NCLEX: Gerontologic care

Gerontologic care: A look at gerontologic care

Focus topic: Gerontologic care

People age 65 and older require health care services more often than any other age-group. Chances are, you’ll care for a great many older adults—especially if you practice in California, New York, Florida, Illinois, Texas, Ohio, Pennsylvania, Michigan, or New Jersey, where 52% of people age 65 and older live. Attitudes about aging are improving among the general public and health care professionals alike. More people have come to view aging as a normal lifelong process that begins at conception and culminates with old age.
The American Nurses Association (ANA) emphasizes holistic care and treatment of elderly patients. Significantly, the ANA now uses the term gerontologic rather than geriatric to describe the process of providing nursing care for older adults. Not just a matter of semantics, this change acknowledges the need to address not only age-related diseases but also associated physiologic, pathologic, psychological, economic, and sociologic issues.


Gerontologic care: Demographic trends

Focus topic: Gerontologic care

The older adult population is growing rapidly and becoming more racially and ethnically diverse, reflecting the demographic changes in the U.S. population. In 2008, 38.9 million people age 65 and older were living in the United States, and the number of older adults is projected to grow to 55 million by 2020.

The old get older

Furthermore, the older adult population of the United States is getting progressively older. In 2006, there were over 5.3 million people age 85 and older.

Gender trends

Older women outnumber older men, and the proportion of women to men increases with age. There are approximately 22.4 million older women, compared with 16.5 million older men.

Health perceptions among the elderly
Contrary to stereotypes, most older adults view their health positively. Even if they have chronic illnesses, four out of five describe their health as good or excellent. Still, the likelihood of having a chronic illness rises with age. More than 20% of people age 65 and over have at least one chronic condition, and many have multiple chronic conditions.

Implications for nursing
These demographic trends have important implications for health care. For one thing, they show a need for increased long-term care services and more gerontologic nurses, especially in states that have high numbers of elderly people.
Also, as the number of elderly women increases, so does the need for information about women’s health across the entire life span.

Gerontologic care: Normal changes of aging

Focus topic: Gerontologic care

With aging comes the loss of some body cells and reduced metabolism in others. These changes lead to altered body composition and reductions in certain body functions. For instance, adipose (fatty) tissue stores typically increase with age, whereas lean body mass and bone mineral content diminish.


Older but not necessarily ill

Although an older person’s body tends to work less efficiently than a younger person’s, illness doesn’t inevitably accompany old age. Certainly, the heart, lungs, kidneys, and other organs are less efficient at age 60 than at age 20, but that doesn’t mean aging always leads to the breakdown of body systems. As a nurse, you must recognize these gradual changes in body function so you can adjust your assessment techniques accordingly. It’s also important to understand how aging increases the risk of developing certain diseases and sustaining certain types of injuries.

Gerontologic care: Nutritional aspects of aging

Focus topic: Gerontologic care

Protein, vitamin, and mineral requirements usually remain stable as we age, but caloric needs decrease. Diminished activity may lower daily energy requirements by about 200 calories for men and women between ages 51 and 75, by 400 calories for women older than age 75, and by 500 calories for men older than age 75.

Notes on nutrition

Other physiologic changes that can affect an elderly patient’s nutritional status include:
• decreased renal function, which heightens susceptibility to dehydration and renal calculi formation
• loss of calcium and nitrogen (in patients who aren’t ambulatory)
• diminished enzyme activity
• reduced pepsin and hydrochloric acid secretion, which may reduce the absorption of calcium and vitamins B1 and B2
• decreased salivary flow and a reduced taste sensation, which may diminish the appetite and lead to greater consumption of sweet and spicy foods
• reduced gastric motility and intestinal peristalsis
• thinning of tooth enamel, causing teeth to become more brittle
• decreased biting force
• diminished gag reflex
• limited mobility (in persons with certain health conditions), which may hamper the ability to prepare food or feed oneself.

