Transcript Chapter 6: Review of the Aging of Physiological Systems

Bonnie M. Wivell, MS, RN, CNS
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Heart chambers enlarge
Thickening of heart walls
◦ Especially left ventricle
◦ Decreased flexibility
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Increase in heart weight
Myocardial cells enlarge
◦ Men- decreased number of myocardial cells
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Heart muscle loses efficiency
Reduced cardiac output under physiologic
stressors
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Arteries
◦ Dilate and stiffen
◦ Reduced elasticity
◦ Atherosclerosis
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Increased peripheral resistance
◦ Hypertension
◦ Positional hypotension
 Decreased stimulation of the baroreceptors leads to
impaired sympathetic nerve response and resistance
in peripheral vessels
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Heart Valves
◦ Calcium deposits accrue leading to stenosis
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Murmurs
◦ Asymptomatic
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Blood Pressure
◦ Systolic ↑
◦ Diastolic ↓
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Pulse
◦ At rest vs. activity
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Alveoli
◦ Flatter, shallow, decreased surface area
◦ Decreased number of capillaries per alveolus
◦ Impaired passage of oxygen from alveoli to the
blood
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Lung
◦ Decreased elastic recoil
◦ Total lung capacity (total vol lungs can expand
during inspiration) remains unchanged
◦ Vital capacity (max amt of air expelled with
exhalation) decreases
◦ Lower lobes have lesser air flow hence decrease gas
exchange
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Chest wall
◦ Stiffer reducing the ability to expand and contract
◦ Loss of rib elasticity – calcification of cartilage
◦ Kyphosis, arthritis of costavertebral joints and
increased rigidity of the thoracic cavity
 Increased anteroposterior diameter
 Flattening of the diaphragm
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Respiratory Infection
◦ 25% of all deaths >85 years
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Chronic Obstructive Pulmonary Disease
◦ Chronic bronchitis, chronic obstructive bronchitis,
emphysema
◦ Environmental irritants cause increased mucous
◦ Alveoli always inflated become fibrous
◦ Excessive cardiac workload as heart tries to
compensate
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Pneumonia
◦ Lung inflammation secondary to infection
◦ Pneumococcal
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Mouth
◦ Teeth less sensitive and more brittle
 Loss is not a normal part of aging
 Dentures
◦ Difficult to chew with no teeth and atrophy of
muscles and jaw bones
◦ Salivary glands
 Same amount as young
 Dry mouth secondary to medication
◦ Less acute taste sensation
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Increased risk for aspiration, indigestion,
constipation
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Esophagus & Pharynx
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Normal until 80 years of age
Stiffening
Absent gag reflex in 40% of healthy older adults
Dysphagia
Reflux/Heartburn – longer duration of episodes
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Stomach
◦ Gastric acid changes
 Decline in gastric defense mechanisms
 Increased potential for mucosal injury
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Small intestines
◦ Decreased acid production and motility
disturbances can lead to bacterial overgrowth
causing malabsorption and malnutrition
◦ Vit A ↑
◦ Vitamin D, calcium, zinc ↓
◦ B1, B12, C, Iron unchanged
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Large Intestine
◦ Medications can affect motility
◦ Endocrine and neurological changes affect motility
 Large intestine loses nerve connections in the smooth
muscle of the colon, increasing colonic transit time
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Liver
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Gallbladder
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Pancreas
◦ Decreased size and blood flow
◦ Drug clearance can be affected but highly variable
◦ Slower emptying rate so less bile secreted when food is
digested
◦ Increased bile volume can lead to gallstones
◦ Decreases in weight
◦ Some histological changes such as fibrosis and cell
atrophy
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Kidneys
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Shrink in length and weight
Decreased glomeruli by 30-40%
Size and number of nephrons decrease
Decreased renal blood flow
Glomerular filtration rate decreased
 Disease, medications can make this worse
 Elimination of waste and toxins declines
 Accumulation of harmful substances such as uric acid
and meds in the body
 Impaired sodium regulation can occur
