Transcript older adult 2016 (3)

CARE OF THE OLDER ADULT
CHARISSE REED, MSN, RN
Demographics
 People aged 65 years and older
 12.9% of the U.S. population
 Number of Older Adults increased
due to:
Improvements in Health Care
Living Longer
Baby Boomers (born 1946-1964)

Baby Boomers. Retrieved from: http://www.birdsonggregory.com/wordpress/wp-cbycontent/uploads/2014/11/baby_boomers.jpg
COMMON MYTHS & STEREOTYPES
• Older adults are ill, disabled, physically
unattractive, and not interested in sex
• They are forgetful and unable to understand
and learn new information
• Older adults live below the poverty level & are
institutionalized
• Myths & stereotypes lead to the undervaluing
of older adults
Developmental Tasks
• According to Erickson- “Ego Integrity vs
Despair”
• Older adults often engage in a retrospective
appraisal of their lives and see it as a
meaningful whole or experience regret of
goals not achieved
• No two individuals age in the same way
Developmental Tasks (con’t)
• Adaptation & adjustment can be easy for
some but other need the assistance of family,
friends, and health care professionals
• Nurses should be sensitive to the effect a loss
can have on an older adult and offer support
Physiological Changes
• Skin- Integumentary System
1. Thinning of all 3 layers of the skin
2. Drier skin because the decreased number of
sebaceous glands results in reduced oil
production
3. Less efficient thermoregulation of heat because
of fewer sweat glands
4. Reduced sensory input, decreased elasticity
Physiological Changes (con’t)
• Interventions for skin-integumentary system
1. Avoid excessive use of soap
2. Skin evaluation & lubrication are necessary to
prevent breakdown
3. Avoid direct application of extreme heat & cold
4. Avoid extreme temperatures, proper clothing,
etc.
5. Proper positioning and prevention of pressure
ulcers
Physiological Changes (con’t)
• Head and Neck
1. Facial features appear asymmetrical because of
missing teeth or improper fitting dentures
2. Visual acuity decrease with age
3. Presbyopia (farsightedness) due to decreased
visual accommodation from loss of lens elasticity
4. Decreased color discrimination, blues & greens
hard to see (due to yellowing of the lens)
5. Decreased tears
Physiological Changes
• Head & neck (Con’t)
6. More light is needed for reading
7. Hearing loss is often compensated by increasing
TV and radio volumes
8. Hearing loss is a combined problem. Majority of
loss due to auditory nerve changes or
deterioration of the structures of the ear.
9. Taste buds and sense of smell decreases
Physiological Changes (con’t)
• Interventions for head & neck
1. Encourage eye exams
2. Encourage the use of hearing aids, if they have
them
3. Eliminate unnecessary background noise
4. Face the older client & speak in a clear, low tone.
Do not yell.
5. Use short simple sentences
Physiological changes: Thorax/ Lungs
 Diameter of the thorax increases.
 OP causes changes in vertebral column
= kyphosis (hunchback)
 Stiffening of chest wall
 Distant breath sounds

Kyphosis. Retrieved from https://depts.washington.edu/bonebio/ASBMRed/diseases/op/kyphosis.jpg
Interventions for thorax/lungs
 Turn patients Q2H
- Decreases secretion build-up.
 Elevate the HOB to 30 degrees
-promotes drainage of secretions.
 Assess breath sounds and O2 Saturation.
 Give O2 at 2L BNC as ordered to promote oxygenation.

Elevated HOB. Retrieved from http://emupdates.com/wp-content/uploads/2011/08/credit-http___goo.gl_yn2pq.jpg
Physiological Changes: cardiovascular
system
 Decreased contractile strength
 Decreased cardiac output
 Thickening and rigidity of blood vessels
 Elevated Blood Pressure
 HTN leads to:
-stroke, heart failure, renal failure, CAD, and PAD.
 Weaker peripheral pulses, but should be
palpable

Hypertension. Retrieved from http://www.drugs.com/health-guide/images/205006.jpg
Interventions : cardiovascular system
 Minimize physical exertion, anxiety, and
prolonged inactivity
 Protect from decreases in circulation.
 Protect feet from injury and provide foot care.
 Assess BP; monitor for orthostatic hypotension
-(fall prevention)
 Instruct patients to change positions slowly.

