Physiologic Changes of Aging Gerontological & Community Based Nursing:

Physiologic Changes of Aging

Gerontological & Community Based Nursing:

Age related changes affecting nutrition & hydration in older adults

Reduced need for caloric intake r/t↓body mass & ↑adipose tissue

Basil metabolism rate ↓ 2 % q decade of life

General ↓ in activity level

∆’s in taste (sweet intact & ↓Sour, salt, bitter)

∆’s in sense of smell believed to be related to other factors (∆’s in CNS function, medications, smoking)

Other factors affecting nutrition

Socialization- eating alone Income- strong relationship between

poor nutrition & low income Transportation –access to shopping Housing- substandard housing (SRO) Dentition (see box 8-3 text) – poor

oral health – risk factor for dehydration & malnutrition; ↑risk oral cancers

Nutrition concerns

Two major concerns: Obesity – exacerbates age related

health issues> type II diabetes, CAD, osteoarthritis,

↓ mobility, Malnutrition – often unrecognized Precursor to frailty

Malnutrition in older adults

Protein – Calorie Malnutrition PCM most common type of malnutritionc/b muscle wasting, low BMI;↓albumin /serum proteins

50% nursing home; 50% hospitalized 44% home health elders - malnourished

Malnutrition - Risk factors

Psychosocial

Mechanical

“I’m Dying of Thirst!”

In young, water makes up about 2/3 of our body weight

The brain is composed of about 95% water

The blood is about 82% water The lungs are about 90% water

In the elderly total body water drops to about 50% of the body’s weight

Hydration

Small changes in water content make a big difference in the elderly because: Kidneys lose their ability to concentrate

urine as effectively There is a decreasing sense of thirst in

the elderly Recommended daily fluid intake for the

elderly is 1500-2000ml of non-caffeinated fluids

Dehydration

Dehydration is one of the most common fluid and electrolyte problems experienced by the elderly

Most often r/t disease process NOT access to water (Thomas et.al. 2008)

Result of - fluid loss + ↓ fluid intake r/t

↓ thirst & ↓kidney function (↓creatinine clearance)

Dehydration

How it happens ↓body fluids ->↑’s concentration of solutes in the

blood (increased osmolality) Na levels ↑ To regain balance between intracellular &

extracellular-H2O molecules shift out of cells into more concentrated blood

With ↓H2O in extracellular space –fluid continues to shift into extracellular space-dry cells become dysfunctional ->dehydration

Dehydration

Dehydration in elderly can cause: Delirium UTI URI Urinary incontinence Constipation Pressure ulcers Cardiovascular symptoms Death

Factors that contribute to Dehydration

MedicationsDiureticsSedativesAntipsychoti

cs

ETOH abuseDementiaSelf feeding

defecits ImmobilityFeverDiarrhea

Physiologic Signs of Dehydration Poor skin turgor

On the forehead or sternum, not the hand or arm

Sunken eyes Dry mucus

membranes Irritability Confusion Dizziness Muscle weakness ↓UOP ↑ HR

Acute weight loss (> 2 pounds in a few days) 2.2 pounds (1

Kg) = 1 liter of water

Orthostatic hypotension

BUN/creatinine ratio >25:1

Tachycardia

Diagnosing Dehydration

All must be present to diagnose clinical dehydration: Suspicion of decreased intake or

increased output Two physiologic signs of dehydration

Dehydration

Prevention preferable to treatment! Adequate water intake

Remember: dehydration and malnutrition often go hand in hand

Oral hydration Water Sports drinks

Treatment for dehydration

Goal – replace missing fluid Avoid hypertonic solutions Encourage salt-free oral fluids (serum Na level elevated) IV fluids (hypotonic low-sodium

fluids eg. D5W)

Hypovolemia – isotonic fluid loss (loss of fluids + solutes) from extracellular space.

r/t excessive fluid loss (bleeding) + reduced fluid intake

Third space fluid shift (eg. Ascites- fluid shifts to abdominal cavity)

Check orthostatic B/P

Bladder Function in the Elderly

Diminished bladder control Warning period between desire to

void and micturation is shortened or lost

Nocturnal frequency is common in men and women

Urinary Incontinence

One of the most common conditions in the care of older adults

Related to Cognitive impairments Difficulty in walking Difficulty manipulating clothing Medications

Diuretics Sedatives Hypnotics(Risk factors – Box 9-4 text)

Incontinence Generates feelings of shame, fear, guilt,

dependence Psychological consequences include

anxiety, embarrassment =>depressive symptoms

Social restriction/isolation Avoidance of sexual activity

Physical consequences include Skin problems Pressure ulcers UTIs Falls

Types of Urinary Incontinence

Categorized based on symptoms Stress Urge Overflow Iatrogenic Mixed Functional

Stress Incontinence (Anatomic Incontinence) Involuntary leaking

of urine while exercising, coughing, sneezing, laughing or lifting

Most common type in women Often develops

after child birth In men usually

related to benign prostatic hyperplasia (BPH)

Pressure on bladder causes leaking

Urge Incontinence (Overactive Bladder)

Frequent, sudden urge to urinate with little control of the bladder Especially when

sleeping, drinking, or listening to running water

May also be a sign of UTI or kidney infection Problems caused by oversensitive

bladder

Overflow Incontinence

Incomplete emptying of bladder

Frequent urination and/or constant dribbling of urine

Generally caused by weakened bladder muscle d/t nerve damage including diabetes Bladder doesn't empty completely, leading

to frequent urination or dribbling.

