Exam 1

chronologic age

length of time since birth

perceived age

people’s estimation of someone’s age

subjective age

person’s perception of their age

functional age

• reflects the cumulative effect of medical & psychosocial stressors on the aging process 

• More clinically relevant 

ageism

stereotypes or generalizations (usually negative) applied to older adults grounded on the basis of age

aging anxiety

fears and worries regarding detrimental effects associated with aging

age attributions

tendency to automatically attribute problems to aging process instead of pathologic treatable conditions

• Examples: problems with memory discounted as “a senior moment” or complaints of pain as “part of getting older” 

myths

• By 75 yrs, people are quite homogeneous as a group 

• Families no longer care for older people 

• By age 70 yrs, psychological growth is complete 

• Increased disability is due to age-related changes 

• Most older adults are constipated primarily due to age-related changes

realities

• Older adults are diverse with different values and lifestyles just like young people 

• In the US, 80% of older adults’ care is provided by their families 

• Some brain functions decline but others continue to develop 

• Many problems attributed to old age are pathological and respond to treatment 

• Constipation is prevalent among older adults primarily due to risk factors and pathological changes

gender distributions of aging

• Women live longer 

• At age 65 or older 

• 23 million women (57%) 

• 17.5 million men (43%) 

• Age 85 or older 

• 70% are women 

• Men who are alive are more likely to be married 

change in cultural groups in older adults

• Trend toward population aging: 

  • ↑ racial/ethnic diversity 

  • ↑ proportion of foreign-born older adults (14% of older adults are foreign born) 

• Cultural diversity implications: 

  • Values, communication, health beliefs & health behaviors are affected 

african americans

• Heterogeneous, have a wide range of socioeconomic conditions 

• Less likely to live alone, may have multi-generational household 

• Consequences of racism are still present and linked to health disparities 

• Factors contributing to poor health outcomes include discrimination, cultural barriers, and lack of access to health care. 

• Suspicion of health care providers linked to history of disparities 

• Trusted leaders/providers in community provides pathway to care—sometimes associated with religious institutions 

asian americans

• There is a large amount of diversity within the group

• Strong value on care of older family members 

• Less likely to use nursing homes 

• More accepting of mental decline in older adult 

• Health is physical and spiritual harmony 

hispanic american

• Diverse group 

• Strong cultural respect for family and for older people 

• Older adults frequently live with family members 

• Health is a gift or reward given as G-d’s blessing 

• Most in US speak both Spanish and English

native

• Value older members of the community, particularly with regard to their roles as grandparents and story tellers. 

• Strong traditions related to spirituality and religious practices, with each tribe having unique expressions 

• Belief in the connection among body, mind, and spirit 

• High rates of all of the following conditions: diabetes, tuberculosis, heart disease, substance abuse, and certain cancers (e.g., liver, cervix, kidney, gallbladder, and colorectal 

• Poorer health associated with low economic conditions, cultural barriers, access to care, and mistrust of health providers 

strategies to mitigate bias

• Cultural Self-Assessment: 

  • An awareness-raising tool for gaining insight into the health-related values, beliefs, attitudes, and practices that have shaped and informed the person the nurse has become when providing care 

• Leverage available resources to learn more about cultural groups that are 

• frequently under your care 

• Ethnogeriatrics

  • the component of geriatrics that integrates the influence of race, ethnicity, and culture on health and well-being of older adults (1987). 

• Realize that educational materials about cultural groups provide general info about particular groups, but each group is made up of unique individuals. 

• Hence, the info should be used as a beginning point for a personalized assessment 

• All health care professionals are encouraged to contact local organizations to obtain culturally specific information about groups that reside in their locale 

Healthy aging

no illness and preserved function

Active aging

high physical and cognitive function

Productive aging

social participation & engagement

Effective aging

the capacity to manage age related life challenges

Successful aging

full concept of aging well 

compression of morbidity

Delay of onset of morbidity to shorten the time that morbidity is acquired between onset and death 

wear and tear theory

Human ‘machine’ declines over time. Longevity affected by genetics & care provided

free radical theory

• organisms age because they accumulate oxidative damage. Fix with antioxidants 

  • vitamins 

Immunosenescence theory

Age-related decline in immune system heightens susceptibility, may lead to autoimmune conditions such as RA 

program theory

• lifespan of every species/cell predetermined by a genetic program 

Caloric restriction theory

Reducing calorie intake by 30-40% without malnutrition ↑lifespan in animals

relevance of biologic theories

• Primary role: identify and address modifiable factors that lead to diseases, disability, death, as well as health-promoting factors 

• Nurses need to understand not only the relationship between aging and disease but also what “causes” healthy aging and longevity 

