NCLEX: Gerontologic care

Gerontologic care: Special considerations

Focus topic: Gerontologic care

Older adults have special health needs that require skilled, knowledgeable care. For instance, people over age 65 use twice as many medications annually as people under age 65. Furthermore, age related physiologic changes may influence drug actions, so you need to understand how drugs affect elderly patients to promote compliance and minimize adverse reactions.
You may also need to help an older adult learn to deal with such age-related concerns as managing multiple chronic illnesses and preventing falls.

Gerontologic care: Drug therapy

Focus topic: Gerontologic care

Four out of five older adults have chronic medical conditions. Accordingly, they buy approximately 400 million prescriptions per year—twice the number bought by people under age 65. For elderly patients with chronic disorders, drug therapy may extend life and enhance its quality. One or more drugs may successfully manage arthritis, diabetes, heart disease, glaucoma, osteoporosis, and hypertension.

The polypharmacy predicament

Focus topic: Gerontologic care

However, if your patient has multiple diseases and takes several different drugs, be sure to watch for problems stemming from polypharmacy (concomitant use of multiple medications) such as drug interactions.

Age-related changes in pharmacokinetics
Drug therapy in elderly people is complicated by age-related changes in body functions, which may influence a drug’s action—how a drug is absorbed into the bloodstream, distributed throughout the body, metabolized, and eliminated. (See How aging influences drug actions.)

Age-related changes in pharmacodynamics
Pharmacodynamic changes can significantly alter a drug’s action and effect in an older adult. Aging alters tissue sensitivity to drugs, enhancing certain drug effects. This is especially true for sleep aids, benzodiazepines such as diazepam, and alcohol.

Dearth of drug receptors

Focus topic: Gerontologic care

Age-related changes in the number or function of tissue and organ receptors may also alter a drug’s effect. For instance, the number of beta-adrenergic receptors decreases with age, reducing betaadrenergic receptor function and influencing the effects of drugs that stimulate or block these receptors (for example, metaproterenol and propranolol).
Similarly, changes in cholinergic and dopaminergic receptors may influence the effect of such drugs as phenothiazines, chlorpromazine (Thorazine), and other psychoactive agents. These changes may contribute to such adverse neurologic reactions as extrapyramidal effects and tardive dyskinesia. To compensate for these pharmacodynamic changes, prescribers usually reduce drug dosages for elderly patients.

GERONTOLOGIC CAREAdverse drug effects
Adverse drug effects and unwanted drug interactions are common in elderly patients and result mainly from physiologic changes and multiple medication use. One troublesome aspect of drug therapy in elderly adults is the potential for misdiagnosing or failing to detect adverse reactions, such as confusion, depression, drowsiness, and urine retention. Caregivers may mistakenly attribute these problems to aging.

Spotting adverse reactions

Focus topic: Gerontologic care

Careful nursing assessment can help identify adverse reactions so that the offending drug’s dosage may be lowered or the drug can be replaced with a safer one. To recognize common adverse reactions, make sure you know both the intended and adverse effects of all the drugs your patient takes.

GERONTOLOGIC CARE

Drug interactions
Many potent drugs commonly used by elderly adults can interact, resulting in hazardous consequences. For example, cimetidine (Tagamet) interacts with aminophylline, phenytoin (Dilantin),
antidepressants, propranolol (Inderal), and other drugs.
Anticholinergics, such as some antidepressants and tranquilizers, may have additive effects when used together. Digoxin (Lanoxin) may have increased toxic effects when taken with a diuretic or other drug that decreases body potassium levels.

Hindering interactions

Focus topic: Gerontologic care

To help prevent harmful drug interactions, make sure you know all the drugs your patient is taking. Keep in mind that he may be taking several drugs prescribed independently by several prescribers.

Adherence with drug therapy
An elderly adult may have any number of reasons for not adhering to the treatment regimen—for example, poor vision or hearing, physical disability, inability to afford drugs, cultural beliefs, or failure to understand the importance of taking a particular drug.

Augmenting adherence

Focus topic: Gerontologic care

Nonadherence can lead to treatment failure. If the prescriber misinterprets this failure as ineffective drug therapy, he may mistakenly increase the dosage or prescribe a second drug, compounding the problem. Helping the patient overcome obstacles to adherence is an important nursing responsibility. To meet it, make sure your patient understands the purpose of each prescribed drug and knows how to take each one correctly.

Gerontologic care: Urinary incontinence

Focus topic: Gerontologic care

Incontinence, the uncontrollable passage of urine, is common among the elderly—but it shouldn’t be considered a normal part of aging. Incontinence can result from bladder abnormalities or neurologic disorders. It may be transient or permanent and may involve large volumes of urine or scant dribbling.

Incontinence categories
Urinary incontinence occurs in four main forms.
• Stress incontinence refers to loss of less than 50 ml of urine triggered by increased abdominal pressure—for example, from coughing or sneezing.
• Overflow incontinence is an involuntary urine loss occurring at somewhat predictable intervals when a specific bladder volume is reached.

• Urge incontinence involves a strong, sudden need to urinate, followed immediately by a bladder contraction that leads to involuntary urine loss.
• Total incontinence is complete lack of urinary control, resulting from the bladder’s inability to retain urine.

What causes it
Urinary incontinence may result from a wide range of conditions, including:
• benign prostatic hyperplasia
• bladder calculi (stones)
• bladder cancer
• chronic prostatitis
• diabetic neuropathy
• drugs, such as diuretics, sedatives, hypnotics, antipsychotics, anticholinergics, and alpha-adrenergic blockers
• Guillain-Barré syndrome
• multiple sclerosis
• prostate cancer
• spinal cord injury
• stroke
• urethral stricture.
In some patients, incontinence follows a prostatectomy (prostate removal) that damaged the urethral sphincter.

