Geriatric nursing

Physiological changes in aging

1. Overview of Normal Aging

Aging is a natural, gradual process marked by biological and functional changes, which vary from person to person. Understanding typical age-related transformations helps distinguish them from abnormal conditions, ensuring proper care and realistic expectations.

A. Integumentary System

1. Skin
   • The epidermis becomes thinner, and subcutaneous fat decreases, contributing to wrinkles and reduced skin elasticity.
   • Reduced function of sebaceous and sweat glands leads to drier skin and challenges in temperature regulation.
   • Skin becomes more fragile, increasing the likelihood of bruising, tears, and pressure ulcers.
2. Hair and Nails
   • Hair loss and graying occur as melanocytes decrease.
   • Nail growth slows, and nails may become thicker or more brittle.

B. Musculoskeletal System

1. Bone
   • Bone density and mass decline, increasing the risk of fractures (e.g., osteopenia and osteoporosis).
   • Vertebral disc thinning may lead to postural changes, such as kyphosis.
2. Muscle
   • Sarcopenia (muscle mass and strength loss) results in diminished endurance and slower movement.
   • Joints may become stiffer, and conditions like osteoarthritis may develop, causing pain and reduced range of motion.

C. Cardiovascular System

1. Heart
   • The left ventricular wall thickens, which can reduce cardiac output under stress.
   • Blood vessels lose elasticity, contributing to systolic hypertension and higher afterload.
2. Blood Vessels
   • Arteriosclerosis (hardened arteries) and slower baroreceptor response increase the risk of orthostatic hypotension.

D. Respiratory System

1. Lung Changes
   • The elasticity of alveoli decreases, resulting in lower vital capacity and higher residual volume.
   • Weakened respiratory muscles lead to less efficient coughing, increasing infection risk.
2. Common Issues
   • Older adults are more prone to respiratory infections like pneumonia and bronchitis.
   • Shortness of breath with physical exertion becomes more frequent.

E. Renal/Urinary System

1. Kidney Function
   • A decrease in glomerular filtration rate (GFR) slows waste removal and increases vulnerability to fluid and electrolyte imbalances.
   • The ability to concentrate urine diminishes, making dehydration a risk.
2. Bladder
   • The bladder’s capacity reduces, leading to more frequent urges and potential incontinence.
   • Men may experience urinary obstruction due to benign prostatic hyperplasia (BPH).

F. Gastrointestinal System

1. Oral Changes
   • Saliva production decreases, and chewing may become challenging, particularly if dentures or missing teeth are present.
2. GI Motility
   • Slower peristalsis can lead to constipation and an increased risk of fecal impaction.
   • Absorption of certain nutrients, like vitamin B12, may decrease.

G. Neurological and Sensory System

1. Neurological Changes
   • Cognitive processes may slow slightly, including longer response times, and the brain may lose some neurons.
   • Decreased proprioception (awareness of body position) can cause balance issues.
2. Sensory Changes
   • Vision: Presbyopia (difficulty focusing), lens stiffening, and issues with glare and depth perception are common.
   • Hearing: Presbycusis (difficulty hearing high frequencies) and reduced sound discrimination are typical.
   • Taste and Smell: Reduced sensitivity may alter appetite or increase the risk of not detecting spoiled food.

2. Common Health Concerns

A. Falls

1. Risk Factors
   • Weak muscles, unsteady walking, poor vision, and certain medications (e.g., sedatives) contribute to fall risk.
   • Chronic illnesses such as arthritis and neuropathy further heighten this risk.
2. Prevention Strategies
   • Conduct home safety evaluations to eliminate hazards, enhance lighting, and install grab bars.
   • Promote strength and balance exercises like Tai Chi.
   • Review medications for sedative effects or those that impact blood pressure when changing positions.
3. Nursing Actions
   • Perform a fall risk assessment (e.g., using the Morse Fall Scale).
   • Encourage use of assistive devices like canes or walkers, and recommend proper footwear.
   • Educate on techniques for standing up slowly to prevent dizziness due to low blood pressure.

B. Sensory Deficits

1. Vision
   • Conditions such as cataracts, macular degeneration, and glaucoma may lead to partial or complete vision loss.
   • Recommend routine eye exams, use of corrective lenses, and adjustments in the environment (e.g., using contrasting colors or large fonts).
2. Hearing
   • For age-related hearing loss (presbycusis), hearing aids may be needed—ensure they are well-fitted and maintained.
   • Communicate by facing the person, speaking clearly without shouting, and minimizing background noise.
3. Nursing Role
   • Modify communication and the environment: use large-print materials, ensure good lighting, and employ demonstrations when teaching.
   • Keep an eye out for signs of social isolation or depression if sensory loss is significant.

C. Polypharmacy

1. Definition
   • Polypharmacy refers to the use of multiple medications (often five or more), a common issue among older adults with chronic health conditions.
2. Risks
   • The risks include drug interactions, adverse side effects, nonadherence, and medication errors.
   • Older adults may experience heightened sensitivity to side effects due to changes in metabolism and excretion.
3. Nursing Actions
   • Perform medication reconciliation, reviewing all medications including over-the-counter and herbal supplements.
   • Work with pharmacists and doctors to eliminate unnecessary medications.
   • Educate patients on using pill organizers, simplifying medication schedules, and involving family members in medication management.

