Chapter 6 Review of the Aging of Physiological

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Chapter 6: Review of the Aging of Physiological Systems Bonnie M. Wivell, MS, RN,

Chapter 6: Review of the Aging of Physiological Systems Bonnie M. Wivell, MS, RN, CNS

Cardiovascular System

Cardiovascular System

Cardiovascular System

Cardiovascular System

Cardiovascular System � Heart chambers enlarge � Thickening of heart walls ◦ Especially left

Cardiovascular System � Heart chambers enlarge � Thickening of heart walls ◦ Especially left ventricle ◦ Decreased flexibility � Increase in heart weight � Myocardial cells enlarge ◦ Men- decreased number of myocardial cells � Heart muscle loses efficiency � Reduced cardiac output under physiologic stressors

Cardiovascular System � Arteries ◦ Dilate and stiffen ◦ Reduced elasticity ◦ Atherosclerosis �

Cardiovascular System � Arteries ◦ Dilate and stiffen ◦ Reduced elasticity ◦ Atherosclerosis � Increased peripheral resistance ◦ Hypertension ◦ Positional hypotension �Decreased stimulation of the baroreceptors leads to impaired sympathetic nerve response and resistance in peripheral vessels

Cardiovascular System � Heart Valves ◦ Calcium deposits accrue leading to stenosis � Murmurs

Cardiovascular System � Heart Valves ◦ Calcium deposits accrue leading to stenosis � Murmurs ◦ Asymptomatic � Blood Pressure ◦ Systolic ↑ ◦ Diastolic ↓ � Pulse ◦ At rest vs. activity

Respiratory System

Respiratory System

Respiratory System � Alveoli ◦ Flatter, shallow, decreased surface area ◦ Decreased number of

Respiratory System � Alveoli ◦ Flatter, shallow, decreased surface area ◦ Decreased number of capillaries per alveolus ◦ Impaired passage of oxygen from alveoli to the blood � Lung ◦ Decreased elastic recoil ◦ Total lung capacity (total vol lungs can expand during inspiration) remains unchanged ◦ Vital capacity (max amt of air expelled with exhalation) decreases ◦ Lower lobes have lesser air flow hence decrease gas exchange

Respiratory System � Chest wall ◦ Stiffer reducing the ability to expand contract ◦

Respiratory System � Chest wall ◦ Stiffer reducing the ability to expand contract ◦ Loss of rib elasticity – calcification of cartilage ◦ Kyphosis, arthritis of costavertebral joints and increased rigidity of the thoracic cavity �Increased anteroposterior diameter �Flattening of the diaphragm

Respiratory System � Respiratory Infection ◦ 25% of all deaths >85 years � Chronic

Respiratory System � Respiratory Infection ◦ 25% of all deaths >85 years � Chronic Obstructive Pulmonary Disease ◦ Chronic bronchitis, chronic obstructive bronchitis, emphysema ◦ Environmental irritants cause increased mucous ◦ Alveoli always inflated become fibrous ◦ Excessive cardiac workload as heart tries to compensate � Pneumonia ◦ Lung inflammation secondary to infection ◦ Pneumococcal

Gastrointestinal System

Gastrointestinal System

Gastrointestinal System � Mouth ◦ Teeth less sensitive and more brittle �Loss is not

Gastrointestinal System � Mouth ◦ Teeth less sensitive and more brittle �Loss is not a normal part of aging �Dentures ◦ Difficult to chew with no teeth and atrophy of muscles and jaw bones ◦ Salivary glands �Same amount as young �Dry mouth secondary to medication ◦ Less acute taste sensation � Increased risk for aspiration, indigestion, constipation

Gastrointestinal System � Esophagus ◦ ◦ ◦ & Pharynx Normal until 80 years of

Gastrointestinal System � Esophagus ◦ ◦ ◦ & Pharynx Normal until 80 years of age Stiffening Absent gag reflex in 40% of healthy older adults Dysphagia Reflux/Heartburn – longer duration of episodes

Gastrointestinal System � Stomach ◦ Gastric acid changes �Decline in gastric defense mechanisms �Increased

Gastrointestinal System � Stomach ◦ Gastric acid changes �Decline in gastric defense mechanisms �Increased potential for mucosal injury � Small intestines ◦ Decreased acid production and motility disturbances can lead to bacterial overgrowth causing malabsorption and malnutrition ◦ Vit A ↑ ◦ Vitamin D, calcium, zinc ↓ ◦ B 1, B 12, C, Iron unchanged

Gastrointestinal System � Large Intestine ◦ Medications can affect motility ◦ Endocrine and neurological

