Older adult

1. Respiratory

1.1. Loss of elasticity and increased rigidity of lung tissue

1.2. Forced expiratory volume reduced

1.3. Blunting of cough and laryngeal reflexes

1.4. Increase in residual capacity

1.5. Alveoli fewer in number and size

1.6. Thoracic muscles more rigid

1.7. Pathology

1.7.1. COPD

1.7.1.1. Asthma

1.7.1.1.1. Higher rates of mortality and cardiac problems

1.7.1.1.2. Nebulizers create risk of cardiac arrhythmia as

1.7.1.2. Chronic bronchitis

1.7.1.2.1. productive cough, wheezing, SOB

1.7.1.2.2. Goal is to remove bronchial secretions

1.7.1.3. Emphysema

1.7.1.3.1. From chronic bronchitis and respiratory irritation

1.7.1.3.2. Tx: postural drainage, bronchodilators, breathing exercises

1.7.1.3.3. Stop smoking

1.7.2. Pneumonia

1.7.2.1. S&S:minimal/no fever or pleuritic pain- confusion, restlessness, cough, fatigue, rapid respiration

1.7.2.2. Pneumococcal vaccine available for over 65

2. Cardiovascular

2.1. Aorta becomes dilated and elongated

2.2. Cardiac output decreases

2.3. Resistance to peripheral blood flow increases

2.4. Less elasticity of vessels

2.5. Valves become thicker and more rigid

2.6. Stroke volume decreases

2.7. Less efficient oxygen utilization

2.8. Pathology

2.8.1. Hypertension

2.8.1.1. SX: Dull headache, impaired memory, disorientation, confusion, epitaxis, slow tremor

2.8.1.2. Reduce sodium intake, possibly reduce weight as well (DASH diet)

2.8.1.3. Medical Tx: antihypertensives, diuretics

2.8.1.4. Nonpharmacologic tx: meditation, yoga, exercise, relaxation fish oil supplements, diet

2.8.2. Coronary Artery Disease

2.8.2.1. Angina: pain may be diffuse and less severe than younger adults

2.8.2.2. SX: vague pain under sternum, coughing, syncope, sweating, episodes of confusion

2.8.2.3. Nitroglycerin is effective- watch for orthostatic hypotension

2.8.2.4. Myocardial Infarction: can be delayed or missed in older adults because of atypical SX and less severe pain

2.8.2.5. SX: pain radiating to left arm, entire chest, neck, jaw and abdomen. Confusion, pale skin, decreased BP

2.8.2.6. Encourage early ambulation after MI- prevents immobility complications and better for heart workload

2.8.2.7. Close observations for signs of bleeding, edema or CHF

2.8.3. CHF

2.8.3.1. Leading cause of hospitalization in older adults

2.8.3.2. CAD and HTN are major causes

2.8.3.3. SX: dyspnea on exertion, confusion insomnia, wandering during night, aviation, SOB, weakness

2.8.3.4. Moist crackles heard ok auscultation

2.8.3.5. TX: bed rest, medications, reduce sodium intake, (encourage pt to sit in chair instead of bed)

3. Endocrine

3.1. Thyroid gland undergoesfibrosis

3.2. Lower basal metabolic rate

3.3. Reduction in triiodothyronine (T3)

3.4. ACTH Secretion decreases

3.5. Pituitary gland decreases in volume

3.6. Delayed and insufficient release of insulin by beta cells

3.7. PATHOLOGY

3.7.1. Diabetes mellitus

3.7.1.1. Affects 20% of older population

3.7.1.2. Diagnosis: fasting blood glucose >126, random blood glucose >200, HbA1c>6.5%

3.7.1.3. Patient education is critical in treatment

3.7.1.4. Drug therapy includes oral anti diabetics (metformin, sulfonylurea, acarbose,

3.7.1.5. Can lead to: PVD, retinopathy to blindness

3.7.2. Hypothyroidism

3.7.2.1. Primary: low T4, high TSH, secondary: low T4, low TSH

3.7.2.2. More common than hyper, more common in women

3.7.2.3. SX: fatigue/weakness, depression, Anorexia, weight gain, impaired hearing, edema, constipation, cold intolerance