• Nurses serve as teachers and advocate for older adults 

• Attitudes of health care professionals 

• Perspective of “what do you expect, you’re old” interferes with treatable conditions 

• Attitude of hopelessness with subscribing to aging as a fatal disease 

activity theory

older people remain socially and psychologically fit if they are actively engaged in life. Volunteering improves QoL

subculture theory

old people interact more among themselves, & status is based on health & morbidity

age stratification theory

address interdependencies between age as an element of the social structure and the aging of people in cohorts as a social process

person environment fit theory

Older individuals with functional limitations need to adapt to their environments in order to remain independent 

relevance of sociological theories

• View older adults in relation to society and environments 

• A better understanding of influences, e.g., culture, family, education, community, ascribed roles, cohort effects, home & living settings, personal & political economics 

• Emphasizes the importance of assessing environmental factors that influence the functioning of an older person

life course theories

• Maslow Human Needs Theory: address the concepts of motivation and human needs

  • Hierarchical order of basic human needs 

• Erikson’ life-course theory: 8 stages of life 

  • Trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. identify diffusion, intimacy vs. self-absorption, generativity vs. stagnation, and ego integrity vs. despair 

psychological theories

• The theory of selective optimization with compensation 

  • Older adults can search for goals while disassociating from others and find resources for those goals 

  • Can compensate for reduced skills with other skills 

    • Hearing aids 

• Socio-emotional selectivity theory 

• Gero-transcendence theory: shifting from materialistic to a transcendent vision (1990) 

relevance of psychological theories

• Nurses can use psychological theories to address response to losses, continued emotional development 

• Maslow’s hierarchy of needs framework is useful for conceptualizing the nature of interventions in institutional or home settings 

• Devoting time and energy to life review and self-understanding can be beneficial for older adults 

• Nurses can facilitate this process by asking sensitive questions and by listening attentively to older adults as they share information about their past 

• Reminiscence: positive experience

Functional consequences theory

• a framework to promote wellness, function, and quality of life for older adults 

• Reflects the evolving understanding of wellness as integral aspect of focused care of older adults 

• Goal: address unique relationships among concepts of person, health, nursing, and environment in context of promoting wellness for older adults

age related changes with FTC

• Age-related changes are inevitable, irreversible & progressive and are not caused by extrinsic or pathologic conditions 

• On physiologic level: changes are typically degenerative 

• On psychological & spiritual levels: potential for growth 

underlying concepts for FTC

• Age-related changes & risk factors increase vulnerability to negative functional consequences 

• Nurses assess age-related changes, risk factors, and functional consequences 

• Goal: to identify factors that can be addressed through nursing interventions 

• Wellness outcomes enable functioning at the highest level despite presence of age-related changes & risk factors 

FTC risk factors

• Conditions that are likely to occur in older adults and have a significant detrimental effect on their health and functioning 

• Sources of risk factors: environments, acute and chronic conditions, psychosocial conditions, or adverse medication effects 

• Risk factors can be modified or eliminated to improve functioning and quality of life for older adults 

• A major focus of wellness-focused nursing is to identify risk factors that can be addressed through health promotion interventions 

functional consequences

• Observable effects of actions, risk factors, and age-related changes that influence the quality of life or day-to-day activities of older adults. 

• Actions: purposeful interventions initiated by either older adults (i.e., self-care) or nurses (i.e., nursing interventions) and other caregivers. 

• Risk factors can originate in the environment or arise from physiologic and psychosocial influences. 

• Negative functional consequences: interfere with a person’s level of function or quality of life or increase a person’s dependency 

• Positive consequences: facilitate the highest level of performance and the least amount of dependency 

wellness outcomes

• Context of the interplay among the many factors that influence health and aging 

• Determinants of living long and well: 

• Inherit good genes 

• Avoid oxidative damage 

• Protect from oxidative damage with antioxidants from natural sources 

• Maintain optimal weight 

• Engage in physical exercise 

• Engage in meaningful social interactions 

• Develop close personal relationships 

• Maintain a sense of spiritual connectedness 

• Reject ageist stereotypes 

wellness outcome for MS changes

Decrease fall incidence and improve MS function 

ADLS vs IADLS

ADLS

• Dressing, Eating, Toileting, Bathing

IADLS

• cooking, transportation, managing finances

assessing decision making capacity

• Occurs over time -- not a one-time occurrence 

• Decisional Capacity may fluctuate “window of lucidity” 

• Decision specific & directly related to risk

• MacArthur Competency Assessment Tool for Treatment (MacCAT-T) is widely used 

• Nursing responsibility – document specifically and descriptively what are patient’s/surrogate’s understanding & wishes 

Elder Abuse

• a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship, or 

• b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm. 