Gastrointestinal System � Large Intestine ◦ Medications can affect motility ◦ Endocrine and neurological changes affect motility �Large intestine loses nerve connections in the smooth muscle of the colon, increasing colonic transit time � Liver ◦ Decreased size and blood flow ◦ Drug clearance can be affected but highly variable � Gallbladder ◦ Slower emptying rate so less bile secreted when food is digested ◦ Increased bile volume can lead to gallstones � Pancreas ◦ Decreases in weight ◦ Some histological changes such as fibrosis and cell atrophy

Genitourinary System

Genitourinary System

Genitourinary System � Kidneys ◦ ◦ ◦ Shrink in length and weight Decreased glomeruli

Genitourinary System � Kidneys ◦ ◦ ◦ Shrink in length and weight Decreased glomeruli by 30 -40% Size and number of nephrons decrease Decreased renal blood flow Glomerular filtration rate decreased �Disease, medications can make this worse �Elimination of waste and toxins declines �Accumulation of harmful substances such as uric acid and meds in the body �Impaired sodium regulation can occur

Genitourinary System � Bladder ◦ Reduced capacity due to decreased size ◦ Develops fibrous

Genitourinary System � Bladder ◦ Reduced capacity due to decreased size ◦ Develops fibrous matter in wall reducing stretching capacity and contractility ◦ Decreased filling capacity ◦ Ability to withhold voiding declines ◦ Increased incidence of detrusor overactivity ◦ Urinary frequency, urgency, nocturia � Incontinence is not a normal part of aging

Female Reproductive System

Female Reproductive System

Female Reproductive System � Overall atrophy, including external structures � Uterus tips backwards �

Female Reproductive System � Overall atrophy, including external structures � Uterus tips backwards � Vagina becomes shorter and narrower � Loss of mucosal layers, decreased lubrication � p. H increases, more alkaline ◦ More infection, vaginitis � Menopause ◦ Estrogen depletion ◦ Average of 51 years (45 -55 yo) ◦ Hot flashes, mood disturbance, weight gain, vaginal dryness, bladder infections, loss of sex drive, fatigue, insomnia, cognitive decline, hair loss, backaches, joint pain � Pelvic muscles atrophy causing decreased support of pelvic organs

Male Reproductive System

Male Reproductive System

Male Reproductive System � Reduction in testosterone and sperm count � Erectile dysfunction ◦

Male Reproductive System � Reduction in testosterone and sperm count � Erectile dysfunction ◦ Increased amount of time to achieve erection ◦ Need more stimulation to maintain the erection ◦ Less intense orgasms and ejaculation ◦ Decreased ejaculatory volume ◦ Longer refractory period �Benign ◦ ◦ prostatic hyperplasia (BPH) Prostate around urethra at base of bladder Enlargement Urinary retention Increased frequency, discomfort with urination, bladder and kidney infections, erectile and ejaculatory dysfunction

Andropause � Androgen deficiency; occurs gradually and doesn’t occur in all males � Low

Andropause � Androgen deficiency; occurs gradually and doesn’t occur in all males � Low libido � Decreased energy, strength, and stamina � Increased irritability � Cognitive changes � ED � Osteopenia/osteoporosis � Breast enlargement � Decreased muscle mass � Shrinkage of testes � Increased fat deposition

Nervous System � Decreased size and weight of brain ◦ Ventricle size increases ◦

Nervous System � Decreased size and weight of brain ◦ Ventricle size increases ◦ Loss of neurons ◦ Increased subdural space – risk of chronic hematoma � Personality remains consistent with that of earlier years in the absence of disease � Learning ability/attention span/memory changes ◦ Acetylcholine decreases ◦ Loss of acetylcholine pronounced in Alzheimer’s

Nervous System � Motor dysfunction due to decreased dopamine receptors ◦ Parkinson’s � Sleep

Nervous System � Motor dysfunction due to decreased dopamine receptors ◦ Parkinson’s � Sleep changes/depression ◦ Norepinephrine and serotonin decreases � Decreased cerebral blood flow � Plaques and tangles are hallmarks of Alzheimer’s disease � Spine ◦ Narrowing ◦ Changes in sensation ◦ Degenerative disease

Endocrine System � Thyroid ◦ Decreased activity ◦ Decreased metabolic rate � Pineal gland

Endocrine System � Thyroid ◦ Decreased activity ◦ Decreased metabolic rate � Pineal gland ◦ Decreased melatonin ◦ Sleep patterns � Glucose Intolerance ◦ Decreased tissue sensitivity to circulating insulin ◦ Delayed and insufficient release of insulin ◦ Reduced ability to metabolize glucose

