Geriatrics and Maltreatment: Comprehensive Study Guide
Demographic and Societal Context of Geriatric Care in Canada
Aging Population Statistics: * In , seniors comprised of the Canadian population. * By , the senior population is projected to reach . * By , life expectancy at birth is expected to rise to years for women and years for men.
Old-age Dependency Ratio: * This ratio compares the number of older individuals in society against the number of potential workers theoretically capable of providing the resources to sustain the population. * As the population continues to age, the demand for caregivers and services will increase, potentially outstripping society's ability to keep up.
Living Arrangements and Trends: * Most geriatric patients do not live in nursing homes. * There is a countertrend toward maintaining independent lives. * Living situations include continuing to reside at home with support from a spouse or family member, assisted-living facilities, or total care nursing homes.
Social, Economic, and Psychosocial Considerations: * Key influences on a senior's well-being include marital status, financial resources, religious beliefs, ethnicity, gender, and general health. * Successful aging may be hampered by psychosocial factors such as feeling no longer useful or productive, bereavement, the likelihood of death, and loneliness or isolation.
Anatomy, Physiology, and General Body Changes in Aging
Process of Aging: * Human growth and development peak in the late and early , at which point the aging process sets in. * Aging varies dramatically between individuals, but all body tissues undergo changes.
Cardiovascular Changes: * Net Effect: A general decrease in efficiency. * Structural Changes: The heart undergoes hypertrophy; cardiac output declines. * Arteriosclerosis: Hardening of the arteries is common. * Electrical Changes: The number of pacemaker cells in the sinoatrial (SA) node decreases, often leading to bradycardia. * Lifestyle Impact: A sedentary lifestyle has a deconditioning effect. Decreased physical activity may be caused by disabilities (like arthritis) or social, financial, and psychological factors.
Respiratory Changes: * Capacity: Significant reductions in respiratory capacity occur with age. * Elasticity: Lungs lose elasticity; respiratory muscles decrease in size and strength. * Cartilage: Calcification of the costochondral cartilage occurs. * Lung Volumes: Vital capacity decreases, while residual volume increases. * Physiological Indicators: Airflow deteriorates; respiratory rates generally increase. * Gas Transfer: Blood flow within the lungs decreases, resulting in a declining (partial pressure of oxygen). * Respiratory Drive: Becomes dulled. * Musculoskeletal Factors: The thoracic cage becomes stiff; kyphosis (hunchback) may develop. Pulmonary muscle mass/strength decreases, limiting chest expansion. * Defense Mechanisms: Cough and gag reflexes decrease; ciliary mechanisms (which clear mucus and debris) are markedly slowed.
Nervous System and Sensory Changes: * Mental Function: Age-associated declines in mental function may include slower thinking speed, memory changes, and slower responses to questioning. * Brain Weight: Brain weight may shrink by to by age . However, the brain has an enormous reserve capacity, and this shrinkage does not necessarily interfere with the capabilities of productive adults. * Vision: Changes include cataracts, glaucoma, and decreased visual acuity, affecting the ability to read, drive, and remain independent. * Hearing: Hearing loss is referred to as Presbycusis. This can lead to decreased ability to communicate. Ménière disease is also noted as a condition. * Speech: Weakness, paralysis, and brain damage can impair speech functions. * Proprioception: The sense of body position becomes impaired, leading to being less steady on one's feet and an increased tendency to fall.
Digestive and Renal changes: * Mouth: Diminished taste and smell lead to decreased appetite. Saliva volume reduces. Note: Dental loss is NOT a normal result of aging. * Stomach: Gastric secretions and motility are reduced; however, enough acid remains to produce ulcers. * Liver: Decline in hepatic enzyme systems and detoxification of medications. This increases the risk of medication toxicity or hepatic damage when taking multiple drugs. * Renal Function: Loss of functioning nephron units means the kidneys may not meet challenges from illness. They respond sluggishly to sodium imbalances. * Continence: Urinary incontinence (stress or urge) has significant social/emotional impacts. It is NOT a normal part of aging. Bladder capacity decreases, and urinary retention may occur due to prostate enlargement in men.
Integumentary (Skin) Changes: * Skin becomes thinner, drier, less elastic, and more fragile as elastin and collagen decrease. * Subcutaneous fat thins, making bruising more common and skin tears more likely. * Sebaceous glands produce less oil; sweat gland activity decreases. * Hair follicles produce thinner hair or stop producing hair; melanin production drops, leading to grey or white hair. * Atherosclerosis affects blood vessels supplying the skin, providing less oxygen at the cellular level. This increases the risk for secondary infections, pressure ulcers, and skin tumours.