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Bladder
◦ Reduced capacity due to decreased size
◦ Develops fibrous matter in wall reducing stretching
capacity and contractility
◦ Decreased filling capacity
◦ Ability to withhold voiding declines
◦ Increased incidence of detrusor overactivity
◦ Urinary frequency, urgency, nocturia
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Incontinence is not a normal part of aging
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Overall atrophy, including external structures
Uterus tips backwards
Vagina becomes shorter and narrower
Loss of mucosal layers, decreased lubrication
pH increases, more alkaline
◦ More infection, vaginitis
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Menopause
◦ Estrogen depletion
◦ Average of 51 years (45-55 yo)
◦ Hot flashes, mood disturbance, weight gain, vaginal
dryness, bladder infections, loss of sex drive, fatigue,
insomnia, cognitive decline, hair loss, backaches, joint
pain
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Pelvic muscles atrophy causing decreased
support of pelvic organs
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Reduction in testosterone and sperm count
Erectile dysfunction
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Increased amount of time to achieve erection
Need more stimulation to maintain the erection
Less intense orgasms and ejaculation
Decreased ejaculatory volume
Longer refractory period
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Prostate around urethra at base of bladder
Enlargement
Urinary retention
Increased frequency, discomfort with urination, bladder
and kidney infections, erectile and ejaculatory
dysfunction
Benign prostatic hyperplasia (BPH)
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Androgen deficiency; occurs gradually and doesn’t
occur in all males
Low libido
Decreased energy, strength, and stamina
Increased irritability
Cognitive changes
ED
Osteopenia/osteoporosis
Breast enlargement
Decreased muscle mass
Shrinkage of testes
Increased fat deposition
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Decreased size and weight of brain
◦ Ventricle size increases
◦ Loss of neurons
◦ Increased subdural space – risk of chronic
hematoma
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Personality remains consistent with that of
earlier years in the absence of disease
Learning ability/attention span/memory
changes
◦ Acetylcholine decreases
◦ Loss of acetylcholine pronounced in Alzheimer’s
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Motor dysfunction due to decreased dopamine
receptors
◦ Parkinson’s
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Sleep changes/depression
◦ Norepinephrine and serotonin decreases
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Decreased cerebral blood flow
Plaques and tangles are hallmarks of Alzheimer’s
disease
Spine
◦ Narrowing
◦ Changes in sensation
◦ Degenerative disease
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Thyroid
◦ Decreased activity
◦ Decreased metabolic rate
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Pineal gland
◦ Decreased melatonin
◦ Sleep patterns
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Glucose Intolerance
◦ Decreased tissue sensitivity to circulating insulin
◦ Delayed and insufficient release of insulin
◦ Reduced ability to metabolize glucose
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Sarcopenia: reduction in muscle mass
◦ Functional disability and frailty
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Osteoarthritis
◦ Most common, affects weight bearing joints from years
of wear, loss of cartilage, increased bone matrix,
decreased joint mobility
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Rheumatoid arthritis
◦ Immune
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Osteoporosis
◦ Reduction in bone quantity and strength
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Tendons shrink and harden
Increased risk of fractures
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Touch
◦ Mechanoreceptors
◦ Inability to acknowledge that an object is touching
or applying pressure to the skin
◦ Decrease in ability to identify where the touch or
pressure is occurring
◦ Inability to distinguish how many objects are
touching the skin
◦ Decreased ability to identify objects just by touch
◦ Proprioception
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Safety issues?
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Smell
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Decreased ability to smell
Decreased odor detection
Inability to identify smells
Affects sense of taste
Safety issues?
Affects on life?
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Taste
◦ Chemoreceptors
◦ Hypogeusia = decrease in taste
◦ Medication, smoking, disease, infections, poor oral
health
◦ Food poisoning and malnutrition of concern
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Safety issues?
Affects on life?
