phatic tissue of the spleen, lymph nodes, thymus, produce antibodies, which are then found in the and red bone marrow. The five types of WBCs are globulin portion of plasma. When the antigen has neutrophils, eosinophils, basophils, lymphocytes, been destroyed, suppressor T cells reduce helper and monocytes. T-cell activity and stop the immune process. Conversely, in cell-mediated immunity, antibodies are not pro- Platelets duced. Instead, activated T cells divide into memory Platelets, more properly called thrombocytes, are not T cells (which recognize the pathogen) and killer T whole cells but pieces of cells. They are produced cells (which destroy bacteria by disrupting their cell when large cells called megakaryocytes fragment and membranes). enter the circulation. Platelets, which remain in circula- tion for approximately 10 days, play an important role EXPECTED AGE-RELATED CHANGES in the blood\u2019s clotting mechanism. The characteristics of blood change somewhat as a person ages (Table 3-5). Plasma viscosity increases LYMPH SYSTEM slightly and is most often related to a general decrease The lymph and circulatory systems are parallel and interdependent. In fact, the lymph system is","Physiologic Changes\u2003 CHAPTER 3\t 49 Table 3-5\u2003 Hematopoietic and Lymphatic Changes older adults to tuberculosis skin testing may be delayed Associated With Aging or less intense than that of younger individuals. PHYSIOLOGIC CHANGE RESULTS COMMON DISORDERS SEEN WITH AGING Anemia Increased plasma Increased risk for vascular Anemia is defined as inadequate levels of RBCs or viscosity occlusion insufficient hemoglobin. The most commonly observed anemias in older adults are iron-deficiency anemia, Decreased red blood Increased incidence of anemia pernicious anemia, and folic-acid-deficiency anemia. cell production Iron-deficiency anemia results from inadequate Decreased mobilization Less effective phagocytosis nutritional intake, blood loss, malabsorption, or of neutrophils increased physiologic demand. Pernicious anemia is associated with decreased intake or absorption of Increased immature Decreased immune response vitamin B12. Folic-acid-deficiency anemia is usually T-cells response caused by poor nutrition, chronic alcohol abuse, or malabsorption syndromes, such as Crohn disease. Lower serum albumin Edema; increased levels of Anemia is common in the older adult population, levels medications that are highly and these problems are explored further in other protein bound chapters. NURSING ASSESSMENTS AND CARE STRATEGIES Leukemia Leukemia is the result of excessive production of RELATED TO HEMATOPOIETIC AND immature WBCs. There are both acute and chronic varieties, and leukemia is also classified by the type of LYMPHATIC CHANGES abnormal cells present. Other blood disorders (e.g., anemia) and hemorrhage (related to a decrease in the NURSING ASSESSMENTS CARE STRATEGIES number or function of platelets) are commonly seen with leukemia. Chronic lymphocytic leukemia is the Monitor laboratory tests, Report abnormal form most often seen in older adults. The average age including Hgb, Hct, WBC, findings promptly to at diagnosis is 72 years (American Cancer Society, and differential. primary care provider. 2014b). Depending on the stage of the disease and the patient\u2019s overall health, life expectancy may vary from Assess nutritional intake for Administer nutritional a few to as many as 20 years after diagnosis. adequacy of protein, iron supplements as and vitamins; assess for ordered. peripheral edema. in total body fluid. Blood cell production in the bone THE GASTROINTESTINAL SYSTEM marrow decreases slightly, resulting in a small decrease in total RBCs and WBCs. Unless extreme physiologic Food and fluids containing the nutrients needed for stress or disease is present, blood levels of RBCs, survival normally enter the body through the GI tract. WBCs, and platelets remain within normal limits. Although it is possible to live without food for several days, the cells require a regular supply of nutrients to The number of T cells in the body does not appear support their normal physiologic activities. to decrease with aging, but more of the cells are imma- ture. The ratio of helper cells to suppressor cells is As appealing as a crispy salad, turkey dinner, or increased. These T-cell changes lead to a diminished bowl of strawberries may be to us, these foods are immune response. Consequently, older adults are at useless to our cells until they are broken down into greater risk for developing infections, particularly simple, usable forms by the GI system. The GI tract respiratory and urinary tract infections (UTIs). Older prepares food for digestion. It then digests, processes, adults are also at increased risk for acquiring nosoco- and absorbs the nutrients, which are used by the cells mial infections. Studies have shown that women older of the body. The GI system also stores and discards than 55 years of age have limited antibody titers to wastes and plays a major role in maintaining fluid tetanus toxoid, raising questions about changes in balance by absorbing water. After we chew and humoral immunity with aging. If the ability to produce swallow food, we do not need to think about its further antibodies is affected by aging, changes in immu\u00ad processing, because the GI system takes care of remov- nization practices for the aging population may be ing the nutrients and discarding the waste. However, necessary. in unusual situations, the GI tract can be bypassed by administering specially prepared nutrients directly Changes in the immune response may modify the into the bloodstream (parenteral nutrition). usual signs and symptoms of infection. Such changes may be difficult to recognize in older adults: body The GI tract begins at the mouth and ends at the temperature may not become significantly elevated anus. Each part of the GI tract performs its own dis- until the infection is severe, and pain may not be tinct functions. present to indicate infection. Some examples include the following: (1) older adults with pneumonia may not have a fever or chills; (2) dysuria is often absent in older adults with UTIs; (3) pain may be absent with peritonitis or appendicitis, even though the individual is obviously ill; and (4) the physiologic response of","50\t UNIT I\u2003 Overview of Aging ORAL CAVITY STOMACH Food normally enters the body through the mouth and The stomach is a muscular sac in which both mechani- is prepared for digestion in the oral cavity. The teeth cal and chemical digestion take place. The stomach is mechanically process food by biting, tearing, grinding, lined with mucous membrane, which helps prevent and chewing it, a process called mastication. The damage to the muscle walls. Special stomach glands normal adult has 28 to 32 permanent teeth with shapes secrete mucus; others secrete enzymes, intrinsic factor, and sizes that vary depending on their function. The and hydrochloric acid. This mixture of enzymes and incisors are used to bite, the canines to tear, and the acids is called gastric juice or digestive juice. The premolars and molars to chew and grind. Each tooth pyloric sphincter at the distal end of the stomach is composed of a crown, which is the part visible above retains the food bolus and the digestive juices within the gingiva (gum), and a root, which is imbedded in a the stomach, where they can be churned, mixed, and socket in either the mandible or maxilla of the jaw. The further broken down for later digestion and absorp- periodontal membrane lines the tooth socket and holds tion. Once the food has been processed in the stomach, the teeth in place. The crown of the tooth is protected it is referred to as chyme. After adequate mixing, small by an extremely hard casing called enamel. The pulp amounts of chyme are released through the pyloric cavity of the tooth contains blood vessels and nerve sphincter into the small intestine. endings. SMALL INTESTINE TONGUE The small intestine is more than 20 feet long and is The tongue is a highly flexible structure controlled by divided into three segments called the duodenum, the and composed primarily of skeletal muscle. Papillae, jejunum, and the ileum (in order of progression away which contain the taste buds, are located on the upper from the stomach). Additional substances are added to surface of the tongue. Cranial nerves control the move- chyme in the small intestine to complete digestion. ment of the tongue and carry the impulses for taste Intestinal digestive glands secrete intestinal juice, perception. The tongue aids in mechanical digestion which is alkaline and contains many enzymes. The by positioning food between the teeth and mixing it common bile duct and pancreatic duct converge and with saliva in the oral cavity. enter the duodenum at the sphincter of Oddi. Bile, which is produced in the liver and stored in the gall- SALIVARY GLANDS bladder, breaks down fat by emulsifying it. Pancreatic Three pairs of salivary glands excrete saliva into juice contains enzymes that break down proteins. The the oral cavity. Saliva is composed primarily of water pancreas also produces sodium bicarbonate; when but also contains the enzyme amylase, which begins released into the duodenum, it neutralizes the hydro- the digestion of starch. Saliva production normally chloric acid from the stomach. After all of these chemi- increases in response to the sight or smell of food. cals have acted on the material in the GI tract, the Inadequate amounts of saliva result in a dry mouth process of digestion is completed, and the nutrients are and difficulty swallowing. When adequately mixed in elementary forms (e.g., glucose and amino acids) with saliva, food reaches a consistency that makes it that can be used by the cells of the body. more suitable for chemical digestion. The tongue lifts against the hard palate, pushing the bolus of food to Absorption of nutrients occurs primarily in the the pharynx at the back of the oral cavity. From here, small intestine. Special villi, fingerlike projections of the food bolus enters the esophagus. the lining of the small intestine that are rich in capil- laries and lymphatic vessels, increase the surface area ESOPHAGUS of the lining. As the digested nutrients pass over these Once in the esophagus, food is moved by a process villi, they are absorbed into the blood and lymph by called peristalsis, a wavelike motion of the smooth the capillary network and lymphatics. musculature that propels material through the entire GI tract. The esophagus is a hollow muscular tube that Once the nutrients have been absorbed, undigested passes from the pharynx through the flat layer of dia- material and water are propelled into the large intes- phragm muscle and to the stomach. The esophagus is tine by peristalsis. A structure called the ileocecal located above the diaphragm, and the stomach is valve is located between the ileum of the small intes- located immediately below the diaphragm. The lower tine and the cecum of the large intestine. This structure esophageal sphincter, also called the cardiac sphincter, prevents waste products from moving backward into is at approximately the same level as the diaphragm, the small intestine. where the esophagus meets the stomach. It allows food to enter the stomach but prevents the stomach LARGE INTESTINE contents from moving backward (refluxing) into the The large intestine is approximately 5 feet long and is esophagus. divided into segments called the ascending, trans- verse, descending, and sigmoid colon and the rectum. The major functions of the large intestine are","Physiologic Changes\u2003 CHAPTER 3\t 51 absorption of water, minerals, and vitamins, and Dental caries (cavities) can soften the enamel and storage and elimination of indigestible wastes. expose nerves in the tooth pulp. The resulting pain can decrease the ability and the desire to eat. As the effluent, or discharge of waste products, moves through the large intestine, water is absorbed Esophageal dilation and problems related to swal- and the mass becomes increasingly solid in consis- lowing may be observed with aging. Commonly, the tency. It is stored in the sigmoid and descending colon. gag reflex is depressed in older adults, even in those When peristalsis causes the effluent to enter the rectum, without neurologic problems. This can lead to epi- its presence there triggers the defecation reflex, in sodes of choking and aspiration. Sphincter muscle which strong peristaltic movements propel the mass tone, particularly the lower esophageal sphincter, may from the rectum and through the anus. Another reflex- decrease, increasing the incidence of esophageal reflux like action, the gastrocolic reflex, occurs when the or heartburn. stomach is distended with food, stimulating vigorous peristalsis of the rectum and a desire to defecate. The In the stomach, atrophy of gastric glands may result internal anal sphincter is an involuntary muscle that in a decreased production of intrinsic factor and hydro- relaxes when the rectum is full. The external anal chloric acid; this, in turn, can interfere with normal sphincter, which is usually under voluntary control digestion and absorption of nutrients. These changes after 2 to 3 years of age, may be contracted to prevent can contribute to anemia and other malabsorptive defecation. When the external sphincter relaxes, wastes problems. A decrease in gastric mucus production are eliminated from the large intestine. leads to risk for injury and bacterial penetration into the systemic circulation. Decreases in gut-associated EXPECTED AGE-RELATED CHANGES lymphoid tissue can have an effect on immune Over time, changes in the GI tract can interfere with response. Peristalsis slows with aging, increasing the normal digestion and medication absorption (Table likelihood of constipation and the incomplete elimina- 3-6). In the oral cavity, gingival tissue may recede and tion of feces. the periodontal bonds holding the teeth in place may loosen. If the teeth are not structurally sound, the COMMON DISORDERS SEEN WITH AGING ability to bite and chew can be impaired. Good oral Hiatal Hernia hygiene can slow these changes. It is not considered A hiatal hernia is the protrusion of the stomach into the normal for older adults to lose some or all of their thoracic cavity through the esophageal opening in the teeth. diaphragm (Figure 3-8). The primary risk factors for hiatal hernia are obesity and being over 50 years of Table 3-6\u2003 Gastrointestinal Changes Associated With Aging PHYSIOLOGIC CHANGE RESULTS Increased dental caries and tooth loss Decreased ability to chew normally; decreased nutritional status Decreased thirst perception Increased risk for dehydration and constipation Decreased gag reflex Increased incidence of choking and aspiration Decreased muscle tone at sphincters Increased incidence of heartburn (esophageal reflux) Decreased saliva and gastric secretions; Decreased digestion and absorption of nutrients; altered absorption of increased gastric pH some medications that are pH-dependent Decreased gastric motility and peristalsis Increased flatulence, constipation, and bowel impaction Decreased liver size and enzyme production Decreased ability to metabolize drugs, leading to increased risk for toxicity NURSING ASSESSMENTS AND CARE STRATEGIES RELATED TO GASTROINTESTINAL CHANGES NURSING ASSESSMENTS CARE STRATEGIES Assess oral cavity for dentition, condition of Educate regarding importance of good oral hygiene; stress need for mucous membranes and hygiene. adequate fluid intake. Dental referral as necessary. Assess swallow and gag reflexes. Encourage posture that facilitates swallowing. Consult with speech therapy for swallow studies and safe dietary regimen. Monitor weight changes. Measure and record weight at least one time per month, more often if fluid balance issues present. Assess intake of nutrients and fluid. Educate regarding recommended dietary intake. Establish calorie count and intake and output if problems are suspected. Assess bowel sounds and bowel elimination Establish bowel routines. Teach importance of adequate fluid, fiber, and patterns. activity. Administer laxatives, stool softeners, suppositories, or enemas as needed to prevent constipation and impaction. Assess effectiveness of medications. Observe for therapeutic effects (or lack thereof); observe for signs of toxicity.","52\t UNIT I\u2003 Overview of Aging Herniated Lower esophageal Herniated Box 3-4\u2003 Medical Treatment of Ulcers portion of sphincter (LES) portion of stomach stomach \u2022\t If caused by H. pylori: antibiotic regimen as prescribed Diaphragm \u2022\t If caused by NSAIDs: substitution of a different Lower medication, or lowering the dose if no effective esophageal alternative is available sphincter \u2022\t Administration of proton pump inhibitors (stops acid (LES) being pumped into the stomach), such as omeprazole and lansoprazole AB \u2022\t Administration of histamine H2-blocking agents (blocks FIGURE 3-8\u2003 Hiatal hernia. A, Sliding hernia. B, Paraesophageal histamine, thereby reducing acid secretion), such as famotidine, cimetidine, and ranitidine hernia. (From Monahan FD, Neighbors M, Sands JK, et\u202fal: Phipps\u2019 \u2022\t Avoidance of tobacco and alcohol, which stimulate medical-surgical nursing: Health and illness perspectives, ed 8, acid release St. Louis, 2007, Mosby.) \u2022\t Administration of antacids to reduce acidity age. Older adults have the highest incidence of hiatal but gastric ulcers are more common. A bacterium, hernia. Some demonstrate no symptoms; others com- Helicobacter pylori or H. pylori, has been implicated as plain of severe distress that may be intermittent or the major cause of gastric ulcers. Drug-induced ulcers continuous. Reflux episodes usually occur after meals, related to the use of iron supplements, aspirin, and especially when the person lies down immediately NSAIDs can also occur in older adults. Diet and nutri- after eating. Complaints may include heartburn, acid tion do not appear to play a role in causing or prevent- reflux, or generalized epigastric distress. Sometimes ing peptic ulcers. Smoking and alcohol do contribute the symptoms can resemble an angina attack. As men- to ulcers, however (National Digestive Diseases tioned, hiatal problems are most likely to occur after Information Clearinghouse, 2014). meals or when the person is at rest; in contrast, angina attacks are most likely to occur with physical exertion. Peptic ulcers in older adults do not cause the classic Vital signs do not normally change in response to epigastric pain that is seen in younger people. Older problems with hiatal hernias. adults suffering from ulcers are more likely to com- plain of generalized pain and to exhibit a decreased Gastroesophageal reflux disease (GERD) is a major activity level, decreased appetite, and weight loss. problem that can occur with hiatal hernias. With Vomiting, melena (dark \u201ctarry\u201d stool containing GERD, the gastric contents move backward into the blood), and generalized signs of anemia may result esophagus, where they increase the risk for aspiration. from gastric bleeding. If a gastric ulcer progresses to This can present serious concerns in older adults who the point of perforation, severe hemorrhage can result. have diminished gag or cough reflexes. Occasionally, If the person has already been weakened by occult the hernia through the diaphragm is reduced surgi- (hidden) bleeding, hemorrhage may be serious enough cally, but typical treatment involves the use of ant\u00ad to result in death. acids, histamine antagonists, proton pump inhibitors, and dietary modifications. Fatty foods, carbonated Early recognition and reporting of symptoms by the beverages, alcohol, and foods that contain caffeine nurse is important so that treatment can be started (e.g., coffee, cola, and chocolate) should be avoided to before serious problems occur. Medical treatment of reduce problems with reflux. Smaller, more frequent ulcers in older adults is generally preferred to surgical meals are often beneficial because overeating is likely correction (Box 3-4). to enlarge the stomach and cause it to bulge into the diaphragm. It is recommended that food and fluids are Diverticulosis and Diverticulitis restricted after the normal evening meal, and affected Diverticula are small pouches or sacs that develop persons should avoid lying down too soon after eating. because of weaknesses in the intestinal mucosa. In severe cases, the head of the bed may need to Between 30% and 40% of persons older than age 50 be elevated during sleep to reduce the risk for have some diverticula, and the incidence of diverticu- aspiration. losis increases with each decade of life. Most people with diverticula experience no symptoms, and there is Gastritis and Ulcers no specific treatment unless symptoms occur. The Chronic atrophic gastritis is an inflammatory change patient should continue to eat a normal diet with ade- in the mucous membranes of the stomach in which the quate fluids and roughage. If rectal bleeding occurs, mucosa becomes thin and abnormally smooth and medical intervention is necessary to determine the may develop hemorrhagic patches. All or part of the source. stomach may be involved. Diverticulitis involves inflammation of one or more Peptic ulcer is a term that refers to both gastric diverticula. This inflammation may result in bowel and duodenal ulcers. Either can occur with aging, obstruction, perforation, or abscess formation. In cases","Physiologic Changes\u2003 CHAPTER 3\t 53 of severe diverticulitis, the patient may need hospital- the kidney. Blood is filtered in the glomerulus of the ization. Oral food intake is restricted and intravenous