GERIATRIC EXAM 3

age-related changes that affect mobility and safety

degenerative changes in...

1. bones

2. muscles

3. joints

older adults experiences bone mass...

LOSS

bone mass peaks around age...

30

by 40, slowly begin to lose bone mass

age-related changes to bones

1. incr bone resorption

2. decr calcium absorption

3. incr serum PTH

4. decr regulation of osteoblast activity

5. fewer functional marrow cells

6. decr estrogen in women and testosterone in men

after the age of 30, adults start LOSING _____ of their muscle mass per decade

3-8%

age-related changes to muscles

1. decr in size and number of muscle fibers

2. loss of motor neurons

3. replacement of muscle tissue by connective tissue and eventually fat

4. deterioration of muscle cell membranes

5. diminished protein synthesis

loss of muscle mass in older adults may lead to a decrease in...

muscle strength

wooooow

older adults experience a reduction in joint...

MOTION

age-related changes to joints

1. diminished viscosity of synovial fluid

2. degeneration of collagen and elastin cells

3. fragmentation of fibrous structure

effective ways of counteracting the effects of aging on joints and mobility

1. exercise

2. balanced nutrition

3. weight management

risk factors affecting mobility

1. musculoskeletal pathologies

2. neurologic and sensory pathologies

3. nutrition deficiencies

4. incontinence

5. medications

what are some examples of musculoskeletal pathologies affecting mobility?

1. osteopenia/osteoporosis

2. arthritis

3. musculoskeletal comorbidities leading to loss of muscle mass, strength, and endurance

what are some examples of neurologic and sensory pathologies affecting mobility?

1. peripheral neuropathy

2. vestibular issues

3. vision and hearing problems

osteoporosis is a ______________ disease

silent

how do you test for bone loss? what is a score diagnostic of osteopenia? what about osteoporosis?

bone density is scored according to standard deviations

T-score between 1-2.5 = osteopenia

T-score < 1 = osteoporosis

what are fragility fractures?

fractures that occur w minimal/no trauma or a fall from standing height or less

most common sites of fragility fractures?

vertebrae, hip, and wrist

risk factors for osteoporosis and fragility fractures

1. inadequate calcium and vitamin D intake

2. lack of weight-bearing activity

3. hormonal changes with regard to estrogen in women

4. small bones

5. increased age

6. tobacco use

7. excessive alcohol consumption

8. current medications

what medications are associated with osteoporosis and incr risk of falls?

1. long-term steroids used for COPD

2. antiepileptic drugs: phenytoin, phenobarbital, carbamazepine, primadone

treatment to osteoporosis includes WHAT 3 THINGS as the foundation for fracture prevention?

1. physical activity

2. fall prevention

3. supplementation with calcium and vitamin D

what is the recommended dose of calcium for older adults?

let's just go with 1200mg/day

what is osteoarthritis?

degenerative inflammatory disease affecting joints and attached muscles, tendons, and ligaments

characterized by pain, swelling, and limited movement of joints

what is self-management for osteoarthritis?

pain management and prevent disability through...

1. aerobic, resistance, and strengthening exercise programs

2. maintain ideal weight

3. use assistive devices as appropriate to relieve weight-bearing joints, improve balance, or achieve independent functioning

intrinsic risk factors for falls

1. advanced age

2. previous falls

3. muscle weakness

4. gait and balance problems

5. poor vision

6. postural hypotension

7. chronic conditions including arthritis, stroke, incontinence, diabetes, parkinson's dementia

8. fear of falling

extrinsic risk factors for falls

1. lack of stair handrails

2. poor stair design

3. lack of bathroom grab bars

4. dim lighting or glare

5. obstacles and tripping hazards

6. slippery or uneven surfaces

7. psychoactive meds

8. improve use of assistive device

what are risk factors for falls in older adults that the nurse needs to assess?

identify MODIFIABLE fall risk factors:

1. vestibular disorder/poor balance

2. vitamin D insufficiency

3. medications linked to falls

4. postural hypotension

5. vision impairment

6. foot or ankle disorder

7. home hazards: lack of stair handrails, dim lighting or glare, obstacles, slippery or uneven surfaces (rugs)

what medications are associated with falls?

1. antihypertensives

2. anticholinergics

3. anticonvulsants

4. diuretics

5. benzodiazepines

6. antipsychotics

7. antidepressants

8. alcohol

9. anticoagulants

what is an OTC anticholinergic that puts older adult at risk of falling?

diphenhydramine

how do anticoagulants play a role in falls?

they are a risk factor for increased severity of consequence of fall

what are interventions and nursing considerations to prevent falls in older adults?

1. cardiovascular conditioning and muscle strengthening

2. medication review!!!!