Orthostatic hypotension. Retrieved from hypotensionclinic.blogspot.com
Physiological changes: GI system
 Alterations in gastric secretions
 Delayed gastric emptying= discomfort
 Decreased appetite/ food intolerance
 Depletion of protein
 Constipation
 Fatty tissue increases with age
 Peristalsis is slowed

Constipation. Retrieved from http://ehealthzine.com/wp-content/uploads/2011/12/large-intense-works1.jpg
Interventions: GI System
 Encourage regular exercise/
mobility
 Appropriate fiber intake
 Do not ignore urges to defecate.
 Nutritional assessment with
patient specific interventions
 Encourage po fluids, especially
water


High fiber diet. Retrieved from www.healthtap.com
Hydration. Retrieved from http://www.easyhealthtips.org/wp-content/uploads/2014/07/man-drinking-water.jpg
Physiological Changes (con’t)
•
Reproductive System
1. Structural & functional changes occur as a result
of hormonal alterations
2. In women, menopause leads to decreases in the
size of the ovaries, and hormone production.
This results in uterine involution, vaginal
atrophy, & loss of breast mass
3. In men, testosterone production & secretion
decrease with age and sperm count. Cessation
of fertility is not definite with aging.
Physiological Changes (con’t)
• Interventions for reproductive system
1. Refer to physician for hormonal replacements
and prescription meds
Physiological Changes (con’t)
•
Urinary System
1. Hypertrophy of the prostate develops in men
causing urinary retention, frequency,
incontinence and UTI’s.
2. Decreased muscle tone contributes to
incontinence & incomplete emptying of the
bladder
3. Bladder capacity decreases
Interventions: Urinary System
 Assist older adults to toilet to immediately when
they ask to void.
 Monitor and record accurate I & O.
 Developing a voiding schedule may help.
 Bladder training
 Use of external catheters, medications, protective
pants


Bedside Commode. Retrieved from http://www.galaxymedical.net/images/bedside-commode.jpg
Incontinence briefs. Retrieved from http://www.biorelief.com/media/catalog/product/cache/1/thumbnail/9df78eab33525d08d6e5fb8d27136e95/a/t/attends_shaped_front.jpg
Condom cathether. Retrieved from Http: //www.tsmmedical.com
Physiological Changes:
Musculoskeletal System
1. Decrease in muscle tone and strength with age
2. Decrease bone density, less so in men than
women
3. Osteoporosis major threat to older adults
4. Arthritis, gait and balance disorders
5. Impairments: hemiparesis, ataxia, spasticity,
coordination or balance problems
Interventions: Musculoskeletal System
 Encourage daily exercises
(weight-bearing, if possible)
 Encourage increased intake of
Calcium/ Vit. D
- Vitamin D tablets
- Oyster Shell Calcium, Oscal
 Encourage walking aids for safety.
-Rolling walker, walker, gait belt, etc.
 Goal: Fall Prevention

Gait belt. Retrieved from http://registrations.dhs.state.mn.us/PCACourse/Module_04/images/Transfer_Belt.jpg
Physiological Changes: Neurological
System
1. Gradual loss in the number of neurons with age,
but no major change in neurotransmitter levels
2. All voluntary reflexes are slower
Interventions: Neurological System
1. Adapt to their pace
2. Allow more time to complete task, eating,
bathing, dressing, learning a new skill
Psychosocial changes: cognition
 Cognitive Changes include:
-Disorientation
-Poor Judgment
-Loss of Language Skills
-These symptoms are NOT normal
 3 Common Conditions That Affect Cognition
- Delirium
- Dementia
- Depression
-
Depression. Retrieved from http://blogs.psychcentral.com/depression/files/2012/04/depressedsenior_crpd.jpg
Cognitive changes: Delirium
 State that causes confusion:
-Acute (reversible)
-Chronic (irreversible)
 Causes:
-
Hypoglycemia
Medications
Electrolyte imbalances
Tumors
Infections
Cerebral Anoxia
 Onset of delirium requires prompt assessment and intervention