nephron, and this filtrate is destined to become urine. fluids are administered to \u201crest\u201d the diseased area. This highly vascular organ receives blood from the Surgical correction, including bowel resection or colos- renal artery, which branches off the abdominal aorta. tomy, may be required if conservative medical treat- Blood returns to the circulation through the renal vein, ment is unsuccessful. which connects to the inferior vena cava. Adequate blood flow to the kidneys is very important; any condi- Cancer tion that decreases renal blood flow interferes with The incidence of colon cancer begins to increase at 40 normal kidney function. years of age and peaks between the ages of 60 and 75. Carcinoma of the colon is more common in women, The kidneys play an important role in fluid and whereas rectal carcinoma is more common in men. electrolyte balance and acid-base balance in the body. Any changes in bowel elimination should be viewed They remove nitrogenous wastes, excess glucose, and with suspicion, especially signs of obstruction or drug metabolites from the bloodstream. They also help bleeding. Routine screening for rectal cancer is recom- regulate blood pressure. The kidneys typically produce mended for those over age 40. between 1 and 2\u202fL of urine every 24 hours. If excessive fluid is lost elsewhere (e.g., in perspiration or diar- Hemorrhoids rhea), urine output normally decreases. Excessive fluid Hemorrhoids, sometimes called piles by older adults, or alcohol intake tends to increase urine production. A are common at all ages but may be particularly trou- single kidney can meet the needs of the entire body. blesome to older patients. People with chronic consti- pation and obese people are most likely to have URETERS AND BLADDER problems with hemorrhoids. Pain and small amounts The ureters are tubes of smooth muscle that allow of bright red blood at the rectum are common com- urine to drain from each kidney into the bladder. When plaints. Most patients with hemorrhoids do not require the body is upright, urine drains by means of gravity. surgery. Diet changes, stool softeners, or bulk laxatives Pressure of the enlarging bladder against the lower are usually effective in reducing problems related to portion of the ureter keeps the ureter closed and pre- constipation and hemorrhoids. vents urine from flowing back toward the kidneys. Rectal Prolapse The bladder is a hollow muscular sac located below Bulging of the rectum through the anus is most likely the peritoneum and normally entirely within the pelvic to occur in women older than age 60, especially those cavity. The bones of the pelvis protect the bladder from who have given birth to many children. Some form trauma. In women, the bladder is located anterior to of medical intervention may be needed if this condi- the uterus; in men, it is superior to the prostate gland. tion causes distress. Surgery may be performed to strengthen the musculature. Insertion of a wire loop at The muscular wall of the bladder is lined with a the anal sphincter may be attempted in very old people. mucous membrane and is capable of stretching to hold large volumes of urine (up to 1000\u202fmL or more). Urine THE URINARY SYSTEM is retained in the bladder by means of the sphincter muscles. The internal sphincter is located at the outlet The urinary system consists of two kidneys, two from the bladder into the urethra. Control of the inter- ureters, the urinary bladder, and the urethra. The nal sphincter is involuntary. The external urethral urinary system supports homeostasis by eliminating sphincter comes under voluntary control at approxi- wastes and excessive fluid from the body. The kidneys mately 2 to 3 years of age. Voluntary contraction of the continuously filter the blood and selectively save or external sphincter prevents urine from leaving the eliminate water, electrolytes, and wastes. Those sub- body. Relaxation of the external sphincter allows urine stances not reabsorbed by the kidneys are eliminated to drain from the body. Voluntary control of urination from the body as urine. may be overcome if the bladder becomes overly KIDNEYS enlarged with urine. In adults, the urge to urinate typi- The kidneys are two bean-shaped organs located on cally occurs when urine volume in the bladder reaches each side of the spine behind the peritoneal lining of approximately 200 to 400\u202fmL. the abdomen and at the lower edge of the rib cage. The left kidney is usually located slightly higher than the The urethra is a tubelike passage that leads from the right kidney. Each kidney is surrounded by an adipose bladder to the outside of the body. At the point of exit, tissue pad and is further protected from trauma by the it is referred to as the urinary meatus. The female urethra muscles of the back. Within each kidney is a maze of is 1 to 1.5 inches long; the male urethra is 7 to 8 inches nearly a million nephrons, the functional portion of long. The urethra is part of the reproductive system in men and is used to transport semen as well as urine; however, ejaculation and urination cannot take place simultaneously. The prostate gland surrounds the urethra. Although this normally causes no problems, an enlarged prostate can interfere with urination.","54\t UNIT I\u2003 Overview of Aging Table 3-7\u2003 Urinary Changes Associated With Aging CHARACTERISTICS OF URINE PHYSIOLOGIC CHANGE RESULTS Urine is approximately 95% water, with the remainder composed of waste products and salts. The specific Decreased number of Decreased filtration rate with gravity (which measures the amount of solids dis- functional nephrons decrease in drug clearance solved in water) of urine is normally maintained within close limits. A specific gravity of 1.010 to 1.025 Decreased blood Decreased removal of body is considered normal. Dilute urine has a low specific supply wastes; increased gravity, and concentrated urine has a high specific concentration of urine gravity. Urine is normally clear, and its color ranges from pale yellow to dark amber. It may be alkaline or Decreased muscle Increased volume of residual acidic, depending on the diet of the individual. High- tone urine protein diets tend to make the urine more acidic; veg- etarian diets tend to lead to alkaline urine. Acidic urine Decreased tissue Decreased bladder capacity is less compatible with bacterial growth than is alka- elasticity line urine and may help reduce the risk for a UTI. EXPECTED AGE-RELATED CHANGES Delayed or decreased Increased incidence of The kidneys decrease in size from approximately 400\u202fg perception of need incontinence at age 40 to only 250\u202fg by age 80. By age 70, they lose to void approximately one-third of their efficiency and they lack functional reserve. Despite this, the kidneys are Increased nocturnal Increased need to awaken to usually able to remove waste adequately to maintain urine production void or episodes of nocturnal normal blood levels. As a person ages (Table 3-7), the incontinence number of functional units or nephrons decreases. In addition, the kidneys lose mass and decrease in size. Increased size of Increased risk for infection; Vascular changes, such as those that occur with athero- prostate (male) decreased stream of urine; sclerosis or arteriosclerosis, lead to decreased blood increased hesitancy and supply to the kidneys. Decreased blood flow results in frequency of urination a diminished glomerular filtration rate. At 90 years of age, the glomerular filtration rate can be as little as half NURSING ASSESSMENTS AND CARE STRATEGIES of what it was at age 20. The blood urea nitrogen RELATED TO URINARY CHANGES remaining in the blood increases significantly with age, from a normal of 10 to 15\u202fmg\/dL in young adult- NURSING ASSESSMENTS CARE STRATEGIES hood to 21\u202fmg\/dL by age 70. Monitor for signs of Promptly notify primary care The nephrons and collecting system of the aging drug toxicity. provider of relevant body are less sensitive to the effects of antidiuretic observations. hormone. Less sodium and water are reabsorbed and more potassium is lost, resulting in the production of Assess for urinary Palpate bladder after voiding or less concentrated urine with aging. frequency. use Doppler to determine whether bladder is emptying Aging results in reduced urinary bladder size, completely. which leads to decreased bladder capacity (i.e., the volume of urine the bladder can hold before a person Assess for signs and Obtain a urine specimen for experiences the urge to void). Many older people need symptoms of urinary analysis. to void when only 100\u202fmL of urine is present. In addi- tract infection. tion, overactivity of the detrusor muscle can result in contraction of the bladder before the bladder is full. Assess frequency and Establish a toileting schedule Either or both of these factors can lead to the urinary timing of episodes based on assessment data. urgency and frequency that is common in older adults. of incontinence. To further aggravate the situation, loss of muscle tone can impair voluntary control of the external sphincter the risk for UTIs, especially in older adults, because muscle. Atonic muscular changes may also occur in retained urine is a good medium for bacterial growth. the wall of the bladder. Loss of tone may result in reduced urinary stream, incomplete or unsuccessful The prostate gland enlarges with age. Most men voiding, continuous dribbling of urine, or urinary older than 60 years of age experience some degree of retention with overflow voiding (a condition in which prostate gland enlargement as a result of benign pros- the person voids frequently but never completely tatic hyperplasia or prostate cancer. Because it sur- empties the bladder). Urinary retention contributes to rounds the urethra, an enlarged prostate gland can compress and narrow the passageway, which, in turn, causes problems with voiding. Hesitancy, frequency, the inability to maintain a steady stream of urine, and urinary retention are common indicators of prostatic hypertrophy. COMMON DISORDERS SEEN WITH AGING Urinary Incontinence Urinary incontinence, the involuntary loss of urine, is not a routine or normal occurrence with aging. Incontinence may occur as a result of physiologic","Physiologic Changes\u2003 CHAPTER 3\t 55 Box 3-5\u2003 Risk Factors for Urinary Tract Infections the nervous system and the endocrine system main- tain homeostasis. \u2022\t Inadequate or improper hygiene related to difficulty in cleansing after toileting Many of the functions of the nervous system (e.g., regulation of heartbeat and body temperature) occur \u2022\t Urinary stasis and incomplete emptying of bladder at an unconscious level. Other activities, such as resulting from physiologic changes and decreased writing, working with tools, or singing, can be done mobility with conscious thought and effort only. Some activi- ties, such as breathing, occur unconsciously but can \u2022\t Coexisting diseases, such as diabetes, hypertension, also be controlled consciously. The nervous system stroke, and dementia functions at an unconscious or reflex level at birth; neurologic control is gained with maturation. With \u2022\t Medical interventions, including catheterization and advanced age, the nervous system becomes prone to repeated use of antibiotics (leading to resistant strains deterioration and is susceptible to many types of injury of bacteria) and illness. Because of the serious consequences of age-related neurologic problems, it is important to \u2022\t Exposure to microorganisms in hospitals or extended- examine this system in greater detail. care facilities The nervous system is composed of highly special- changes, other medical problems such as UTIs, neuro- ized cells called neurons. Each neuron consists of a cell logic problems, or changes in the ability to function. body, which contains the cell nucleus; multiple den- Several classifications of medication can contribute drites, which are fibers that transmit impulses (mes- to incontinence. Urinary incontinence is discussed in sages) to the cell body; and one axon, which carries greater detail in Chapter 18. impulses away from the cell body. Urinary Tract Infection Nerve impulses are electrochemical in nature. An The incidence of UTIs increases significantly with age. impulse travels through the neuron by fast-moving ion Women are more likely to develop a UTI because of shifts across progressive segments of the cell mem- anatomical reasons; 40% will experience a UTI at some brane until it reaches the end of the axon. Axons and point in their lives. Men also develop UTIs, but they dendrites do not touch each other. A small gap called are less common in men and develop at an older age. a synapse separates these structures. Special chemicals Both the normal changes of aging and the increased called neurotransmitters are released by the axon to incidence of health problems contribute to this stimulate a receptor site on another nerve cell. This increased incidence of UTIs (Box 3-5). allows the nerve impulse to move from one nerve cell to another. When the receptor has been stimulated, Chronic Renal Failure the neurotransmitter activity is halted by an inactivat- Chronic renal failure may be a result of other chronic ing chemical that stops prolonged transmission of health conditions, such as hypertension, DM, chronic impulses. In the peripheral nervous system, the most UTIs, or urinary tract obstructions. It may also result common neurotransmitters are acetylcholine and nor- from acute renal failure caused by hypovolemia, hypo- epinephrine. In the central nervous system, dopamine, tension, or antibiotic toxicity. serotonin, and norepinephrine are important. Each neurotransmitter has a specific inactivator. The symptoms of chronic renal failure are extensive and often mimic those of other conditions. These The nervous system consists of two major divisions: symptoms include changes in urine output, muscle the central nervous system and the peripheral nervous weakness, edema, nausea and vomiting, itchy and dry system. skin, and numerous neurologic symptoms. Blood tests reveal significant changes, particularly elevated levels CENTRAL NERVOUS SYSTEM of blood urea nitrogen and creatinine. Chronic renal The central nervous system is composed of the brain failure consists of medications and dietary changes to and the spinal cord. The brain is the master integrator attempt slowing of the disease process. Chronic renal of the nervous system. Thought, decision making, failure may become end-stage renal failure, which is behavior, and all life processes are controlled by the treated by dialysis or kidney transplant. various segments of the brain. THE NERVOUS SYSTEM Medulla The medulla oblongata extends from the spinal The nervous system processes and controls body func- column to the pons of the brain. This area controls tions and links us with the outside world. Through the many vital functions, including heart rate, constriction nervous system, we perceive sensations and detect of blood vessels (affecting blood pressure), and respi- changes in our environment. We store information ration. Reflex centers for coughing, vomiting, swallow- about the world within the nervous system and use ing, and sneezing are also located in this area. Severe this information to respond to the world. A function- trauma to this area of the brain is life-threatening. ing nervous system is necessary for survival. Internally,","56\t UNIT I\u2003 Overview of Aging system and the autonomic nervous system. The peripheral nervous system is a relay system that Pons and Midbrain detects changes in both the internal and external envi- The pons also exerts control over respiratory patterns ronments and relays this information to the central and works with the medulla to regulate breathing nervous system. It also transmits impulses from the rhythm. The midbrain integrates visual and auditory brain and spinal cord to the appropriate end organs. reflexes and helps maintain balance and equilibrium. To prevent messages from short-circuiting each other in the peripheral nervous system and to speed impulse Cerebellum conduction, the axons of many types of nerves are sur- The cerebellum works to coordinate body movement rounded by Schwann cells, which form the protective at an unconscious level. It allows excitation of muscles myelin sheath. Probably because of the myelin sheath, by neurons higher in the brain while it inhibits unnec- injured peripheral nerves can be surgically repaired or essary impulses; thus, it enables smooth movements they may even regenerate spontaneously if the damage without jerkiness. Picking up a cup of coffee and is not too severe. Neurons in the central nervous bringing it to your mouth in a coordinated way is an system lack this guiding sheath; if damaged, they example of the activity of the cerebellum. If you had usually die. to think consciously of all of the individual movements to accomplish this activity, the coffee would be cold EXPECTED AGE-RELATED CHANGES before you could drink it. Many cellular changes have been observed in the aging brain, including a reduction in its size and Hypothalamus weight resulting from a decrease in the volume of the The hypothalamus, a small area of the brain above the cerebral cortex. There is approximately a 3% reduction pituitary gland, is the coordinating center for the auto- in brain tissue in each decade from age 50 to 90. Brain nomic nervous system. It also secretes releasing and shrinkage has been linked to a decrease in the number inhibiting hormones that affect the secretions of the of functional cortical neurons (Table 3-8). Mental func- pituitary gland (such as growth-hormone-releasing tion is often changed as these cells are lost or undergo factor) and thus results in various effects on the endo- functional changes. Cerebral blood flow decreases crine system. Other hormones are produced in the with aging because of the gradual accumulation of hypothalamus, move to the pituitary, and are released fatty deposits (i.e., arteriosclerosis). Decreased blood by that gland, including antidiuretic hormone and flow also results in a slower rate of cerebral metabo- oxytocin. The hypothalamus regulates body tempera- lism. A progressive decrease in the number of branches ture, controls food intake, and is involved with visceral responses, such as the increased heart rate that occurs Table 3-8\u2003 Neurologic Changes Associated With Aging with anger. PHYSIOLOGIC CHANGE RESULTS Cerebrum The cerebrum is the largest part of the human brain. Decreased number Slowed thought processes, It is divided into lobes, which are named according to of brain cells decreased ability to respond to the cranial bones under which they lie. Because of the multiple stimuli and tasks manner in which nerve impulses are routed in the central nervous system, the left lobes control the right Decreased number Decreased reflexes, decreased side of the body and the right lobes control the left side of nerve fibers coordination, decreased of the body\u2014they function contralaterally. The frontal proprioception lobes control voluntary motor activity, judgment, planning, organization, problem solving, and behavior Decreased amounts Decreased perception of stimuli regulation. Broca area, which controls the movements of neuroreceptors related to speech, is found on the left frontal lobe in right-handed individuals. The parietal lobes interpret Decreased Decreased motor responses, impulses and sensations from the skin and muscles. In peripheral nerve increased risk for ischemic addition, they are responsible for facial, shape, and function paresthesia in extremities color recognition. Taste sensation overlaps both the parietal and temporal lobes of the brain. The temporal NURSING ASSESSMENTS AND CARE STRATEGIES lobes receive auditory (hearing) and olfactory (smell- RELATED TO NEUROLOGIC CHANGES ing) impulses and are devoted to new memory, learn- ing, music, and emotions. The occipital lobes deal NURSING ASSESSMENTS CARE STRATEGIES with vision, depth perception, and three-dimensional perception. Assess alertness level, Report abnormal findings to cognition, and primary care provider. Refer PERIPHERAL NERVOUS SYSTEM functional abilities. for neurologic evaluation. The peripheral nervous system consists of the cranial and the spinal nerves and includes the somatic nervous Assess balance and Educate regarding safety reflexes. precautions and use of assistive devices. Structure tasks to reduce confusion; allow adequate time to perform tasks.","Physiologic Changes\u2003 CHAPTER 3\t 57 and the connections between dendrites occurs over Disease Dementia, or PDD (Taylor & O\u2019Brien, 2012). time. Studies of neurotransmitters show that sero- Personality changes, frustration, and depression are tonin levels increase with aging, and norepinephrine common. levels decrease. Levels of monoamine oxidase, which metabolizes catecholamines, increase. In the periph- Medical treatment aimed at decreasing the symp- eral nervous system, the velocity of nerve conduction toms of Parkinson disease includes medications, such decreases as much as 30% between 20 and 90 years as levodopa (combined with carbidopa), amantadine, of age. bromocriptine, and anticholinergic drugs. These medi- cations may allow less severely affected individuals to Because of these physiologic changes, motor function almost normally. Unfortunately, the effects of responses take longer in older individuals. Simple these drugs lessen over time, or the symptoms worsen. actions, such as walking and talking, often become Various combinations of medications are often ordered slower with age. Reflex movements become sluggish, to maximize benefit. Because stress worsens the symp- and reactions