• Any knowing, intention, or negligent act that causes harm or a serous risk of harm to a vulnerable older adult 

Physical Abuse

• Inflicting pain or injury on an older adult 

• Hitting, slapping, punch, kicking, bruising, restraining by physical or chemical means 

• Signs 

  • Broken bones 

  • Bruises 

  • Head trauma

  • Bruising on areas of body like abdomen/back 

  • Signs of strangulation

  • Inconsistent stories or stories that don’t line up 

Sexual Abuse

• Nonconsensual sexual contact 

• Remember that those with neurocognitive disorders may not be able to give consent 

• Signs: 

  • Unexplained STIs 

  • Bruises on thighs/genitals 

  • Bleeding on thighs/genitals 

  • Inappropriate relationships between caregiver and elder

Financial Abuse

• Illegal taking, misuse, or concealment of funds/property/assets of an older adult for someone’s benefit 

• Signs: 

  • Large sums of money missing from bank statements 

  • Cannot access own bank records 

  • Provides monetary gifts in exchange for companionship 

  • Unexplained transactions 

Emotional Abuse

• Inflicting mental pain, anguish, instilling fear or distress on an older adult through verbal or nonverbal acts

• Signs:

  • Hesitation to talk freely

  • Isolation

  • Suffering from anxiety/depression

Neglect

• Failure to provide food, shelter, healthcare, or protection to a vulnerable older adult by the caregiver

• Signs:

  • Pressure ulcers

  • Lack of basic hygiene

  • Missing medical supplies (walkers, dentures, medications)

  • Uninhabitable living condition

Abandonment

• Desertion of vulnerable older adult for anyone who has assumed the responsibility or custody of care of the individual

• Signs:

  • Being left alone without food

  • If they cannot care for themselves and are left alone

Scams

• Phone and email scams are incredibly prevalent

• Important to educate the older adult about to help avoid becoming the victim of this type of elder abuse

Self-neglect

• Failure of a person to perform essential self-care tasks

• Threatens their own health/safety

• Signs:

  • Failure to thrive

  • Can warrant involuntary hospitalization

risk factors for elder abuse

• Functional dependence or disability

• Poor physical health

• Cognitive impairment

• Low income

• Being Female

• Financial Dependence

• Race/ethnicity (Hispanic experience lowest rate of elder abuse)

• Perpetrator risk factors

  • Ageism

  • Cultural norms

• Perpetrator Risk factors

  • Mental health issues

  • Substance use issues

  • Dependency on older adult

  • Ineffective coping – high rates of stress

elder abuse screening

• United States Preventive Services Task Force

  • Insufficient evidence to recommend for or against routine screening for elder

    abuse

  • Only recommended in pregnant women/women of childbearing age

• Screening tool: Elder Mistreatment Assessment

• Patients should be interviewed by themselves to avoid intimidation by possible abusers

• Asked about family situation and living arrangements

• Patients should be asked directly about abuse, neglect or exploitation:

  • Has anyone at home ever hurt you?

  • Has anyone ever touched you without your consent?

  • Has anyone taken anything that was yours without asking?

  • Are you alone a lot of the time?

• Should look for indicators of abuse, including poorly explained injuries; evidence of neglect

  • (dehydration, malnutrition, poor hygiene, lack of medical compliance); isolation; fear of a caretaker; or transfer of funds to a caretaker

nurse responsibilities

• Mandated Reporting

  • Any person having reasonable cause to believe that an older adult, or someone within the state who is 60 years of age or older, is in need of protective services may report such information to the agency which is the local provider of protective services

• The first obligation of nurse is to assure the safety of the older adult.

  • A home visit may sometimes be needed to make that determination → collaboration with case managers, community workers, etc.

  • Adult Protective Services reporting

Reserve

inherent ability to maintain homeostasis amidst external stressors

Resilience

ability to recover quickly from illness

Atypical presentation

vague presentation, altered presentation or non-presentation of illness

vital sign changes

• Core body temperature

  • Circadian fluctuation less pronounced.

  • Reduction in fever response—slight increase in temp may indicate serious infection in the oldest

• Resting heart rate often slightly higher.

  • Maximal heart rate decreases.

  • Heart rate variability decreases – decreased ability to respond to stress

• Apical pulse more accurate.

• Respiratory rate generally unchanged at rest; increase to compensate for decreased minute volume.

  • Increases risk for pulmonary infection.

• Blood pressure – systolic hypertension with widened pulse pressure often occurs.

  • Arterial wall stiffness requires higher pressures to achieve forward flow.

