Transcript Chapter_048

Assisting in Geriatrics
Chapter 48
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
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Define, spell, and pronounce the terms listed
in the vocabulary.
Apply critical thinking skills in performing
patient assessment and care.
Discuss the impact of a growing aging
population on society.
Role-play the effect of sensorimotor changes
of aging.
Explain the changes caused by aging in each
of the body systems.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives
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Summarize the major diseases and
disorders faced by older patients.
Describe various screening tools for
dementia, depression, and malnutrition.
Explain the effect of aging on sleep.
Differentiate among independent, assisted,
and skilled nursing facilities.
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3
Learning Objectives
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Summarize the role of the medical assistant
in caring for aging patients.
Determine the principles for effective
communication with older adults.
Identify legal and ethical issues regarding
aging patients.
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4
Aging Population
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According to the Administration on Aging, the
aging population—those 65 years of age and
older—numbered almost 37.3 million in 2006.
The “oldest old” (people older than 85)
comprise the most rapidly growing age group.
It is projected that people older than 65 years
will represent 16% of the population in 2020
and increase to 20% by 2030.
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Older Population by Age, 1900–2030
From the U.S. Administration on Aging. Available at: www.aaa.gov.
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6
Aging Health Problems
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The most frequently occurring health
problems seen in the elderly:
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Hypertension, arthritis, heart disease, cancer, and
diabetes
Significant numbers also suffer from strokes,
asthma, emphysema, and chronic bronchitis
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7
Services for the Aging
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The aging process includes physical and
sensory changes in older people.
The healthcare professional recognizes the
special needs of the aged and develops
effective management and communication
skills for better service for the older client.
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Myths about Aging
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Senility inevitable
Disease unavoidable
Older workers less productive
Long-term care inevitable
No interest in or ability for sexual relations
Resistant to change
Cannot learn new things
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9
Critical Thinking Application
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When Bill first started working with aging
patients, he believed many of the stereotypes
regarding persons over the age of 65 years.
Since working with Dr. Kennedy, he realizes
that many of these myths have no foundation
in actual practice. Based on the myths
mentioned in the text, what do you think
about these beliefs on aging?
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Aging Changes
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Table 48-1 in your textbook summarizes the
changes in anatomy and physiology associated
with aging in all body systems.
Normal age-related changes can be expected
and compensated for, but these become more
serious in the presence of poor health habits
and chronic disease.
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11
Aging Changes
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General changes include:
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An increase in arteriosclerosis
An increase in time needed to learn new material
A sharp decline in estrogen for women and
increased risk of osteoporosis
An increase in malabsorption problems and
constipation
A decrease in muscle mass
Less elasticity in lungs and gradual stiffening of the
chest wall
A tendency to gain weight
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12
Aging Changes
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A deterioration of joint cartilage
Presbycusis and presbyopia
An enlargement of the prostate and weakened
bladder muscles
Impotence not a symptom of normal aging
Menopause causes vaginal narrowing and dryness
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13
Management of Changes
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Age-related changes can be managed through:
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Regular aerobic exercise and strength training
 Weight control
 A diet rich in fruits, vegetables, and whole grains
and low in fat
 Avoidance of sun damage to skin
 Pelvic muscle exercises
 Annual physical examinations with health screening
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14
Health Issues
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The major health issues for aging people are
related to an increase in atherosclerosis and
potential cardiovascular disease.
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Hypertension
 Type 2 diabetes mellitus
 Tendency to hyperthermia and hypothermia
 Seborrheic keratosis
 Arthritis
 Osteoporosis
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Increased risk of injury from falls
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15
Cardiovascular System and Aging
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Most frequent cause of death, illness, and
disability.
CHF most common reason for hospitalization.
Aging causes structural changes in the heart.
Heart rate decreases.
Heart has to work harder to circulate blood
through calcified vessels.
Increased incidence of orthostatic hypotension.
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16
Shingles Management
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Zostavax vaccine is available to reduce the risk of
shingles in people 60 years of age and older.
The varicella-zoster virus causes both shingles and
chickenpox; after an active chickenpox infection the
virus lies dormant in a nerve dermatome.
As people age, they are at risk of the virus
reactivating and causing the formation of shingles.