3. mobility and physical function assessments

4. home safety review

5. fall risk assessments

6. pt/family teaching about risks, safe mobility practices

7. post-fall huddle to identify causes, previously unknown risks of future falls

8. correct vision/hearing deficits

9. alarms, devices, equipment

examples of performance-based (functional) assessments

1. timed up and go

2. 30-second chair stand

examples of fall risk assessments

1. hendrich II

2. Morse

3. Johns Hopkins

othersss

which statement related to musculoskeletal function and the older adult population is true?

diminished muscle strength is attributed primary to age-related loss of muscle mass

which statement related to risk factors for falls and the older adult is true?

the risk of falling increases in proportion to the number of risk factors

physiologic functions of the integumentary system

1. sensation

2. thermoregulation

3. synthesis of vitamin D

4. excretion of metabolic wastes

5. protection of underlying structures

6. maintains fluid and electrolyte balance

the epidermis includes...

1. keratinocytes: produce keratin (strengthens, supports, heals)

2. melanocytes: produce melanin (pigmentation, UV protection)

function of epidermis

prevents loss of fluids and entry of pathogens, also skin pigmentation

age-related changes to the epidermis

1. decr epidermal proliferation

2. incr size of epidermal cells

3. decr moisture content

4. decr number of melanocytes

functional consequences of age-related changes to epidermis

1. cosmetic effects: paler, irregular pigmentation

2. delayed wound healing and incr risk of skin problems

3. increased vulnerability to photoaging: skin changes due to exposure to UV radiation, even without sunburn

describe what it means for older adults to have delayed wound healing and incr risk of skin problems

1. incr risk for postop wound disruption

2. decr tensile strength of healing

3. incr risk of secondary infections

regeneration of healthy skin takes __________ as long for 80yo compared to 30yo

twice

older adults have increased susceptibility to cutaneous _____________ infections

FUNGAL

describe what photoaging may look like

1. coarse, leathery, ruddy, or yellowed appearance

2. deep wrinkles, particularly on face and neck

3. pathologic lesions including actinic keratosis

4. numerous freckles

the dermis includes...

1. collagen

2. elastin

3. sebaceous glands: secrete sebum (nourishes)

4. sweat glands

5. Sensory receptors

function of dermis

sensory perception, nourishment, and temperature regulation

age-related changes to dermis

1. flat dermal-epidermal function

2. decr vascular bed

3. decr macrophages

4. decr fibroblasts and collagen

5. decr dermal thickness

6. decr elastin quality

7. decr skin turgid and elasticity

8. decr sensory fibers

9. decr sweat and sebaceous glands function

functional consequences of age-related changes to dermis

1. diminished comfort: dry skin

2. decline in tactile sensitivity

3. decr ability to maintain body temp

describe what sensations are diminished due to age-related changes in the dermal layer?

decr sensation of pressure, vibration, light touch, and temperature (!)

function of subcutaneous tissue

storage of kcal, insulation, and temp regulation

age-related changes to subcutaneous tissue

1. overall incr in adipose tissue

2. decr subcutaneous fat in face, hands, lower legs, and plantar surface

functional consequences of age-related changes to subcutaneous tissue

decreased ability to maintain body temp

reminder: do age-related changes cause major functional deficits?

NO!

but they are exacerbated and MAY cause functional deficits with added risk factors such as medications and lifestyle

genetic risk factors that affect skin health

inherited fair skin/hair is more sensitive to effects of UV radiation, more skin wrinkling

sociocultural risk factors that affect skin health

hygiene and skin care vary by culture and societal attitudes

is it recommended for older adults to take daily baths?

no. this will dry out their skin

environmental risk factors that affect skin health

1. low humidity (<30%) exacerbates dry skin

2. UV radiation without sun protection

health behavior risk factors that affect skin health

1. smoking

2. sun exposure

3. emotional stress

4. alcohol abuse

may accelerate photo aging and incr the risk of skin cancer

what SPF is recommended for ALL?

spf 15

medication risk factors that affect skin health

certain meds may cause...

1. photosensitivity

2. cutaneous small vessel vasculitis

3. dermatoses

4. fixed drug eruptions

meds that cause photosensitivity

1. amiodarone

2. furosemide

3. naproxen

4. thiazides

5. phenothiazines

6. sulfonamides

7. tetracyclines

8. st. john's wort

meds that cause cutaneous small vessel vasculitis

1. hydralazine

2. minocycline

3. penicillins

4. cephalosporins

5. sulfonamides

meds that causes dermatoses (rashes)

1. antibiotics

2. anticonvulsants

3. NSAIDs

4. antihypertensive agents

meds that cause fixed drug eruptions

favored sites include the mouth, genitalia, face, and sacral areas

1. NSAIDs

2. antibiotics

risk factors for skin tears and pressure ulcers

1. various medical devices: masks, orthotics, tubing, immobilizers, stockings, boots, etc.

2. immobility

3. poor nutrition

4. incontinence

others...

skin care interventions for prevention of pressure ulcers

1. cleanse skin promptly after episodes of incontinence or exposure to moisture or wetness

2. use skin moisturizer twice daily

overall interventions for prevention of pressure ulcers

1. avoid positioning on an area of erythema or pressure injury

2. reposition all individuals at risk for pressure injury, unless contraindicated

3. use pressure redistribution surfaces and support surfaces to protect vulnerable areas

4. use protective foam or breathable dressings under medical devices

5. use heel offloading devices or foam dressings to protect heels

how to assess pressure ulcers?

