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Nursing Care of the Elderly

Introduction
Old age has been considered as a stage of life when capacities and opportunities decline rather than expand. The meaning of old age varies depending on the expectations and attitudes of the culture and society towards the old person, for example, in Egyptian rural societies, older people tend to be more respected, and their skills tend to be more effectively than in modern societies. Furthermore, any society is a collection of people in different ages, and stages of development affect their perception and definition of old. The fact is people become unique when they grow older, not more alike. There are increased efforts to explain the cause of aging either from a disease or pathology. Its clear that aging was not connected with illness or disease, but specific factors expose individual to illness and diseases. Some factors associated with aging which cannot be modified such as genetics, gender, and age. Others can be modified such as nutrition, exercise, smoking and stress management. Since some factors can be modified depending on lifestyle modification, we can promote healthy aging.

Theories of Aging
There is no explanation to why and how biological changes occur, and there is no evidence to prove adequate explanation of the complex aging process. Biological agents vary from genetic influence to changes at the cellular level, other consider the entire organ changes. Psychological and psych-social theories were developed trying to explain aging process. Biological theories are classified into 2 types; 1. Stochastic theories, which view aging as caused by series adverse changes over time that causes replicative errors within the cellular structure. Examples are;
a. b. c. d. Wear and tear theory Error theory Cross linking theory Free radical theory

2. Non-stochastic theories, which view aging as occurs by replicated errors in the cell. Examples are:
a. Aging programmed theory b. Immunological theory

Psychological theories consider the experience gained over years that contribute behavior in later years. Examples are;
a. Eriksons stage theory of development b. Pecks tasks of middle and old age

Therefore, human behavior is affected by physiological, psychological and social factors, and they involve a complex interrelationship. Every individual remains unique throughout his life and can only properly understood from a holistic perspective.

Normal physiological changes common in elderly

Some people may believe that it is normal for elderly to experience forgetfulness and deterioration in vision and hearing. However, this is not true. These are signs and symptoms of early cognitive impairment. Failure to early diagnose and treat this cognitive impairment will result in progression of a disease as well as further problems in health. The Cardiovascular System Some anatomical and functional changes may occur to a geriatric cardiovascular system as a part of normal aging process. Normal changes are mentioned below:
1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 4. 5. 6. Heart becomes larger in size and occupies a bigger space within the chest Reduction in the size of functional muscle mass of the heart Decreased amount of blood that is pumped throughout blood circulation More adventitious S4 heart sounds Premature contractions and arrhythmias Slower blood flow that slower wound healing and impact on medication metabolism Low diastolic pressure Increased pulse pressure

Nursing interventions
Cardiomyopathy can be done; its referred to diagnostic tests. Inform the patient that exercise can reduce the strain on the heart Hurt murmurs require further tests to determine the effect. Fatigue, dizziness, sudden weight gain, or changes in cognitive function When taking medication, it will take time to get the action Inform the patient that low diastolic pressure indicates a risk for cerebrovascular accident or stroke 7. Inform the patient that exercise lowers blood pressure.

The Peripheral Vascular System

Normal changes are mentioned below; 1. Increase the peripheral vascular resistance 2. Valves in the veins dont function efficiently and form a nonpathological edema Nursing interventions 1. Inform the patient that age, diet, genetics and lack of exercise can convert nonpathological to pathological (atherosclerosis and arteriosclerosis) which can result in CVD. 2. Monitor cholesterol levels to prevent atherosclerosis and arteriosclerosis 3. Inform the patient that exercise decrease cholesterol levels 4. Discuss that the right medication and exercise programme and diet slow the progression of cardiac changes Respiratory system Normal changes are mentioned below; 1. Decreased vital respiratory capacity 2. Lungs lose elasticity 3. Loss of water and calcium in bones effect on the thoracic cage. 4. Decreased amount of cilia lining system 5. Decreased cough reflex Nursing interventions 1. Note that auscultating sounds is difficult so it must be done all lung fields in a quiet environment. 2. Inform the patient that pollution and smoking worsens the cilia 3. Tell patients that there is a risk for choking 4. Frequently access respiratory functions 5. Encourage regular exercise Integumentary system Normal changes are mentioned below; 1. Skin becomes thinner and more fragile

2. Skin is dry and loses elasticity 3. Sweat glands, decreases which leads to less perspiration 4. Subcutaneous fat and muscle layers begin to diminish. 5. Dryness 6. Skin tears 7. Fingernails and toenails become thick and brittle 8. Hair becomes gray 9. Facial hair on women 10. Decreased body hair on men and women Nursing interventions 1. Promote the use of sun block and tell patients to avoid overexposure 2. keep skin moist by using lotions 3. Protect elbows and heels with padding 4. Help older adult to maintain personal appearance. Gastrointestinal System Normal changes are mentioned below; 1. Inflamed gums 2. Periodontal disease 3. Sensitive teeth 4. Tooth loss 5. Decreased peristalsis of esophagus 6. Decreased gut motility, gastric acid production and absorption of nutrients 7. Constipation 8. Fecal incontinence Nursing interventions