3.7.2.4. TX: replacement of thyroid hormone (low dose initially to higher dose)

4. Integumentary

4.1. Reduced thickness and vascularity of dermis

4.2. Collagen fibers become coarser

4.3. Reduced skin elasticity

4.4. Lines, wrinkles, sagging become evident

4.5. Increased presence of age spots due to clustering of melanocytes

4.6. Hair thins and grays due to loss of pigment cells

4.7. PATHOLOGY

4.7.1. Pruritus

4.7.1.1. RF: diabetes, arteriosclerosis, hyperthyroidism, uremia, liver disease, cancer, pernicious anemia, excessive bathing

4.7.1.2. Prompt recognition to treat dry skin or underlying problem

4.7.1.3. Vitamin supplements and vitamin rich diets are encouraged

4.7.1.4. Meds: topical zinc oxide, antihistamines, topical steroids

4.7.2. Vascular lesions

4.7.2.1. Stasis ulcers

4.7.2.1.1. Control infections, remove necrotic tissue to facilitate healing

4.7.2.1.2. Leg ulcers from stasis dermatitis

4.7.2.1.3. Good nutrition and high vitamins

4.7.2.1.4. Promote venous return by elevating legs and wearing elastic stockings

4.7.2.2. Pressure injury (ulcer)

4.7.2.2.1. Pressure leads to tissue anoxia and ischemia resulting in necrosis, sloughing and ulceration of tissue

4.7.2.2.2. RF: fragile skin that damages easily, poor nutrition, reduced sensation and pain, typically more immobile

4.7.2.2.3. Require longer to heal than younger persons— PREVENT

4.7.2.2.4. Sometimes need more frequent movement than turning every 2 hours, avoid shearing forces, use pillows/water beds/pads,

4.7.2.2.5. Sheets should be wrinkle free and free of foreign bodies

4.7.2.2.6. High protein, vitamin rich diet, skin clean and dry

5. Reproductive

5.1. M: reduction in sperm count

5.2. M: prostate enlarges

5.2.1. Leads to BPH

5.3. M: venous/arterial sclerosis of penis

5.4. F: fallopian tunes and uterus atrophy

5.5. F: Ovaries become thicker and smaller

5.6. F: Cervix and uterus become smaller

5.7. F: Drier, less elastic vaginal canal

5.8. PATHOLOGY: female

5.8.1. Vaginitis

5.8.1.1. SX: soreness, pruritus, burning, reddened vagina, foul smelling vaginal discharge

5.8.1.2. TX: estrogens in suppository creams, avoid douches, perfumed soaps

5.8.2. Cancer of cervix

5.8.2.1. SX: vaginal bleeding and leukorrhea, pain is not a SX, can develop urinary retention and incontinence, fecal incontinence

5.8.2.2. TX: radium or surgery

5.8.2.3. Women over 65 years should have regular screening

5.8.3. Cancer of breast

5.8.3.1. Second leading cause of cancer deaths for women

5.8.3.2. Regular breast exams and self exams

5.9. PATHOLOGY: male

5.9.1. Erectile dysfunction

5.9.1.1. Causes: alcoholism, diabetes, dyslipidemia, hypertension,hypogonadism, multiple sclerosis, renal failure, thyroid conditions

5.9.1.2. TX: oral agents (sildenafil, vardenafil, tadalafil), drugs injected into penis, penile implants, vacuum pump devices

5.9.2. Benign prostatic hyperplasia

5.9.2.1. SX: hesitancy, decreased force ofurinary stream, frequency, and nocturia, dribbling may occur, overflow incontinence, bleeding

5.9.2.2. TX: prostatic massage, urinary antiseptics, urethral surgery,

6. Gastrointestinal

6.1. Decreased taste sensation

6.2. Esophagus more dilated

6.3. Reduced saliva and salivary ptyalin

6.4. Liver smaller

6.5. Reduced intestinal blood flow

6.6. Decreased esophageal motility

6.7. Less production of HCl, pepsin, lipase, and pancreatic enzymes

6.8. Fewer cells on absorbing surface of intestines

6.9. PATHOLOGY

6.9.1. Periodontal disease

6.9.1.1. Predispose older adults to systemic infection

6.9.2. Dysphagia

6.9.2.1. GERD is major cause

6.9.2.2. Prevention of aspiration and promotion of adequate nutritional status are major goals

6.9.2.3. Soft diet, thickened liquids recommended, eat in upright position, small bites

6.9.2.4. Have suction available in case of choking!!

6.9.3. Diverticular disease

6.9.3.1. Multiple pouches of intestinal mucosa of large bowel

6.9.3.1.1. Inflammation and infection lead to diverticulitis

6.9.3.2. SX: slight bleeding, constipation/diarrhea, tenderness of LLQ

6.9.3.3. Common problem in western societies from low fiber/residue diets

7. Urinary

7.1. Decreased size of renal mass

7.2. Decreased tubular function

7.3. Decreased bladder capacity

7.4. Decrease in nephrons

7.5. GFR decreases

7.6. Weaker bladder muscles

7.7. PATHOLOGY

7.7.1. urinary tract infections

7.7.1.1. Most common infection of older adults

7.7.1.2. Result from poor hygiene, prostate problems, catheterization, dehydration, diabetes, arteriosclerosis, neurogenic bladders