Confusion. Retrieved from http://feedyoursoul.com/wp-content/uploads/2014/08/confused.jpg
Terms related to Delirium
• Hyperkinetic: most common including
psychomotor hyperactivity, excitability, and
hallucinations
• Hypokinetic: characterized by lethargy,
sleepiness and decreased psychomotor activity;
the quiet patient who often goes undiagnosed
• Mixed variant: fluctuating between these two
states
Delirium Signs and Symptoms
Symptoms
Characteristics
Interventions
Disorganized thinking
Speech, rambling, incoherent,
pressured
Continual assessment of cognitive
status
Easily distracted
Cannot focus on topic
Redirect
Disoriented
Time and place—rarely to person;
recent memory impaired
Reorient as needed
Impaired reasoning
Goal directed behavior impaired
Short concise instructions
Misperceptions of environment
Hallucinations or illusions
Adequate lighting
Level of consciousness affected
Sleep/wake cycle disturbed;
fluctuates between hypersomnolence (daytime) and
insomnia (nighttime); vivid dreams
and nightmares
Functional assessment (eyewear,
hearing aids, usual activity level)
Restore a normal sleep cycle
(medications, activity, etc.)
Psychomotor
Agitated, not purposeful: restless,
hyperactivity, striking out at
nonexistent objects, vegetative
state resembling catatonic stupor
Line of sight, guardrails, low beds
Delirium Signs and Symptoms (con’t)
Symptoms
Characteristics
Interventions
Emotional lability
Crying, cursing, muttering,
moaning, fear, aggression
Expression of feelings
Autonomic manifestations
Tachycardia, sweating,
facial flushing, dilated
pupils, increased BP
Medications
Cognitive Changes: Dementia
 Impairment of intellectual functioning
 Interferes with social/occupational
functioning
 Gradual inability to perform ADLs
 Gradual, progressive disease that is
irreversible