Musculoskeletal System � Sarcopenia: reduction in muscle mass ◦ Functional disability and frailty �

Musculoskeletal System � Sarcopenia: reduction in muscle mass ◦ Functional disability and frailty � Osteoarthritis ◦ Most common, affects weight bearing joints from years of wear, loss of cartilage, increased bone matrix, decreased joint mobility � Rheumatoid ◦ Immune arthritis � Osteoporosis ◦ Reduction in bone quantity and strength � Tendons shrink and harden � Increased risk of fractures

Sensory System � Touch ◦ Mechanoreceptors ◦ Inability to acknowledge that an object is

Sensory System � Touch ◦ Mechanoreceptors ◦ Inability to acknowledge that an object is touching or applying pressure to the skin ◦ Decrease in ability to identify where the touch or pressure is occurring ◦ Inability to distinguish how many objects are touching the skin ◦ Decreased ability to identify objects just by touch ◦ Proprioception � Safety issues?

Sensory System � Smell ◦ ◦ Decreased ability to smell Decreased odor detection Inability

Sensory System � Smell ◦ ◦ Decreased ability to smell Decreased odor detection Inability to identify smells Affects sense of taste � Safety issues? � Affects on life?

Sensory System � Taste ◦ Chemoreceptors ◦ Hypogeusia = decrease in taste ◦ Medication,

Sensory System � Taste ◦ Chemoreceptors ◦ Hypogeusia = decrease in taste ◦ Medication, smoking, disease, infections, poor oral health ◦ Food poisoning and malnutrition of concern � Safety issues? � Affects on life?

Sensory System � Vision � Presbyopia � Narrowing of visual field � Impaired color

Sensory System � Vision � Presbyopia � Narrowing of visual field � Impaired color discrimination (blue/yellow) � Decreased night vision � Diseases, not normal aging process ◦ Cataracts, glaucoma, macular degeneration, diabetic retinopathy � Safety issues? � Affects on life?

Sensory System � Hearing � Presbycusis ◦ Age related hearing loss � Most common

Sensory System � Hearing � Presbycusis ◦ Age related hearing loss � Most common of all sensory deficits � Safety issues? � Affects on life?

Integument System � Decreased � Thinning � Increased � Fragile � Wrinkles elasticity dryness

Integument System � Decreased � Thinning � Increased � Fragile � Wrinkles elasticity dryness � Decreased blood flow ◦ Cooler skin � Subcutaneous and belly layer increases around hips

Integument System � Hair ◦ Thinning, loss, gray � Nails ◦ Slower growth, thinner,

Integument System � Hair ◦ Thinning, loss, gray � Nails ◦ Slower growth, thinner, more brittle � Glands ◦ Decreased sweating � Safety issues? � Affects on life?

Immune System � Depressed immune response � T-cell activity declines ◦ Fewer naïve T-cells

Immune System � Depressed immune response � T-cell activity declines ◦ Fewer naïve T-cells so respond slower to new antigens � Increased potential for infection � Reactivation of dormant viruses ◦ Varicella zoster, mycobacterium tuberculosis � Vaccinations good for this age but body responds slower

Hematopoietic System � No significant changes with ages, unless disease mediated � Hct and

Hematopoietic System � No significant changes with ages, unless disease mediated � Hct and Hgb unchanged � Anemia ◦ Due to other disease processes, medications

Thermoregulation � Lower normal body temperature ◦ 96. 9 degrees F - 98. 9

Thermoregulation � Lower normal body temperature ◦ 96. 9 degrees F - 98. 9 degrees F � Reduced ability to respond to cold temperatures � Differences in response to heat

Chapter 7: Assessment of the Older Adult Bonnie M. Wivell, MS, RN, CNS

Chapter 7: Assessment of the Older Adult Bonnie M. Wivell, MS, RN, CNS

Functional Assessment �Activities of Daily Living ◦ Katz – distinguished between independence and dependence

Functional Assessment �Activities of Daily Living ◦ Katz – distinguished between independence and dependence in certain skills ◦ Barthel Index – measures functional levels of selfcare and mobility ◦ Refined ADL Assessment Scale – task segmentation ◦ Functional Independence measure (FIM) – used in rehab ◦ Eating, dressing, bathing/washing, grooming, walking/ambulation, ascending/descending stairs, communication, transferring, toileting

Functional Assessment � IADLs: more complex than ADL ◦ Lawton and Brody in 1969

Functional Assessment � IADLs: more complex than ADL ◦ Lawton and Brody in 1969 ◦ Telephone, taking medications, shopping, finances, preparing meals, laundry, housekeeping, yardwork, home maintenance, transportation, recreation