1. pressure area may appear with non-blanchable redness, darker, or purple

2. look for variation in skin tones

3. feel for change in temperature

4. assess for local pain

5. use evidence-based tools such as Braden Scale

what Braden Scale score indicates high risk for pressure ulcer?

less than 18

stage 1 pressure ulcer

skin intact but with nonblanchable redness

stage 2 ulcer

partial thickness loss of skin with exposed dermis

stage 3 ulcer

full thickness loss of skin in which adipose is visible and granulation tissue and epibole (rolled wound edges) are often present

stage 4 ulcer

full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

what happens to core body temperature as we age? what about febrile response to illness?

decreases

diminished

age-related response to cold temperatures

1. decr response to cold temperature

2. dull perception of cold and lack of stimulus to initiate protection

3. decr subcutaneous tissue

4. decr shivering

5. inefficient vasoconstriction

risk factors for hypothermia

1. alcohol

2. diseases: stroke, dementia, diabetic ketoacidosis, endocrine, malnutrition, parkinson's, renal failure, meds

age-related response to hot temperatures

1. decr ability to adapt to hot environment

2. decr sweating

3. decr peripheral circulation

4. decr thirst

risk factors for heat-related disease

1. alcohol

2. dehydration

3. diabetic ketoacidosis

4. hyperthyroidism

5. excessive exercise in hot and humid environments

6. meds

what meds serve as risk factors for heat-related disease?

1. diuretics

2. CV meds

3. anticholinergic agents: antihistamines, phenothiazines, tricyclic antidepressants

how to screen for skin cancer?

ABCDE

1. asymmetry: draw a line through mole, two halves wont match in size

2. border: edges are uneven, crusty, or notched

3. color: a variety of colors, especially white and/or blue is bad

4. diameter: larger in diameter than a pencil eraser (usually)

5. evolving: changes in size, shape or color, or begins to bleed or scab = danger

definition of major cognitive disorder

evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

1. concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function

2. a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment

with major neurocognitive disorder, the cognitive decline interferes with WHAT and is not explained by WHAT?

interfere with independence in everyday activities (i.e., at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications)

are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia)

with MCD, the cognitive deficits do not occur exclusively in the context of...

delirium

healthy older have no ______________________ but __________________ may be noted

significant cognitive impairments; MINOR deficits

age-related changes that affect cognitive function

1. minor loss of recent memory

2. delayed response time to stimuli

3. gradual decline in abstraction, calculation, verbal fluency, spatial orientation

4. diminished ability to learn complex information

5. decr ability to accomplish tasks especially those that require multiple steps (e.g. navigating a new city's subway system)

cognitive functions dependent on experience and well-practiced tasks DO or DO NOT decr in healthy older adults?

do NOT

age-related cognitive changes occur at a __________________ rate

slow linear

rapid changes likely = pathological

personal, social, and attitudinal risk factors that affect cognitive wellness

1. low SES (self esteem?)

2. sensory deficits

3. aging

4. decr expectations in society

nutritional risk factors that affect cognitive wellness

low levels of beta carotene and vitamin B,C,D

lifestyle risk factors that affect cognitive wellness

1. smoking

2. physical inactivity

3. inadequate sleep

chronic conditions that affect cognitive wellness

diabetes, HTN which decr sensory ability

medication risk factors that affect cognitive wellness

1. anticholinergic effects

2. hypoglycemia

3. decr cerebral flow

environmental risk factors that affect cognitive wellness

1. second hand smoke

2. occupational/environmental exposure to toxins like lead and mercury

nursing interventions to promote cognitive wellness

1. nutrition

2. mental exercise (crosswords)

3. physical exercise

4. sleep hygiene

5. maintain healthy weight

6. challenging leisure activities

7. strong social networks

8. adapting health education materials

9. activities that foster sense of control and mastery

delirium: general presentation and course

acute change in cognition that...

1. develops over a short period of time (hours to days)

2. FLUCTUATES over course of day

3. can persist for months

dementia: general presentation and course

1. insidious

2. progressive

3. degenerative, chronic

depression: general presentation and course

1. acute or insidious onset (may coincide with life events)

2. may be chronic

risk factors for delirium

1. dementia

2. old age

3. comorbid illness

4. severity of illness

5. infection

6. high risk meds

7. sleep deprivation

8. elevated BUN/Cr

9. polypharmacy

10. decr ADLs

11. immobility

12. sensory impairment

13. urinary catheterization

14. electrolyte imbalance

15. malnutrition

16. length of hospital stay

17. physical restraints

18. anemia

risk factors for dementia

these were acquired from a website soo

1. age

2. family hx

3. lifestyle: smoking and alcohol use

4. atherosclerosis

5. cholesterol levels

6. DM

7. mild cognitive impairment

risk factors for depression

1. chronic medical illness

2. women, caregivers, widows/widowers

3. loss of a loved one

4. relocation

5. disability

symptoms of delirium

1. disturbed attention

2. disorganized thinking

3. impaired consciousness

4. fragmented sleep

may present with HYPERACTIVE, HYPOACTIVE, or mixed motoric subtypes of delirium