Physiologic Changes of Aging

1. Gerontological & Community Based Nursing: Physiologic Changes of Aging

2. 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)

3. 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

5. Nutrition concerns Two major concerns: • Obesity – exacerbates age related health issues> type II diabetes, CAD, osteoarthritis, ↓ mobility, • Malnutrition – often unrecognized • Precursor to frailty

6. Malnutrition in older adults Protein – Calorie Malnutrition PCM most common type of malnutrition c/b muscle wasting, low BMI; ↓albumin /serum proteins 50% nursing home; 50% hospitalized 44% home health elders - malnourished

7. Malnutrition - Risk factors • Psychosocial • Mechanical

8. “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

9. 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

10. 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)

11. 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

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

13. Medications Diuretics Sedatives Antipsychotics ETOH abuse Dementia Self feeding defecits Immobility Fever Diarrhea Factors that contribute to Dehydration

14. 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 Physiologic Signs of Dehydration

15. Diagnosing Dehydration • All must be present to diagnose clinical dehydration: • Suspicion of decreased intake or increased output • Two physiologic signs of dehydration

16. Dehydration • Prevention preferable to treatment! • Adequate water intake • Remember: dehydration and malnutrition often go hand in hand • Oral hydration • Water • Sports drinks

17. 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)

18. 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

19. 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

20. 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)

21. 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

22. Types of Urinary Incontinence • Categorized based on symptoms • Stress • Urge • Overflow • Iatrogenic • Mixed • Functional

23. 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)

24. 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

25. 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

26. 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

27. 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

28. Nursing Interventions • Environmental • Dietary changes • Bowel training • Sphincter training exercises • Biofeedback training • Medication • Surgery (see Box9-6 text)

29. 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

30. Fecal Incontinence • Inability to control passage of stool • Devastating social implications for individuals and families • Multifactorial

31. Nursing Intervention • Fecal incontinence is symptom, nurses should seek out cause • Attitude • Goal setting • Planned • Realistic • Consistent

32. Maslow’s Hierarchy • Elimination is key to maintenance of physiologic and biologic integrity • What other implications does it have?

33. 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

34. Skin • Subject to damage • Photo aging • Development of skin cancer • Sunscreen • Skin cancers • Basal Cell Carcinoma • Squamous Cell Carcinoma • Melanoma

35. 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

36. Basal cell –most common malignant skin cancer Squamous cell 2nd most common skin cancer Carcinomas of the skin

37. 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.

38. Lower Extremity Arterial Disease • Claudication • discomfort, cramps or pain in the hips, thighs or calves with walking

39. 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

40. 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

41. 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.

42. 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).

43. 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

44. Stage I through IV Pressure ulcer

45. Stage IErythemia within 30 minutes of pressure Stage II Partial thickness loss of epidermis & dermis Stage III Full thicknessloss through to subcutaneous tissue Stage IV Deep tissue destruction

46. Determining Risk for Pressure Ulcers • Important factors • Severity of illness • Involuntary weight loss • Hypoproteinemia • Dehydration • Vitamin deficiencies • Braden Scale—risk assessment tool • Sensory perception • Skin moisture • Activity • Mobility • Friction and shearing • Nutritional status (very important)

47. 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

48. 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

49. Nursing interventions • Proper toenail care • Reducing dependent edema • Promoting foot massage to stimulate circulation