are slowed. Some loss of coordination is toms, it is particularly important to minimize frustra- common. Tasks that require quick perception of stimuli tion and emotional upset in these individuals. Deep and highly coordinated responses (e.g., driving in brain stimulation, or DBS, is a surgical procedure that rush-hour traffic) may pose a risk to those with signifi- can bring dramatic results to some individuals with cant neurologic loss. Many aging people recognize Parkinson disease. During this procedure, electrodes these changes and modify their lifestyles to avoid are surgically implanted into targeted areas of the potentially dangerous situations. brain and are connected to an impulse generator, similar to a cardiac pacemaker. Although it does not COMMON DISORDERS SEEN WITH AGING cure or even slow disease progression, it can dramati- Parkinson Disease cally reduce symptoms and enhance quality of life for Parkinson disease, also called paralysis agitans, is a some patients. progressive, degenerative disorder of the central nervous system. The cause of Parkinson disease is Dementia unknown. Specific neurons in the brain that produce Dementia is a general term for a permanent or progres- the neurotransmitter dopamine are lost. Symptoms sive organic mental disorder. Dementia is character- usually begin after age 40 years and appear gradually. ized by personality changes; confusion; disorientation; The incidence of Parkinson disease increases in older deterioration of intellectual functioning; and impaired age groups. control of memory, judgment, and impulses. Dementia can be a result of drug intoxication, trauma, disease People suffering from Parkinson disease may mani- processes, hormonal imbalances, and vitamin deficien- fest a variety of symptoms. The initial signs of the cies. Some forms are treatable and reversible, particu- disease tend to be unilateral and include slight tremors larly when an early diagnosis is made. Other forms on one side, in addition to a more general weakness do not respond to any known treatment. The most and slowing down. As the disease progresses, these common type of dementia is Alzheimer disease. Other tremors become typical and obvious at rest, decrease forms of dementia more commonly found in older with conscious movement, and are totally absent adults include the following: during sleep. Emotional stress or fatigue often worsens \u2022\t Vascular dementia, previously known as multi- the tremors. Later in the course of the disease, both sides of the body become affected. Tremor increases, infarct dementia, is the second most common form the body becomes more rigid, and movements become of dementia. It results from hemorrhage or ischemic slower. The face takes on a flat, open-mouthed, mask- brain lesions, and the exact symptoms depend on like expression, and eye blinking decreases in fre- the area of the brain affected. Onset of vascular quency. Speech slows and may be unclear. Swallowing dementia is usually sudden, unlike the gradual may be affected. Many have trouble either starting to onset of Alzheimer disease, and usually follows an walk or stopping once they have begun. Gait changes, episode of reduced blood flow to the brain tissue, and the affected individual appears to lean forward such as stroke or multiple transient ischemic attacks and walk with short, shuffling steps that occur (TIAs). Persons with hypertension or other types of faster and faster until the person almost runs in an cerebrovascular disease are most likely to develop attempt to avoid falling. It is common for people with this form of dementia. Risk for vascular dementia Parkinson disease to fall both forward and backward, can be reduced by identifying and treating factors because with increasing rigidity they lose the ability to that contribute to the development of vascular compensate for shifts in their center of gravity. In disease, including high lipid (cholesterol) levels, severe cases, the affected person may become extremely elevated homocysteine levels, high blood pressure, rigid and unable to move. smoking, and obesity. \u2022\t Dementia with Lewy bodies (DLB) is caused by Changes in mental processes may accompany phys- microscopic protein clumps in the brain (Lewy ical changes. It is now recognized that as many as bodies) that cause damage to nerve cells. In addi- 80% of people with idiopathic Parkinson disease will tion to classic symptoms of dementia, visual develop dementia within 10 years; it is called Parkinson","58\t UNIT I\u2003 Overview of Aging 30 Cognitive symptoms hallucinations are characteristic of this form of dementia. Many individuals with this form of 25 dementia develop Parkinson-like symptoms, including slowness, limb and facial stiffness, and MMSE score 20 Diagnosis tremors. Loss of functional \u2022\t Parkinson Disease Dementia (PDD) usually occurs 15 independence with progression of Parkinson disease caused by protein clumps in the substantia nigra of the brain 10 Behavioral problems 7 89 and can resemble both DLB and Alzheimer disease. 5 \u2022\t Mixed dementia can occur when more than one 0 Nursing home placement form of dementia is present. This will present as 01 Death primarily one type of dementia (e.g., Alzheimer) with features of other dementias. 2 345 6 Alzheimer Disease Years Alzheimer disease (or senile dementia, Alzheimer type) is the most common form of dementia and is FIGURE 3-9\u2003 Typical progression of Alzheimer disease. (From typically seen in individuals older than 65 years of Feldman H, Gracon S: Alzheimer\u2019s disease: Symptomatic drugs age. From age 65 onward, the incidence of Alzheimer under development. In Gauthier S, editor: Clinical diagnosis and disease doubles approximately every 5 years. By age management of Alzheimer\u2019s disease, London: England, 1996, Martin 85, almost half of the population is affected. More Dunitz Ltd.) women than men have Alzheimer disease, primarily because they live longer. Researchers estimate that the (Figure 3-9). The financial and social costs of Alzheimer incidence of Alzheimer disease and other dementias disease are staggering, as evidenced by the following: will double and may triple by 2050 (Alzheimer\u2019s \u2022\t The Alzheimer\u2019s Association states that the cost of Association, 2012). care for individuals who suffer from Alzheimer Cultural Considerations disease for health care, long term care, and hospice in 2012 was $200 billion. \u2002 \u2022\t This number is expected to increase to $1.1 trillion by 2050. Alzheimer Disease \u2022\t Family members who become caregivers represent $33.6 billion in lost productivity to the workforce. \u2022\t Older Hispanics are 1.5 times more likely to have \u2022\t The average lifetime cost of care for an individual Alzheimer disease and other dementias than are older with Alzheimer disease is $174,000. whites. The cause of Alzheimer disease is unknown. Extensive research is taking place worldwide to identify a cause \u2022\t Older African-Americans are about twice as likely to have so that a cure can be found. Advancing age is the Alzheimer disease and other dementias as are older biggest risk factor for Alzheimer disease. Family whites. history of the disease is another, with genetics playing a role. Children of people with Alzheimer disease have \u2022\t The greater incidence of Alzheimer disease and other an increased risk of developing the disease. The apo- dementias in these groups seems to be related to lipoprotein E (APOE-e4) gene has been implicated as increased incidence of diseases that increase risk of a risk factor, or a risk gene; however, everyone has dementia, such as diabetes and hypertension, rather than some form of apolipoprotein E (other forms are genetic factors. APOE-e3 and APOE-e2). If a person receives a copy of the APOE-e4 gene from one or both parents, the risk \u2022\t Despite these higher incidence rates, researchers believe of Alzheimer disease increases. APOE-e4 may be a Alzheimer disease is under diagnosed in the Hispanic and factor in one quarter of Alzheimer disease cases. It is African-American populations. estimated that about 15% of the population has the genetic form of APOE. The fact that a person has the Alzheimer disease is a chronic, progressive, degenera- affected gene does not mean that person will develop tive disease in which large numbers of brain cells and the disease, but the risk is greater. Less than 5% of tissues are affected by atrophy, beta-amyloid plaques, Alzheimer cases are linked to a deterministic gene and neurofibrillary tangles. The brain level of the that directly causes the disease. These genes, fortu- neurotransmitter acetylcholine decreases, leading to nately only found in a few hundred extended families a disturbed ability to reason and retain new informa- worldwide, guarantee that recipients of the gene will tion. Levels of norepinephrine and dopamine are also develop Alzheimer disease. Members of these families decreased in Alzheimer disease. develop the disease at a young age, showing symp- toms as early as in their thirties. The disease progresses from mild forgetfulness to a Other factors implicated in Alzheimer disease total loss of function. It is suspected that changes in include head trauma, especially when severe or the brain may begin up to 20 years before obvious repeated, and any type of cardiovascular disease. symptoms are noticed. The diagnostic criteria for Other areas being studied include inflammatory Alzheimer disease, revised in 2011, reflect this belief (see Box 10-5). The time from diagnosis to death ranges from the average of 8 years to more than 20 years","Physiologic Changes\u2003 CHAPTER 3\t 59 processes, immunologic changes, and elevated glucose levels. Scientists are also studying diet, exercise, edu- hyperazine A, and coral calcium have been recom- cational level, social activity patterns, and environ- mended as \u201cnatural\u201d remedies for the treatment of mental factors to determine if lifestyle factors may Alzheimer disease. Doses are varied and have not been contribute to the problems or help reduce the inci- evaluated by the FDA for effectiveness nor safety. dence or severity of the disease. Additionally, many older adults, particularly those diagnosed with Alzheimer disease, have lower than Physical examination and laboratory tests are typi- normal levels of melatonin. Melatonin, a hormone cally performed to rule out reversible causes of demen- secreted by the pineal gland, plays a role in sleep tia, such as hypothyroidism or vitamin B12 deficiency. rhythms. There is potential but limited evidence that Empirical diagnosis is made based on the evaluation melatonin, which is available over the counter, or pos- of behavioral changes; psychometric testing to measure sibly new drugs that have more targeted responses memory, attention, and problem solving; and brain might provide some benefits by improving sleep pat- scans, such as CT or PET. terns and decreasing the incidence of the behavioral changes seen at the end of the day called \u201csundown- Until very recently, no definitive diagnostic test for ing.\u201d Because \u201cnatural\u201d remedies can interact with pre- Alzheimer disease existed. The only way to confirm scription medication, these substances should only be the diagnosis was a postmortem examination of the used under the direction of the primary care provider. brain tissues. In 2010, researchers in Belgium identified specific proteins that could not only be used diagnosti- Clinical trials are being conducted to determine the cally, but also had a high predictive significance for the benefits of a passive vaccine containing manufactured development of this form of dementia. Spinal fluid antibodies designed to change blood levels of beta- levels that are low in beta amyloid proteins and high amyloid. Other research is focused on a vaccine in tau proteins are highly indicative of Alzheimer designed to use antibodies to directly attack beta- disease. Identified changes in these protein levels may amyloid plaques. Yet another group of researchers precede the first classic symptoms of the disease by a have identified a compound called AF267B that they decade. These tests are still in the research stage and believe will affect both the plaque and tangles classi- are not available to the public. More scientific study cally observed in Alzheimer disease. Perhaps one of needs to be done. These studies and others offer these research projects or some other scientific break- promise of earlier detection, better treatment, and through will bring an end to Alzheimer disease. hope for a cure for this devastating illness. Transient Ischemic Attack Currently, older adults suffering from Alzheimer TIAs are brief episodes of cerebrovascular insuffi- disease are treated with several classifications of drugs. ciency that are usually the result of cerebral blood Cholinesterase inhibitors are used for patients with vessel obstruction. Such obstruction is usually caused mild-to-moderate disease. These drugs are designed to by an embolus or atherosclerotic plaque. TIAs occur prevent the breakdown of acetylcholine, the neu- most commonly in middle-aged and older people. rotransmitter that plays an important role in memory and thinking skills. Drugs in the class include donepe- TIAs occur without warning. Most episodes last zil (Aricept), rivastigmine (Exelon), and galantamine only a few minutes, but some may persist as long as (Razadyne). 24 hours. A person may have several attacks within a day or may go for months without experiencing Another drug, memantine (Namenda), has been another attack. A variety of symptoms may indicate a approved to treat moderate-to-severe Alzheimer TIA. Common symptoms include blurred, tunnel, or disease. This drug is believed to work by regulating double vision; blindness; vertigo; transient numbness the level of glutamate, a neurotransmitter that helps and weakness; aphasia or slurred speech; and gait dis- the brain process, store, and retrieve information. turbances. The person generally remains conscious Drugs specific to Alzheimer treatment are often sup- throughout the attack. The symptoms of TIAs disap- plemented with antidepressants, anxiolytics, and even pear spontaneously and do not cause permanent neu- antipsychotics, which are prescribed based on behav- rologic damage. ioral or psychotic symptoms that frequently coexist with Alzheimer symptoms. The use of antipsychotic TIAs may be warnings of an impending stroke, but medications is controversial, however, as less than one this is not necessarily the case. Some individuals who third demonstrate improvement of behavioral symp- suffer from TIAs never have a stroke. toms, whereas the risk of death from these medications is 1.6 to 1.7 times higher than treatment with placebo. Stroke The FDA issued a \u201cblack box\u201d warning about the risks Stroke, formerly called a cerebrovascular accident of these medications when used for dementia patients (CVA), is a disturbance of the blood supply to the (Lunde, 2012). brain. Most strokes are related to atherosclerosis, Alternative treatments for Alzheimer disease.\u2002 Vita\u00ad hypertension, diabetes, or a combination of these. mins C and E, coenzyme Q10, selenium, ginkgo biloba, They can occur at any age, most commonly affecting individuals over age 65. Strokes are often fatal and are","60\t UNIT I\u2003 Overview of Aging Box 3-6\u2003 Signs and Symptoms of Right Brain a leading natural cause of death in the United States. Hemisphere Damage The likelihood of stroke fatality increases with advanced age. Stroke occurs slightly more often in \u2022\t Left hemiparesis (weakness of the left arm and\/or leg) men than in women. African-Americans are affected \u2022\t Impaired sense of humor more often than other groups, possibly because there \u2022\t Disorientation to time, place, and person is a higher incidence of hypertension in the African- \u2022\t Difficulty recognizing people American population. Even when not fatal, stroke is a \u2022\t Visual\/spatial problems, including loss of depth leading cause of disability. perception There are two main categories of stroke: (1) ischemic, \u2022\t Neglect of the left visual field (may not see objects or where there is lack of blood and oxygen flow caused by embolus or thrombus, comprising 87% of all strokes, hazards on the left side of body) and (2) hemorrhagic, in which weakened vessels or \u2022\t Loss of impulse control (may strike out, cry, or shout if aneurysms that rupture spontaneously or as a result of hypertension. upset) \u2022\t Unaware of neurologic function loss (may try to stand If a stroke is suspected, care is directed at support- ing essential life functions\u2014maintaining an open or walk despite hemiparesis) airway, providing adequate oxygenation, and prevent- \u2022\t Poor judgment (may deny illness or problems or tend ing trauma. Stroke is a medical emergency requiring a 911 call (or Code Stroke Alert if hospitalized). to overestimate the ability to perform activities) Immediate hospitalization is critical in order for the \u2022\t Inappropriate responses (may smile continually or patient to be eligible for the best care possible: if tissue plasminogen activator (tPA) is given within 3 hours, demonstrate euphoric behavior even in serious or the clot can be dissolved, the damage minimized, tragic situations) and rehabilitation shortened significantly. Because \u2022\t Confabulation (may make up detailed but inaccurate some strokes are hemorrhagic, however, this must be explanations to compensate for memory losses, which ruled out first with a CT scan. Unfortunately, many can be very believable to persons who are not aware stroke patients are discovered in the morning by a of the facts) family member; if the onset of symptoms is unknown, they are ineligible for tPA. The length of hospitaliza- Box 3-7\u2003 Signs and Symptoms of Left Brain tion and rehabilitation or extended care is based on the Hemisphere Damage individual\u2019s particular situation. The onset of a stroke may be sudden, or symptoms may progress gradually. \u2022\t Right hemiparesis (weakness of the right arm and\/or The nature of symptoms varies with the type of stroke, leg) the area of the brain that is affected, and the extent of the damage (Boxes 3-6 and 3-7). Because the two \u2022\t Language disturbances: sides of the brain serve very different functions, the \u2022\t Aphasia\u2014defective or absent language skills that symptoms depend on which side is affected. Effects of may be expressive (motor), in which words cannot strokes are contralateral: damage to the right hemi- be formed; receptive (sensory), in which language sphere affects the left side of the body; and damage to is not understood; or mixed, in which both the left hemisphere affects the right side of the body. processes are affected Some individuals manifest mild symptoms, whereas \u2022\t Agraphia\u2014loss of the ability to write in others, the symptoms are more severe. A few victims \u2022\t Alexia\u2014inability to comprehend written words; of stroke recover completely, but most have some lin- reading problems gering deficits. Most improvement occurs within the first 6 months after a stroke. Any deficit lasting longer \u2022\t Neglect of the right visual field (may not see objects or than 6 months is likely to be permanent. Recurrence of hazards on the right side of body) stroke is common, and each occurrence is likely to cause additional problems. \u2022\t Behavior changes (slow, cautious, and anxious when attempting new activities) THE SPECIAL SENSES \u2022\t Mood changes (tendency toward worry or depression; The special senses, including sight, hearing, balance, verbalization of feelings of worthlessness or guilt; smell, and taste, are integrally connected to the central anger and frustration) nervous system by the cranial nerves. The other senses include touch, pressure, and proprioception, which is relationship to this world. The special senses provide the awareness of body movement and position in our first line of protection against environmental space. These senses are the means by which we gather hazards. Unless all of these senses function properly information from the world around us and about our and provide us with good information, we are at risk for suffering from these hazards. It is important to understand the visual and audi- tory changes that occur with aging, because these changes may have serious safety implications. A great deal of the information in the world that we receive and respond to comes to us through our senses of sight and hearing. We may think older adults are confused or senile, when actually their sensory perceptions are merely impaired because of the changes associated with aging.","Physiologic Changes\u2003 CHAPTER 3\t 61 THE EYES between the cornea and the lens, and it contains The eyes are two globe-shaped structures located aqueous humor, a fluid formed by capillaries in the in the orbits of the skull on each side of the nose. choroid. This fluid passes from the posterior chamber Because the eyes are so important, they have sur- through the pupil to the anterior chamber, and it sup- rounding structures designed to protect them from plies the nourishment for the lens and cornea, which both physical and biologic hazards. have no blood supply. Because aqueous humor is pro- duced continuously, some must be absorbed or the The eyelids are controlled by skeletal muscle and amount of fluid becomes excessive. Normally, absorp- are lined with a smooth mucous membrane called the tion takes place through small veins located at the conjunctiva. The eyelids can close; thus, they and the juncture of the iris and cornea. The presence of excess eyelashes located on their margins