Administered as a single subcutaneous injection.
Recommended that all individuals over the age of
60 years receive the Zostavax vaccination.
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17
Endocrine System
Most common problem is diabetes type 2
 10% over age 60
 Causes increased risk for multiple health problems
 Patients display different symptoms because of
insidious onset—weight loss, slow wound healing,
recurrent infections, changes in mental state,
cataracts, macular disease, muscle weakness,
angina, foot ulcers, uremia
 Patient education is essential
 What teaching adaptations may be needed?
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Factors That Can Affect Diabetes
Management
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Modifying lifestyle risk factors may be more
difficult because of poor nutrition, inability to
exercise, and long-standing habits such as
smoking and diets high in fat and calories.
Previously diagnosed health conditions, such as
hypertension and heart disease, and age-related
declines in kidney and liver function increase the
challenge of treating diabetes.
Older people are more likely to be prescribed
multiple medications (polypharmacy), which
increases the risk of adverse drug interactions.
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19
Factors That Can Affect Diabetes
Management
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Elderly diabetics are more prone to hypoglycemia
and may not recognize and respond quickly to
the signs of low blood glucose levels.
Diabetic complications can develop quickly
because of a long history of prediabetes before
diagnosis.
Older people may have decreased physical
and/or mental abilities that make it difficult for
them to understand and adhere to a complicated
treatment regimen.
Older patients may not be able to afford the
medications and supplies needed to maintain
health.
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20
Gastrointestinal System
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Decrease in HCl affects digestion of calcium and iron
Decrease in intrinsic factor causes fatigue
Increased rate of passage through small intestine
causes poor absorption of vitamins and minerals
Poor eating habits, reduced fluid intake, and some
medications contribute to constipation
Liver size decreases in size and weight after age
70 years
Increase in the incidence of GI diseases such as
GERD, peptic ulcers, diverticulosis, cholelithiasis,
and colorectal cancer
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Integumentary System
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Age-related changes and sun exposure combine to
cause changes in appearance and function.
Terms: seborrheic keratosis and alopecia.
Epidermis reproduces more slowly, so skin appears
thinner, tends to tear; increased bruising, infections.
Why is there decreased vitamin D synthesis and
increased photosensitivity?
Dermis loses 20% of mass:
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Vascular supply and SC layer decrease
 Hypothermia and hyperthermia
 Increased pain tolerance
 How can the elderly prevent and treat dry skin?
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Treating/Preventing Dry Skin
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A room humidifier to moisten the air
Bathe less frequently, using warm rather than
hot water
Use a mild soap or cleansing cream such as
Aveeno, Basis, or Dove
Wear protective clothing in cold weather
Moisturize dry skin
Creams and moisturizers should be applied
after getting out of the bathtub or shower to
decrease the possibility of falls
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Musculoskeletal System
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Muscular changes related to activity level.
How can the MA help prevent falls?
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Why are aging people at greater risk for injuries
from falls?
Osteoporosis causes hip and vertebral
fractures.
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What are common risk factors?
What are methods of prevention and treatment?
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Helping Patients with Musculoskeletal
Conditions
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Use assistive devices
Assist with gripping as needed
Older adults may need more time to complete
tasks but prefer to do so independently, so slow
down.
Stroke victims should be supported on the
weak side when walking or transferring from
chair to examination table.
Physician may recommend physical therapy for
range-of-motion exercises.
Encourage activity
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Osteoporosis Risk Factors
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Female (women have a five times greater risk
than men)
Small-boned frame, thin
Family history of osteoporosis
Estrogen deficiency before age 45 years
Racial background—white and Asian women at
highest risk
Aging
Anticonvulsant drugs, prednisone, and thyroid
hormone medications
Sedentary lifestyle, smoking, excessive alcohol
intake, lack of calcium and vitamin D
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26
Preventing Falls
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Hearing and vision testing to be aware of possible
dangers
Understand the side effects of medications
With orthostatic hypotension, rise slowly and stand still for
a moment
Limit alcohol
Consistently use assistive devices
Wear low-heeled, rubber-soled shoes with good support
Avoid going outside in icy weather
Engage in regular weight-bearing exercise
Keep hallways, stairs, and bathrooms well lit
Assess home for possible danger areas; remove throw
rugs; use handrails on steps and grab bars in bathrooms;
keep emergency numbers handy
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Critical Thinking Application
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The family of a 73-year-old patient,
Mrs. Rita Schaeffer, is concerned about the
risk of falls. Mrs. Schaeffer was recently
diagnosed with osteoporosis and lives alone.