3. Age-Related Changes in Drug Metabolism and Excretion

A. Pharmacokinetics in Older Adults

1. Absorption
   • Absorption may decrease slightly due to reduced gastrointestinal motility and lower gastric acid levels, though this change is generally less impactful compared to other factors like drug distribution or excretion.
2. Distribution
   • With less total body water, there is a higher concentration of water-soluble medications.
   • Increased fat storage leads to a prolonged half-life for fat-soluble medications (e.g., benzodiazepines), causing them to stay in the body longer.
3. Metabolism
   • A decrease in liver blood flow and enzyme activity results in slower drug metabolism, which increases the risk of toxicity for medications that are cleared by the liver (e.g., warfarin, certain statins).
4. Excretion
   • Diminished renal function (lower glomerular filtration rate or GFR) results in slower drug clearance, which can lead to the buildup of medications that are primarily excreted by the kidneys (e.g., digoxin, certain antibiotics).

B. Safety Measures in Prescribing and Administration

1. Start Low, Go Slow
   • Initiate treatment with the lowest possible effective dose and gradually adjust upwards.
   • Carefully monitor for side effects before increasing the dosage.
2. Frequent Monitoring
   • Regularly assess renal function (e.g., creatinine clearance, estimated GFR) before making any adjustments to medication doses.
   • For medications with a narrow therapeutic range (e.g., digoxin, lithium, some anticonvulsants), monitor blood levels periodically.
3. Beers Criteria
   • This guideline identifies medications that may not be appropriate for older adults.
   • It suggests safer alternatives or additional monitoring techniques to minimize risks.
4. Nursing Role
   • Watch for signs of drug toxicity or confusion, which can be early indicators of medication-related issues in older adults.
   • Reinforce the importance of adhering to prescribed regimens and educating patients about potential side effects.

Chronic Disease Management

4. Dementia vs. Delirium

A. Dementia

1. Definition and Characteristics
   • Dementia is a chronic, progressive cognitive decline, often irreversible, involving memory impairment along with deficits in language, spatial awareness, or executive functions.
   • Onset: Gradual progression over months to years.
   • Types: Alzheimer’s disease (most common), vascular dementia, Lewy body dementia, frontotemporal dementia.
2. Clinical Presentation
   • Early signs include short-term memory loss that impacts daily functioning, difficulty completing familiar tasks, disorientation, and language issues.
   • Behavioral changes may include mood fluctuations, agitation, or wandering in later stages.
3. Management Approaches
   • Pharmacotherapy: Cholinesterase inhibitors (e.g., donepezil, rivastigmine) for mild to moderate dementia; memantine for moderate to severe stages.
   • Non-Pharmacological: Use of structured routines, environmental cues, reality orientation, and redirection techniques when appropriate.
   • Supportive Measures: Education for caregivers, enhancing safety (e.g., locks, alarms), providing respite care, and offering psychosocial support.
4. Nursing Considerations
   • Ensure consistency in routines and surroundings to alleviate anxiety.
   • Provide clear, simple instructions and use visual cues or gestures to facilitate communication.
   • Observe for behavioral changes that may indicate unmet needs, such as pain, hunger, or toileting needs.

B. Delirium

1. Definition and Characteristics
   • Delirium is an acute, fluctuating disturbance in attention and cognition, often reversible if the underlying cause is addressed.
   • Onset: Rapid, occurring within hours to days, often worsening at night (known as “sundowning”).
2. Causes
   • Common causes include infections (e.g., UTI, pneumonia), metabolic imbalances (e.g., electrolyte disturbances), medications (especially polypharmacy or sedatives), acute illnesses, and sensory deprivation or overstimulation.
3. Signs and Symptoms
   • Symptoms include difficulty maintaining attention, disorganized thinking, and altered levels of consciousness (e.g., hyperactive, hypoactive, or mixed states).
   • Perceptual disturbances (e.g., hallucinations, illusions) and confusion about time and place are also common.
4. Management
   • The key is to identify and address the underlying cause (e.g., infection, medication side effects, dehydration).
   • Reorientation strategies, such as clocks, calendars, and familiar objects, should be used. Ensure hearing aids or glasses are accessible to address sensory deficits.
   • Minimize environmental stress by ensuring proper lighting, reducing noise, and, if possible, having consistent caregivers.
5. Nursing Considerations
   • Differentiate delirium from dementia: Delirium typically presents suddenly with fluctuating symptoms.
   • Regular mental status assessments (e.g., Confusion Assessment Method) and vital signs monitoring are essential.
   • Prevent complications such as falls or aspiration, which may occur due to inattention or altered mobility.