provide protection fluid increases the anterior chamber pressure. The pos- from dust and flying debris. Tears are produced by the terior cavity of the eye, the vitreous, is much larger lacrimal glands located at the upper and outer corners and contains a gelatinous substance called the vitreous of the eye. These glands lubricate the eye, prevent humor. Vitreous humor holds the retina in contact particles of debris from scraping the surface, and with the choroid of the eye. inhibit the growth of bacteria by means of the enzyme lysozyme. Tears leave the eye at the medial corner REFRACTION through the lacrimal sac and the nasolacrimal duct The eye functions much like a camera. Light waves that drains into the nose. enter the eye through the cornea and then pass through the aqueous humor, lens, and vitreous humor to the The eye itself is composed of three layers. The out- retina. When light waves strike the retina, they stimu- ermost layer, the sclera (commonly called the white of late the receptors in the cones and rods. The rods react the eye), is composed of fibrous connective tissue and chemically to the amount of light and regulate nerve supports the inner structures of the eye. The anterior impulses to the brain based on this information. part of the sclera is the cornea, a transparent structure Different cones respond to different wavelengths of that refracts or bends light rays. The sclera contains light rays (different colors) and thus determine the small capillaries that are sometimes visible on its perceived color of objects. Based on information gath- surface. The cornea does not contain any capillaries or ered from the rods and cones, the image projected on nerves. the retina is translated into nerve impulses by the retina, which then sends the information through the The middle layer of the eye, the choroid, contains optic nerves to the visual centers of the cerebral cortex pigments that absorb light and keep the interior of the in the occipital region. The optic nerves from both eye dark. The choroid is highly vascular and supplies eyes meet at the optic chiasm just under the pituitary nourishment to the surrounding tissue. Located in the gland. At the optic chiasm, the medial fibers (from the anterior portion of the choroid are the iris (the colored image on the part of the retina closest to the nose) cross portion), the pupil (an opening in the iris through to the opposite side of the brain, whereas the lateral which light enters the eye), the lens (a transparent oval fibers (from the outside part of the retina) do not cross. disk), and the ciliary body (muscles that change the This allows visual centers on both sides of the brain to shape of the lens to refract light waves). The lens does process messages from both eyes and is important for not contain any capillaries or nerves. binocular vision. Because of position, each eye \u201csees\u201d things somewhat differently from the other and sends The innermost layer of the eye is the retina. This slightly different messages to the brain. The brain structure covers the posterior two-thirds of the eye receives messages from both eyes, correlates the infor- and contains the visual receptors, highly specialized mation, and makes sense of it. Binocular vision is also structures called rods and cones. These receptors important for depth perception, the sense of how far use chemical changes in their pigments to detect light. you are from another person or object. Cones are most abundant near the center of the retina. They detect color and discriminate among different For information to be received accurately, all of colors based on the wavelength of the incoming light. the eye\u2019s structures must function together to focus the Rods are more abundant near the periphery of the light rays. The shape of the lens is controlled by the retina and detect the presence or absence of light. ciliary body, which muscles relax or contract to change Vitamin A is essential to the formation of the pigment the shape of the lens so that it can bend the light waves in the rods that enables their response. Rods are impor- correctly and bring an object into clear focus. This tant for vision in low-light situations. Nerves in the change in lens shape is called accommodation. retina transmit messages from the rods and cones to the optic nerve, which sends the information to the EXPECTED AGE-RELATED CHANGES vision centers of the brain. The macula lutea (yellow Refractive errors, or errors in focusing ability, occur spot) is an area less than 2\u202fmm in size near the when the cornea is misshapen or when the lens cannot center of the retina that provides us with sharp central appropriately change shape to focus images. vision. The greatest part of the eye mass is made up of two fluid-filled cavities. The small anterior cavity is located","62\t UNIT I\u2003 Overview of Aging Table 3-9\u2003 Vision Changes Associated With Aging PHYSIOLOGIC CHANGE RESULTS Increased risk for eye injury Decreased number of eyelashes Decreased tear Increased risk for eye irritation production Increased Decreased color perception discoloration of lens Decreased tissue Increased blurring elasticity FIGURE 3-10\u2003 Arcus senilis. (From Yanoff M, Fine BS: Ocular Decreased muscle Decreased diameter of pupil; pathology, St. Louis, 2002, Mosby.) tone increased refractive errors; decreased night vision; 50 years of age experience some degree of farsighted- increased sensitivity to glare, ness, also called hyperopia or presbyopia, which literally decreased peripheral vision means \u201caging eye.\u201d Refractive errors become increas- ingly common as the ciliary muscles lose their ability NURSING ASSESSMENTS AND CARE STRATEGIES to contract easily, and progressive rigidity of the lens restricts accommodation. A combination of these RELATED TO VISUAL CHANGES changes makes it increasingly difficult to focus on close objects, perform detailed close work, or read. NURSING Presbyopia is usually corrected by the use of contact lenses or eyeglasses that help the aging person focus ASSESSMENTS CARE STRATEGIES on close objects. Laser surgery is an option for some individuals. Assess for signs Encourage regular use of synthetic of irritation, tear preparations to help reduce Astigmatism, a malformation of the cornea, causes inflammation, irritation caused by inadequate blurring of images at all distances. People of all ages and dryness. tear production. can have astigmatism, but younger people compen\u00ad sate for it by quickly refocusing the blurred and un- Assess visual Encourage or schedule regular blurred images. When this ability decreases with acuity. professional eye examinations. aging, astigmatism appears to worsen. Corrective Educate regarding importance \t lenses help with this. of adequate light with minimum glare. Explain importance of using A decrease in tear production is common in older eyeglasses appropriately for adults, because the volume of body fluids and secre- reading or distance, particularly tions decreases with age. An 80-year-old person pro- when driving. duces only 25% of the tears he or she produced during the teenage years. Environmental factors, such as Assess ability to Provide adequate lighting and central heating, dry climate, and wind or air pollution, detect objects contrast in colors to highlight can worsen the problem. Many older adults complain within the important structures such as the of dry, burning, or itching eyes caused by friction from environment. edge of stairs, light fixtures, the lids or from small particles of debris. The decline faucets, etc. in tear production also reduces the antibacterial pro- tection provided by enzymes and can contribute to With aging, many structural and functional changes bacterial eye infections. may occur in the eye (Table 3-9). The eyelids become less elastic and sag. Eyelashes tend to be shorter, Older adults may have poor dark adaptation thinner, and in some cases, absent. A grayish haze of responses and may experience a decrease in the ability the peripheral cornea, arcus senilis (Figure 3-10), to adjust from light to darkness and darkness to light. develops with aging and is more common in dark- Night blindness, the inability to see well in dim light, skinned persons. grows increasingly common with aging. Legal blindness is defined as visual acuity of 20\/200 Color vision and the ability to detect changes in or less in the worse eye even with the best correction, color contrast are affected by aging. The lens of the eye or a visual field extent of less than 20 degrees in diam- tends to yellow with age, possibly leading to color eter. Vision impairment is defined as having vision misperception. All dark colors may be perceived as worse than 20\/40 with correction. The rate of legal black, and subtle differences in shades may not be blindness and visual impairment increases signifi- detectable. Younger people who find \u201cblue-haired cantly in later years of life, particularly after age 75. women\u201d amusing should look at them through a lens According to research done by the National Eye that is slightly tinted yellow. Amazingly, the hair looks Institute (2010), blindness affects blacks more than clean and white. whites or Hispanics, until after age 80 when blindness among whites jumps from 0.9% to 9%. Refractive errors are the most common visual problem in the United States. Most people older than","Physiologic Changes\u2003 CHAPTER 3\t 63 Peripheral vision and depth perception often de- peripheral vision is affected. Tunnel vision and, even- crease with aging. It is important to recognize these tually, permanent blindness may be the result. The changes, because they significantly increase the risk for incidence of glaucoma increases with age. Additional accidents and injuries. risk factors include family history, diabetes, African- American ancestry, hypertension, and steroid use. Another common occurrence with aging is floaters. Many older adults report seeing flecks, spots, cobwebs, Persons with glaucoma seldom experience obvious or brilliant crystals within their eyes. These are harm- symptoms, so serious damage usually occurs before less but can be frustrating because they interfere with the disease is even recognized. However, a test for many visual activities, such as reading, sewing, or increased intraocular pressure can be performed easily. doing other detailed work. The test for glaucoma is simple, painless, and takes only minutes. It is normally part of a routine ophthal- COMMON DISORDERS SEEN WITH AGING mic examination, and everyone older than 40 years of Blepharitis age should be tested routinely for glaucoma. Early Blepharitis, a chronic inflammation of the eyelids, is detection and treatment can delay progression of the one of the most common disorders of the eye. disease. Medications, surgery, and laser therapy can be Symptoms of blepharitis include burning, itching, and used to treat glaucoma, but any damage already done sensitivity to light. Discomfort is often worse on awak- cannot be reversed. ening. Blepharitis can be caused by Staphylococcus bac- teria, by sebaceous gland dysfunction, or in conjunction Age-Related Macular Degeneration and with skin conditions, such as seborrhea or rosacea. Retinal Detachment There is no definitive cure for this disorder, but treat- The macula, the small area in the center of the retina ment can reduce the severity of the problem. Common where visual acuity is best, is susceptible to damage treatment includes the use of warm compresses, eyelid and destruction. Age-related macular degeneration massage, lid scrubs, and the use of antibiotic oint- (AMD) occurs most often in people over age 50. The ments. Dietary intake of antioxidants has been pro- incidence of this disorder increases significantly after posed as being of some benefit. age 75 and is more common in whites, people who smoke, and those with family history of AMD. The Diplopia exact cause of macular degeneration remains unknown, Diplopia, or double vision, is not normal and indicates but two types of the disorder have been identified. The some disturbance of the nervous system that requires more common atrophic form, also called dry AMD, is further investigation by the primary care provider. a result of inadequate nutrient supply or waste removal resulting from vascular changes. When cells atrophy Cataracts or die, the macula is damaged and central vision is Cataracts, which cause a clouding of the lens of the significantly diminished. Vision is restricted but not eye, are increasingly common with aging. Cataracts totally lost, because noncentral vision remains. A major can occur in one\u2019s forties and fifties; by age 80, over clinical trial with 3,600 participants, the Age-Related half of Americans have a cataract. Factors that increase Eye Disease Study (AREDS), demonstrated that a spe- the risk for cataracts include smoking, alcohol, dia\u00ad cific formula of antioxidants and zinc, the AREDS betes, and prolonged sunlight exposure. Cataracts Formulation, can reduce the risk of developing AMD develop over time and result in progressive, painless by 25% (National Eye Institute, 2011). This formulation vision loss. The amount of vision loss depends on the consists of specific doses of vitamins C and E, beta- degree of lens opacity and the area of the lens that is carotene, zinc, and copper. Use of these substances, of affected. Vision in bright light or glare may be particu- course, should be done under the direction of the larly difficult with certain types of cataracts. Individuals primary care provider. with cataracts require frequent changes in eyeglass prescriptions while the cataract matures. When vision The neovascular form of macular degeneration, also is severely affected, surgical removal of the cataract or called wet AMD, results from abnormal growth of tiny the lens is the treatment of choice. Today, this surgery blood vessels (neovascularization) under the retina. is common and, in most cases, can be performed on an These vessels ruin vision by leaking fluid and blood, outpatient basis. Once the cataract is removed, vision which cause the retina to become swollen and dis- is usually corrected with surgically implanted lenses; torted. This form is more likely to cause severe vision in some individuals, contact lenses or cataract glasses loss. Laser surgery or microsurgery may be attempted may be needed. to seal leaking vessels, slow their growth, and prevent further vision loss. Glaucoma Glaucoma is a disease characterized in most cases by Circulatory changes in the blood vessels of the eyes increased fluid pressure (intraocular pressure) within are common with DM, resulting in a condition called the eye that may result in damage to the retina. Initially, diabetic retinopathy. This condition is characterized by the hemorrhaging of small blood vessels into the vitreous humor and has effects similar to neovascular","64\t UNIT I\u2003 Overview of Aging Table 3-10\u2003 Auditory Changes Associated With Aging macular degeneration (i.e., loss of vision). As many as PHYSIOLOGIC CHANGE RESULTS 25,000 people with diabetes develop blindness each year (Alvarado, 2011). Retinopathy is related not to age Decreased tissue Decreased ability to distinguish but rather to the severity and duration of hyperglyce- elasticity high-frequency sounds mia. Diabetic retinopathy is increasing at a rapid rate in older adults because of the higher incidence of dia- Decreased joint mobility Decreased hearing ability betes with aging. Decreased ceruminous Increased risk for cerumen Normal shrinkage of the eye and changes in the cells in external ear impaction causing consistency of the vitreous humor are common with canal conductive hearing loss aging and may result in retinal detachment, which is the separation of the retina from the choroid. Any or Atrophy of vestibular Increased problems with all of these changes can result in the loss of central structures and in the balance; decreased number vision. inner ear of hair cells THE EARS The ear is composed of three distinct portions: outer NURSING ASSESSMENTS AND CARE STRATEGIES ear, middle ear, and inner ear. The two main functions RELATED TO AUDITORY CHANGES of the ear are the detection of sound and the mainte- nance of balance. NURSING ASSESSMENTS CARE STRATEGIES The outer ear consists of the visible curved struc- Assess hearing and Refer for audiometric testing as ture, called the pinna, or auricle, and the external ear balance. needed. canal. The pliable auricle is made of cartilage. The size or shape of the external ear has little influence on Inspect ear canal for Administration of prophylactic hearing. cerumen impaction. drops may reduce likelihood of impaction formation. The middle ear begins at the eardrum, or tympanic Irrigation may be needed if membrane. This transparent membrane stretches impaction is present. across the end of the ear canal and separates it from an air-filled chamber called the middle ear. Air pressure Assess functioning of Check that batteries are in the middle ear is controlled through the Eustachian hearing aid if used. working and that device is tube, which connects the middle ear to the nasophar- not plugged with cerumen. ynx. Attached to the tympanic membrane is a series of Keep an amplifying device on three small bones: the malleus (hammer); incus (anvil); each patient care unit to use and stapes (stirrup). Sound waves enter the ear through with hard of hearing the external ear canal and cause the tympanic mem- individuals who do not have a brane to vibrate. This, in turn, causes movement of the functional hearing aid. three small bones, which then transmit the vibrations to the oval window, the opening into the inner ear. Assess for social Encourage socialization in areas isolation or without excessive changes. The inner ear is a complex, fluid-filled structure that behavioral has several functions. A portion called the cochlea con- background noise. tains the hearing receptors, which consist of hair cells with fine movable projections that are set in motion atrophy with advanced age. Arthritic changes affect when sound waves reach their fluid surroundings. the joints between the small bones of the middle ear, When these hairs move, impulses are carried through and hair cells in the inner ear often deteriorate. the auditory nerve (a cranial nerve) to the midbrain and then to the temporal lobe of the brain, where the Presbycusis, defined as an alteration in the hearing sound is heard. capacity related to aging, affects an estimated 13% of people older than 65 years of age. Men appear to be Other specialized hair cells are found elsewhere more affected by this problem than women. The aging in the inner ear: the vestibule and the semicircular person with presbycusis loses the ability to perceive canals. Hair cells from these structures transmit infor- high frequency tones. Speech sounds such as s, sh, ch, mation in response to gravity, change of position, and and soft t may not be audible, so the aging person may motion through the cranial nerves. The central nervous hear only parts of spoken words. Simple words such system processes this information and maintains as cat, hat, sat, and that may all sound the same. If other equilibrium. noises are present in the environment, sounds become EXPECTED AGE-RELATED CHANGES even less distinct. The aging individual may have dif- Just as other body tissues become thinner with age, so ficulty sorting out words and making sense of what is does the tympanic membrane (Table 3-10). The small being said. muscles that support the membrane show signs of COMMON DISORDERS SEEN WITH AGING Otosclerosis Otosclerosis, a hardening or fixing of the stapes to the oval window, interferes with sound-wave transmis- sion into the inner ear. This condition occurs slightly","Physiologic Changes\u2003 CHAPTER 3\t 65 more often in women than in men. Surgical correction The frequency of attacks is unpredictable. M\u00e9ni\u00e8re is possible. disease tends to affect one ear, and it can result in nerve deafness that sometimes persists even if treatment Tinnitus relieves the other symptoms. Tinnitus, or ringing in the ears, is commonly reported by aging people. Tinnitus may be a result of trauma to TASTE AND SMELL the ear, pressure from cerumen against the eardrum, The receptors for our sense of taste are located in the otosclerosis, presbycusis, or M\u00e9ni\u00e8re disease. Tinnitus papillae, or taste buds, on the superior surface of the can also be caused by certain medications, such as tongue. In these papillae are chemical receptor cells antibiotics and diuretics. If tinnitus is suspected to be that are sensitive to salty, sweet, sour, and bitter chemi- medication related it must be reported promptly, as it cals. When mixed with moisture, such as saliva or can indicate medication toxicity and risk of (prevent- water, food releases chemicals that are detected by able) deafness. these receptors. Foods get their subtle flavors by their unique interaction with various receptors. The detec- Deafness tion of odors occurs when the olfactory receptors in the Deafness, the inability to hear sounds fully, may be upper nasal cavities respond to airborne chemicals. temporary or permanent, depending on the cause. When vapors escape from food or other volatile Deafness can be unilateral (affecting one ear only) or substances, they enter the nose and stimulate the bilateral (affecting both ears). receptors. Conductive hearing loss occurs when something Information from both taste and smell receptors interferes with transmission of the sound waves. A is then transported to the nervous system through plug of cerumen (earwax) in the external canal, the cranial nerves. When these senses are intact eardrum rupture