GI problems
Reduced intestinal motility may lead to such GI disorders as constipation. Other factors that may contribute to constipation in older adults include:
• nutritionally inadequate diets that are high in soft, refined foods and low in dietary fiber
• physical inactivity
• emotional stress
• use of certain medications
• inadequate fluid intake due to decreased thirst perception.

Laxative overload

Some older adults abuse laxatives, resulting in rapid transport of food through the GI tract. This, in turn, decreases digestion and absorption.

Socioeconomic and psychological factors
Socioeconomic and psychological factors that can affect an older person’s nutritional status include:
• loneliness
• perceived decline in his importance to the family
• susceptibility to nutritional misinformation
• lack of money to buy nutritionally beneficial foods
• lack of regular dental care.

Gerontologic care: Skin, hair, and nails

Focus topic: Gerontologic care

Age-related subcutaneous fat loss, dermal thinning, and decreasing collagen lead to the development of facial lines (crow’s feet) around the eyes, mouth, and nose. Women’s skin, which is thinner and drier than men’s, shows signs of aging about 10 years earlier. Also, the supraclavicular and axillary regions, knuckles, and hand tendons and vessels become more prominent, as do fat pads over bony prominences. Cell replacement decreases by 50%.

High and relatively dry

Mucous membranes become dry, and sweat gland output lessens as the number of active sweat glands decreases. Body temperature grows harder to regulate as sweat glands decrease in size, number, and function and subcutaneous fat is lost.

Pigmentary plotlines

Skin also loses elasticity with age, to the point where it may seem almost transparent. Although the production of melanocytes (skin cells that produce the pigment melanin) decreases, localized melanocyte proliferation is common. Thus, older people tend to have brown spots (senile lentigo), especially in areas regularly exposed to the sun.
Hair pigment decreases with age as the number of melano cytes declines, so the hair may turn gray or white. Hair also thins; by age 70, it may be baby fine. Hormonal changes cause pubic hair loss. Facial hair generally increases in postmenopausal women and decreases in aging men.

News about nails

With age, nail growth slows and longitudinal ridges, thickening, brittleness, and malformations may increase. Toenails may become discolored.

Tags, tumors, and keratosis

Other common skin conditions in elderly people include:
• senile keratosis—overgrowth and thickening of the horny epithelium
• acrochordon—benign skin tags
• senile angiomas—benign tumors made up of blood vessels or lymph vessels.
Also, wounds take longer to heal.

Gerontologic care: Eyes and vision

Focus topic: Gerontologic care

Aging brings changes to both the eye structure and visual acuity. With advancing age, the eyes sit deeper in the bony orbits and the eyelids lose their elasticity, becoming baggy and wrinkled. The conjunctiva (the membrane coating the eye’s outer surface) becomes thinner and yellow, and pingueculae (yellowish spots) may develop on the bulbar conjunctiva.

No more tears?

As the lacrimal apparatus gradually loses fatty tissue, tears diminish in quantity. Tears also tend to evaporate more quickly, increasing the risk of eye infection. The cornea loses its luster and flattens. The iris fades or develops irregular pigmentation, turning pale. Increased connective tissue may cause hardening of the eye sphincter muscles.

Let there be (more) light

The pupil shrinks, decreasing the amount of light that reaches the retina. To see objects clearly, older adults need about three times as much light as younger people. Aging also diminishes night vision and depth perception. The sclera becomes thick and rigid, and fat deposits cause yellowing. Senile hyaline plaques may develop.

Floaters and rings

The vitreous humor (the glassy substance behind the lens) may degenerate over time, revealing opacities and floating vitreous debris on examination. Also, the vitreous may detach from the retina, appearing as an empty space. Through an ophthalmoscope, the detached vitreous looks like a dark ring in front of the optic disk.

Lens lessons

The lens enlarges and loses transparency with age. Accommodation diminishes from decreased lens elasticity. This leads to presbyopia, a vision defect in which objects very close to the eye can’t be seen clearly without corrective lenses.