Circulatory Function �Family and patient history �Chest pain �Medications (include OTC and herbs) �Sources

Circulatory Function �Family and patient history �Chest pain �Medications (include OTC and herbs) �Sources of stress �Vital signs �Heart sounds �Other tests prn: CBC, Lytes, ECG, Echo, Exercise stress test

Respiratory Function � Family and patient history � Shortness of breath – describe �

Respiratory Function � Family and patient history � Shortness of breath – describe � Medications � History of smoking � Air pollutant exposure � Coughing � Energy level � Sitting up at night to help breathing � Check lung sounds, posture � Possible tests: sputum, lung function, chest x-ray

Gastrointestinal Function �History �Oral cavity ◦ own teeth ◦ hygiene ◦ dentures well-fitting �Diet

Gastrointestinal Function �History �Oral cavity ◦ own teeth ◦ hygiene ◦ dentures well-fitting �Diet ◦ Appetite, vomiting, stomach pain, changes in stooling �Appetite ◦ Decreased body weight ◦ Risk for injury, less energy, psychological changes

Gastrointestinal Function �Nausea, vomiting, indigestion ◦ note that c/o indigestion unrelieved by antacids may

Gastrointestinal Function �Nausea, vomiting, indigestion ◦ note that c/o indigestion unrelieved by antacids may indicate heart-related problems in older adults

Gastrointestinal Function �Usual bowel patterns ◦ Constipation (check fluids, activity, positioning, timing, meds) �Medications

Gastrointestinal Function �Usual bowel patterns ◦ Constipation (check fluids, activity, positioning, timing, meds) �Medications �Possible tests: barium enema, GI series, stool specimens, sigmoidoscopy, colonoscopy

Genitourinary Function �History �Pre-existing diseases such as diabetes or hypertension associated with renal failure

Genitourinary Function �History �Pre-existing diseases such as diabetes or hypertension associated with renal failure �UA �Incontinence ◦ ◦ ◦ Type: stress, urge, functional, overfow Frequency Nocturia Voluntary flow Use of pads

Sexual Function � History � Significant other, Spouse, Partner, Widowed � Number of children

Sexual Function � History � Significant other, Spouse, Partner, Widowed � Number of children � Present problems � Changes in function � Erectile dysfunction (males) or dyspareunia (females) � Chronic illnesses � Medications that can interfere with sexual function or libido

Neurological Function �Patient and family history �History of seizures �Medications �Reflexes �Balance �Sleep patterns

Neurological Function �Patient and family history �History of seizures �Medications �Reflexes �Balance �Sleep patterns �Cognition �Communication

Neurological Function �Speech �Memory �Energy level �Motor and sensory function �Neuro checks ◦ ◦

Neurological Function �Speech �Memory �Energy level �Motor and sensory function �Neuro checks ◦ ◦ ◦ Vital signs PERRLA Grip strength Orientation Cranial Nerves

Musculoskeletal Function �Patient �ROM and family history �Daily activities �Signs of arthritis ◦ ◦

Musculoskeletal Function �Patient �ROM and family history �Daily activities �Signs of arthritis ◦ ◦ ◦ Pain Joints affected Inhibits daily activities Medications used Other pain relief methods used and their effectiveness

Musculoskeletal Function �Posture �Devices for mobility �Postmenopausal ◦ Risk for osteoporosis �The Up and

Musculoskeletal Function �Posture �Devices for mobility �Postmenopausal ◦ Risk for osteoporosis �The Up and Go Test

Sensory Function �Five senses �Vision ◦ Presbyopia ◦ Signs of common problems �macular degeneration

Sensory Function �Five senses �Vision ◦ Presbyopia ◦ Signs of common problems �macular degeneration �cataracts �glaucoma

Sensory Function �Hearing ◦ History of recent hearing loss �presbycusis �cerumen impaction �foreign body

Sensory Function �Hearing ◦ History of recent hearing loss �presbycusis �cerumen impaction �foreign body ◦ Hearing aids used

Sensory Function �Taste �Smell ◦ Taste and smell connected ◦ Ask about satisfaction with

Sensory Function �Taste �Smell ◦ Taste and smell connected ◦ Ask about satisfaction with how things smell and taste �Touch ◦ Any changes in sensation

Integumentary Function �Patient and family history �Present skin conditions/complaints ◦ ◦ Rashes Itching Dryness

Integumentary Function �Patient and family history �Present skin conditions/complaints ◦ ◦ Rashes Itching Dryness Breakdown �Braden risk assessment scale (pg. 501 -502) ◦ Bruising ◦ Skin tears �Nutrition �Weight �Circulation