or scarring, the presence of fluid and functioning well, many people salivate and can or an infection in the middle ear, or any condition \u201ctaste\u201d a meal while it is being prepared. Without a that interferes with movement of the middle ear sense of smell, food has little flavor. Most of us have small bones may result in conductive hearing loss or had severe nasal congestion from colds or allergies and deafness. have found that without smell, food has either a strange taste or no taste at all. Some individuals with Nerve or sensorineural deafness occurs when chronic nasal congestion report ongoing problems either the receptors in the inner ear or the cranial with appetite because food has little flavor or appeal. nerves are damaged or destroyed. Some antibiotics People with permanent damage to the olfactory senses and viral infections can cause nerve deafness. Chronic report a permanent change in taste (hypogeusia) that exposure to loud noise can speed up the degeneration often results in a loss of appetite. Alterations in taste of the hair cells. Many young people today are experi- sensation may also be a side effect of brain tumors, encing significant hearing loss from excessive expo- gingival disease, periodontitis, systemic disorders sure to extremely loud music, and this will have serious such as DM or hypothyroidism, and medications. implications as they age. Work-related noise has also Research is being conducted to determine the correla- been shown to have negative effects on hearing. Many tion between loss of smell and the onset of Alzheimer aging individuals who worked in foundries or other disease. noisy places may have suffered employment-related hearing loss. The Occupational Safety and Health EXPECTED AGE-RELATED CHANGES Administration now requires employers to protect With aging, there is a decrease in the number of func- employees from excessive exposure to loud noise on tional receptors in both the nasal cavities and papillae the job. on the tongue (Table 3-11). By age 60, it is estimated that half of adults will experience some alteration in Central deafness is caused by trauma or disease in smell and taste. The changes in taste particularly affect the temporal lobes of the brain. This may be a result the receptors for sweet and salty tastes. Because salt of tumors, stroke, or injury. Central deafness is not enhances the flavor of food, older adults often add salt common. in an attempt to add flavor. Complaints of flavorless food are common even if the food seems well seasoned M\u00e9ni\u00e8re Disease and tasty to younger individuals. Good oral hygiene, M\u00e9ni\u00e8re disease is a chronic disorder of the inner ear better food preparation, and flavor enhancers are observed in people after age 40. Persons suffering from sometimes helpful in improving taste. this disorder experience severe vertigo (not simple diz- ziness) to the point that they may be unable to stand The term burning mouth syndrome is used to or walk. They may also report nausea, tinnitus, hearing describe the oral sensation of burning or tingling. This loss, and a sensation of pressure in the ear. Diaphore\u00ad may be associated with a vitamin B deficiency, inade- sis, vomiting, and nystagmus (rapid, involuntary eye quate saliva production, allergies, GERD, trauma, and movement) may also be observed. Episodes generally diabetes. appear suddenly and may last for minutes or hours.","66\t UNIT I\u2003 Overview of Aging Table 3-11\u2003 Olfactory Changes Associated With Aging pituitary until needed. The major secretion of the pos- terior pituitary gland is the antidiuretic hormone. This PHYSIOLOGIC CHANGE RESULTS hormone maintains fluid balance in the body by Decreased ability to taste causing the kidneys to reabsorb fluid; in the absence Decreased number of of the antidiuretic hormone, the kidneys excrete more papillae on tongue fluid. By controlling fluid balance, the antidiuretic hormone helps maintain blood pressure. Oxytocin, Decreased number of Decreased ability to receptors another posterior pituitary hormone, stimulates nasal sensory and to detect smells uterine contraction during childbirth and milk ejection from the breast during lactation. NURSING ASSESSMENTS AND CARE STRATEGIES RELATED TO OLFACTORY CHANGES The anterior pituitary produces many hormones. Growth hormone increases the rate of protein synthe- NURSING ASSESSMENTS CARE STRATEGIES sis and aids in the transport of amino acids to cells. In adults, this hormone also participates in fat release Assess ability to smell Teach importance of storing from adipose tissue and the use of this fat as energy. and taste. food properly and checking Thyroid-stimulating hormone stimulates the normal expiration dates. Keep drugs growth and activity of the thyroid gland. Adreno\u00ad and chemicals separated corticotropic hormone (corticotropin) stimulates the from foods. activity of the adrenal cortex. Gonadotropic hormones include follicle-stimulating hormone and luteinizing THE ENDOCRINE SYSTEM hormone, which are responsible for gonad matura- tion and function, and prolactin, which supports The endocrine system and the nervous system perform lactation. the major integrating and regulating functions of the body. The endocrine glands secrete chemical sub- THYROID GLAND stances called hormones to regulate body processes. The thyroid gland surrounds the trachea and is located Hormones are secreted directly into the capillaries of just below the larynx (voice box). The major hormones the bloodstream, where they circulate until they reach produced by the thyroid gland are thyroxin, triiodo- their target organs and cause specific effects. Some thyronine, and calcitonin. The thyroid hormones triio- endocrine glands produce a single hormone; others dothyronine and thyroxin increase metabolic rate; produce several different hormones. Some hormones regulate the metabolism of fat, carbohydrates, and have one target organ only; others target multiple protein in the cells; and increase body temperature. organs. The production of hormones is regulated by a They also affect cardiac, neurologic, and musculoskel- negative feedback process in which the endocrine etal functions. The function of calcitonin is to keep glands constantly monitor the effects of hormones cir- calcium and phosphate within the bone matrix. culating in the system. If the effect is adequate, the gland decreases production. If it is inadequate, the PARATHYROID GLANDS gland increases production. The process of regulation The parathyroid glands are located on the posterior is similar to a system consisting of a thermostat and a surface of the lobes of the thyroid gland. PTH, an furnace in a home. When the temperature reaches that antagonist of calcitonin, stimulates the movement of for which the thermostat is set, the thermostat signals calcium and phosphorus from the bones into the blood. the furnace to stop producing heat. If the temperature drops below the preset level, the thermostat signals the PANCREAS furnace to produce more heat. In a highly complex The pancreas is both an exocrine and an endocrine manner, the endocrine glands constantly monitor the gland. It functions as an exocrine gland during diges- effects and the levels of the many hormones circulating tion by secreting pancreatic fluid into the duodenum. in the body and increase or decrease production as The endocrine secretions of the pancreas are produced needed to meet the body\u2019s demands. by \u03b1 cells and \u03b2 cells in the islets of Langerhans. The \u03b1 cells produce glucagon, which stimulates the liver PITUITARY GLAND to convert glycogen to glucose. The \u03b2 cells produce The pituitary gland is often referred to as the master insulin, which increases the permeability of cell mem- gland of the body because of the many functions it branes and enables the cells to use glucose, amino regulates. It is located within the skull cavity and is acids, and fatty acids. connected directly to the hypothalamus. There are two major segments of the pituitary gland: the anterior ADRENAL GLANDS pituitary and the posterior pituitary. The posterior The adrenal glands are located on the top of each pituitary is the site of connection between the nervous kidney. The adrenal medulla is the inner portion of system and the endocrine system. The posterior pitu- itary hormones are actually produced in the hypo- thalamus of the brain and are stored in the posterior","Physiologic Changes\u2003 CHAPTER 3\t 67 the gland, and the adrenal cortex is the outer portion. Table 3-12\u2003 Endocrine Changes Associated The adrenal medulla secretes epinephrine and With Aging norepinephrine, which are the major neurotransmit- ters of the sympathetic portion of the autonomic PHYSIOLOGIC CHANGE RESULTS nervous system. The adrenal medulla can be viewed Decreased muscle mass as the \u201ccrash cart\u201d of your body. These hormones Decreased pituitary secretions increase cardiac activity, blood pressure, release of (growth hormone) energy reserves, and other functions necessary for sur- vival when faced with danger, while decreasing func- Decreased production of Decreased metabolic tions that are less important at that time. thyroid-stimulating hormone rate The adrenal cortex releases mineralocorticoids, glucocorticoids, and small amounts of sex hormones. Decreased insulin production Increased risk for type 2 The mineralocorticoid aldosterone is important in or increased insulin diabetes mellitus the regulation of fluid and electrolyte balance and resistance blood pressure maintenance. The glucocorticoid cortisol is involved in the conversion of glycogen Decreased production of Increased blood calcium to glucose and in antiinflammatory activities. DHEA, parathyroid hormone levels (seen with dehydroepiandrosterone, is a hormone that the osteoporosis) body can convert into estrogen and testosterone. Production of this hormone increases dramatically at NURSING ASSESSMENTS AND CARE STRATEGIES puberty and peaks in the mid twenties. Levels then decrease over the years so only about 20% remains by RELATED TO ENDOCRINE CHANGES age 70. OVARIES AND TESTES NURSING ASSESSMENTS CARE STRATEGIES The testes and ovaries secrete the hormones involved in sexual maturation and function. The primary Monitor laboratory values, Educate patient hormones secreted by the ovaries are estrogen and paying special attention to regarding dietary progesterone. These hormones are responsible for mat- minerals, such as calcium needs and self-testing uration of the ova, stimulation of the uterine endome- and sodium levels, and of blood glucose. trium, and the development of the secondary female blood glucose. sexual characteristics. The testes secrete the major male sex hormone, testosterone, which is responsible for Assess for body temperature, Notify primary care sperm maturation, and development of secondary weight, hair distribution or provider of male sexual characteristics. behavioral changes, which assessment findings. EXPECTED AGE-RELATED CHANGES may indicate endocrine With aging, a variety of endocrine function changes imbalance. occur (Table 3-12). The pituitary gland continues to produce adequate levels of critical hormones in osteoporosis, where it appears to increase. Elevated throughout life. It produces less growth hormone levels of PTH may lead to increased blood calcium with age, leading to decreased muscle mass. In levels. This is of concern particularly for older women, recent studies, growth hormone was administered who may manifest symptoms of confusion, kidney to older men, resulting in a significant increase in stones, and osteoporosis. muscle mass. Growth hormone is expensive, may have undesirable side effects, and is currently an investiga- Pancreatic function appears to decrease with aging; tional drug. however, barring the onset of some form of diabetes, its function remains adequate to meet normal body A decrease in the production of thyroid-stimulating functioning. hormone is seen in some older adults. Basal metabolic rate begins to decrease in young adulthood and con- Adrenal function is not altered significantly with tinues to decrease gradually throughout life. Because advancing age. Adequate hormone levels are pro- lean body mass also decreases, the overall metabolic duced to meet bodily needs. rate does not change significantly. In response to a decreased thyroid function, some older people become The levels of gonadotropic hormones decrease more more sensitive to cooler temperatures. significantly in women than in men. After menopause, estrogen and progesterone production drops signifi- Studies of parathyroid function reveal conflicting cantly. As the production of female sex hormones information. PTH appears to decrease with age, except decreases with aging, some changes in secondary sexual characteristics may be observed, such as the development of facial hair and genital atrophy. Studies indicate that estrogen depletion in postmenopausal women has negative effects on bone density, cardio- vascular function, memory, and cognition (Comple\u00ad mentary and Alternative Therapies box). Because production of the male hormone testosterone decreases gradually with aging, changes are gradual and often indistinguishable.","68\t UNIT I\u2003 Overview of Aging disease with multiple causes that is characterized by abnormal metabolism of carbohydrates, protein, Complementary and Alternative Therapies and fats, resulting in elevated plasma glucose levels. Long-term complications include retinopathy (result- \u2002 ing in a loss of vision), nephropathy (resulting in renal failure), peripheral neuropathy (resulting in Hormone Therapy and Human Growth Hormone foot ulcers and amputation), autonomic neuropathy (resulting in GI, genitourinary, and cardiovascular Research is being done to determine the safety and effective- symptoms and sexual dysfunction), atherosclerotic ness of hormone therapy (HT) in slowing or reversing common vascular problems (resulting in an increased incidence physiologic changes of aging. HT, long thought to prevent of cardiovascular, cerebrovascular, and peripheral vas- cardiac problems, osteoporosis, vaginal discomfort, and skin cular disease), hypertension, cognitive changes, and changes in women, was frequently prescribed for postmeno- periodontal disease. pausal women. However, a large study, the Women\u2019s Health Initiative, was stopped 3 years early because of unexpected The most current classification system categorizes negative results including lack of cardioprotective effects and DM according to its etiology, or cause. The first cate- increased risk of stroke. HT use changed abruptly after results gory, type 1 diabetes mellitus, is defined as being a of this study became known. Other risks of HT demonstrated result of either autoimmune destruction of the \u03b2 cells included blood clots, breast and endometrial cancer, cardio- of the pancreas or unknown idiopathic causes. The vascular disease, and gallbladder disease (NIH, 2011). Despite second category, type 2 diabetes mellitus, results from this, some researchers believe that HT can have benefits for a combination of resistance to insulin action and inad- early menopausal women when taken for a short duration; equate compensatory insulin secretion. In the third a study called KEEPS has shown some benefit including category, other specific types of DM are identified by improved high-density lipoprotein (HDL), low-density lipopro- their unique etiologies, including genetic defects or tein (LDL), and lower insulin resistance (Kronos, 2012), but the syndromes, exocrine diseases of the pancreas, diseases choice for any woman should be an individual one made in of the endocrine system, drugs or chemicals, infec- collaboration with the primary care provider considering one\u2019s tions, or other uncommon immune-mediated disor- risk\/benefit profile. ders. A fourth category, gestational diabetes mellitus, exists only during pregnancy. Diagnosis of DM is Human growth-hormone therapy, which can cost up to made based on symptoms and on elevated plasma $15,000 per year, has been marketed as a \u201ccure\u201d for aging. glucose levels. A casual (no specific relation to meals) Proponents say that it is a veritable \u201cfountain of youth\u201d that plasma glucose level of 200\u202fmg\/dL or higher, particu- provides the following benefits: larly with symptoms, warrants further testing. This \u2022\t Increased muscle mass can be done using the oral glucose tolerance test or the \u2022\t Increased bone mass fasting plasma glucose (FPG) level (no calorie intake \u2022\t Improved energy by expanding cardiac and pulmonary for at least 8 hours). The FPG level is the more com- monly accepted test, because it is less costly and less function time-consuming. FPG levels less than 110\u202fmg\/dL are \u2022\t Extended life span considered normal. FPG levels between 110 and 126\u202fmg\/dL are classified as impaired fasting glucose. In fact, some propose that growth-hormone replacement FPG levels of 126\u202fmg\/dL or higher warrant a provi- therapy should start earlier in life to produce maximal benefits. sional diagnosis of diabetes. Abnormal results must Opponents state that this therapy is not a panacea. They be confirmed on a subsequent day to make the believe it is essential to consider the risks and side effects of diagnosis. growth-hormone therapy, which include the following: Type 1 diabetes mellitus.\u2002 Type 1 DM can occur at any \u2022\t Fluid retention age, but usually before age 25. Approximately 10% to \u2022\t Increased blood pressure 15% of people with diabetes have type 1 DM. Type 1 \u2022\t Increased incidence of cancer DM typically has a sudden onset, although it may \u2022\t Gynecomastia (enlarged breast tissue) in men occur slowly, depending on the rate of pancreatic \u03b2 cells destruction. People suffering from type 1 DM Use of hypothalamic hormones is now under study, but no produce little or no insulin because of \u03b2-cell destruc- conclusive information is available. tion. Absolute lack of insulin production results in excessively high levels of glucose in the blood (hyper- There are unsupported claims that supplementary use of glycemia) and leads to the classic symptoms of diabe- DHEA can help fight aging, yet there is little or no conclusive tes: polyuria (excessive and frequent urination), evidence. Short-term use has not shown significant adverse polydipsia (excessive thirst), polyphagia (excessive effects but long-term use has not been proven safe, and theo- appetite), and weight loss. The patient with type 1 DM retically, it could increase the incidence of hormone-dependent is prone to further metabolic problems. When the body cancers, such as breast, prostate, and ovarian cancer (Mayo Clinic, 2014). The primary care provider should be consulted before use. COMMON DISORDERS SEEN WITH AGING Diabetes Mellitus The incidence of DM increases with age. The likeli- hood of acquiring diabetes rises sharply with each decade of life. The CDC (2012b) reports that the number of older adults with diabetes is seven times higher than adults ages 20 to 44. According to the American Diabetes Association, in 2011, nearly 27% of persons older than 65 years of age have diabetes. DM is a","Physiologic Changes\u2003 CHAPTER 3\t 69 is unable to use glucose because of inadequate insulin production, starvation at the cellular level occurs. The results in a spontaneous decrease in plasma glucose body may attempt to meet cell needs by using fat or levels and reduced insulin resistance. If diet alone is muscle as a source of fuel. This results in an accumula- not successful, oral hypoglycemic agents may be pre- tion of ketones (by-products of incomplete metabo- scribed. When under physical stress resulting from lism of fatty acids) in the bloodstream. As the blood infection or surgery, persons with type 2 DM may ketone level increases, the acid-base balance is altered, experience abnormally high plasma glucose levels. In the blood becomes too acidic, and a condition called these cases, the classic symptoms of DM may occur, ketoacidosis occurs. The body attempts to maintain and the person may require insulin administration to acid-base balance through the compensatory systems maintain normal plasma glucose levels. Once these of the kidneys and lungs. When a severe imbalance levels are normal and the stressor is removed, insulin occurs, ketonuria may occur, and acetone (or \u201capple administration is typically discontinued. Plasma glu\u00ad pie\u201d) breath may be detected. Severe acidemia can cose levels should be monitored frequently to ensure result in a deep and rapid pattern of breathing called that they remain within normal limits. Kussmaul respirations. If not recognized and treated, type 1 DM results in death. Long-term glycemic control is monitored using the glycated hemoglobin A1C. An A1C of 7% or less is Type 1 DM requires continuous, careful monitoring desirable. Good glucose control has been shown to and medical supervision. Treatment involves a careful reduce the risk of vascular complications. balance of diet, insulin therapy, exercise, and stress management. Each patient requires an individualized Hypoglycemia program that meets their particular needs. Hypoglycemia is a potentially serious problem for people receiving insulin or oral hypoglycemic agents. Changes in diet or activity, infections, and stress can Classic signs of hypoglycemia include headache, easily cause problems for the patient with type 1 dia- nausea, weakness, tremors or trembling sensations, betes. The plasma glucose levels of a patient receiving pallor, anxiety, irritability, tachycardia, sweating, and insulin therapy must be monitored closely. Plasma hunger. Many of these symptoms can be easily missed glucose levels may be determined by the laboratory or or misinterpreted in the older adult population. If by self-testing devices. Any significant changes in hypoglycemia is suspected, the plasma glucose level plasma glucose levels should be reported promptly to should be measured promptly. Treatment is based on the primary care provider. the specific plasma glucose level. Those with levels of 40 to 60\u202fmg\/dL respond best to foods such as milk and Patients with type 1 diabetes who live indepen- crackers, and those with levels of 20 to 40\u202fmg\/dL dently must be taught the importance of following the respond best to refined carbohydrates such as honey, prescribed balance of diet, insulin, and exercise. They juice, or sugar. If unconscious, the patient is treated should be strongly urged to call the doctor immedi- with an intramuscular injection of glucagon or an ately if they have any signs of infection, particularly intravenous infusion of 50% glucose. Individuals who any infection that results in vomiting. Special medical are prone to hypoglycemia should be taught to carry identification bracelets or necklaces are advisable. a carbohydrate source, such as hard candy or glucose Such devices can help ensure that proper care is pro- tablets. vided in emergencies. Type 2 diabetes mellitus.