Homeostasis and Metabolic Changes: * Homeostasis (maintaining a constant internal environment via feedback) becomes less efficient. * Older adults are more vulnerable to environmental stresses and may show an absence of febrile (fever) responses to infection. * Blood Glucose: The regulatory system becomes impaired; elevated blood glucose levels are common.
Musculoskeletal Changes: * Widespread decrease in bone mass makes bones brittle and prone to breakage. * Synovial fluid in joints thickens, while cartilage decreases; joints lose flexibility. * Height decreases due to compression in the spinal column. * Tendons/ligaments lose elasticity; muscle mass and strength decrease.
Cardiovascular and Respiratory Pathophysiology
Cardiovascular System: * Heart Disease: Remains the leading cause of death among older adults in Canada, with Coronary Artery Disease (CAD) being the primary culprit. * Myocardial Infarction (MI): Presentation may be atypical. While chest pain is common, some patients report only dyspnea, syncope (fainting), weakness, confusion, nausea, or fatigue. * Heart Failure: The most common reason for hospitalization in seniors. * Dysrhythmias: Electrical malfunctions. The most common is Atrial fibrillation. Bradycardia is also frequent. * Aneurysm: A balloon-like defect in an artery. Incidence increases with age. * Aortic Disruption: Inner wall of the artery tears (often due to trauma or hypertension), allowing blood to collect between layers; susceptibility to rupture increases. * Hypertension: Affects more than one-half of seniors. Isolated systolic hypertension (due to loss of arterial elasticity) is common. * Stroke: Significant cause of death and the leading cause of long-term disability. Risk doubles every decade after age . * Transient Ischemic Attacks (TIAs): Temporary disturbances in blood supply; symptoms match a stroke but last less than hours. These are warning signs of a future stroke.
Respiratory System: * Pneumonia: Inflammation of the lung due to infection. Presentation can be atypical (acute confusion, normal temperature, minimal cough). Preventative measures include the Pneumococcus vaccine (given once, with boosters every to years). * COPD (Chronic Obstructive Pulmonary Disease): Includes chronic asthma, chronic bronchitis, and emphysema. Involves bronchial obstruction and airway inflammation. Even minor activities (position changes, walking) can become difficult. * Asthma: Affects approximately in older adults; onset can occur in old age. * Pulmonary Embolism: Blockage of lung blood vessels by a clot. Risk increases due to immobility and vascular stasis (Deep Vein Thrombosis - DVT) in lower extremities.
Neurological, Endocrine, and Gastrointestinal Pathophysiology
Nervous System: * Delirium: An acute brain syndrome or confusional state. It is a symptom/temporary condition, not a disease, and is usually reversible. * Dementia: Irreversible brain failure caused by vascular or neurological impairment. Most common types are Alzheimer disease and multi-infarct (vascular) dementia. Diagnosed when two or more cognitive/psychomotor functions are impaired. * Alzheimer Disease: Age is a risk factor, but not the cause. Symptoms are subtle at onset and may progress to forgetting identities of close family. * Parkinson Disease: Caused by degeneration of the substantia nigra. Diagnosed by two or more of: resting tremor, slowness of movement, rigidity, or poor balance. * Seizures: Incidence increases in the geriatric population due to increased risk factors.
Gastrointestinal Pathophysiology: * Constipation: A frequent and significant problem. * Conditions: Diverticulosis, appendicitis (hard to diagnose), and peptic ulcer disease (main symptom: dyspepsia). * Bowel Obstructions: Likely causes include cancer, impacted stool, sigmoid volvulus, or adhesions from previous surgeries. * Peptic Ulcer Disease: Often caused by regular NSAID use or infection with Helicobacter pylori.
Endocrine Pathophysiology: * Diabetes Mellitus: Pancreatic activity is impaired. Common risk factors include chronic disease, obesity, and genetics. Symptoms: Polyuria, polydipsia, polyphagia. * Hyperglycemic Hyperosmolar Syndrome (HHS) / Hyperosmolar Nonketotic Coma (HONK): Frequently caused by infection; presents with hyperglycemia, acute confusion, and dehydration. * Thyroid Abnormalities: Adult hypothyroidism is common; signs may mimic normal aging.
Musculoskeletal Pathophysiology: * Osteoporosis: Decreased bone mass and strength. Bone loss is most rapid in women post-menopause. * Osteoarthritis: Destroys cartilage and promotes bone spurs; affects several joints. * Rheumatoid Arthritis (RA): A long-term autoimmune disorder causing joint inflammation, typically bilateral (hands, feet, etc.).
Toxicology and Medication Management
Pharmacokinetics and Aging: * Medication metabolism changes due to diminished hepatic and renal function. * Changes in body composition and CNS responsiveness affect drug impact. * General principle for dosing: "Start low, go slow."
Polypharmacy: * The geriatric population consumes more than of all prescribed and over-the-counter medications in Canada. * Taking medications from multiple physicians increases the risk of toxicity.