1. Asses older adults ability to chew 2. Refer older adult for further oral evaluation if necessary 3. Assist older adult with making changes within eating habits 4. Assess nutritional health frequently 5. Encourage older adult to drink water 1.5 liter 6. Enemas and laxative medications maybe given in severe situations 7. Bowl habits training Urinary System Normal changes are mentioned below; 1. a loss of nephrons and glomeruli 2. Bladder tone and volume capacity decreases 3. Incontinence (occurs in response) Nursing interventions 1. Assess urinary incontinence 2. Kegel exercise 3. Voiding schedules (for cognitive impaired) Musculoskeletal System Normal changes are mentioned below; 1. Decrease in total muscle and bone mass 2. Diminish of muscle units that combine to form muscle groups Nursing interventions 1. Encourage exercise daily Reproductive System Normal changes are mentioned below; 1. Decrease in testosterone hormone in men, and estrogen hormone in women

Men: - Increase time needed for erections and ejaculation. Women: - Follicular depletion in the ovaries - Presence of fatty tissue in the breast instead of natural tissue - Labia shrinks - Decrease in vaginal lubrication and shortening and narrowing of the vagina - Strength of orgasmic contraction diminishes, and orgasmic phase decreased Nursing interventions 1. Help older adult feel comfortable when discussing sexuality 2. Give vaginal lubricants to females 3. Inform men to increase the time between erections 4. Mention the use of oral erective agents Sensory Systems Normal changes are mentioned below; 1. Eyes: - Visual acuity declines - Decrease pupil constriction in response to stimuli decreases - Peripheral vision declines - Lens of the eye often becomes yellow - Arcus senilis 2. Ears: - Increased amount of hard cerumen 3. Taste and smell: - Diminish of 30% of taste buds

Nursing interventions 1. Collect an early baseline eye assessment and follow up eye exams yearly 2. Help older adult remove cerumen 3. Obtain a diet history Nervous System Normal changes are mentioned below; 1. Total brain weight decrease 2. Shift in proportion of gray matter to white matter 3. Loss of neurons 4. Increase in the number of senile plaques 5. Blood flow to the cerebrum decreases Nursing interventions 1. Help older adult to maintain an active body and mind 2. Encourage them to participate in cognitive activities Dementia and Delirium In older adults, three pathological cognitive and psychological conditions occur frequently which lead to cognitive impairment. Those conditions are - Delirium - Dementia - Depression They occurs from completely different diseases process but they are all lead to similar symptoms of cognitive decline

Age-related health problems

The Cardiovascular System - Atherosclerosis - Coronary Heart Disease

- Hypertension Respiratory system - Chronic bronchitis and emphysema Gastrointestinal System - Gastritis and peptic ulcer - Carcinoma of the stomach - Constipation Urinary System - Urinary incontinence Musculoskeletal System - Osteoarthritis - Osteoporosis - Fractures Sensory Systems

Vision

- Cataract - Glaucoma - Macular degeneration

Hearing

Health Promotion and Exercise

1. Primary prevention - Promote ideal behaviors which include quieting smoking, limited alcohol consumption, good nutrition, exercise, adequate sleep, safe lifestyle, and updated immunization. We will go through health promotion for older adults, and give recommendations

2. Secondary prevention - Maintaining a high quality of life is to consider healthy behaviors. However, secondary level of prevention is important to early diagnose the disease which is at more treatable stage. Strategies are developed to detect disease at early stage through annual physical examinations, laboratory tests for detecting tumors, cholesterol level and diagnostic imagining. Detection and prevention of diseases as cardiovascular diseases, cancer and diabetes are very important among older adults. - According to National Cancer Register of Egypt (NCRPE), Breast cancer incidence among females aged more than 65 years in Aswan, Egypt at 2008 was 38.6%.

Nutrition

Healthy old adult generally require fewer calories than younger persons, and the same or higher levels of nutrients. Older male adult require about 2,900 to 3,000 calorie comparing to older woman who require from 1,600 to 2300 calorie of CHO, protein, fats daily. Energy required changes by with age due to reduced physical activity; decreased in metabolic rate and altered body weight and composition

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Medications and the Elderly

Treatment of illness usually requires medications. For every symptom there is a list of treatment from which to choose. These treatments include prescribed and non-prescribed, over the counter medications. Excessive use of inappropriate medications among older adults has a harmful effect on their health. Medication usage among older adults is determined with several issues; normal aging has a great effect on utilizing medications. These changes effect on the way of absorption of medications through gastrointestinal tract, skin, or muscular; disturbed via circulatory system; metabolized by the liver; cleared from the body through the kidneys.

Pharmacokinetics and pharmacodynamics - Pharmacokinetics refers to drug absorption, distribution, protein binding, hepatic metabolize, renal excretion. - Pharmacodynamics refers to the effect of the drug on the body Pharmacokinetic changes related to aging - Medication absorption a) Increase in gastric PH and change of the amount of fluid in the stomach

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b) Decrease in the time required for gastric emptying content c) The nutrients takes longer to move across the membrane d) Increased time needed for medications to become effective e) Increase time may also increase the amount of medication absorbed f) Vitamin A & C are more readily absorbed - Medication distribution a) Reduced lean body mass b) Increase body fats c) Water decrease 15% intracellular and extracellular d) Alteration in plasma protein binding - Medication metabolism a) Reduced blood flow to the liver b) Decreased in functional liver cells c) The enzymes used to breakdown medicines are reduced - Medication elimination a) Reduction in mass and number of nephrons b) Reduced glomerular c) Decreased renal tubular secretions d) Increased medication half life