\u2002 The form of DM that is most Hypothyroidism often observed in older adults is type 2 DM, which Reduced function of the thyroid gland, called primary accounts for 85% to 90% of all persons with diabetes. hypothyroidism, is more common in older than in This form of DM is more commonly observed in indi- younger persons. The symptoms of hypothyroidism viduals who are older than 40 years of age, who are include cold intolerance, dry skin, dry and thin body obese, or whose family history includes type 2 DM. hair, constipation, depression, and lack of energy. The symptoms of type 2 DM are usually mild and Because many of these changes are commonly observed unrecognized by an aging person. Diagnosis often with aging, the changes may not be recognized as occurs during routine medical visits or when the signs of hypothyroidism. Diagnosis is made by means person seeks medical attention for visual disturbances, of blood tests. Treatment of hypothyroidism with very delayed wound healing, or recurrent vaginal or yeast high levels of thyroid hormone has been shown infections. to reduce bone density in older women but not in older men. With type 2 DM, the individual may have normal or even elevated levels of insulin. Despite this, glucose THE REPRODUCTIVE AND does not enter the cells normally. It is suspected that a GENITOURINARY SYSTEMS problem with the receptor sites on the cells prevents normal cellular functioning. In both men and women, the genital and urinary systems are located close to each other. As mentioned Physicians prefer to control type 2 DM by dietary means. Weight loss is encouraged, because it often","70\t UNIT I\u2003 Overview of Aging Table 3-13\u2003 Reproductive Changes Associated With Aging previously, many structures in men are used for both the sexual and elimination functions. In women, the PHYSIOLOGIC CHANGE RESULTS structures of elimination are completely separate from Decreased vaginal secretions those of reproduction. Female FEMALE REPRODUCTIVE ORGANS Decreased estrogen The primary female sexual organs include the ovaries, levels fallopian tubes, uterus, and vagina. These structures, which are necessary for normal human reproduction, Decreased tissue Decreased pubic hair; increased are located in the pelvic cavity between the bladder elasticity vaginal tissue fragility; and the bowels. It is important to visualize their loca- increased tissue irritation; tion to understand the symptoms that may occur if the decreased size of uterus; size, shape, or position of these organs changes. During decreased vaginal length and the reproductive years, the ovaries produce the hor- width; decreased size of mones estrogen and progesterone. Under the influence vaginal opening; increased pain of these hormones, the ova mature in the ovaries, and with intercourse (dyspareunia); the endometrium of the uterus changes in vascularity decreased breast tissue mass to support a possible pregnancy. Upon reaching meno- pause (sometime between the age of 45 and 60), ovarian Increased vaginal Increased risk for infection hormone function decreases then ceases in the female. alkalinity Recent technology and extensive medical intervention can allow pregnancies to occur after menopause, but Male Decreased amount of facial and the number of women who choose to become pregnant pubic hair this late in life is likely small. Most women who reach Decreased menopause are either resigned or delighted to reach testosterone levels the end of the reproductive stage. Decreased Decreased rate and force of MALE REPRODUCTIVE ORGANS circulation ejaculation; decreased speed The male organs of reproduction consist of the testes, gaining an erection a series of ducts and glands, and the penis, which contains the passageway by which sperm, the male sex NURSING ASSESSMENTS AND CARE STRATEGIES cells, leave the body in the ejaculate. The testes are RELATED TO REPRODUCTIVE CHARGES suspended in a tissue sac called the scrotum, which hangs between the thighs. The testes produce the NURSING ASSESSMENTS CARE STRATEGIES hormone testosterone, which is responsible for sperm production and maturation. Testosterone is also Assess for signs and Report unusual vaginal responsible for the secondary sex changes in men, symptoms of discharge to primary care including body hair patterns, voice changes, and infection or provider. Administer treatment muscle development. A series of ducts and glands pro- inflammation. as prescribed. vides additional fluid volume to the ejaculate and adds nutrients needed for sperm maturation and develop- Assess factors that Discuss normal physiologic ment. The prostate gland is located just below the may interfere with changes and the possible urinary bladder. The prostate produces an alkaline sexual activity. effects of medications on secretion that increases sperm motility, and it contracts sexual function. Educate to aid in sperm ejaculation. females regarding use of artificial lubrication. Possible EXPECTED AGE-RELATED CHANGES referral of males to primary Changes in Women care provider for Several significant changes occur with menopause pharmacologic treatment of (Table 3-13). Production of progesterone and estrogen erectile dysfunction. diminishes. There is no longer the need to produce ova to be fertilized, and there is no need to prepare a site decreases. This results in a flattening of the tissue of to support a pregnancy. Other changes related to the the external genitalia, or labia, and decreased amount decline in hormones are not as desirable. Along with and distribution of pubic hair. Vaginal epithelial tissue other body tissue, the tissues of the external female becomes thinner and less vascular. The tissue of the reproductive organs atrophy as a result of vascular vagina is drier and more alkaline, and fewer rugae changes. The tissues of the reproductive organs become (folds) are present within the vagina. The uterus, less elastic, and the amount of subcutaneous tissue cervix, ovaries, and fallopian tubes decrease in size and may be difficult to palpate on examination. The decrease in hormone production and resulting tissue changes may lead to more fragile, more easily irritated vaginal tissue. Decreased vaginal secretions may lead to vaginitis, which can cause vulvar soreness and pru- ritus or dyspareunia (painful intercourse). Once meno- pause has occurred, vaginal bleeding is considered","Physiologic Changes\u2003 CHAPTER 3\t 71 abnormal. Older women who receive HT may experi- COMMON DISORDERS SEEN WITH AGING ence fewer reproductive tissue changes, and, in some Uterine Prolapse cases, the lining of the uterus responds to these supple- Prolapse of the uterus (into the vagina) is commonly mental hormones. Vaginal bleeding may occasionally observed in older women. This is particularly a be observed in these women. problem for those who have had many pregnancies or for those who delivered children with little medical The breasts are part of the secondary female sexual assistance. Most often, the first signs of uterine pro- organs. Because of the decrease in hormones with lapse involve changes in either urine or bowel elimina- aging, breast tissue atrophies. As supporting muscle tion. Urinary frequency, urinary retention, recurrent tissue atrophies, the breasts tend to sag and decrease UTIs, back pain, and constipation may be symptoms. in size. In some cases, the cervix and uterus may prolapse through the vagina and be observed protruding outside Changes in Men of the vulva. Surgical correction may be required. Male age-related changes in the reproductive system are less noticeable because testosterone continues to be Vaginal Infection produced into old age, although the amount decreases. Change in vaginal pH may lead to increased incidence Men, even in their late 80s, have successfully fathered of vaginal infections, particularly yeast infections. children. This is most often manifested by increased vaginal discharge, irritation, odor, and itching. With aging, there is some change in the size and firmness of the testes. The penis retains the ability to Breast Cancer become erect, although it may take longer and require Breast cancer continues to be a major cause of cancer more stimulation. Once achieved, erection may last deaths in women, and the incidence of this form of longer than at a younger age. Ejaculations tend to be cancer continues to increase with age. It is important slower and less forceful in aging men and may not that regular breast examinations (including mammog- occur during each sexual encounter, particularly if raphy) continue as a woman ages. Any sign of dim- intercourse is frequent. pling; masses; nipple retraction; or breast drainage, discharge, or bleeding is suspicious and requires Enlargement of the scrotum may indicate problems further medical attention. with the testes or part of the duct system. The penis should remain free from any tissue changes, and the Prostate Cancer presence of ulcers, nodules, or other changes is abnor- There are no obvious changes in function to indicate mal. The prostate gland commonly enlarges with age. the presence of prostate cancer. Therefore, it is impor- Most aging men experience some degree of prostate tant for aging men to have regular medical examina- enlargement. The signs and symptoms most often tions. A skilled clinician who palpates the prostate may experienced include urinary frequency, hesitancy, detect changes that indicate malignancy. Prostatic dysuria, decreased force when voiding, dribbling, noc- cancer is a major cause of death in aging men. turia, increased incidence of UTIs, and decreased force during ejaculation. In cases of benign prostatic hyper- plasia, surgical intervention, such as a transurethral prostatectomy, may help reduce the symptoms. Get Ready for the NCLEX\u00ae Examination! Additional Learning Resources Key Points Go to your Evolve website at http:\/\/evolve.elsevier .com\/Williams\/geriatric for the additional online resources. \u2022\t Nurses must possess knowledge about the normal structures and functions of all body systems so that Review Questions for the NCLEX\u00ae Examination deviations from the norm can be detected. 1.\t Your older female patient is complaining because she is \u2022\t All body systems are affected to a greater or lesser having frequent urinary tract infections. Which normal degree by aging. Although these changes are normal age-related change is most likely to be a contributing and expected, they can have a significant impact on factor? the older person\u2019s functional ability, self-image, and 1.\t Increased nocturnal urine production lifestyle. 2.\t Decreased perception of the need to void 3.\t Decreased bladder muscle tone \u2022\t In addition to age-related changes, a variety of 4.\t Urinary incontinence diseases are increasingly common in the aging population. \u2022\t Nurses must be careful to distinguish between normal physiologic changes and abnormal alterations that indicate the need for prompt medical attention.","72\t UNIT I\u2003 Overview of Aging 2.\t Which are normal age-related changes? (Select all 5.\t What should the nurse explain when discussing that apply.) expected changes in the female reproductive system to 1.\t Decreased visual acuity an older adult? 2.\t Increased heart rate 1.\t Increased pubic hair is expected 3.\t Decreased long-term memory 2.\t Uterine enlargement is normal 4.\t Increased gastric pH 3.\t Vaginal tissues become more vascular 5.\t Increased muscle mass 4.\t Production of vaginal secretions decreases 6.\t Decreased depth of respiration 7.\t Increased calorie requirements 6.\t The nurse performs a skin assessment of an older 8.\t Decreased serum albumin adult. Which finding is abnormal and needs to be 9.\t Increased subcutaneous tissue reported? 10.\t Decreased rate of peristalsis 1.\t Increased patches of dark pigmentation on exposed skin 3.\t What are patients who have had Parkinson disease for 2.\t A dark, elevated patch that bleeds when touched 10 years likely to exhibit? (Select all that apply.) 3.\t Deep wrinkles and frown lines around the mouth 1.\t Rigidity and tremors when at rest and eyes 2.\t Hemiparesis and aphasia 4.\t Numerous brown or flesh-colored skin tags around 3.\t Dementia the neck 4.\t Unilateral tremors with movement 5.\t Tremors present during sleep 7.\t The nurse encourages the patient to maintain a steady weight in the recommended range to decrease risk \t 4.\t An older adult is coming to your clinic for treatment for of which common endocrine disease observed in \t a gastric ulcer. Which treatment would the nurse expect older adults? to be ordered? 1.\t Hypothyroidism 1.\t Antibiotics 2.\t Hyperthyroidism 2.\t Stress-reduction classes 3.\t Diabetes mellitus 3.\t NSAIDs 4.\t Diabetes insipidus 4.\t Iron supplements before breakfast and dinner","Unit II\u2003 Basic Skills for Gerontologic Nursing chapter Health Promotion, Health Maintenance, 4\u2003 and Home Health Considerations Objectives http:\/\/evolve.elsevier.com\/Williams\/geriatric 1.\t Describe recommended health-maintenance practices, 8.\t Identify selected nursing diagnoses related to health- and explain how they change with aging. maintenance problems. 2.\t Discuss the relationship of culture and religion to health 9.\t Describe nursing interventions that are appropriate for practices. older adults experiencing alterations in health maintenance. 3.\t Identify how perceptions of aging affect health practices. 4.\t Describe how health maintenance is affected by 10.\t Discuss the role of home health as it relates to health promotion and health maintenance in the older adult. cognitive and sensory changes. 5.\t Discuss the impact of decreased accessibility on 11.\t Differentiate between unpaid and paid home health care providers. health-maintenance practices. 6.\t Describe methods of assessing health-maintenance 12.\t Identify the factors to consider when seeking home health care assistance. practices. 7.\t Identify older adults who are most at risk for noncompliance\u2002 (p. 84) prophylactic\u2002 (pr\u014d-f\u012d-L\u0102K-t\u012dk, p. 76) experiencing health-maintenance problems. Although older adults make up only approximately Key Terms 13% of today\u2019s population, they account for 40% of all health care expenditures (Goozner, 2012). The health maintenance\u2002 (p. 74) older adult population has primarily benefited from health promotion\u2002 (p. 74) improvements in medical care. Advances in surgery, nonadherence\u2002 (p. 84) technology, and pharmacology have enabled us to prolong life in situations that even a few years ago As people live longer and the percentage of older would have been impossible. adults in the population increases, society faces several major challenges. One of the most significant of these This level of care is not without substantial cost. challenges involves meeting the health care needs of Because a significant portion of older adults\u2019 health the aging population. care expenses is covered by Medicare and Medicaid, the burden on the younger members of society is Today\u2019s older adults are generally healthier than the becoming overwhelming. Despite steady increases in older adults of previous generations. Improvements payroll taxes on the working population, Medicare has in sanitation, public health, and occupational safety operated at a deficit since the start of the twenty-first implemented during the twentieth century have century. Because there is a fixed amount of taxpayer helped raise the age at which a person can expect to money, society must identify appropriate and accept- experience a life-threatening disease. able ways to control health care costs. Older adults can and do experience acute, life- One way of dealing with a steady increase in threatening medical conditions just as younger persons demand for health care services involves rationing do, but acute episodes in older adults are more likely the type and amount of care provided to older adults. to be associated with chronic conditions. Either an This approach would prohibit or severely limit the acute condition is caused by a chronic problem, or type of care provided, particularly in cases in which a chronic problem persists after an acute episode. the potential for significant improvement in health According to the Centers for Disease Control and status is limited. For example, some of the more costly Prevention (CDC), 80% of older adults live with a chronic condition, and 50% have three or more coexist- 73 ing chronic conditions. Common chronic problems include arthritis, hypertension, diabetes, heart disease, and vision or hearing disorders. Most of those with chronic illness are able to manage quite well; however, some require care to meet their needs.","74\t UNIT II\u2003 Basic Skills for Gerontologic Nursing Box 4-1\u2003 Advice for the Young and Not-So-Young Adult \u2022\t Accept that you are getting older\u2014adjust to the changes, and plan for possibilities. \u2022\t Explore options for the future\u2014look for things you want to accomplish in your life. \u2022\t Find work or creative outlets that make you happy\u2014 look for ways to grow throughout your life. \u2022\t Modify your lifestyle to promote health\u2014exercise, eat healthy foods, and manage stress. \u2022\t Develop and maintain relationships\u2014bonds formed with friends and loved ones provide support; we can never have too many. treatments and procedures (e.g., renal dialysis and FIGURE 4-1\u2003 Exercise is important to older adults for health bypass surgery) could be refused if the person were promotion and maintenance. (From Ignatavicius DD, Workman ML: older than a predetermined age. This method has been Medical-surgical nursing: Patient-centered collaborative care, ed 7, adopted in some countries but is unpopular in the St. Louis, 2013, Saunders.) United States. To avoid rationing health care, we must find ways to maximize the effectiveness of our include \u201cMyPlate\u201d and \u201cFruits and Veggies: More health care expenditures. The Patient Protection and Matters,\u201d promoting consumption of fruits and\/or Affordable Care Act (Chapter 1) of 2010 is an attempt vegetables (Chapter Resources). Some changes in to reduce spiraling health care costs. caloric intake and protein and vitamin needs appear to be desirable with aging (Chapter 6). Most studies reveal that it is more cost-effective to prevent problems than to cure or treat them. Therefore, When special diets are indicated, older adults need more health care providers and the public (including to learn how to read and interpret the information older adults) are beginning to recognize the need to provided on packaging labels. This is particularly devote more attention to health promotion and health important with sodium-restricted diets, because maintenance. sodium is common in foods that do not necessarily taste salty. Because food labels are often printed in very Health promotion is not a new concept. For decades, small type, older adults should bring their eyeglasses health care providers have stressed the importance of or a magnifying glass when they shop. If someone else good nutrition, exercise, and regular medical care. shops for them, that individual needs to understand Although most of this information was directed toward the dietary restrictions of the older adult and how to younger people, many older people who desired to shop wisely. live longer, healthier lives also paid attention. As the benefits of healthy lifestyle choices became obvious, EXERCISE television, radio, and other media joined health care Daily exercise should be part of the plan for older providers in promoting health awareness. Awareness adults (Figure 4-1). Exercise can help keep joints flex- of the importance of good health-maintenance prac- ible, maintain muscle mass, control blood glucose tices increased. Many individuals have modified their levels and weight, and promote a sense of well-being. lifestyle and health care practices to improve their Exercise does not need to be aerobic to benefit older overall health and quality of life (Box 4-1). Those who adults. Walking, swimming, golfing, housekeeping, are unaware or are unwilling to heed this advice persist and active lawn work or gardening are all considered in risky, health-threatening behavior. Nurses need to exercise. To be most beneficial, exercise should consist be aware of the health promotion and maintenance of at least 30 minutes of continuous activity. The type, practices