Chapter 13

• This chapter introduces age-related changes
• Gradual decline and chronic illness characterize aging
• Communicating with the aged can be challenging but if successful can lead to better outcomes

• Older adults have depressed immune systems and often present with atypical signs and symptoms
• The “graying of America” increases the importance of understanding the special needs of this population

The Importance of
Patient-Clinician Interaction
• Principles of communication
• Avoid ageism: discrimination against the aged
• This can cause practitioners to not listen well to older patients
• Treat the aged with compassion

• Communication barriers:
• Sensory deficits of hearing or visual impairment
• Speech may be impaired by poor fitting dentures, stroke, head injury, or
Alzheimer’s disease
• Emotional barriers such as depression
• Bridging these barriers facilitates communication

The Importance of
Patient-Clinician Interaction (cont’d)
• Reduce communication barriers
• Always approach patient in a caring manner
• Address by last name and appropriate title
• Avoid condescending terms: “sweetie,” “dear”
• Adjust heat, lights, etc. for patient comfort
• Introduce yourself and explain your purpose
• Eliminate background noise and interruptions
• Do not rush the patient

• Hearing impairment
• Presbycusis: age-related, progressive hearing loss often causing diminished functional independence
• This condition affects:
• 23% of adults between ages 65 and 75
• 50% of adults between ages 70 and 80
• Assess hearing impairment by whispering a simple question while out of view but close to the patient

• Vision impairment
• Presbyopia: age-related change to the lens of the eye
• Typically results in correctable farsightedness
• More serious disorders include cataracts, glaucoma, diabetic retinopathy, macular degeneration
• Age is a major factor in the development of cateracts
• Places patients at high risk for falls

• Compensating for vision loss/impairment
• Leave everything where patient wants it
• Patients memorize where items are
• If eyeglasses are used, make sure they are clean and properly positioned
• Verbal communication more important
• Speak clearly and explain procedure thoroughly
• If patient must move, offer an arm of support

• Cardiovascular system
• Cardiovascular diseases common in elderly
• Normal CV changes include:
• Increased LV afterload results in LV wall thickening
• 1/3 of patients older than 70 years of age have calcium deposits in the aortic or mitral valves
• The occurrence of CHF doubles for each decade of life between 45 and
75 years

• Normal pulmonary system changes include:
• Smooth muscle progressively replaced with fibrous connective tissue
• Alveolar septa gradually deteriorate reducing surface area for gas exchange
• Lungs have less elastic recoil; chest wall more rigid: result is increased FRC and RV
• At ~55 years respiratory muscles begin to weaken
• Epithelial lining of tracheobronchial tree degenerates, ciliary action slows, and phagocytic activity decreases

• Immunity
• Aged have a reduced cell-mediated immunity
• May impair ability to fight infections placing them at greater risk for pneumonia, sepsis, etc.
• Increased frequency of reactivation tuberculosis
• Diminished response to vaccines

• http://www.medcomrn.com/mtsac/
• 113. VIDM267A-T How the Body Ages,
Part 1: Cardiovascular, Respiratory, and
Musculoskeletal Systems (w/Video)

• Presentation of older person with specific illness often different from younger person
• Could be due to a number of reasons
• Patients may just consider it “old age”
• Peripheral sensitivity decreases, diminishes pain
• Tachycardic response to hypoxia/sepsis reduced
• Aging organ systems may lose their ability to compensate for other systems
• Diminished inflammatory response

• Pneumonia may present with:
• Reduced appetite, fatigue, decreased ability to perform daily activities, weakness
• Nausea, vomiting, diarrhea, myalgia, arthralgia
• Most sensitive sign of pneumonia is increased respiratory rate (>28 beats/min)
• Chest radiograph may not show infiltrate if patient dehydrated (detectable 24-48 hr after rehydration)
• Lack of fever!
• Consider bronchoscopy to identify cause

• Heart failure: leading cause for hospitalization in adults
>65
• 50% of people older than 75 years die of an MI
• They often have atypical presentation of MI
• What is the most common complaint from a patient suffering from a MI?
• Complaints of shoulder, throat, or abdominal pain
• Bilateral elbow pain
• Syncope, acute confusion, weakness, and fatigue
• Dyspnea or dizziness may be only complaints
• Cough, wheezing and hemoptysis

• Asthma often misdiagnosed
• Typically considered a childhood disease
• Should be considered in elderly patients with wheezing or dyspnea even if they do not have:
• Nocturnal or early morning symptoms
• History of allergies
• Immediate response to bronchodilators
• Underdiagnosis may relate to underuse of objective measurement by spirometers and peak flowmeters