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Vision
Presbyopia
Narrowing of visual field
Impaired color discrimination (blue/yellow)
Decreased night vision
Diseases, not normal aging process
◦ Cataracts, glaucoma, macular degeneration,
diabetic retinopathy
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Safety issues?
Affects on life?
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Hearing
Presbycusis
◦ Age related hearing loss
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Most common of all sensory deficits
Safety issues?
Affects on life?
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Decreased elasticity
Thinning
Increased dryness
Fragile
Wrinkles
Decreased blood flow
◦ Cooler skin
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Subcutaneous layer increases around hips
and belly
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Hair
◦ Thinning, loss, gray
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Nails
◦ Slower growth, thinner, more brittle
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Glands
◦ Decreased sweating
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Safety issues?
Affects on life?
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Depressed immune response
T-cell activity declines
◦ Fewer naïve T-cells so respond slower to new
antigens
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Increased potential for infection
Reactivation of dormant viruses
◦ Varicella zoster, mycobacterium tuberculosis
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Vaccinations good for this age but body
responds slower
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No significant changes with ages, unless
disease mediated
Hct and Hgb unchanged
Anemia
◦ Due to other disease processes, medications
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Lower normal body temperature
◦ 96.9 degrees F - 98.9 degrees F
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Reduced ability to respond to cold
temperatures
Differences in response to heat
Bonnie M. Wivell, MS, RN, CNS
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Activities of Daily Living
◦ Katz – distinguished between independence and
dependence in certain skills
◦ Barthel Index – measures functional levels of selfcare and mobility
◦ Refined ADL Assessment Scale – task
segmentation
◦ Functional Independence measure (FIM) – used in
rehab
◦ Eating, dressing, bathing/washing, grooming,
walking/ambulation, ascending/descending
stairs, communication, transferring, toileting
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IADLs: more complex than ADL
◦ Lawton and Brody in 1969
◦ Telephone, taking medications, shopping,
finances, preparing meals, laundry,
housekeeping, yardwork, home maintenance,
transportation, recreation
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Family and patient history
Chest pain
Medications (include OTC and herbs)
Sources of stress
Vital signs
Heart sounds
Other tests prn: CBC, Lytes, ECG, Echo,
Exercise stress test
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Family and patient history
Shortness of breath – describe
Medications
History of smoking
Air pollutant exposure
Coughing
Energy level
Sitting up at night to help breathing
Check lung sounds, posture
Possible tests: sputum, lung function, chest
x-ray
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History
Oral cavity
◦ own teeth
◦ hygiene
◦ dentures well-fitting
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Diet
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Appetite
◦ Appetite, vomiting, stomach pain, changes in
stooling
◦ Decreased body weight
◦ Risk for injury, less energy, psychological
changes
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Nausea, vomiting, indigestion
◦ note that c/o indigestion unrelieved by antacids
may indicate heart-related problems in older
adults
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Usual bowel patterns
◦ Constipation (check fluids, activity, positioning,
timing, meds)
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Medications
Possible tests: barium enema, GI series,
stool specimens, sigmoidoscopy,
colonoscopy
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History
Pre-existing diseases such as diabetes or
hypertension associated with renal failure
UA
Incontinence
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Type: stress, urge, functional, overfow
Frequency
Nocturia
Voluntary flow
Use of pads
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History
Significant other, Spouse, Partner, Widowed
Number of children
Present problems
Changes in function
Erectile dysfunction (males) or dyspareunia
(females)
Chronic illnesses
Medications that can interfere with sexual
function or libido
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Patient and family history
History of seizures
Medications
Reflexes
Balance
Sleep patterns
Cognition
Communication
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Speech
Memory
Energy level
Motor and sensory function
Neuro checks
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Vital signs
PERRLA
Grip strength
Orientation
Cranial Nerves
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Patient and family history
ROM
Daily activities
Signs of arthritis
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Pain
