MIDTERMS : CARE OF OLDER ALDULT (LEC)
LESSON 1: PHYSIOLOGICAL CHANGES &
PROCESSES IN AGING
SENSORY
1. decreased salivation
2. decreased taste buds for sweet & salty [most
tastes are bitter/sour]
3. decreased visual acuity
4. decreased sensitivity to sound
5. decreased response to pain
6. decreased thirst sensation
7. decreased motor skills
8. changes in dentition
CARDIOVASCULAR SYSTEM
1. increased myocardial irritability
2. increased dysrhythmias (increased PVC's &
PAC’s)
3. increased A/V blocks
4. decreased maximal heart rate
5. decreased sinus rate
6. decreased arterial compliance
7. increased systolic blood pressure
8. decreased cardiac output
9. increased circulation time
10. decreased cutaneous tissue perfusion
CENTRAL NERVOUS SYSTEM
1. decreased neuronal density
2. decreased reflexes
3. decreased sympathetic response
4. decreased proprioception
5. decreased baroceptor response (postural
hypotension)
RENAL SYSTEM
1. decreased bladder capacity
2. decreased blood flow
3. decreased glomerular filtration
4. decreased renal clearance of drugs &
metabolites
GASTROINTESTINAL SYSTEM
1. decreased gastrointestinal absorption
2. decreased gastric emptying
3. decreased hepatic blood flow / drug clearance
4. decreased drug absorption
5. decreased motility
6. decreased transit time
METABOLIC SYSTEM
1. decreased basal metabolic rate
2. increased risk for hypothermia
3. decreased temperature regulation response
IMMUNE SYSTEM
1. decreased neurohumoral response
2. decreased white blood cell (WBC) reserve
(secondary to bone marrow / splenic sclerosis)
3. “Sluggish” T cell response
BODY COMPOSITION
1. decreased lean muscle mass
2. decreased subcutaneous fat
3. increased overall body fat
4. decreased sweat glands
5. decreased skin pigmentation
6. decreased serum protein binding
RESPIRATORY SYSTEM
1. decreased tidal volume
2. decreased vital capacity
3. increased residual volume
4. decreased lung capacity
5. decreased compliance
6. decreased response to hypoxemia/hypercapnia
ENDOCRINE SYSTEM
1. increased or decreased thyroid function
[hypo/hyperthyroidism]
2. decreased insulin sensitivity
3. decrease in growth hormone levels
4. decrease in estrogen & testosterone levels
ORTHOPEDIC
Osteopenia
1. increased risk of fractures
2. decreased range of motion
3. increased ligamentous stiffness
NORMAL AGING
NORMAL AGEING – the result of a complex
process
that is progressive in nature, in the absence of
disease
• Commonly described as healthy lifestyle
habits contribute positively to normal ageing,
the following actions:
✓ physical exercise
✓ a healthy diet
✓ restorative sleep
✓ abstaining from tobacco & alcohol use
STAGES OF AGING
1. INDEPENDENCE
➢ Between 50s and 60s.
➢ They can handle everyday needs on their
own.
➢ Transportation, finances, health care, and
house chores present no big challenge.
➢ Mental and physical activity may exhibit a
minor decline, but not enough to impact
their lives.
➢ For women, this stage often encompasses
the significant hormonal shifts of
menopause.
➢ Aging males also see somewhat
decreased levels of testosterone. This can
result in lower energy levels and loss of
muscle mass.
4. CRISIS MANAGEMENT
➢ Crisis management – the final stage of
aging
5. END OF LIFE
➢ Vast majority of people reach these last 2
stages, they need more or less round-theclock care.
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2. INTERDEPENDENCE
➢ Between 70s and 80s
➢ An interdependent senior may need a
caregiver to handle certain monthly, weekly,
or daily activities (i.e., paying bills, mowing
the lawn, or driving).
➢ Another common scenario: they can still do
everything solo... Just slower.
3. DEPENDENCY
➢ 80 & above
➢ Have trouble handling quite a few everyday
tasks by themselves.
➢ This stage is usually less dependent on age
and more dependent on how their medical
narrative progresses.
➢ many seniors in this situation end up feeling
disoriented and even depressed
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INTEGUMENT
Dermis – decreases in thickness by about 20%.
As it thins it loses vascularity, cellularity and
sensitivity.
The skin's ability to dissipate or retain internal
heat is diminished.
The skin becomes thin, fragile and slow to heal.