• Vital signs in the elderly
• Temperature
• Tends to be lower, >90 years may be 96˚ to
97˚ F
• Obtaining a temperature may be difficult
• Aged may not be able to keep mouth closed
• Axillary method may not be accurate due to muscle wasting
• Rectal method is accurate but not tolerated well
• Tympanic method, expensive but accurate and fast

• Vital signs in the elderly
• Pulse
• Healthy older adults may have normal resting pulse
• Inactive older adults may have resting pulse of 50 to 55 beats/min
• Arrhythmias with rapid pulse are poorly tolerated
• Any changes in pulse should be immediately investigated

• Vital signs in the elderly
• Blood pressure (BP)
• Generally rises with age, particularly systole
• 60% of older adults have elevated systolic or diastolic blood pressure
• Risk of CV disease doubles with every 20/10 increment
• It is key to control HTN

• Vital signs in the elderly
• Respiratory rate (RR)
• Normal RR is 16 to 25 breaths/min
• Tachypnea may be due to:
• Ambulation
• Anxiety
• Hypoxemia, acidemia, or pneumonia
• Bradypnea may be due to:
• Medication or being asleep
• Alkalosis or hypothermia

• Inspection of the elderly
• Skin turgor (assess hydration)
• Tenting cannot be used because muscle wasting provides a false positive
• Condition of tongue better indicates dehydration
• Clubbing
• Elderly have higher incidence of chronic diseases thus also have higher incidence of clubbing
• May indicate connective tissue disease

• Inspection of the elderly
• Edema
• Often peripheral edema indicates CHF or
DVTs
• Not always a reliable indicator of CHF
• A gain of more than 5 lb in one week may indicate fluid retention
• Jugular venous distention (JVD)
• JVD is indicative of right heart failure

• Pulmonary auscultation
• May not be able to sustain deep breathing
• Best effort may produce 3 or 4 breaths followed by rest
• Start posterior basal portions first
• Breath sounds may be reduced even if healthy making vesicular sounds hard to hear
• Adventitious breath sounds will be just as with other patient groups

• Gas exchange in the elderly
• Reduced VC and PEF
• Slight reduction in Pa
O
2 secondary to loss of alveolar surface area and increased
V/Q mismatch

• Arterial blood gases
• Pa
O decreases with age, roughly –0.245
2 mm Hg/year (see Table 13-2)
• Blood gas drawn from supine patient has
Pa
O
2 of 5 mm Hg less than if patient sitting
• After age 75 Pa
O
2 tends to be higher in males
• Pa
O should be adequate in absence of
2 disease
• Hypercapnia occasional in healthy aged
• Not predictable and usually mild http://www.rtmagazine.com/issues/articles/2006-02_04.asp

• Pulse oximetry (Sp
O
2
)
• The lower Pa
O
2 common in elderly results in a slightly lower Sp
O
2
• If the Pa
O
2
(93% to 94%) stays at 60 mm Hg or greater the fall in Sp
O
2 will not be clinically significant
• A good, measurable pulse is essential to measure Sp
O
2
• Some older patients have poor circulation, so obtaining a reading can be a problem

• Pulmonary function studies (PFTs)
• After age 25, pulmonary function declines
• Residual volume almost doubles with older age
• Important to use age-appropriate norms
• FVC and FEV
1 diminish by approximately 30 ml/yr for men and 23 ml/yr for women decline not linear but worse after age • D
LCO
40
• PFTs may require extra time
• Talk to the pulmonologist about the patient’s level of comprehension and performance

• Important goal: improve functional ability
• Quantified by activities of daily living (ADL)
• Personal hygiene, feed self, use toilet, dress self
• Instrumental activities of daily living (IADL)
• A way of quantifying the complex ADL
• Money management, telephone use, writing skills, ability to shop
• Deterioration of functional ability: early sign of illness; noting this may maintain quality of life

• Effective communication will improve patient care
• Taking extra time with older adults is worth the effort
• Disease presentation is often atypical in the elderly
• Vital signs and functional anatomy are often altered in the aged
• Preventive interventions to keep older patients healthy and functional and at home is the best medical care we can offer

• Gas exchange in the elderly
• Reduced VC and PEF
• Increased closing volume reduces ventilation to bases while increases ventilation of upper lung fields
• Results in an increased V/Q ratio
• Slight reduction in Pa
O
2 secondary to loss of alveolar surface area and increased
V/Q mismatch