Joints affected
Inhibits daily activities
Medications used
Other pain relief methods used and their
effectiveness
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Posture
Devices for mobility
Postmenopausal
◦ Risk for osteoporosis
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The Up and Go Test
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Five senses
Vision
◦ Presbyopia
◦ Signs of common problems
 macular degeneration
 cataracts
 glaucoma
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Hearing
◦ History of recent hearing loss
 presbycusis
 cerumen impaction
 foreign body
◦ Hearing aids used
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Taste
Smell
◦ Taste and smell connected
◦ Ask about satisfaction with how things smell and
taste
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Touch
◦ Any changes in sensation
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Patient and family history
Present skin conditions/complaints
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Rashes
Itching
Dryness
Breakdown
 Braden risk assessment scale (pg. 501-502)
◦ Bruising
◦ Skin tears
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Nutrition
Weight
Circulation
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Color
Hydration
Circulation
Intactness
Wounds
Also check hair and nails
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Brittleness
Dryness
Thickness
Texture
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Patient or family history of disease
◦ Esp. diabetes and thyroid problems
Changes in weight and appetite
Fatigue
Vision problems
Slow wound healing
Gastrointestinal problems
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Signs of diabetes
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Signs of hypothyroidism
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Diagnostic tests as needed
◦ Polyphagia, polydipsia and polyuria
◦ Skin changes, sensitivity to cold, fatigue, weight
gain, constipation
◦ Glucose testing, thyroid screening and/or panel
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Check for signs of anemia
◦ Esp. iron deficiency – skin color, food choices
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Lab tests: CBC, Hct, HGB
History of infection
Takes vaccines for flu or pneumonia
HIV/AIDS – sexual assessment
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Attention, memory, language, visual-spatial
skills, orientation
◦ Mini Mental State Examination (MMSE)
◦ Mini-Cog: 3 item recall and clock drawing
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Signs of dementia
Social abilities
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Giving and receiving attention
Participating in conversation
Appreciating humor
Helping others
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Quality of life
◦ Attitude, beliefs, and feelings about aging and
mental health
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Depression
◦ Geriatric Depression Scale (pg. 250)
◦ Persistence of symptoms
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Social support
◦ Family, friends, neighbours, church
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Living arrangements
Resources
Insurance
Finances
Independence and need for assistance
Potential for isolation
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Spirituality
Religion
Worship practices
Religious artefacts
Spiritual leader/advisor
Check for signs of spiritual distress
Ten Principles of Comprehensive Assessment:
1. The cornerstone of an individualized plan
of care for an older adult is a
comprehensive assessment.
2. Comprehensive assessment takes into
account age-related changes, ageassociated diseases, heredity and lifestyle.
3. Nurses are members of the health care
team, contributing to and drawing from
the health team to enhance the
assessment process.
4. Comprehensive assessment is not a
neutral process.
5. Ideally, the older adult is the best source of
information to assess his or her health. When
this is not possible, family members or
caregivers are acceptable and secondary
sources of information. When the older adult
cannot self-report, physical performance
measures may provide additional information.
6. Comprehensive assessment should first
emphasize “ability” and second, should
address disability. Appropriate interventions
to maintain and enhance ability, and to
improve or compensate for disability should
follow from a comprehensive assessment.
7. Task performance and task capacity are
two difference perspectives. Some
assessment tools ask “Do you dress
without help?’ (performance) while others
ask, “Can you dress without help?”
(capacity). Asking about capacity will
result in answers that emphasize ability.
8. Assessment of older adults who have
cognitive limitations may require “task
segmentation” or the breaking down of
tasks into smaller steps.
9. Some assessment tools or parts of
assessment tools may be more or less
applicable depending on the setting, that is,
community, acute care or long-term care
settings.
10. In comprehensive assessment, it is important
to explore the meaning and implications of
health status from the older adult’s
perspective. For example, the same changes
in visual acuity for two older adults may have
quite different meanings and implications for
everyday life.