that will most benefit older adults. Nurses level, and amount of exercise that is best differ for each also need to understand why some older adults choose person and should be based on the recommendations to adopt positive health behaviors, whereas others of the primary care provider. persist in seemingly self-destructive behavior. TOBACCO AND ALCOHOL RECOMMENDED HEALTH PRACTICES It is never too late to stop smoking. Even the body of FOR OLDER ADULTS an older person can repair damage once smoking is discontinued. Cessation may be difficult when smoking DIET has been a long-standing habit, but various aids are Older adults should consume a well-balanced, plant- now available to help smokers quit. Before using based diet with the recommended daily allowances of any of these aids, older adults should seek guidance nutrients. Helpful nutrition guides for healthy eating","Health Promotion, Health Maintenance, and Home Health Considerations\u2003 CHAPTER 4\t 75 from their primary care providers because they may seen with aging can contribute to gait changes that need to follow some special precautions related to may result in imbalance or falls. When gait problems existing health problems. are identified, physical therapy for gait retraining and strengthening exercises, use of assistive devices, and Excessive consumption of alcoholic beverages is environmental modification are appropriate. never recommended. Alcoholism is an all too common problem in the older adult population for both men Vision should be checked yearly to monitor for and women because alcohol may be used as a means glaucoma or other eye problems. Refractive examina- of coping with a variety of problems. Occasional or tions can detect the need for a change in eyeglass pre- moderate alcohol consumption by older adults usually scription. Hearing examinations need not be done on is not prohibited unless some medical condition or a yearly basis unless a problem is suspected. When medication precludes its use. Some primary care pro- signs of diminished hearing are present, audiometric viders even recommend a glass of wine or beer as an testing is appropriate. appetite enhancer in certain situations. Blood tests for hypothyroidism or diabetes, electro- PHYSICAL EXAMINATIONS AND PREVENTIVE cardiograms, and other diagnostic tests are not OVERALL CARE routinely part of the physical examination. Blood cho- Older adults should be examined annually by their lesterol screening should be done every five years primary care providers more often if known health (CDC, 2013a). Older adults should be aware of the problems exist. Some older adults resist this because need to communicate any symptoms they experience of the cost or fear about what the primary care pro- so that their primary care providers can determine the vider may find. Cost is a real concern to many older need for additional testing. adults, but inadequate health maintenance should be of more concern. A delay in the recognition of prob- In addition to regular physical examinations, older lems may make them more difficult and expensive to adults should be sure to obtain immunization against treat. Physical examinations provide an opportunity diseases, such as pneumonia and influenza, which are to detect problems before they become more serious, more common in older adults. Research has shown to monitor and treat chronic conditions, and to prevent that older adults over age 50 were 76% less likely to be some health problems. hospitalized from flu-related illnesses when given the flu shot (CDC, 2013b). Because the immune system is Physical examinations in older adults should less responsive in the older adult, it is important that include evaluations of height and weight, blood pres- they receive vaccinations in a timely manner. sure, and a rectal examination. In addition, women Pneumococcal vaccine: The pneumonia vaccine is should have a pelvic examination, mammogram, Papanicolaou (Pap) test, and bone mineral density given starting at 65 or 70 years of age; repeating the (after age 65 or earlier, depending on risk factors). vaccination every 10 years is recommended. Older men need a prostate examination and blood test Influenza (flu) vaccine: The influenza vaccine must be to rule out prostate cancer. Persons with identified risk obtained on a yearly basis, usually in the fall, factors for colon cancer require occult blood screening because the strain of the virus changes frequently. and, possibly, a colonoscopy. Flu shots can be obtained from primary care provid- ers, clinics, and most pharmacies. Even with immu- Evaluation of joints, feet, and gait should be part of nization, a larger percentage of older adults contract the physical examination. Problems with the knees influenza. and shoulder joints can cause pain; limitation of activ- Tetanus, diphtheria, pertussis vaccines: The Tdap ity; poor sleep; and decreased overall function. Some vaccine protects against the contagious and deadly problems require surgical correction, whereas others diseases tetanus, diphtheria, and pertussis. Tdap only can be treated using analgesics, antiinflammatory needs to be given once in a lifetime. Td is a booster medications, or physical therapy. Inspection of the feet given every 10 years (or after an exposure to tetanus, often reveals problems. Many older adults have diffi- e.g., a deep puncture wound) and protects against culty caring for their toenails because of poor vision, tetanus and diphtheria. Before 2005, only children inability to reach the feet, or hypertrophic nail changes. could receive the Tdap vaccine; however, pertussis Bunions, calluses, and corns also cause problems for rates have continued to rise (probably because of older adults. Neglecting the feet can lead to discom- inadequate vaccination), and Tdap is now recom- fort, restricted mobility, and a poorer quality of life. If mended for anyone who has never had the vaccine, the feet are not properly cared for, the risks for infec- including adults over age 65. Although tetanus tion and even amputation increase, particularly in infection is rare in the United States, approximately those with compromised circulation. Older adults half of tetanus cases affect the older adult popula- should be encouraged to wear properly fitted shoes tion. People who have not yet had the Tdap vaccine with good support. Regular visits to a podiatrist can should receive one dose in place of one of their significantly reduce foot problems. Joint or foot prob- 10-year tetanus (Td) boosters. lems, illness, pain, and other conditions commonly Shingles (zoster) vaccine: The risk of developing shin- gles, a herpes zoster infection that causes a classic","76\t UNIT II\u2003 Basic Skills for Gerontologic Nursing Box 4-2\u2003 Signs and Symptoms Indicating a Need for Prompt Medical Attention rash and painful neuralgia, increases with age. The shingles vaccine has been available since 2006. This \u2022\t Severe pain; radiating or crushing chest, neck, or jaw vaccination is recommended for people over age 60, pain; severe unremitting headache provided they have a normal immune system. Benefits of this vaccine should be determined based \u2022\t Difficulty breathing on individual risks, preferences, and the primary \u2022\t Loss of consciousness care provider\u2019s recommendations. It is very expen- \u2022\t Loss of movement or sensation in any body part(s) sive and is effective approximately 50% of the time. \u2022\t Sudden vision changes The need for the hepatitis-B immunization is based on \u2022\t Unusual drainage or discharge from any body cavity individual risk factors and should be discussed with a \u2022\t Wounds that do not heal primary care provider. \u2022\t Nausea or vomiting over 24-hour duration Prophylactic use of medications such as aspirin \u2022\t Elevated body temperature (to prevent cardiovascular disease) and vitamin E \u2022\t Inability to urinate (thought to decrease risk for stroke, heart attack, and \u2022\t Swelling of the lower extremities Alzheimer disease) is gaining increased acceptance \u2022\t Excessive (greater than 10%) weight gain or loss in the medical community. Older adults should be \u2022\t Sudden or dramatic behavior changes encouraged to discuss the possible benefits of this type \u2022\t Sudden changes in speech or ability to follow of therapy with their primary care provider and then follow the recommendations. directions Use of prescription and over-the-counter medica- tions is common in the aging population. Older people \u2022\t Keep a card with names of all medications, dose, and with medical conditions must understand the reasons name of primary care provider with you at all times. for and the importance of their treatment plans. They should keep a record card listing all of their medica- \u2022\t Keep the card up to date. tions and the physicians who prescribed them. This \u2022\t Show the card to all health care providers. card should be shown to all licensed professionals they \u2022\t Wear a medical alert bracelet, listing serious diseases and see to prevent serious drug interactions. Older adults must know how and when to take prescribed medica- allergies. tions, how to use over-the-counter medications safely, \u2022\t Do not use OTC medication without consulting primary how to store their medications, and when to report side effects. Sharing prescription medications with care provider or pharmacist. friends or neighbors is dangerous and should be \u2022\t Do not take anyone else\u2019s medication or share your avoided. Medications can be confusing and even over- whelming to many people. Additional precautions medication with anyone. regarding medications are discussed in Chapter 7. To keep track of medical appointments, older adults DENTAL EXAMINATIONS AND PREVENTIVE should have a calendar or datebook to record appoint- ORAL CARE ments and reminders for things, such as immuniza- tions. They also should be aware of signs and symptoms Dental examinations should be obtained and an inspec- that indicate a need to seek medical attention that tion of the oral cavity performed at least annually. exceeds routine yearly examinations. Signs and symp- Today\u2019s older adults are keeping their natural teeth toms indicating the need for prompt medical attention longer than previous generations were able to because are listed in Box 4-2. of better nutrition and improved dental care. Gum Older adults who have health problems or allergies, disease and tooth decay are major causes of tooth those taking medications such as heparin, and those loss. To prevent or slow the progress of these dental with implanted medical devices such as pacemakers problems, older adults should brush their natural should wear a Medic Alert bracelet or necklace. If they teeth twice daily using fluoride toothpaste and should do not wish to wear such a warning device, these indi- floss carefully between the teeth. Mouthwash may viduals should at least carry a card in their wallets or help refresh the breath, but it cannot replace regular purses to provide the necessary health information. brushing. Health Promotion It is recommended that older adults use soft-bristle brushes to clean all tooth surfaces, particularly those \u2002 individuals suffering from arthritis, because they may have difficulty holding and brushing with a standard Medications toothbrush. Enlarging the brush handle using tape, \u2022\t Take prescription medications only as ordered. wide rubber bands, sponges, or polystyrene or length- \u2022\t Store medication as directed. ening the brush by attaching a wood or plastic strip \u2022\t Report any suspected side effects to your primary care may make it easier to hold. Some older adults prefer an electric toothbrush that provides the proper provider. movement. Circular or short back-and-forth brushing works best to clean the teeth. Close attention should be paid to remove all plaque from along the gum line. Red,","Health Promotion, Health Maintenance, and Home Health Considerations\u2003 CHAPTER 4\t 77 swollen, or bleeding gums indicate the need to see a A dentist. People should have their teeth professionally cleaned twice a year to remove stains and other debris B missed by routine brushing. FIGURE 4-2\u2003 Many older people continue to work and learn after the Older adults who wear dentures still need regular traditional retirement age. (A, From Sorrentino SA, Gorek B: Mosby\u2019s oral examinations, because people older than 65 years textbook for long-term care, ed 4, St. Louis, 2003, Mosby. B, From of age account for more than half of the new cases of Cooper K, Gosnell K: Foundations of Nursing, ed 7, St. Louis, 2015, oral cancer each year. Good oral hygiene is also neces- Mosby.) sary. Dentures must be brushed or cleaned at least once a day to remove food debris, bacteria, and stains, and schools, literacy centers, or other community agencies to prevent gum irritation or bad breath. Some denture is a popular and desirable activity, because it helps wearers prefer to brush the dentures using a special promote a sense of value and self-worth (Figure 4-2). dentifrice, whereas others prefer to use a soaking solu- Many older adults continue to remain active in the tion that works overnight. Either cleansing method is workforce. This may be out of financial necessity or as appropriate, but the chemicals should be rinsed thor- a way to remain a productive, contributing member of oughly from the dentures before they are put back into society. A decrease in social interaction can contribute the mouth. to the deterioration of cognitive and adaptive skills. Nurses cannot force an individual to participate An older person wearing dentures for the first time beyond his or her wishes, but encouragement and needs to become adept at inserting and removing information about options can help stimulate the older them. Eating with dentures is often awkward, neces- person\u2019s interests. sitating some relearning so that the wearer can chew effectively. Taking smaller pieces of soft, nonsticky FACTORS THAT AFFECT HEALTH PROMOTION foods and chewing more slowly are recommended. AND MAINTENANCE Because dentures make the mouth less sensitive to heat, cold, and foreign objects, such as bone fragments, The actions taken to promote, maintain, or improve special care is required when eating. health are based on that individual\u2019s perception of his or her health. Health perceptions influence day-to- Poor fit is a major reason that some older adults fail day choices regarding hygiene practices; nutrition; to wear their dentures regularly. This contributes to exercise; use of alcohol, drugs, and tobacco; accessing problems with nutrition and digestion. A few extra health care; and many other activities. Health- appointments with the dentist are often necessary to maintenance practices include safety precautions taken help fit the dentures properly. These adjustments are to prevent injury from automobile accidents, falls, important because poorly fitting dentures can cause poisoning, and other hazards. Health perceptions and irritation to the gums or mucous membranes of the mouth. Additional adjustments may be needed if the denture wearer gains or loses weight. Other changes in the oral cavity (e.g., dryness) are also common with aging. Although saliva production does not decrease in all older adults, a variety of medical conditions, medications, and treatments can cause or contribute to dry mouth. Dry mouth can best be relieved by drinking more water. Excessive use of hard candy, caffeine beverages, alcohol, or tobacco increases dry mouth. MAINTAINING HEALTHY ATTITUDES Strong connections exist between the mind and body. Older adults who maintain a positive outlook on life tend to follow good health practices and remain healthier longer. Regular interaction with other people of all age groups helps maintain a positive attitude toward life. It is recommended that older adults get out of the house as often as possible, even if only for shopping or dinner. Keeping in touch with family and friends is important. When spouses or friends are lost through death or relocation, older adults benefit from attempt- ing to establish new relationships by joining church or community social groups. Volunteering in hospitals,","78\t UNIT II\u2003 Basic Skills for Gerontologic Nursing FIGURE 4-3\u2003 While providing information in a home care setting, this nurse compares traditional and Western remedies. Culture influences health-maintenance practices in older adults are influ- how health, illness, and pain are perceived. The nurse must take enced by personal beliefs, religious and cultural beliefs, cultural variations into account to communicate effectively with socioeconomic status, education, and life experiences. patients and their families. (From Leahy JM, Kizilay PE: Foundations of nursing practice: A nursing process approach, Philadelphia, 1998, As people mature, they establish a set of beliefs, Saunders.) perceptions, and values related to health. These per- ceptions include basic ideas regarding what health is The following groups have higher rates of the following and how to best maintain it. These beliefs form the disorders: foundation for each person\u2019s health practices. Based on \u2022\t Hypertension: African-American population their unique beliefs, most people perform activities \u2022\t Diabetes: African-American, Hispanic\/Latino, American- they perceive to be helpful in maintaining their health and avoid activities they perceive as harmful. It is dif- Indian, Asian-American, and Pacific Islander\u2013American ficult to change a person\u2019s lifetime health practices. populations Only those who are highly motivated to change are \u2022\t Stomach cancer: Hispanic-American, African-American, likely to be successful. and Asian\/Pacific Islander populations RELIGIOUS BELIEFS \u2022\t Cervical cancer: Hispanic-American and African-American Religious beliefs contribute to an individual\u2019s percep- populations tions. These beliefs can promote health maintenance or \u2022\t Breast cancer: White women interfere with good health practices and result in \u2022\t Obesity: African-American, American-Indian\/Alaskan increased health risks. For example, some religions Native, and Hispanic-American populations teach that the body is a temple, stressing the impor- tance of avoiding alcohol, tobacco, and other behaviors As our society becomes increasingly diverse, nurses that are harmful to health. Individuals with these reli- need to become more aware of the religious and cul- gious beliefs tend to live longer, healthier lives than do tural factors that affect the health-maintenance prac- people who do not share these values. Other people, tices of all persons (Figure 4-3). Information about the whose religions teach that illness is a punishment for beliefs and practices of organized religions and major sins, may feel that they are not worthy of health and cultural groups is available through sources such as must endure illness as atonement for things they have textbooks on transcultural nursing. Although nurses done wrong in their lives. These individuals may be can gain valuable insight from such sources, we must less inclined to practice health promotion and may be careful not to generalize. It is common for two have a more fatalistic approach to health and illness. individuals from similar religious and cultural back- CULTURAL BELIEFS grounds to have widely disparate perceptions and Cultural beliefs and practices also play a significant practices. A general understanding of cultural factors role in health perception and health maintenance. For is important; however, the best source of accurate example, reliance on home remedies is common in information about a person\u2019s beliefs and practices is many cultures. Some home remedies are harmless, that individual. An overview of common health prac- whereas others are quite dangerous. Problems can tices helps nurses understand the underlying values occur when home remedies are used in place of con- and beliefs that motivate each individual. ventional medical care, when the remedies interact with prescription medications, or when their use KNOWLEDGE AND MOTIVATION results in delayed care, which can be serious or even fatal if the illness is a serious one. Culture also plays a Factors other than religious and cultural beliefs significant role in the selection of food and the methods also play a part in health perceptions and health- used for food preparation. These preferences and prac- maintenance practices. Knowledge plays a key role in tices play an important role in health promotion and maintaining health and promoting safety; knowledge maintenance. Plant-based diets consisting mainly of of recommended health practices is essential to make fruit, vegetables, and grains are common in some cul- tures, whereas diets high in fat and sodium are preva- lent in others. These variations can contribute to the good health of some ethnic populations or to the health problems seen in others. Cultural Considerations \u2002 Biocultural Differences Considerable evidence still exists that race and ethnicity con- tribute to disparities in health throughout the United States.","Health Promotion, Health Maintenance, and Home Health Considerations\u2003 CHAPTER 4\t 79 good choices. Health and safety teaching must start normal and expected with aging may do little to early and be reinforced throughout life. Whenever prevent loss of function, simply accepting the changes. there is a significant change in a person\u2019s health status, It is common to hear these older adults say, \u201cWhy additional teaching is necessary to ensure the safety should I bother to see the doctor? It\u2019s just old age.