  • Decline in autonomic sensitivity—increased risk for hypotension

    • Worry about high diastolic

cosmetic changes

• Skin becomes fragile, loose, and transparent (hands/forearms); purple patches/macules called actinic purpura are frequently seen.

• Risk for skin tears increases.

• Nails lose luster, yellow, and thicken, especially toes

• Hair loses pigment and hairline recedes; also loss of hair occurs elsewhere such as trunk, pubic area, axillae and limbs, which is normal

• Turnover rate of cells decreases with age –takes longer to re- epithelialize, i.e. wounds take longer to heal

sensory changes

• eyeballs recede into orbit 

• corneas lose luster 

• pupils become smaller 

• dry eyes are a common complaint 

• presbyopia occurs to nearly everyone. 

• Need for “Readers” 

respiratory function

• Clinical implications of age-related changes: 

• ↓Cough & gag reflexes 

  • Increased risk of aspiration pneumonia 

• Compromised chest expansion. 

• ↑Use of accessory muscles. 

• ↓Efficiency of gas exchange. 

• Diminished lung sounds. 

• No effect in daily functional activity 

• Diminished pulmonary reserve: fatigue with stressors, ↑risk of infection 

• Risk Factors 

  • Tobacco use 

  • Secondhand smoking 

  • Lack of immunization (e.g., pneumonia & influenza vaccine) 

  • Immobility 

  • Exposure to air pollution 

• Pathological conditions 

  • COPD/Other lung diseases (e.g., URTI, pneumonia, etc)

cardiac changes

• Arteries with less elasticity -increased peripheral resistance- Increase in BP 

• Decreased ability to compensate to stressor 

• Decreased cardiac contractility- cardiac output 

• Decrease integrity of heart valves 

• No effect in daily functional activity 

• These result in decrease in cardiac reserve: 

  • ↓Exercise tolerance 

  • Fatigue, SOB with exercise 

  • Slower recovery from tachycardia 

  • Intolerance of volume depletion 

GU changes

Kidneys 

• Decrease in volume and weight of the kidneys 

• Decline in the total # of glomeruli Decreased GFR 

  • 80 yr old – 50 

  • 90 yr old – 40 

  • Normal is greater than 60 

• Decreased creatinine clearance  risk of drug toxicity 

Bladder 

• Bladder capacity decreases 

• Decrease in detrusor muscle contractility 

• Alterations in sensation of needing to void 

Prostate 

• Proliferation of prostate epithelial and stromal tissue, known as benign prostatic hyperplasia, 90% of men >age 80 have symptomatic BPH 

genitalia changes

• Female genitalia: menstrual periods cease between ages 48 and 55; women often experience hot flashes for up to five years and may have vaginal dryness, incontinence, or dyspareunia; within 10 years, the ovaries are usually no longer palpable 

• Male genitalia: sexual interest remains intact with aging but frequency declines; ; gradual decline in fertility; decreased sperm production; erection is more dependent on tactile stimulation 

endocrine changes

• Progressive deterioration in number and function of insulin- producing beta cells 

• Decrease in lean body mass with relative increase in adiposity 

• Increased insulin resistance 

• Decrease in renal concentrating function with even mild hyperglycemia can lead to osmotic diuresis 

• May develop (transient) hyperglycemia especially with stress (surgery) 

MS changes

• Significant shortening becomes obvious in old age with most loss of height occurring in the trunk as intervertebral discs become thinner and vertebral bodies shorten/collapse from osteoporosis 

• Bone loss: increased bone resorption, diminished calcium absorption, impaired regulation of osteoblast activity 

• Skeletal muscles decrease in bulk and power: size & number of fibers, loss of motor neurons, replacement of muscle tissue by connective tissue, eventually fat tissue 

• Joints: range of motion diminishes 

nervous system changes

• Aging may affect all aspects of the nervous system, from mental status to motor and sensory function and reflexes 

  • Reaction times decrease – issues driving 

• Most older adults do well on mental status exam, but selected impairments become evident 

• Nerve cells in the brain decrease  a small loss of brain mass 

• Decrease in the synthesis & metabolism of the major neurotransmitters 

• Autonomic nervous system performs less efficiently  orthostatic hypotension 

• Neurologic changes affect gait and balance 

GI changes

• Dysphagia (difficulty swallowing) 

• Gastric mobility slow modestly -> delayed emptying of stomach contents and early satiety 

• Constipation is not a normal aspect of aging even though gastric motility slows 

• Diminished secretion of gastric acid and pepsin, result of pathologic conditions rather than normal aging 

• Diminished absorption of nutrients in the small intestine (calcium and vitamin D) 