End-of-Life Care and Palliative Considerations

1. Hospice Care and Comfort Measures

A. Hospice Care

1. Definition
   • Hospice care is a type of palliative care specifically for patients nearing the end of life, often when the prognosis is six months or less, assuming the disease progresses as expected.
   • The primary focus is to improve the quality of life by managing symptoms and providing emotional and spiritual support, rather than aiming for curative treatments.
2. Core Principles
   • Interdisciplinary Team: Care is provided by a team consisting of nurses, doctors, social workers, chaplains, and volunteers, addressing physical, emotional, and spiritual needs.
   • Patient-Centered Goals: The emphasis is on managing symptoms like pain and breathlessness, and respecting the patient’s preferences regarding care options.
   • Family Involvement: Families are included in education about the patient’s condition, receive grief counseling, and have access to respite care services.
3. Eligibility and Settings
   • Hospice care can be provided in a variety of settings, including the patient’s home, dedicated hospice facilities, nursing homes, or designated hospital units.
   • To qualify for hospice, patients generally need to discontinue curative treatments and focus on comfort and dignity.

B. Comfort Measures in End-of-Life Care

1. Symptom Management
   • Pain Control: Opioids like morphine or hydromorphone are adjusted for comfort, with adjuncts like gabapentin for nerve pain.
   • Dyspnea Relief: Low-dose opioids, proper positioning, and oxygen (if beneficial), alongside relaxation techniques, can alleviate shortness of breath.
   • Nausea/Vomiting: Medications like ondansetron or metoclopramide, along with dietary adjustments, can manage nausea.
   • Anxiety/Agitation: Short-acting anxiolytics, a calming environment, and providing reassurance can help soothe agitation.
2. Non-Pharmacological Approaches
   • Positioning the patient or repositioning them regularly can reduce discomfort from pressure or breathing difficulty.
   • Maintaining good oral hygiene, moisturizing the lips, and using therapeutic touch or music therapy can provide additional comfort.
3. Nutrition and Hydration
   • In the final stages, patients often experience a reduced appetite, and attempts to force feed can lead to discomfort.
   • Oral care remains essential even if the patient is not eating much.
   • Respecting the patient’s or family’s wishes is crucial, but it is important to educate them on the potential risks and benefits of artificial nutrition or hydration.
4. Spiritual and Emotional Support
   • Address the spiritual needs of patients through chaplain visits or allowing personal rituals, helping the patient find peace.
   • If desired, support patients in legacy-building activities such as writing letters or creating memory boxes.

2. Communication with Families and Caregivers

A. Therapeutic Presence and Empathy

1. Active Listening
   • Create an open space for family members to express their emotions, fears, and concerns.
   • Reflect their emotions back to them to help them feel understood, using phrases like, “It seems like you are concerned about…”.
2. Validation
   • Acknowledge the emotional strain and grief families may be experiencing.
   • Normalize a range of emotions such as sadness, guilt, and anger, assuring them these are common reactions during difficult times.

B. Discussing Prognosis and Wishes

1. Advance Care Planning
   • Encourage early conversations about care goals, including advance directives and power of attorney, to ensure clarity in decision-making.
   • Use clear, compassionate language to explain the progression of the illness and any changes in the patient’s condition.
2. Goals-of-Care Conversations
   • Discuss with the patient and family what matters most to them—such as comfort, staying at home, or experiencing specific milestones—and align care options accordingly.
   • Offer practical options like home hospice care, inpatient comfort care, or continuing certain medications for symptom relief.
3. Breaking Bad News
   • Use structured approaches like the SPIKES protocol to guide the conversation: Setting, Perception, Invitation, Knowledge, Empathy, Strategy/Summary.
   • Ensure privacy, offer time for questions, and use plain language rather than medical jargon to promote understanding.

C. Cultural Sensitivity

1. Respect Diverse Beliefs
   • Be aware that cultural differences may influence how death is perceived, when it’s appropriate to discuss it, or how decisions are made.
   • Ask open-ended questions to understand the family’s beliefs and practices regarding death and dying, as well as how decisions are made within the family.
2. Language Services
   • Ensure communication is clear and accurate by using professional interpreters if necessary, especially in cases where language barriers exist.

3. Nursing Considerations and Roles

A. Advocate for Patient and Family

1. Honor Patient Autonomy
   • Ensure the patient’s expressed wishes or any previously documented advance directives are respected when making care decisions.
   • If conflicts arise between family desires and patient directives, consider consulting with ethics professionals to find a resolution.
2. Symptom Assessment
   • Utilize validated pain scales to assess the patient’s pain levels, especially for those who cannot verbally communicate, and pay attention to non-verbal signs like grimacing or restlessness.
   • Continuously monitor the patient’s comfort and address new or worsening symptoms promptly.

B. Provide Psychosocial and Grief Support

1. Emotional Support
   • Acknowledge the anticipatory grief that families may experience and encourage them to ask questions and express their emotions.
   • Offer resources for bereavement counseling or provide referrals to support groups.
2. Team Collaboration
   • Collaborate with hospice teams, social workers, and chaplains to offer holistic support for the patient and their family.
   • Take an active role in family meetings to ensure the care plan is aligned with the patient’s wishes and the family’s needs.