Dementia. Retrieved from http://www.centerforbrain.com/wp-content/uploads/2014/03/memory-loss-dementia.jpg
Dementia
• Classified
– Primary –where dementia itself is the major sign
of some organic brain disease, not directly related
to any other organic illness (Alzheimer’s disease)
– Secondary – caused by or related to another
disease or trauma
• HIV
• Vascular dementia
• Korsakoff’s syndrome (caused by thiamine deficiency)
Dementia—Alzheimer’s Type (Stages)
Stage
Characteristics
Manifestations
Stage 1
No apparent symptoms
None noticeable
Stage 2: Forgetfulness
Aware of the decline in mental
status- not noticeable to others;
loss of short term memory; loses
things
Anxiety and depression common;
makes lists; has very structured
routines
Stage 3: Mild cognitive decline
Symptoms noticeable to others;
impaired concentration;
organizational skills decline
Get lost while driving a car;
difficulty recalling names; inability
to concentrate
Stage 4: Mild to moderate
cognitive decline; confusion
Task performance declines
(shopping independently or
managing personal finances);
Memory loss significant (forgets
major events, like child’s birthday,
wedding day)
Confabulation: creates imaginary
events to fill in memory gaps;
unconscious attempt to maintain
self-esteem; Depression and social
withdrawal are common
Stage 5: Moderate cognitive
decline; early dementia
Memory loss declining (names of
close relatives) ADLs impaired;
disorientation to place/time, but
maintains orientation to self
Inability to perform ADLs
independently; frustration,
withdrawal and self-absorption are
common
Dementia—Alzheimer’s Type (Stages)
Stage
Characteristics
Manifestations
Stage 6: Moderate to
severe decline: middle
dementia
Memory loss severe:
(unable to recall major life
events, names of
immediate family
members); disorientation
to surroundings;
institutional placement
common
Sundown syndrome:
wandering, obsessive,
agitation, aggressive
(symptoms worse as day
progresses); intermittent
fecal/urinary incontinence;
falls; loss of language
Stage 7: Severe cognitive
decline: late dementia
Extreme memory loss
(inability to recognize
family members; loss of
language skills); secondary
infections common; death
Pneumonia, UTIs/sepsis;
weight loss, dysphagia;
decubiti, contractures;
death usually associated
with aspiration or infection
Communication Guidelines for Clients with Dementia
DO:
DO NOT:
Simplify environment stimuli before beginning
interaction
Don’t argue or reason with the client, instead use
distraction; validation therapy
Look directly at the client when talking
Avoid confrontation
Refer to the client by surname (Ms. Jones, not Mary)
Don’t use slang, jargon, or abstraction
Try to identify the emotions behind the client’s words
or behavior
If attention lapses, do not persist. Let client rest
before trying to regain attention
Identify and minimize environmental distractors that
create anxiety
Don’t focus on difficult behavior; look for the
underlying problem or anxiety and redirect
Watch YOUR body language; convey interest and
acceptance
Avoid restraints
Repeat simple messages; speak slowly and calmly; give Avoid small objects that could be choking risk
direct, simple directions in a step-by-step manner
Direct conversation towards concrete, familiar objects
Communicate appropriately with touch, smiles, and
gentle redirection
Medications used in Dementia
• Cholinesterase inhibitors ( mild to moderate
DAT-Dementia Alzheimer’s Type)
• Mainstay of dementias
• Inhibit acetylcholinesterase which results in an
increase in cholinergic activity; this slows the
progression of cognitive decline
• Donepezil (Aricept) SE: insomnia, dizziness, GI upset,
HA $$$
• Rivastigmine (Exelon) SE: dizziness, HA, GI upset
• Cognex –no generic SE: dizziness, HA, fatigue, GI upset
Medications used in Dementia(con’t)
• NMDA receptor antagonist (moderate to severe
DAT)
– Memantine (Namenda) SE: dizziness, HA, constipation
• High levels of glutamate is thought to increase symptoms in
clients
• Glutamate plays a role in learning and memory by triggering
NMDA receptors to allow a controlled amount of calcium
flow into a nerve cell
• In DAT, there is sustained release of glutamate and an influx
of calcium, which leads to a disruption and death of neurons
• Namenda protects the cells by partially blocking NMDA
receptor
Medications used in Dementia (con’t)
•
•
•
•
Antipsychotics
SSRIs (Selective Serotonin Reuptake Inhibitors)
Anti-anxiety
Sedative-hypnotic (benzodiazepine)
Outcomes for Dementia
• Client:
– No physical injury
– No harm to self or others
– Ability to communicate individual needs with
consistent caregiver
– Fulfills ADLs with assistance
• Caregiver
– Verbalized understanding of disease process
• Realistic expression/expectation of disease process
Outcomes for Dementia
• Caregiver (con’t)
– Verbalizes management of the illness
•
•
•
•
•
Ensuring safety
Maintaining orientation
Nutritional information
Difficult behaviors (aggression, wandering, pacing)
Hygiene and toileting
– Verbalizes available resources
• Professional counseling
• Home Health
Outcomes for Dementia
• Caregiver (con’t)
– Verbalizes available resources (con’t)
• Respite Care
• Referrals
–
–
–
–
–
Alzheimer’s Association http://www.alz.org
http://nimh.gov/publicat/medicate.html
http://www.aarp.org
Day care centers
Legal/financial services
Psychological Changes (con’t)
• Cognitive Changes (con’t)
**Depression
Reduce overall happiness & contibutes to
physical & social limitations
It complicates the treatment of other medical
conditions & increases the risk of suicide
Late life depression is not a normal part of aging
Due to lifestyle transitions and loss
Psychosocial Changes (con’t)
•
Retirement
1. Causes stressors such as economic,
relationship, and financial
2. Affect spouses, adult children, &
grandchildren
3. Planning for retirement allows a
smoother transition into retirement
Psychosocial Changes (con’t)
•
Social Isolation
1. The degree of social isolation increases with age
2. Isolation can be by choice or due to a response
to a condition that inhibits the ability to interact
with others. It may arise for attitudinal,
presentational, behavioral, or geographical
factors.
3. Attitudinal occurs due to personal or cultural
values
Psychosocial Changes (con’t)
•
Social isolation(con’t)
4. Presentational results from a persons
unacceptable appearance
5. Behavioral result for the persons unacceptable
behaviors
6. Geographical occurs from institutional barriers,
distance from family & friends, and
environmental crime
Elder Abuse
• 10 % over the age of 65 are victims to abuse
or neglect
• Often a relative who lives with the elderly
person or may be an assigned caregiver
• Types of abuse: Psychological, neglect,
physical, financial, sexual
Contributing Factors to Elder Abuse
•
•
•
•
Longer Life
Dependency
Stress
Learned violence
Identifying & Recognizing Elder Abuse
•
•
•
•
•
Psychological Abuse
Physical Abuse
Neglect
Sexual Abuse
Financial Abuse
Elder Victims Response to Abuse
• Often minimize/deny the abuse
• Unwilling to disclose information – fear of
retaliation
• Protective toward a family member or
unwilling to institute legal action due to fear
of retaliation.
• Often isolated so their mistreatment is less
likely to be noticed by those who might be
alert to symptoms of abuse.
Healthcare Workers
• Responsibilities of the RN with Abuse
– If there is suspicion of abuse/neglect – REPORT
IT!!!
– If you are uncertain, discuss with another
coworker and STILL REPORT IT!!!!
– If you feel intimidated when confronted with
cases of elder abuse, refer to an individual who
has experience in management (Unit Manager,
Social Worker, etc.) of such victims may be the
MOST effective approach.
Nursing and Violence-Therapeutic
Nursing Care
• Explore one’s own attitude toward the
survivor
• Recognize attitudes and seek to change
negative feelings
• Gain experience through educational
programs or volunteer in programs for
survivors assistance
Psychosocial Changes (con’t)
•
Sexuality
1. Older adults should express sexual feelings
2. Sexuality plays a role in maintaining self-esteem
3. Physical changes & medications affect sexual
functioning
Psychosocial Changes (con’t)
•
Housing and environmental
1. Changes may be necessary because of death of
spouse, physical impairments, and health
problems
2. Housing arrangement depend on activity level
restrictions, financial status, and support
systems
Psychosocial changes: Death
 Older adults may experience death of spouse, children, friends, or
family members.
 Grieving Process: Kubler-Ross Stages of Dying
-Denial, Anger, Bargaining, Depression, Acceptance
 Nurses provide support to pt.
 Help patients cope with losses.
 Facilitate adjustment to life changes.