• At increased risk of constipation (constipation is still not normal)

health promotion

• Patient Centered Decision Making 

• Risks and Benefits 

• Cultural and Socioeconomic Considerations 

• Silver Sneakers and other Medicare Programs availible 

orthostatic hypotension

• A drop in SBP by ≥20 mmHg or DBP by ≥ 10 mmHg within 3 mins of standing from a supine or sitting position 

• Affects >30% of older adults. May lead to falls,↓ function & ↓ QoL 

• Orthostatic vital signs are indicated for: 

• Patients at risk for falls, hypovolemia 

• History of syncope or near syncope (dizziness, fainting) 

 Management

• Drink 1.5-2 L of water/day 

• Avoid excess alcohol 

• Incorporate more salt into diet if no other contraindications 

• When waking in the morning, sit on the edge of the bed for 5 min before standing 

• Sleep with head of bed elevated 15-20 degrees 

• Wear compression socks 

• Perform calf exercises 

postprandial hypotension

• a condition in which there is a systolic blood pressure drop of 20mm Hg in a supine/sitting position within 120 minutes after eating a meal. 

• PPH occurs more often than postural hypotension (PH), and infrequently together with PH, among older adults. 

• Studies from long-term care facilities suggest prevalence of PPH at 24-36% 

Management 

• Adjust activities around meals, lying down or walking may help after meals 

• Adjust drug timing: should not take antihypertensive drugs within an hour before meals 

• Eating small, low-carbohydrate meals more frequently rather than large meals 

• Avoid alcohol before and after meals 

Changes in renal function

• ↓ renal blood flow 

• ↑ half life of many drugs 

• ↓ GFR & renal tubules function 

• After age 40, creatinine clearance ↓ an average of 8 mL/min/1.73 m2/decade 

• Note: Despite the ↓ Cr clearance, older adults' serum Cr may be normal because they produce less creatinine. It is critical to evaluate creatinine clearance: Cockcroft and Gault equation:  CrCl = [(140 - age) x IBW] / (Scr x 72) (x 0.85 for females): 

Hepatic changes

• ↓ hepatic blood flow 

• ↓ first pass effect 

• ↓ Detoxification & conjugation 

• Changes in enzymatic function esp. cytochrome P-450 system 

• Warfarin and phenytoin levels may be higher because of altered metabolism 

• Note: Beware of food effects (e.g., grapefruit juice contains chemicals that inhibit CYP3A4) 

Body Composition

• ↑ adipose tissue = ↑ volume of distribution = prolonged action (increased half-life) of lipophilic drugs (e.g., diazepam)  

• ↓ total body water = ↓ volume of distribution = higher concentration of water-soluble drugs (e.g., atenolol) 

• ↓ lean muscle mass may lead to hypoalbuminemia and ↓ distribution of protein-bound drugs (e.g., warfarin) thus ↑ concentration of unbound (free or active) form of drugs 

• Note:  In patients with an acute disorder or malnutrition, rapid ↓ in serum albumin may lead to ↑ serum concentrations of unbound drug and enhanced drug effects/toxicity. 

Receptor sensitivity

• ↑receptor sensitivity to narcotics, alcohol, bromides, ACEIs, diazepam = ↑potency 

• ↓receptor sensitivity to beta blockers, furosemide, dopamine, propranolol = delayed signs of toxicity 

• Multiple drugs acting on the same or interrelated receptor sites: additive, synergistic/antagonistic effects 

• Baroreceptor sensitivity decreases with age 

medication interactions

narrow therapeutic index

• aminoglycosides, digitalis, lithium, heparin, coumadin (warfarin)

affecting vital physiology of the body

• antihypertensive, anti-diabetics, anticoagulants

with high plasma protein binding capacity

• NSAIDs, Warfarin, Sulfonylureas

common drugs

• warfarin

• insulin - really excreted

• oral anti platelets

• oral hypoglycemic agents

• benzos, NSAIDs

• HEDIS and BEERS drugs

ADE risk factors

• >6 chronic disease 

• >12 doses/day 

• ≥ 9 medications 

• Low BMI (<22kg/m2) 

• Age >85 years 

• Creatinine clearance < 50 mL/min 

• History of prior ADE 

BEERS criteria

• Consensus-based list of potentially inappropriate medications for older adults 

• Published 1991, latest revision 2019 

• Statistical association with ADEs has been documented 

• Adopted for nursing-home regulation 

• Does not account for the complexity of the entire medication regimen 

• Anticholinergic medications 

• Decongestants 

• Hypertension 

• Bladder outflow obstruction 

• Meperidine 

• Benzodiazepines