\u201d and highest possible level of wellness for that indi- Some older adults often ignore early signs of illness or vidual. People cannot make informed decisions regard- attribute them to aging. This often results in a delay ing their health and safety unless they know the before seeking medical care. Others, particularly those ramifications of various behaviors. Individuals experi- who have followed good health practices throughout encing cognitive changes resulting from disease pro- their lives, believe that old age is not synonymous with cesses or chemical dependence may not be able to disease or loss of function. They continue to follow understand the need for safety or health-maintenance high-level health-maintenance practices in all aspects practices despite repeated teaching. People with severe of their lives, including diet, exercise, rest, and medical cognitive or perceptual problems are likely to experi- attention. ence injuries and alterations in health-maintenance practices. Perceptions regarding aging greatly affect a per- son\u2019s motivation and willingness to participate in Health maintenance requires motivation in addition health-maintenance activities. Someone who feels to knowledge. People experiencing grief, depression, capable and in control of life is more likely to change hopelessness, or low self-esteem may not be motivated behaviors and to work at maintaining health. Older to maintain good health practices. Motivating indi- adults who feel useless, helpless, or without purpose, viduals to maintain health is often difficult. All of the particularly the newly widowed or those who are teaching in the world will not replace the desire to live estranged from their families, are less likely to be moti- a healthy life. vated to maintain their health. MOBILITY IMPACT OF COGNITIVE AND Even people who are knowledgeable and motivated to SENSORY CHANGES maintain their health may have trouble if they cannot Cognitive and sensory changes related to aging or obtain the goods or services they need. People with disease can lead to problems with health maintenance. limited physical mobility, transportation, or money are Even the normal sensory changes of aging can increase likely to experience difficulty. A person who knows the the risks for personal neglect or injury. When signifi- importance of nutritious food but who cannot get to a cant cognitive or perceptual problems occur, the risks store or afford the food will have difficulty maintain- are even greater. ing good health. A person who knows that it is impor- tant to see a physician but who can neither get to the An older person with changes in vision and smell office nor pay for medical care is similarly at risk. may have body odor or wear soiled clothing because he or she cannot see or smell soiling. Changes in vision, Assessment of the values, perceptions, knowledge hearing, smell, sensation, taste, and memory can also level, motivations, and lifelong health practices of indi- lead to decreased awareness of normal environmental viduals provides an understanding of the likelihood of hazards. Sensory changes increase the risk for injuries problems with health maintenance. Previous behavior from falls, poisoning, fire, and other traumatic events. is a good indicator of future practice and motivation. Vision changes can cause the older person to miss the edge of a step or a curb, resulting in a fall. Changes in Many adaptive and assistive devices have been smell and taste can result in consumption of spoiled, developed to promote safe mobility for people experi- unsafe food. Changes in sensation can lead to the use encing difficulty moving about or performing many of overly hot bath water, resulting in burns. Changes of the activities of daily living. The Department of in the sense of smell can cause the older adult to not Education\u2019s website has information on thousands of perceive a burning odor, leading to the increased likeli- products designed to assist people with physical limi- hood of injury from fire. tations to help themselves (Chapter Resources). Older adults who are seriously impaired either per- PERCEPTIONS OF AGING ceptually or cognitively commonly lack awareness of Many beliefs about health and health maintenance are their own needs. They may ignore parts of their formed early in life. The longer a belief is held, the hygiene or completely forget to perform routine health- harder it is to change that belief. Therefore, it can be maintenance activities, such as bathing, eating, or difficult to change the health behaviors of older adults. taking medication. Common health practices may be neglected, even though the person is physically capable Perceptions of good health and good health prac- of performing the activities. tices vary widely among the aging population. Older adults have their own beliefs about what is normal and Cognitively impaired older adults are at serious risk expected with aging. Some are willing to accept declin- for injury because they are unable to recognize the ing health as a normal part of aging, whereas others danger of their actions or inactions. They may forget are not. Those who perceive a decline in health as to turn off the burner on the stove, forget to put on a","80\t UNIT II\u2003 Basic Skills for Gerontologic Nursing Many injure themselves trying to shovel snow or mow the lawn. coat when going outside in winter, turn up the furnace instead of turning it off, or walk into a busy street HOME HEALTH without looking for traffic. Severely impaired persons are at great risk for experiencing problems related to As already discussed, older adults typically wish to safety and health maintenance, often requiring some remain at home for as long as possible. To accomplish form of supervised living or institutional care for this, additional assistance will likely be needed. Some safety. of this assistance can be provided by family members. More complex interventions require the expertise of IMPACT OF CHANGES RELATED specialized caregivers. As the number of older adults TO ACCESSIBILITY has increased, the demand for home care services has Aging persons are likely to experience more problems also increased and promises to continue to grow for accessing goods and services than are younger people. the foreseeable future. Home health interventions can Access may be limited by decreased physical mobility, both promote health and help the older person main- lack of transportation, or limited finances. If more than tain the highest level of function possible for the one of these factors is present, the risk for ineffective longest period of time. Assistance in the home can help health maintenance increases dramatically. overcome problems related to noncompliance by pro- viding motivation, verifying that care is completed, Physical limitations, including loss of motor skills, and providing better access to health care services. decreased strength and endurance, and the presence of disease, make health-maintenance activities more According to the National Association for Home difficult. Decreased physical strength and agility can Care and Hospice, more than 12 million people in the interfere with normal health-maintenance practices. United States require some form of home or hospice Simple acts, such as bathing, cooking, and cleaning, care. The majority of these are over age 65. Medicare can be too physically demanding for some older adults, and Medicaid spending for home health care reached who may be too fatigued to even attempt normal self- $60 billion in 2011. Current projections estimate these care activities. This lack of strength or energy often costs to more than double to nearly $126 billion by results in poor health-maintenance practices. 2021 (Centers for Medicare and Medicaid Services, 2011). However, because of mandatory federal budget Transportation difficulties present many problems cuts, or \u201csequestration,\u201d resulting from the Budget for older adults. Simply getting to the grocery store, Control Act of 2011, Medicare (but not Medicaid) pay- pharmacy, or physician\u2019s office when necessary ments will be reduced by 2%, which would decrease can be a major impediment to health maintenance. the 2021 estimate by about $1.2 billion unless the law Even if older adults desire to practice good health is changed. These are massive numbers, yet they do maintenance, they may be hindered by a lack of not include unpaid care provided by family members, transportation. friends, or volunteers, which makes the true cost even greater. Researchers estimate that in the year 2009 Finances cannot be ignored when discussing health unpaid caregivers provided services that had an eco- maintenance. Although Social Security, Medicare, and nomic value of $450 billion. Without the dedicated Medicaid offset some financial concerns, they do not help of all these individuals, the health care delivery cover the entire cost of health care prescriptions or system would be overwhelmed, and many older adults meals. The lack of these resources may cause older would experience a poorer quality of life. adults to limit medical care. Many older adults persist UNPAID CAREGIVER in trying to treat themselves before seeking medical Most unpaid caregivers are family or friends of the attention. They may try to stretch the time between older adult, although they may be volunteers from a medical visits or take less than the prescribed amount church or other charitable organizations. Caregivers of medications to conserve money. Financial con- can be divided into primary and secondary classifica- straints can also affect the ability of the older person tions. Primary caregivers provide for most of the day- to purchase special foods and equipment necessary to to-day needs of older adults. These are usually close promote or maintain health. family members, such as spouses or children, but they may be paid employees. Secondary caregivers help Finances can also affect safety. Many older adults intermittently with things like shopping, transporta- live in older housing, which is more likely to contain tion, and home maintenance. Usually, those family safety hazards, such as poor electric wiring, steep stair- members who reside closest to the older person provide wells, and inadequate lighting. High crime rates in the most direct assistance, whereas those who live poorer areas make older adults who live there particu- farther away are less involved. This can be a source larly vulnerable to rape, mugging, and theft. Even if of interfamily strife. One family member may be these factors are not a problem, simple home mainte- nance can increase the risk for injury. Because it is costly to hire people to do even routine home- maintenance chores, many older adults attempt these tasks alone. Some fall from chairs or ladders while trying to paint walls, clean windows, or hang pictures.","Health Promotion, Health Maintenance, and Home Health Considerations\u2003 CHAPTER 4\t 81 resentful of doing everything, while others do little or PAID CAREGIVERS nothing. Of course, this is not always the case; some Almost any kind of home help can be arranged, from families develop a good balance and distribution of the simplest to the most complex. Agencies that effort. Even family members who live at great dis- provide home health services have proliferated in tances from older relatives can provide high-level recent years. Many of these are highly ethical organi\u00ad long-distance support, usually through an intermedi- zations that provide valuable service to older adults. ary agency. Others are less scrupulous and may even increase the risks for a vulnerable older person. Informal refer- Most caregivers are women. They are of all ages, rals from friends, senior citizen centers, churches, with the average being in the mid to late forties. They or volunteer organizations may be helpful in locat- come from all ethnic, racial, and religious backgrounds. ing a reliable caregiver. Additional help with identi- Most are providing care to older adults in spite of fying qualified help can be obtained from the local multiple other responsibilities, including their chil- Area Agency on Aging offices, state or local social dren, homes, and jobs. Many caregivers experience service agencies, or tribal councils. Although some exhaustion, anxiety, and burnout as a result of multiple assistance may be provided free of charge by volun- demands, particularly when they feel that their assis- teer organizations and some may be covered by insur- tance is not appreciated. Often, they will require teach- ance or Medicare, the services of most independent ing, guidance, and assistance while learning how to contractors or private agencies require considerable perform new skills and effective ways to respond to out-of-pocket expense. It is wise to verify the cost of the needs of the older adult. This teaching needs to be services before making any commitments. Home care done in a kind and courteous manner. According to is usually less expensive than care in an institutional interviews with unpaid caregivers, overly judgmental setting, but this is not always the case. Much will nurses and other professionals made them feel inept, depend on the extent and complexity of the care inadequate, and anxious. Nurses should be careful not needed. Cost is always an issue, whether providers to denigrate the services or capabilities of these care- admit it or not. Even wealthy people need to be givers. Unpaid caregivers should not be criticized or cautious that they spend their money wisely; those made to feel guilty that they are not doing enough. with average incomes need to pay even more attention Instead, the nurse should work to develop a partner- to costs. ship with family caregivers including ongoing assess- ment, teaching, coaching, psychological support, and It is always wise to check references before hiring guidance. Nurses and other professionals need to be anyone to work with older adults. Because the care- kind to unpaid caregivers, to recognize the value of giver is often alone and unsupervised with the older their service, and to provide positive feedback. Box 4-3 adult, any signs of unscrupulous or abusive behavior lists agencies that provide assistance and information must be investigated. Ideally, paid caregivers will have to older caregivers. a history of punctuality and reliability because an older adult often becomes anxious if the caregiver is Box 4-3\u2003 Older Adult Information and Services unreliable. These caregivers should provide certifica- tion that they are free of communicable diseases, \u2022\t Administration on Aging (www.aoa.gov)\u2014202-619- including tuberculosis. A background check should be 0724 conducted to ensure that they have committed no serious criminal acts. Reputable home care agencies \u2022\t Eldercare Locator (www.eldercare.gov)\u2014800-677- often provide these checks as part of their service and 1161 may also bond their employees to protect the patient against loss because of thefts or property damage. It is \u2022\t Medicare benefits (www.medicare.gov) also advisable to plan an introductory visit and trial \u2022\t National Institute of Medicine (www.medlineplus.gov) sessions to determine the compatibility of the care- \u2022\t National Institute on Aging Information Center (www.\t giver and the older adult. Box 4-4 provides a list of important questions to ask when selecting a home nia.nih.gov)\u2014800-222-2225 health agency. \u2022\t National Council on Aging (www.benefitscheckup.org)\t TYPES OF HOME SERVICES \u2014202-479-1200 Older adults require different levels of home assis- \u2022\t Federal, state, or local government benefits (www.\t tance. The level of care needed is likely to change as the person\u2019s health\u2009status changes over time. An older govbenefits.gov)\u2014800-333-4636 adult who is generally healthy may require only trans- \u2022\t Department of Veterans Affairs (www.va.gov) portation to appointments and assistance with house- \u2022\t USA.gov (USA.gov\/Topics\/Seniors.shtml) hold chores, such as mopping, vacuuming, laundry, \u2022\t Department of Housing and Urban Development grocery shopping, and meal preparation, all consid- ered unskilled interventions. (www.hud.gov)\u2014202-708-1112 \u2022\t Low-Income Home Energy Assistance Program (www.\t liheap.org)\u2014202-429-8855 \u2022\t National Resource Center on Supportive Housing and Home Modification (www.homemods.org)\u2014213-740-\t 1364 \u2022\t LeadingAge (www.leadingage.org)\u2014202-783-2242","82\t UNIT II\u2003 Basic Skills for Gerontologic Nursing facilitate communication with other agencies or facili- ties, particularly if the patient needs to be admitted to Box 4-4\u2003 Questions to Ask When Selecting a Home a hospital or health care facility. Social workers also are Health Agency responsible for the assessment of family dynamics and possible intervention in suspected cases of neglect or \u2022\t How long has the agency been in business in this abuse. A chaplain may be part of the team; home community? hospice is likely to have chaplains available for end- of-life issues. In addition, the case manager may have \u2022\t What services does the agency provide? responsibility for arranging that all necessary equip- \u2022\t How much do these services cost? Is financial aid ment and supplies (such as oxygen, wheelchairs, and hospital beds) are available and remain in good oper- available? How are charges billed? ating condition. \u2022\t Is the agency certified by Medicare? Is it accredited NURSING PROCESS FOR INEFFECTIVE by any organization such as The Joint Commission Long Term Care accreditation program? \u2002 \u2022\t Does the agency have a Bill of Rights for older adults? \u2022\t Does the agency have a specific written plan of care HEALTH MAINTENANCE AND INEFFECTIVE for the older adult that is developed with patient and HEALTH MANAGEMENT family input? \u2022\t What kind of screening is done when hiring Older adults, who are unable to identify or seek out employees? Are references available to the family? help and those who are unable to follow through with \u2022\t How are caregivers trained and supervised? a therapeutic regimen, are at risk for serious health- \u2022\t What level of professional supervision is provided? related problems (Nursing Care Plan 4-1). Assessment \u2022\t Is there a registered nurse on-call 24 hours a day? of health perceptions and health maintenance practices \u2022\t How and when is information communicated between is necessary to take into account the unique problems, the agency and the family? beliefs, and perceptions of each aging person. It is \u2022\t What is done to protect confidentiality? important to assess both past and current health- \u2022\t How are conflicts or complaints resolved? management practices, because these are good predic- tors of future health practices. Modified from the U.S. Department of Health and Human Services ASSESSMENT\/DATA COLLECTION Administration on Aging Fact Sheet, \u201cHome Health Care: A Guide for Families.\u201d \u2002 An infirm older adult may need additional help \u2022\t How does the person rate his or her current with hygiene and dressing. Older adults with altered health? cognition may also need ongoing supervision for safety and help with medication preparation and \u2022\t Does the person feel in control of the conditions that administration. More compromised older adults may affect his or her health? require assistance with dressing changes, management of wounds, pain management, or other skilled inter- \u2022\t What does the person routinely do to maintain his ventions. Even end-of-life hospice care may be pro- or her health? vided in the home. \u2022\t How does the person manage illnesses? A thorough assessment by a trained professional, \u2022\t What are the person\u2019s religious or cultural beliefs usually a registered nurse (RN) or social worker, can best determine how much and what kind of help will regarding health and health practices? most benefit each older adult. Working in conjunction \u2022\t How do the person\u2019s health practices compare with with the patient\u2019s physician, the case manager (typi- cally an RN) will assess, plan, supervise, and coordi- recommended health practices? nate services. Services are best delivered by a team \u2022\t How often does the person see a physician, dentist, that includes RNs, licensed practical nurses (LPNs)\/ licensed vocational nurses (LVNs), health aides, house- or other health professional? keepers, dietitians, and social workers, as well as occu- \u2022\t Does the person undertake high-risk behaviors pational, physical, and speech therapists. Nursing supervision of unlicensed personnel is critical for safe such as smoking, excessive alcohol intake, or drug home care. Aides must have adequate training to consumption? perform safely in the care setting, and they need to \u2022\t Does the person have adequate financial resources know the limits within which they must work. For to maintain his or her health? example, aides are generally not permitted to measure \u2022\t Does the person have access to the goods and ser- and dispense medications, although they may be per- vices necessary to maintain health? mitted to give medications to the older adult if the \u2022\t Is the person\u2019s knowledge adequate to make nurse or a family member first sets these up in prela- informed decisions regarding his or her health? beled and timed packaging. Social workers help See Box 4-5 for a list of the characteristics of older manage the financial aspects of care, as well as adults who are at risk for alterations in health maintenance. NURSING DIAGNOSES \u2002 Ineffective health management Ineffective health maintenance"]