What to look for
If your patient has urinary incontinence, be sure to cover these factors in your assessment:
• Ask the patient when he first noticed the problem and whether it began suddenly or gradually.
• Have him describe his typical urinary pattern: Does incontinence usually occur during the day or night? Does he have any urinary control or is he totally incontinent? If he sometimes urinates with control, what are the usual times he voids and the amounts of urine voided?
• Ask about other urinary problems, such as hesitancy, frequency, urgency, nocturia, and decreased force or interruption of the urine stream.
• Evaluate the patient’s fluid intake.
• Obtain a medical history, especially noting urinary tract infection, prostate conditions, spinal injury or tumor, stroke, or surgery involving the bladder, prostate, or pelvic floor.
• Determine if the patient is taking any medications, particularly sedative-hypnotics, anticholinergics, or diuretics.

• After completing the history, have the patient empty his bladder. Inspect the urethral meatus for obvious inflammation or anatomic defects. Have a female patient bear down; note any urine leakage.
• Gently palpate the abdomen for bladder distention, which signals urine retention.
• Perform a complete neurologic assessment, noting motor and sensory function and muscle atrophy.

GERONTOLOGIC CARE

Nursing interventions
• Prepare the patient for diagnostic tests, such as cystoscopy, cystometry, and a complete neurologic workup.
• As appropriate, implement a bladder retraining program.
• Make sure the patient receives an adequate fluid intake.

• Have him void regularly.
• If his incontinence has a neurologic basis, monitor him for urine retention, which may warrant periodic catheterizations.
• If appropriate, teach the patient how to catheterize himself.

Gerontologic care: Falls

Focus topic: Gerontologic care

In people age 75 and older, falls cause three times as many accidental deaths as motor vehicle accidents. Several factors can make falls ominous for elderly patients—lengthy convalescence and immobility, the risk of incomplete recovery, and inability to cope physiologically. Also, injuries caused by falls can be psychologically devastating, leading to loss of independence and self-confidence.

Accident or omen?

Focus topic: Gerontologic care

Falls can be accidental or result from temporary muscle paralysis, vertigo, postural hypotension, or central nervous system (CNS) lesions. Accidental falls commonly result from environmental factors, such as poorly lighted stairs, throw rugs, and highly waxed floors. Sometimes, an accidental fall stems from physiologic factors, such as decreased visual acuity, loss of muscle strength, or poor coordination.
Temporary muscle paralysis may explain falls that occur with no apparent cause. This phenomenon presumably results from compromised blood supply to the reticular formation in the brain’s medulla. This, in turn, is caused by spondylosis (vertebral joint fixation or stiffness) that results from head and neck movement in the presence of cervical arthritis.

Other falling factors

Focus topic: Gerontologic care

Vertigo, as from a middle-ear disturbance or infection, may cause the patient to lose his balance and fall. Orthostatic hypotension may cause dizziness, which leads to a fall when the patient rises too quickly from a lying or sitting position. CNS lesions, as from a stroke, may affect nerve impulses and set the stage for falls.

What to look for
If your patient is found on the floor or reports falling, don’t move him until he has been evaluated. Relieve his anxiety as you rapidly assess his vital signs, mental status, and functional capacity. Note such signs and symptoms as confusion, tremors, weakness, pain, dizziness, or shortening of one leg. Take steps to control any bleeding, and assess whether the patient hit his head. Obtain an X-ray if you suspect a fracture. Observe and monitor the patient’s status for the next 24 hours.

Chasing down clues

Focus topic: Gerontologic care

After the patient’s condition is stabilized, include these factors in your assessment:
• Review events that preceded the fall to help avoid future episodes. Did the patient make an abrupt position change or other movement? If he normally wears corrective lenses, was he wearing them when he fell?
• Review his use of such medications as tranquilizers and opioids, which can cause drowsiness that leads to a fall.
• Assess for other contributing factors, such as gait disturbances, poor vision, improper use of assistive devices, and environmental hazards.

What to do
• Provide measures to relieve pain and discomfort. Give an analgesic if ordered. Apply cold compresses for the first 24 hours and warm compresses thereafter to reduce the pain and swelling of bruises.
• If the patient is bedridden, encourage him to stay as active as possible to avoid becoming bed bound and immobile.
• Provide appropriate care for the patient who has sustained a fracture.
• If indicated, arrange for visiting nurse services for the recovery period after the patient’s release.

Fashion tips for safety

Focus topic: Gerontologic care

• Teach the patient how to reduce the risk of accidental falls by wearing well-fitting shoes with nonskid soles, avoiding long robes, and wearing eyeglasses if he needs them.
• Advise him to sit on the edge of the bed for a few minutes before rising and to use a walking stick, cane, or walker if he feels even slightly unsteady on his feet.
• Suggest ways he can adapt his home to guard against accidental falls—for instance, applying nonskid treads to stairs and installing handrails to walls around the bathtub, shower, and toilet.
• Teach the patient how to fall safely by protecting his hands and face. If he uses a walker or wheelchair, make sure he knows how to cope with a fall, should one occur. Teach him to survey the room for a low, sturdy piece of furniture (for example, a coffee table) he can use for support. Then teach him the proper procedure for lifting himself off the floor and either standing up with the walker or getting into the wheelchair.

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