Functional Incontinence

Unable to control bladder before reaching the BR R/t limitations of moving, thinking or

communicating Iatrogenic

Associated with medication side effects

Mixed Incontinence More than one type of incontinence Typically stress incontinence and

urge incontinence

Nursing Interventions Understanding type of incontinence Goal setting

Curing incontinence versus Minimizing effects

Attitude Nurses should not demonstrate:

Acceptance of inevitability of incontinence

Disgust—decreases self-worth of elder and increases dependence

Nurses should: Treat incontinence as curable Adopt a teaching role

Nursing Interventions

Environmental Dietary changes Bowel training Sphincter training exercises Biofeedback training Medication Surgery(see Box9-6 text)

Nursing Care

All health care providers should strive to understand the causes of incontinence, risk factors and evidence-based interventions

Failure to address continence promotion has enormous consequences in terms of economics and burden of care

Fecal Incontinence

Inability to control passage of stool Devastating social implications for

individuals and families Multifactorial

•Intestinal transit time

•Pelvic floor and sphincter tone

•Pelvic musculature

•Rectal sensitivity

•Accessibility of toilet

•Presence of urge

•Medications •Use of laxatives

•Bulk in diet

•Fluid intake •Exercise •Presence of hemorrhoids

Nursing Intervention

Fecal incontinence is symptom, nurses should seek out cause

Attitude Goal setting

Planned Realistic Consistent

Maslow’s Hierarchy Elimination is

key to maintenance of physiologic and biologic integrity

What other implications does it have?

Healthy Skin and Aging

Skin is the largest organ in the body Many purposes

Protects underlying structures Heat-regulating mechanism Sense organ Metabolism of salt and water Stores fat Gas exchange Conversion of vitamin D

Skin

Subject to damage Photo aging

Development of skin cancer Sunscreen

Skin cancers Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma

Other Skin Problems

Seborrheic Keratosis Benign growths

mainly on trunk, face, scalp

Candida albicans Fungal infection Usually found in

folds of skin R/t antibiotics,

steroid use

Carcinomas of the skin

Basal cell –most common malignant skin cancer

Squamous cell 2nd most common skin cancer

Vascular Insufficiency

Leads to complications of skin: mild dermatitis ulcerations gangrene

Arterial insufficiency r/t atherosclerotic plaques ischemia Symptoms:

Pain with exercise Pain at rest

Susceptible to infections 2o to even mild trauma

Affects 10% of those > 65 y.o.

Lower Extremity Arterial Disease

Claudication discomfort, cramps

or pain in the hips, thighs or calves with walking

LEAD Risk Factors

Same as those associated with coronary artery disease Smoking High blood pressure (hypertension) High levels of blood cholesterol or triglycerides

(hypercholesterolemia, hyperlipidemia) Obesity Sedentary lifestyle Diabetes Family history of heart disease or arterial

disease

LEAD Signs & Symptoms

Decreased hair growth on the legs and feet Discoloration of the affected leg or foot when

dangling (from pale to bluish-red) Diminished or absent pulses in the affected leg or

foot Temperature difference in affected leg or foot

(cooler than other extremity) Change in sensation (numbness, tingling, cramping,

pain) Presence of non-healing wound on affected lower

extremity Shrinking of calf muscles Presence of thickened toenails Development of gangrene

Venous Insufficiency—Signs & Symptoms

Symptoms of CVI may include: Varicose veins; Ulceration or skin breakdown; Reddened or discolored skin on the leg; Edema or swelling.

CVI—Risk Factors

CVI can also be caused by: A thrombus, or blood clot, that blocks blood

flow in a vein, called deep vein thrombosis; or Phlebitis, an inflammation of a superficial vein

that causes a blood clot to form. Risk factors may include:

Heredity; Obesity; Pregnancy; Sedentary lifestyle; Smoking; Jobs requiring long periods of standing or

sitting in one place; and Age and sex (women in their 50s are more

prone to developing CVI).

Pressure Ulcers

Pressure ulcers develop as a result of compression between a bony prominence and another hard surface

Serious and costly problems Lead to severe complications and

death

Stage I through IV Pressure ulcer

Stage I Erythemia within 30 minutes of pressure

Stage II Partial thickness loss of epidermis & dermis

Stage III Full thickness loss through to subcutaneous tissue

Stage IV Deep

tissue destruction

Determining Risk for Pressure Ulcers

Important factors Severity of illness Involuntary weight loss

Hypoproteinemia Dehydration Vitamin deficiencies

Braden Scale—risk assessment tool1. Sensory perception2. Skin moisture3. Activity4. Mobility5. Friction and shearing6. Nutritional status (very important)

Nursing Implication

Prevention!! An ounce of prevention is worth a pound

of cure Turning schedule Supportive surfaces Activity level Meticulous cleaning and skin care Nutrition Avoid sedative medications

Feet Number and severity of foot

problems increase with age Nursing assessment can identify

potential problems and actual problems needing attention

Useful guide for assessment in box 11-6

Guide for comprehensive assessment of the lower extremities (LEs) in figure

Nursing interventions

Proper toenail care Reducing dependent edema Promoting foot massage to

stimulate circulation