Integumentary Function �Color �Hydration �Circulation �Intactness �Wounds �Also ◦ ◦ check hair and nails

Integumentary Function �Color �Hydration �Circulation �Intactness �Wounds �Also ◦ ◦ check hair and nails Brittleness Dryness Thickness Texture

Endocrine & Metabolic Function �Patient or family history of disease ◦ Esp. diabetes and

Endocrine & Metabolic Function �Patient or family history of disease ◦ Esp. diabetes and thyroid problems �Changes �Fatigue �Vision in weight and appetite problems �Slow wound healing �Gastrointestinal problems

Endocrine & Metabolic Function �Signs of diabetes �Signs of hypothyroidism ◦ Polyphagia, polydipsia and

Endocrine & Metabolic Function �Signs of diabetes �Signs of hypothyroidism ◦ Polyphagia, polydipsia and polyuria ◦ Skin changes, sensitivity to cold, fatigue, weight gain, constipation �Diagnostic tests as needed ◦ Glucose testing, thyroid screening and/or panel

Hematologic & Immune Function �Check for signs of anemia ◦ Esp. iron deficiency –

Hematologic & Immune Function �Check for signs of anemia ◦ Esp. iron deficiency – skin color, food choices �Lab tests: CBC, Hct, HGB �History of infection �Takes vaccines for flu or pneumonia �HIV/AIDS – sexual assessment

Cognitive Assessment �Attention, memory, language, visual-spatial skills, orientation ◦ Mini Mental State Examination (MMSE)

Cognitive Assessment �Attention, memory, language, visual-spatial skills, orientation ◦ Mini Mental State Examination (MMSE) ◦ Mini-Cog: 3 item recall and clock drawing �Signs of dementia �Social abilities ◦ ◦ Giving and receiving attention Participating in conversation Appreciating humor Helping others

Psychological Assessment �Quality of life ◦ Attitude, beliefs, and feelings about aging and mental

Psychological Assessment �Quality of life ◦ Attitude, beliefs, and feelings about aging and mental health �Depression ◦ Geriatric Depression Scale (pg. 250) ◦ Persistence of symptoms

Social Assessment �Social support ◦ Family, friends, neighbours, church �Living arrangements �Resources �Insurance �Finances

Social Assessment �Social support ◦ Family, friends, neighbours, church �Living arrangements �Resources �Insurance �Finances �Independence and need for assistance �Potential for isolation

Spiritual Assessment �Spirituality �Religion �Worship practices �Religious artefacts �Spiritual leader/advisor �Check for signs of

Spiritual Assessment �Spirituality �Religion �Worship practices �Religious artefacts �Spiritual leader/advisor �Check for signs of spiritual distress

Individualized Plan of Care Ten Principles of Comprehensive Assessment: 1. The cornerstone of an

Individualized Plan of Care Ten Principles of Comprehensive Assessment: 1. The cornerstone of an individualized plan of care for an older adult is a comprehensive assessment. 2. Comprehensive assessment takes into account age-related changes, ageassociated diseases, heredity and lifestyle.

Individualized Plan of Care 3. Nurses are members of the health care team, contributing

Individualized Plan of Care 3. Nurses are members of the health care team, contributing to and drawing from the health team to enhance the assessment process. 4. Comprehensive assessment is not a neutral process.

Individualized Plan of Care 5. Ideally, the older adult is the best source of

Individualized Plan of Care 5. Ideally, the older adult is the best source of information to assess his or health. When this is not possible, family members or caregivers are acceptable and secondary sources of information. When the older adult cannot self-report, physical performance measures may provide additional information. 6. Comprehensive assessment should first emphasize “ability” and second, should address disability. Appropriate interventions to maintain and enhance ability, and to improve or compensate for disability should follow from a comprehensive assessment.

Individualized Plan of Care 7. Task performance and task capacity are two difference perspectives.

Individualized Plan of Care 7. Task performance and task capacity are two difference perspectives. Some assessment tools ask “Do you dress without help? ’ (performance) while others ask, “Can you dress without help? ” (capacity). Asking about capacity will result in answers that emphasize ability. 8. Assessment of older adults who have cognitive limitations may require “task segmentation” or the breaking down of tasks into smaller steps.

Individualized Plan of Care 9. Some assessment tools or parts of assessment tools may

Individualized Plan of Care 9. Some assessment tools or parts of assessment tools may be more or less applicable depending on the setting, that is, community, acute care or long-term care settings. 10. In comprehensive assessment, it is important to explore the meaning and implications of health status from the older adult’s perspective. For example, the same changes in visual acuity for two older adults may have quite different meanings and implications for everyday life.