Evaporative heat loss is reduced due to
reduced efficacy of sweat glands and
diminished peripheral circulation.
Subcutaneous fat deposition is altered in the
elderly.
Muscle, blood vessels and bone become
more visible beneath the skin due to thinning of
subcutaneous fat on the extremities.
Fat deposition occurs mainly on the abdomen
and thighs.
One of the most common physical changes that
people associate with aging is
✓ Wrinkling
✓ Pigment alteration
✓ Thinning of the skin
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This is the system with the most obvious
changes because this involves the skin, hair,
and nails.
The skin loses its moisture and elasticity
which make older people more susceptible to
skin tears and shearing injuries.
The hair loses color and the nails become
thickened and brittle.
Progressive loss of subcutaneous fat and
muscle tissue accompany the previously
mentioned integumentary changes.
As a result, muscle atrophy, “double” chin,
wrinkling of skin, and sagging of eyelids and
earlobes are frequently observed in older
people.
In older women, breasts become less firm and
may sag.
Tolerance to cold also decreases because of
loss of subcutaneous fats.
There are also fewer hair follicles on the scalp
and the growth rate of hair decreases in the
scalp, armpits, and pubic areas.
However, hair growth actually accelerates and
thickens in places like nostrils, ear and
eyebrows, especially in men.
Older women often have an increase in facial
hair as their estrogen levels decrease.
Muscles of the face are capable of
tremendous movement.
“Smiles, laughter, frowns, disappointment, ager,
rage, and surprise are all recorded.”
The hand of time captures these expressions
and outlines them on the face....By the age of
40, most people bear the typical lines of their
expressions.”
MUSCULOSKELETAL
Muscle mass is a primary source of metabolic
heat. When muscles contract, heat is
generated. The heat generated by muscle
contraction maintains body temperature in the
range required for normal function of its various
chemical processes.
Third decade of life there is a general
reduction in the size, elasticity and strength of
all muscle tissue.
The loss of muscle mass continues
throughout the elder years. Muscle fibers
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continue to become smaller in diameter due to
a decrease in reserves of ATP, glycogen,
myoglobin and the number of myofibrils.
As a result, as the body ages, muscular
activity becomes less efficient and requires
more effort to accomplish a given task.
NEUROMUSCULOSKELETAL
Normal ageing is characterized by a decrease
in bone and muscle mass and an increase in
adiposity
Speed and power of muscle contractions are
gradually reduced with age. While exercise can
strengthen muscles, there would be steady
decrease in muscle fibers by age 50.
This condition is called sarcopenia.
Also, loss in overall stature occurs with age.
Kyphosis, osteoporosis, and pathologic
fractures are consequently common.
Reaction time also slows with age. Decreased
muscle tone further reduces reaction time. This
is because diminished physical activity can
decrease muscle tone.
Skeletal muscle strength (force-generating
capacity) also gets reduced with ageing
depending upon genetic, dietary and,
environmental factors as well as lifestyle
choices. This reduction in muscle strength
causes problems in physical mobility and
activity of daily living.
The total amount of muscle fibers is
decreased due to a depressed productive
capacity of cells to produce protein.
There is a decrease in the size of muscle
cells, fibres and tissues along with the total
loss of muscle power, muscle bulk and muscle
strength of all major muscle groups like
deltoids, biceps, triceps, hamstrings,
gastrocnemius
By the time of AGE 80, most lose an average
height of about 2 INCHES.
LESSON 2: ASSESSMENT OF THE HEALTH
STATUS OF OLDER PERONS
FACTORS AFFECTING THE HEALTH STATUS
OF OLDER PERSONS
AGING
• Aging – process that starts from the beginning
of life
• Aging does not happen at same rate for all
aging, progressive physiological changes in an
organism that lead to SENESCENCE, or a
decline of biological functions and of the
organism's ability to adapt to metabolic stress.
• the physiological developments are normally
accompanied by psychological and behavioral
changes, and other changes, involving social
and economic factors,
• The biological-physiological aspects of
aging include both the basic biological factors
that underlie aging and the general health
status.