What information should Bill give the family
to help them prevent accidents in their
mother’s home? Her 43-year-old daughter is
concerned about developing osteoporosis as
well. What methods should the daughter
employ to prevent the disease?
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28
Nervous System
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What affects cognitive ability?
Is dementia inevitable?
What can cause signs and symptoms of
dementia?
What is the best method for maintaining mental
function?
What are risk factors for cognitive decline?
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29
Signs and Symptoms of Alzheimer’s
Disease
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Repeatedly asking the same questions
Unable to remember common words or
mixing words up when describing something
Unable to complete simple tasks and
misplacing items
Getting lost when driving familiar routes
Sudden mood swings for no apparent reason
Difficulty following simple directions
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Alzheimer’s Disease
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Progressive deterioration of the brain because of
amyloid plaques and neurofibrillary tangles
First rule out other organic causes
What medications are used for treatment?
Stages:
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First—2–4 years before diagnosis; memory loss, confusion,
disorientation, withdrawal
Second—2–10 years after diagnosis; increased symptoms,
restless, repetitive statements, mood changes, motor
problems.
Third—lasts 1–3 years; weight loss, does not recognize family,
incontinent, requires complete care
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Critical Thinking Application
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Maria Angelone is an 86-year-old patient of
Dr. Kennedy who is in the second stage of
AD. Her husband and children are showing
signs of stress from the continuous care
required by Mrs. Angelone. Her family still
does not understand what is happening to her
and what to expect in the future. What
information can Bill share with them about the
disease, and what resources could be helpful
to the family in dealing with the stress of
caring for a loved one with dementia?
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32
Pulmonary System
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Maximum lung function decreases with age
Lungs lose elasticity; alveoli enlarge; number of
capillaries is reduced
Ribs and vertebrae stiffen; respiratory muscles
weaken making it harder to cough deeply enough to
clear mucus from lungs
Sleep apnea and sleep disorders increase
All of these factors combine to put older adults at
greater risk for pneumonia and aspiration as well as
reactivation of TB
Larynx changes cause a change in the pitch and
quality of the voice
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33
Vision Changes
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Presbyopia
Cataracts
Decreased lacrimation
Glaucoma
Macular degeneration
Color blindness
Decreased depth perception
Nyctalopia
Need six times as much light and have difficulty
with glare
How can the MA help?
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34
Assisting Visually Impaired Patients
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When escorting an older person allow the client to
place his or her hand above your elbow.
Use high levels of evenly distributed glare-free light.
Ask the pharmacist to use large lettering when
labeling medicine bottles.
Use paper that has a nonglare finish, and use large
print for forms.
Make distinct differences (e.g., size of containers or
color-coding with bright primary colors) for pills that
are similar in size and color.
Place all objects within the visual field and avoid
clutter.
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35
Hearing Changes
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Presbycusis and depression
Tinnitus
How can the MA interact effectively with a
hearing-impaired aging person?
What type of questions are asked in the
Geriatric Depression Scale?
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36
Assisting Hearing-Impaired Patients
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Stand in the patient’s direct line of vision and
gently touch the person to get attention.
Use gestures, pictures, and large, bold print.
Talk in short sentences into the ear with
better hearing.
Do not increase the volume of your speech.
Use expanded speech—lower the tone of
your voice and talk in distinct syllables.
Avoid background noise.
Check to see if hearing aid is on.