Color curtailment

Many older adults have impaired color vision, especially in the blue and green ranges, as the photoreceptive retinal cones deteriorate. Decreased reabsorption of intraocular fluid may predispose older adults to glaucoma.

Gerontologic care: Ears and hearing

Focus topic: Gerontologic care

Many elderly persons lose some degree of hearing. Hearing loss sometimes results from gradual cerumen buildup in the ear. More often, though, hearing loss progresses slowly, resulting in presbycusis (sometimes called senile deafness). This irreversible, bilateral, sensorineural hearing loss usually starts during middle age and slowly worsens. Presbycusis affects men more than women.

A hush at high pitches

The most common form of presbycusis, called sensory presbycusis, results from atrophy of the organ of Corti (which contains special hearing receptors) and the auditory nerve. Hearing loss occurs mostly in the higher pitch ranges.
By age 60, most adults have difficulty hearing above 4,000 Hz. (The normal range for speech recognition is 500 to 2,000 Hz.) Many older adults have trouble distinguishing higher-pitched consonants, such as s, sh, f, ph, ch, z, t, and g.

No dearth of deafness

Aging results in degenerative structural changes in the entire auditory system. In fact, hearing loss in elderly people may be more common than statistics indicate. Some people may not be immediately aware of the onset or progression of a hearing defect. Others may recognize the problem but view it as a natural part of aging— and thus not seek medical help.

Gerontologic care: Respiratory system

Focus topic: Gerontologic care

Age-related anatomic changes in the upper airways include nose enlargement from continued cartilage growth, tonsil atrophy, and tracheal deviations caused by changes in the aging spine. In the thorax, anteroposterior chest diameter may increase from altered calcium metabolism and costal cartilage calcification. This, in turn, reduces chest wall mobility. Kyphosis (curvature of the thoracic spine) advances with age from such factors as osteoporosis and vertebral collapse. Respiratory muscle degeneration or atrophy may also occur, reducing pulmonary function.

Lung changes
Ventilatory capacity diminishes as the lungs’ diffusing capacity declines. Also, decreased inspiratory and expiratory muscle strength diminish vital capacity. Lung tissue degeneration reduces the lungs’ elastic recoil, causing higher residual volume. (In fact, aging alone can cause emphysema.)

Out of oxygen

Furthermore, closing of some airways impairs ventilation of the basal areas, decreasing both the surface area available for gas exchange and the partial pressure of arterial oxygen (PaO2). Thus, maximum breathing capacity, forced vital capacity, vital capacity, and inspiratory reserve volume all diminish, reducing the tolerance for oxygen debt.

Aging and alveoli

With age, the lungs become more rigid and the number and size of alveoli decline. A 30% reduction in respiratory fluids and a decrease in ciliary action and macrophages increase the risk of respiratory tract infection and mucus plugs.

Gerontologic care: Cardiovascular system

The heart usually becomes slightly smaller with age (except in people with hypertension or heart disease). By age 70, many people experience a 35% decrease in cardiac output at rest.

Stiffer valves, thicker walls

The heart muscle becomes less efficient and loses contractile strength, fibrotic and sclerotic changes thicken the heart valves and reduce their flexibility. The valves may become rigid and unable to close completely, leading to systolic murmurs. Also, the left ventricular wall grows 25% thicker between ages 30 and 80. The heart’s ability to respond to physical and emotional stress may diminish markedly with age; for instance, the heart rate takes longer to return to normal after exercise. Also, elderly adults may develop obstructive coronary disease and fibrosis of the cardiac skeleton.

Vessels in distress

Aging commonly contributes to arterial and venous insufficiency, as blood vessels lose strength and elasticity. These factors contribute to a higher incidence of cardiovascular disease, especially coronary artery disease. As myocardial irritability increases with age, extra systoles may occur, along with sinus arrhythmias and sinus bradycardias. Increased fibrous tissue infiltrates the sinoatrial node and internodal atrial tracts, possibly causing atrial fibrillation and flutter.