TYPES OF AGING
1. PRIMARY AGING
describes the biological factors that are largely
beyond our control. It’s basically the notion that, like
it or not, getting older is part of the natural life cycle;
purely biological (intrinsic)
2. SECONDARY AGING
• describes the environmental aspect of aging
(extrinsic)—lifestyle choices can certainly
have an impact on long-term wellbeing and
even the aesthetic effects of aging. This can
range from diet and physical activity to stress
and even factors like where we choose to live
• Changes must occur in the individual which
make him or her more and more vulnerable to
diseases
• Performance of many organs such as the heart,
kidneys, brain, or lungs shows a gradual
decline over the life span. Part of this decline is
due to a loss of cells from these organs, with
resultant reduction in the reserve capacities of
the individual. Furthermore, the cells remaining
in the elderly individual may not perform as well
as those in the young. Certain cellular
enzymes may be less active, and thus more
time may be required to carry out chemical
reactions. Ultimately the cell may die.
AGING EFFECTS:
1. FUNCTIONAL STATUS
Functional status is an individual's ability to
perform normal daily activities required to meet
basic needs, fulfill usual roles, and maintain health
and well- being
➢ Functional status can be assessed in
several different ways, usually with a focus
on the person’s abilities to perform basic
activities of daily living
➢ (ADL) – include basic self-care such as
bathing, feeding, and toileting and
instrumental activities of daily living (IADL),
which includes activities such as cooking,
shopping, and managing one’s own affairs.
2. MEMORY LOSS AND CONFUSION
Forgetfulness can be a normal part of aging. As
people get older, changes occur in all parts of the
body, including the brain. As a result, some people
may notice that it takes longer to learn new things
➢ Cognitive aging means that as one get
older, mental functions become less nimble
and flexible, and many aspects of the
memory get a little worse.
➢ Older person become more easily distracted
by busy environments, and it takes more
effort to work through complex problems
and decisions.
➢ May have effect on the Health
maintenance behavior such as forgetting
to eat,, take a bath, or take medicines;
➢ SAFETY OF THE OLDER PERSON.
3. VISUAL & HEARING IMPAIRMENT
Sensory deficiencies will affect the health status
of older persons.
➢ Mobility around the house/neighborhood
➢ Prone to accidents
➢ Communications may be difficult
4. DECREASED ORGAN RESERVES
"Organ reserve" refers to the ability of an organ to
successfully return to its original physiological
state following repeated episodes of stress. ...
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If metabolic excess capacities or organ
reserves are impaired or exhausted, the ability
of the cell to cope with stress is reduced.
This reserve declines with age and may explain
some functional deterioration in the elderly,
such as decreases in strength, balance, and
cognition.
PRINCIPLES & TECHNIQUES IN ASSESSMENT
OF THE HEALTH STATUS OF OLDER PEOPLE
ASSESSMENT
Assessment an evaluation during which
“information is collected to identify the patient’s
needs and formulate a treatment plan”
➢ Assessment is a combination of formal and
informal practice
➢ Assessment allows health professionals to
gain insight into individual needs and thus
provide person-centered care.
➢ Older people often have complex health
needs requiring a multidimensional and
multidisciplinary approach, so conducting
assessments is a highly skilled activity.
GERIATRIC ASSESSMENT
➢ include non-medical domains
➢ emphasize functional ability and quality
of life
HISTORY TAKING & PHYSICAL EXAMINATION
HISTORY TAKING
• The ability to obtain an accurate history and
carefully perform a physical examination is
fundamental to providing comprehensive care
to adult patients
• Obtain a patient's history in a logical,
organized, and thorough manner, covering
the history of present illness; past medical
history (including usual source of and access to
health care, childhood and adult illnesses,
injuries, surgical procedures, obstetrical history,
psychiatric problems, hospitalizations.
GENERAL SURVEY
Deepen the observations about the patient that you
have been compiling since the visit began. What is
the patient’s apparent state of health and degree of
vitality? It’s hygiene and how the patient is dressed.
How does the patient walk into the room?
➢ Vital Signs
➢ Skin. Note physiologic changes of aging
➢ HEENT (Head, Eyes, Ears, Nose, Throat)
FACTORS THAT AFFECT VALIDITY OF
ASSESSMENT
1. Aging effects & presence of disease –
history taking is not conducted properly; older
person not properly oriented on the purpose of
interview
2. Presentation of illness – many older persons
do not report signs & symptoms of diseases
3. Expertise of the person doing the
assessment – person must be knowledgeable
about the normal changes brought about by
aging as well as the pathologic sign &
symptoms of diseases. Must also possess
certain attitudes
4. Place and time where/when assessment is
done
COMPREHENSIVE GERIATRIC ASSESSMENT
• This is “a multidimensional interdisciplinary
diagnostic process focused on determining a
frail older person’s medical, psychological and
functional capability to develop a coordinated
and integrated plan for treatment and long-term
follow-up”
• The assessment of an older person should:
➢ Be multidimensional (addressing at least
medical, psychological and functional
domains);
➢ Involve interdisciplinary teamwork and
an integrated and coordinated team
approach;
➢ Include a treatment plan and long-term
follow-up.