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37
Nutritional Status
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Comprehensive interview should consider:
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Oral health
 GI complaints
 Sensorimotor changes
 Financial considerations
 Disease-related diet restrictions
 Alcohol consumption
 Depression
 Support systems
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38
Urinary System
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Decreased blood flow and decreased number of
nephrons cause kidneys to be less efficient at
filtering waste from blood
Structural changes in the bladder lead to
increased frequency of urination and urinary
retention
Changes in the urinary system make older
persons more vulnerable to incontinence, but
factors such as infection, confusion, difficulty with
mobility, and side effects from medications
contribute to the development of the problem
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39
Additional System Issues
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Pneumonia, aspiration, and reactivation of
tuberculosis
Malnutrition
Increased urinary tract infections, incontinence,
and prostate enlargement
Menopausal changes in the vaginal mucosa
Sleep disorders such as apnea and periodic limb
movement disorder (PLMD)
Impact of medications on general health
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40
MMSE
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A commonly used screening tool for dementia
is the Folstein Mini Mental Status Exam
It is a 5-minute screening test to evaluate basic
mental function in the patient’s ability to recall
facts, to write, and to calculate numbers, to
determine if more in-depth testing is needed.
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41
Depression
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To screen for depression the physician may
use the Geriatric Depression Scale short form
that questions the patient about daily activities,
interests, and feelings.
Nutritional status can be assessed through a
comprehensive patient interview that considers
all potential barriers to adequate nutrition.
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42
Nutritional Status
The nutritional status of older patients involves:
 Oral health
 Gastrointestinal (GI) complaints
 Sensorimotor changes
 Diet influences
 Social and mental influences
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43
Sleep Problems
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Complaints of sleeping difficulties increase
with age.
Sleeping time may be slightly longer, but the
quality of sleep decreases.
Older people are often light sleepers and have
periods of wakefulness in bed.
Other factors influencing sleep patterns are
medications, caffeine, alcohol, depression, and
environmental or physical changes.
Common sleep problems in older adults include
PLMD and sleep apnea.
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44
Caregivers
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Aging persons prefer to remain in their homes
as long as possible.
Adult day care centers can provide supervision
for older adults who are taken care of by family
members in the evening. They also provide
respite for a caregiver.
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45
Assisted Living
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Assisted-living facilities are appropriate for
older adults who need assistance with some
activities of daily living, such as bathing,
dressing, and walking.
Skilled nursing facilities provide 24-hour
medical care and supervision.
In addition to medical care, residents receive
physical, personal, occupational, and speech
therapy.
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46
Medical Assistant’s Role
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Develop effective communication skills
reflective of age-related sensorimotor changes.
For independence to be reinforced, aging
patients require more time and should be
scheduled for longer appointments.
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47
Elder Care Considerations
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Provide adequate lighting in the waiting room,
with forms in large print
Make certain the examination room is
equipped with furniture, magazines, and
treatment folders especially designed for the
elderly patient
Have a professional in the management of the
elderly patient provide in-service training to
improve the quality of elder care.
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48
Therapeutic Communication
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Ask the patient directly what is wrong rather than
discussing the patient with family members.
Give the patient your full attention rather than
continuing with multiple tasks while he or she is
speaking.
Older people may take a little longer to process
information, but they are capable of
understanding.
Do not hurry through explanations or questions,
but take time to review a form or give
instructions.
Use referrals and community resources for
patient and family support.
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49
Therapeutic Communication
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Address the patient with an appropriate title.
Introduce yourself and explain the purpose of a
procedure before touching the patient.
Establish eye contact and get the patient’s
attention before beginning to speak.
Use expanded speech, gestures,
demonstrations, or written instructions in block
print.
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50
Therapeutic Communication
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Repeat the message as needed for
understanding.
Observe the patient’s nonverbal behaviors as
cues to indicate if he or she understands.
Allow time to process information.
Avoid distractions.
Involve family members as needed.
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51
Advance Directives
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Provide written instructions specifying the type of
medical care a person wishes to receive in the
event she or he becomes incapacitated
Designates someone as durable power of
attorney—an authorization for making medical
decisions if that individual is unable to make his or
her own treatment decisions
Provides a list of specific instructions for a proxy to
follow – DNR orders; use of life-sustaining
treatments
Copy should be included in patient’s medical
record
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52
Identifying Elder Abuse
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Poor general appearance and poor hygiene
Pattern of changing doctors and frequent
emergency room visits
Skin lesions, signs of dehydration, bruises
(signs of new and old bruising together),
abrasions, welts, burns, or pressure sores
Recurrent injuries caused by accidents
Signs of malnutrition and weight loss without
related illness
Any injury that does not fit the given history
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