7.7.1.3. SX: burning, urgency, fever, incontinence, delirium

7.7.1.4. Carefully watch intake and output!

7.7.1.5. Severe UTIs can lead to septicemia and prostatitis (men)

7.7.1.6. Avoid catheterization at all costs

7.7.2. Incontinence

7.7.2.1. Stress

7.7.2.1.1. Weak support in pelvic muscles

7.7.2.2. Urgency

7.7.2.2.1. Spasms of bladder

7.7.2.3. Overflow

7.7.2.3.1. Bladder neck obstructions or meds

7.7.2.4. Neurogenic

7.7.2.4.1. Reflex, problem with neural pathway

7.7.2.5. Functional

7.7.2.5.1. Inability to reach bathroom

7.7.2.6. Mixed

7.7.2.6.1. Combination

8. Musculoskeletal

8.1. Shortening of vertebrae

8.2. Bones more brittle

8.2.1. Increased risk for injury

8.3. Slight knee, hip, and wrist flexion

8.4. Slight kyphosis

8.5. PATHOLOGY

8.5.1. Fractures

8.5.1.1. Trauma, cancer metastasis to bone, osteoporosis contribute to fractures

8.5.1.2. Neck of femur and distal radius are common fractures

8.5.1.3. Heal at slower rates and lead to immobility

8.5.1.4. Avoid risky activities, prevent orthostatic hypotension, proper shoe wear, safety supports in home

8.5.1.5. SX: pain, change in shape/length of limb, restricted motion of limb, edema, discoloration

8.5.2. Osteoarthritis

8.5.2.1. Progressive deterioration of joint cartilage

8.5.2.2. Leading cause of disability in older adults

8.5.2.3. No inflammation (unlike rheumatoid arthritis)

8.5.2.4. Excessive use of joint, trauma, obesity, low vitamin D levels, and genetic factors can predispose

8.5.2.5. SX: crepitus, bony nodules, more uncomfortable during damp weather and with extended use,

8.5.2.6. Acetaminophen is first drug choice

8.5.2.7. Rest, heat/ice, tai chi, aqua therapy, acupuncture

8.5.2.8. Arthroplasty may be recommended if other treatments do not work

8.5.3. Rheumatoid arthritis

8.5.3.1. Most develop earlier in life, before 65

8.5.3.2. Inflammation of synovial fluid causing pain and edema

8.5.3.3. SX: pain during rest and activity, swollen, red, warm, fatigue, malaise, weakness, weight loss, fever, anemia

8.5.3.4. Anti-inflammatory meds, corticosteroids, immunosuppressive drugs,

8.5.3.5. Foods to avoid: potatoes, peppers, eggplants, tomatoes

8.5.3.6. Herbs to improve SX: green tea and ginger

9. Nervous

9.1. Decreased conduction velocity

9.2. Decreased brain weight

9.3. Reduced blood flow to brain

9.4. Changes in sleep pattern

9.5. Slower response and reaction time

9.6. PATHOLOGY

9.6.1. Parkinson’s disease

9.6.1.1. Impaired function of basal ganglia, imbalance of dopamine and acetylcholine cause problems with motor control

9.6.1.2. More common in men, most frequently after 5th decade

9.6.1.3. Faint tremor is first sign, followed by muscle rigidity and weakness

9.6.1.4. Bradykinesia and poor balance, shuffling gait is key sign

9.6.1.5. Meds: carbidopa/levodopa, dopamine agonists, anticholinergics

9.6.1.6. Active/passive ROM, warm baths, massages all help with muscle rigid diet and prevention of contracture

9.6.2. Cerebrovascular accident

9.6.2.1. Third leading cause of death, major cause of disability

9.6.2.2. RF: HTN, severe arteriosclerosis, diabetes, gout, anemia, hypothyroidism, TIAs, smokers

9.6.2.3. Ischemic (thrombus/embolus) more common, also hemorrhagic from ruptured cerebral blood vessel

9.6.2.4. SX: hemiplegia, hemianopsia, aphasia, dizziness, headache, drop attack

9.6.2.5. Recovery: after acute care, physical/speech therapy

10. Sensory

10.1. Eyes

10.1.1. More opaque lens

10.1.2. Decreased pupil size

10.1.3. More spherical cornea

10.1.4. PATHOLOGY

10.1.4.1. Cataracts

10.1.4.1.1. Clouding of lens