Medication Noncompliance: * Refers to not following instructions, failure to fill prescriptions, improper administration, or taking inappropriate medications.
The "Dirty Dozen" (Medications most commonly causing toxic reactions): * Anti-inflammatory agents (NSAIDs, corticosteroids): Dizziness, GI bleeding. * Antibiotics: GI signs, seizures. * Anticholinergics/Antihistamines: Urination difficulty, restlessness. * Anticoagulants (warfarin): Ecchymosis (bruising), hematuria (blood in urine). * Antidysrhythmics (amiodarone, lidocaine): Hypotension, bradycardia. * Antidepressants (tricyclics, SSRIs): Confusion, delirium. * Antihypertensives (diuretics, beta blockers, ACE inhibitors): Hypotension, fluid retention. * Antipsychotics: Drowsiness, tachycardia. * Digoxin: Fatigue, depression. * Insulin/Antidiabetics: Hypoglycemia. * Narcotics: Respiratory depression, apnea. * Sedative-hypnotics: Incoordination, cognitive disturbance.
Substance Abuse: * Alcohol is the preferred substance of abuse. Approximately one-third of abusers develop problems after a major life-changing event.
Assessment of the Geriatric Patient
Misconceptions: * Older adults are NOT typically hypochondriacs; they are actually less likely to complain and may view significant symptoms as a normal part of aging.
The GEMS Diamond: * G (Geriatric): Recognize the patient is elderly; check for atypical presentation. * E (Environmental): Assess home temperature, safety hazards, and cleanliness. * M (Medical): Review history and medications (polypharmacy). * S (Social): Assess the social network (death of spouse) and needed assistance with daily living.
Patient History and Communication: * Introduce yourself and use respect; use active listening; speak slowly. * Chief Complaint: May be complex or trivial-sounding. Use a review of systems to differentiate from chronic issues. * Physical Examination: Maintain warmth. Check for "tenting" (skin elasticity loss, though this may not always mean dehydration in seniors). Listen for lung crackles (may be present without acute pathology). Look for edema in the legs (which can signify chronic venous insufficiency rather than heart failure).
Trauma and Environmental Injuries
Environmental Injuries: * Internal temperature regulation is slowed. Seniors account for one-half of all hypothermia deaths, and hyperthermia death rates are more than double for this group.
Trauma Risk Factors: * Slower reflexes, visual/hearing deficits, equilibrium disorders, and reduced agility. * Falls: The leading cause of injury. While often not immediately fatal, they lead to higher mortality, loss of confidence, and "postfall syndrome." * Motor Vehicle Collisions: The second leading cause of accidental death.
Specific Trauma Types: * Head Trauma: Vulnerability to intracranial bleeding; headache is the most important early symptom. * Cervical Spine: Degenerative changes can lead to nerve root compression; sudden neck movement can cause spinal cord injury. * Orthopedic: Hip fractures are the most common injury from falls, largely due to osteoporosis. * Burns: Carry a significant risk of morbidity/mortality.
Maltreatment, Neglect, and Assault
Elder Maltreatment: * Includes physical, sexual, emotional, neglect, and financial abuse (improper use of funds/assets). * Profile of At-Risk Seniors: Often women, those over years, care-dependent, or socially isolated. * Profile of Abusers: Often live with the victim, dependent on them financially, or have a history of drug/alcohol abuse and domestic violence. * Active vs Passive Neglect: Active is intentional withholding of care; passive is unintentional (caregiver unable to provide care).
Child Maltreatment: * CHILD ABUSE Mnemonic: Consistency of injury with age, History inconsistent, Inappropriate parental concern, Lack of supervision, Delay in seeking care, Affect, Bruises of varying ages, Unusual injury patterns, Suspicious circumstances, Environmental clues. * At-Risk Profile: All socioeconomic strata; younger children at higher risk for fatal abuse.
Domestic and Sexual Assault: * Domestic Maltreatment: Occurs in heterosexual and same-sex relationships. Power and control are maintained through intimidation, isolation, and threats. * Sexual Assault Care: Primarily involves professional compassion, building trust, and preserving evidence. Advise victims NOT to bathe, brush teeth, or urinate if penetration occurred to maintain the chain of custody for evidence.
Documentation in Abuse Cases: * Patient Care Reports (PCRs) are permanent records. Use objective facts only. Place subjective statements in quotation marks.
End-of-Life Care
- DNR Orders: "Do Not Resuscitate" does not mean "do not respond to needs."
- Approach: Maintain a caring and concerned attitude. Seek information on local hospice care availability for terminal patients.
Questions & Discussion
- The transcript concludes by asking if there are "Any Qweeessstions?" following the summary of abuse topics including child, elder, domestic, and sexual maltreatment.