Pressure surge

Coronary artery blood flow decreases 35% between ages 20 and 60. The aorta grows more rigid, causing systolic blood pressure to rise proportionately more than diastolic blood pressure (resulting in a widened pulse pressure). The veins also dilate with age, and blood tends to pool in the extremities. Electrocardiographic changes may include increased PR and QT intervals, decreased QRS complexes, and a leftward shift of the QRS axis.

Gerontologic care: GI system

When assessing the elderly patient’s GI system, pay special attention to the physiologic changes that accompany aging. Normal changes include diminished mucosal elasticity and reduced GI secretions, which in turn may alter digestion and absorption.

Dawdling digestion

GI tract motility, lower esophageal sphincter tone, bowel wall and anal sphincter tone, and abdominal muscle strength may decrease with age. These changes may cause signs and symptoms ranging from appetite loss to esophageal reflux to constipation.

Losses of the liver

In the liver, normal age-related changes include decreased liver weight, reduced regenerative capacity, and diminished blood flow.

Gerontologic care: Urologic system

After age 40, renal function may diminish; by age 90, it may decrease by up to 50%. Age-related changes in renal vasculature that disturb glomerular hemodynamics reduce the glomerular filtration rate.
Renal blood flow decreases 53% from reduced cardiac output and age-related atherosclerotic changes. Tubular reabsorption and renal concentrating ability also decline as the size and number of functioning nephrons decrease.
Also, the bladder muscles weaken, possibly causing incomplete bladder emptying and chronic urine retention—conditions that set the stage for bladder infection. Residual urine, urinary frequency, and nocturia also grow more common.

Renal reductions

Other age-related changes affecting renal function include diminished kidney size, impaired renal clearance of drugs, reduced bladder size and capacity, and decreased renal ability to respond to variations in sodium intake. Blood urea nitrogen levels rise about 20% by age 70.

Gerontologic care: Female reproductive system

Declining estrogen and progesterone levels cause various physical changes in aging women. As estrogen levels decrease and menopause approaches (usually at about age 50), a host of physiologic changes occur.

The breast’s glandular, supporting, and fatty tissues atrophy with age. As Cooper’s ligaments lose their elasticity, the breasts become pendulous. The nipples become smaller, flatter, and nonerect. Inframammary ridges grow more pronounced.

Disappearing disease

Any fibrocystic breast disease present before menopause usually diminishes and disappears.

Ovulation usually stops 1 to 2 years before menopause. As the ovaries reach the end of their productive cycle, they become unresponsive to gonadotropic stimulation.

Pelvic support structures
Pelvic support structures typically relax after menopause. Such relaxation may first occur with labor and delivery—but clinical effects may go unnoticed until menopause, when relaxation is accelerated by estrogen depletion and loss of connective tissue elasticity and tone.
Signs and symptoms include pressure and pulling in the area above the inguinal ligaments, low backache, a feeling of pelvic heaviness, and difficulty rising from a chair. Urinary stress incontinence may become a problem if urethrovesical ligaments weaken.

After menopause, the uterus atrophies rapidly to one-half its premenstrual weight. Uterine regression continues until the organ reaches about one-fourth of its premenstrual size. The cervix shrinks and no longer produces mucus for lubrication, and the endometrium and myometrium become thinner.

Atrophy causes the vagina to shorten and the mucous lining to become thin, dry, pale, and less elastic. In this state, the vaginal mucosa is highly susceptible to abrasion. Also, the pH of vaginal secretions rises.

The vulva atrophies with age. Pubic hair loss occurs, and the labia majora flatten. Vulval tissue shrinks, exposing the sensitive area around the urethra and vagina to abrasions and irritation (for instance, from undergarments). With age, the introitus (vaginal opening) constricts, vaginal tissues lose their elasticity, and the epidermis thins from 20 layers to about 5. Despite such body changes, older women can continue to remain sexual throughout their lives.




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