• Geriatric assessment (GA) encompasses
cognition, emotion, nutrition, mobility, basic, and
instrumental activities of daily living (IADL), and
social functioning.
TECHNQUES IN CONDUCTING ON
ASSESSMENT
1. ESTABLISHING AN ATMOSPHERE OF TRUST
& RESPECT, ENSURING COMFORT &
SAFETY, AND COMMUNICATING
EFFECTIVELY ARE SOME OF THE
TECHNIQUES THAT ARE IMPORTANT IN THE
CONDUCT OF ASSESSMENT.
2. PREPARING THE PHYSICAL SETTING
➢ Distractions should be minimal; noise from
televisions, radios, and public address
systems should not be loud enough to
distract the older adult or interfere with his
or her ability to distinguish words and
understand questions
➢ Lighting should be diffuse because bright
lights or glare may make it difficult for the
interviewee to see clearly.
➢ Furniture should be comfortable. Privacy is
very important.
➢ The room should be comfortably warm and
should be free from drafts that might cause
discomfort
➢ It’s advisable either to assist them to the
bathroom or to tell them that a bathroom is
available nearby should they require it.
3. ESTABLISHING RAPPORT
➢ It’s most appropriate to begin the interview
by greeting the older person &
introducing yourself
➢ It is best to address the person using his or
her formal name (e.g., “Mr. Smith” or “Mrs.
Adams”). Appropriate use of names
indicates respect and helps build rapport.
➢ Briefly explain the purpose of the
interview so that the individual will know
what to expect
➢ Explain how long he or she expects the
interview to last, as well as what will happen
after it is completed.
➢ Nurses should focus on and speak directly
to the older person being interviewed.
4. STRUCTURING THE INTERVIEW
➢ Try not to accomplish too much during a
single interview. The effort involved in
communication can be fatiguing to an older
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individual, particularly one with health
problems. It is better to have several brief
interactions lasting less than 30 minutes
each rather than one long interview that
leaves the patient exhausted
Stay alert for signs of fatigue (e.g.,
sagging head or shoulders, sighing, altered
facial expression, and irritability), which
indicate the need to end the interview.
Avoid using medical jargon and should use
only words that the older person
understands.
The nurse should speak slowly and clearly
and keep messages simple but should not
patronize older adults. When the patient is
speaking, the nurse should not interrupt.
The nurse must listen to both the verbal and
nonverbal messages being sent.
The nurse should remain attentive and calm
and should allow the patient to complete his
or her own sentences.
The nurse should try not to end an interview
too abruptly.
Setting a time for further interaction by
saying, “We’ll talk again tomorrow morning”
or “I’ll set up another appointment so we
can talk more” can help maintain rapport.
COMMUNICATION TECHNIQUES
Good communication is at the heart of
assessment. It entails understanding of what is
said, what is felt and what could help the other
person.
➢ Factors that may affect communication
should be identified at the start of the
meeting
➢ The presences of sensory and cognitive
impairment can adversely affect
communication with the older person
➢ At the beginning of the session with an older
person, ask if he/she wears eyeglasses or
a hearing aid and request that these be
worn during assessment
➢ For older person with hearing impairment,
provide non-verbal cues during face to face
communication ( the person speaking to the
older person is facing the light)
TIPS FOR COMMUNICATION EFFECTIVELY
WITH OLDER ADULTS
• Provide a well-lit, moderately warm setting
with minimal background noise and safe chairs
and access to the examining table.
• Face the patient and speak in low tones; make
sure the patient is using glasses, hearing
devices, and dentures if needed.
• Adjust the pace and content of the interview to
the stamina of the patient; consider 2 visits for
initial evaluations when indicated.
• Allow time for open-ended questions and
reminiscing; include family and caretakers when
needed, especially if the patient has cognitive
impairment.
• Make use of brief screening instruments, the
medical record, and reports from allied
disciplines.
• Carefully assess symptoms, especially fatigue,
loss of appetite, dizziness, and pain, for clues to
underlying disorders.
• Make sure written instructions are in large
print and easy to read.