10.1.4.1.2. Leading cause of low vision

10.1.4.1.3. Proper use of sunglasses helps to prevent cataracts

10.1.4.1.4. SX: night vision decreased, feeling of film over eye, glare from sunlight/bright lights, eventually pupil turns from black to cloudy white

10.1.4.2. Glaucoma

10.1.4.2.1. Acute (closed angle)

10.1.4.2.2. Chronic (open angle)

10.2. Smell

10.2.1. Impaired ability to identify and discriminate among odors

10.3. Taste

10.3.1. Taste impairment

10.3.2. Usually from reasons other than normal aging

10.4. Touch

10.4.1. Reduction in tactile sensation

10.5. Ears

10.5.1. Atrophy of hair cells of organ of Corti

10.5.2. Tympanic membrane sclerosis and atrophy

10.5.3. Increased cerumen and concentration of keratin

10.5.4. PATHOLOGY

10.5.4.1. Hearing loss

10.5.4.1.1. Exposure to noise, recurrent otitis media, certain drugs can all impair hearing

10.5.4.1.2. Vascular probs, viral infections, presbycusis affect inner ear

10.5.4.1.3. Encourage audio metric examination

10.5.4.1.4. Hearing aids: come in variety of forms, help with issue do not completely solve it

11. Sexuality

11.1. Menopause

11.2. Andropause

11.3. Decrease in sexual responsiveness and a reduction in the frequency of orgasm

11.4. Older men are slower to erect, mount, and ejaculate

11.5. Older women may experience dyspareunia (painful intercourse) as a result of less lubrication

11.6. Many older women gain a new interest in sex

11.7. PATHOLOGY

11.7.1. HIV

11.7.1.1. Incidence increasing twice as quickly in patients over 50

11.7.1.2. 44% are among gay/bisexual men

11.7.1.3. Less use of condoms because no risk of becoming pregnant

11.7.1.4. Many embarrassed to seek treatment, symptoms may not be recognized as HIV because of common aging problems

12. Sleep

12.1. Insomnia

12.1.1. Difficulty falling asleep or staying asleep

12.2. Phase advance

12.3. More time in stage 1-2, less time in REM (stage 3-4)

12.4. Sleep latency

12.4.1. Delay in onset of sleep, more sensitive to noises while sleeping

12.4.2. Nurses should be aware and limit noisy activities at night

12.5. PATHOLOGY

12.5.1. Restless leg syndrome

12.5.1.1. Uncontrollable urge to move the legs

12.5.1.2. Uncomfortable, electrical, itching, pins and needles, pulling, painful

12.5.1.3. Causes: iron deficiency anemia, uremia, Parkinson’s disease, rheumatoid arthritis, diabetes, neurological lesions

12.5.1.4. TX: dopaminergic drugs, benzodiazepines, opioids, anticonvulsants, adrenergic, iron supplements

12.5.2. Sleep apnea

12.5.2.1. At least 5 episodes of cessation of breathing, Lawton at least 10 seconds, occur per hour of sleep, accompanied by day time sleepiness

12.5.2.2. Snoring accompanies this

12.5.2.3. Sleep disorder clinics and TX: weight reduction, medications, continue Luis positive airway pressure, surgery

12.5.2.4. Can be caused by defect in CNS, blockage in upper airway, or mixed

13. Immunity

13.1. Decline in immune function

13.1.1. Reduced antibody response

13.2. High prevalence of chronic conditions

13.3. Thymus gland decreases in size

13.4. T-cell function declines

13.5. Reduced thickness of skin, decreased circulation of skin

13.6. PATHOLOGY

13.6.1. Cancer

13.6.1.1. Changes in immune system impair body’s ability to recognize cancerous cells and destroy them

13.6.1.2. Prolonged closure to carcinogens

13.6.1.3. Additional screening with increased age

13.6.1.4. Conventional treatment: surgery, radiation, chemotherapy, biological therapy

13.6.1.5. Complementary therapy: special diets, psychotherapy, spiritual practices, vitamin supplements, herbal remedies