Holding Hands. Retrieved from https://www.michaeljfox.org/files/blog/Patient-Doctor-Hands.jpg
Psychosocial Interventions
 Therapeutic Communication is very important.
 Must be genuinely concerned for welfare of pt
 Never underestimate the power of touch:
-Provides sensory stimulation
-Provides comfort
 Reality orientation
 Refer to support groups/ community activities.
 Encourage adaptive coping. (Social support, religious faith, counseling/therapy)
 Discourage maladaptive coping. (use of alcohol/ drugs to deal with pain)
Sleep and rest
 Deficient sleep hours can negatively effect the pt’s functioning
in daytime hours.
-Negatively effects health
 Causes of Sleep Disturbances:
-Medications (Beta-blockers, decongestants, anti-psychotics)
- Sleep Apnea
-Restless Leg Syndrome
-Pain
-Cardiac/ Pulmonary disorders
Pain Management
 Older adults often suffer from Chronic Pain.
-Osteoarthritis
-Neuropathies
-Central/ neuropathic pain
following a CVA
-Postherpetic neuralgia
-Phantom Limb pain
 Goal: Maintain acceptable level of
comfort
Pain. Retrieved from http://www.cirpd.org
 Inadequate pain management leads to:
-Decreased quality of life
-Depression, Suicidal Ideations
-Isolation/ decreased socialization
-Decreased appetite
-Increased costs/ healthcare utilization
Pain Management. Retrieved from humb7.shutterstock.com/display_pic_with_logo/56934/178866611/stock-photo-pain-management-and-palliative-care-issues-andconcepts-word-cloud-illustration-word-collage-178866611.jpg
Pain management
"Maybe"
When I wander
don’t tell me to come and sit down.
Wander with me.
It may be because I am hungry, thirsty, need the
toilet.
Or maybe I just need to stretch my legs.
When I call for my mother
(even though I’m ninety!)
don’t tell me she has died.
Reassure me, cuddle me, ask me about her.
It may be that I am looking for the security
that my mother once gave me.
When I shout out
please don’t ask me to be quiet…or walk by.
I am trying to tell you something,
but have difficulty in telling you what.
Be patient. Try to find out.
I may be in pain.
When I become agitated or appear angry,
please don’t reach for the drugs first.
I am trying to tell you something.
It may be too hot, too bright, too noisy.
Or maybe it’s because I miss my loved ones.
Try to find out first.
When I don’t eat my dinner or drink my tea
it may be because I’ve forgotten how to.
Show me what to do, remind me.
It may be that I just need to hold my knife and fork
I may know what to do then.
When I push you away
while you’re trying to help me wash or get dressed,
maybe it’s because I have forgotten what you have said.
Keep telling me what you are doing
over and over and over.
Maybe others will think
you’re the one that needs the help!
With all my thoughts and maybes,
perhaps it will be you
who reaches my thoughts,
understands my fears,
and will make me feel safe.
Maybe it will be you
who I need to thank.
If only I knew how.
-Author unknown
“Maybe”. Retrieved from http://www.walking-in-their-shoes.com/-maybe-poem.html