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Chapter: Medical Surgical Nursing: Health Care of the Older Adult

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Physical Health Problems in Older Populations

1. Geriatric Syndromes: Multiple Problems With Multiple Etiologic Factors 2. Acquired Immunodeficiency Syndrome in Older Adults

Physical Health Problems in Older Populations

GERIATRIC SYNDROMES: MULTIPLE PROBLEMS WITH MULTIPLE ETIOLOGIC FACTORS

 

The frail elderly frequently experience multiple problems, or syndromes. Illness, whether acute or chronic, generally results from several factors rather than from a single cause. When com-bined with a decrease in host resistance, these factors lead to ill-ness or injury. Although the problems may have developed slowly, the onset of symptoms is often acute. 

Furthermore, the presenting symptoms may appear in other body systems before becoming apparent in the affected system. The term “frail” is used to describe those elders who are at highest risk for adverse health outcomes or geriatric syndromes. There are no standard clinical criteria for frailty. According to the most widely agreed on definition, frail people are those who are most vulnerable to significant problems because they meet one or more of the fol-lowing conditions:

 

·      Being 85 years of age or older

 

·       Being unable to perform IADLs or ADLs independently

 

·       Suffering from multiple chronic diseases

 

As with specific illnesses, geriatric syndromes are never a normal consequence of aging. Early intervention can prevent further complications and help to maximize the quality of life for many older people (Hazzard et al., 1999).

 

Impaired Mobility

 

The causes of decreased mobility are many and varied. Common causes are Parkinson’s disease, diabetic neuropathy, cardiovascu-lar compromise, osteoarthritis, osteoporosis, and sensory deficits. Environmental barriers and iatrogenic factors are also significant. Elderly patients should be encouraged to stay as active as possible to avoid the downward spiral of immobility. During illness, bedrest should be kept to a minimum, because even brief periods of bed rest quickly lead to deconditioning and, consequently, to a wide range of complications. When bed rest cannot be avoided, the patient should perform active range-of-motion and strength-ening exercises with the unaffected extremities, and the nurse should perform passive range-of-motion exercises on the affected extremities. Frequent position changes help offset the hazards of immobility. Both the staff and the patient’s family can assist in maintaining the current level of mobility (Tappen, Roach, Applegate, & Stowell, 2000).

Dizziness

Older people frequently seek help for dizziness, which presents a particular challenge because there are so many possible internal and external causes. For many, the problem is further compli-cated because of an inability to differentiate between the true dizziness (a sensation of disorientation in relation to position) and vertigo (a spinning sensation). Other similar sensations include near-syncope and disequilibrium. The causes for these sensations range in severity from minor, as in a buildup of ear wax, to severe, as in dysfunction of the cerebral cortex, cerebellum, brain stem, proprioceptive receptors, or the vestibular system. Even a minor reversible cause, such as an ear wax impaction, can result in a loss of balance and a subsequent fall and injury. Because of the many predisposing factors, nurses should seek to identify potentially treatable factors related to the dizziness. This impairment reduc-tion strategy may reduce the vulnerability of older persons to in-jury (Tinetti, Williams, & Gill, 2000).

Falls and Falling

Falling is a common and preventable source of mortality and morbidity in older adults. As the major cause of trauma in the el-derly, falls are not often fatal but do threaten health and the qual-ity of life. Normal and pathologic consequences of aging that contribute to increased falls include visual changes such as loss of depth perception, susceptibility to glare, loss of visual acuity, and difficulty in light accommodation. Neurologic changes include loss of balance, dizziness, loss of position sense, and delayed re-action time (Ruckenstein, 2001). Cardiovascular changes may re-sult in cerebral hypoxia and postural hypotension. Cognitive changes include confusion, loss of judgment, and impulsive be-havior. Musculoskeletal changes include altered posture and de-creased muscle strength. Use of many medications, medication interactions, and alcohol precipitate falls by causing drowsiness, incoordination, and postural hypotension. Osteoporosis-related fractures can have a negative effect on the individual’s ability to maintain an independent living arrangement (Peterson, 2001).

 

Overall, elderly women who fall sustain a greater degree of in-jury than do elderly men. The most common fracture occurring from a fall is hip fracture resulting from the combined comor-bidities of osteoporosis and the condition or situation that pro-voked the fall. Studies have shown that elderly people who fall experience a greater decline in their ability to perform ADLs and social activities, have a greater chance of being institutionalized, and use more health care services than elderly people who do not fall (Capezuti, 2000; Tinetti, Williams, & Gill, 2000).

 

In institutionalized elderly people, restraints in the form of physical modalities (lap belts; geriatric chairs; vest, waist, and jacket restraints) and chemical modalities (medications) are known to precipitate many of the injuries they were meant to prevent. Documented injuries and deaths resulting from these restraintsinclude strangulation, vascular and neurologic damage, pressure ulcers, skin tears, fractures, increased confusion, and significant emotional trauma. The time required to supervise restrained pa-tients adequately is better used addressing the unmet need that provoked the behavior that resulted in the use of restraint. Because of the overwhelming negative consequences of restraint use, the accrediting agencies of nursing homes and acute care facilities now maintain stringent guidelines concerning their use.

Urinary Incontinence

Urinary incontinence can be acute, developing during an illness,or it can develop chronically over a period of years. The older pa-tient often does not report this very common problem unless specifically asked. Transient causes may be attributed to delirium and dehydration; restricted mobility and restraints; inflamma-tion, infection, and impaction; and pharmaceuticals and polyuria (use the acronym DRIP to remember them). Once identified, the causative factor can be eliminated. Established incontinence may be a result of neurologic or structural abnormalities (Degler, 2000b).

 

The pelvic floor serves as the supporting mechanism or “ham-mock” for the bladder, uterus, and rectum. It may have become weakened as a result of pregnancy, labor and delivery, prior pelvic surgeries, or work that required prolonged standing or lifting. Dysfunction of the pelvic floor can be greatly improved with Kegel exercises. Other measures that help prevent episodes of in-continence include having quick access to toilet facilities and wearing clothing that can be unfastened easily.

 

The patient with this problem should be urged to seek help from appropriate health personnel, because incontinence can be as emotionally devastating as it is physically debilitating. Nurses who specialize in behavioral approaches to urinary incontinence management are particularly successful in assisting an individual either to regain continence or to significantly improve the level of continence. Although medications such as anticholinergics may decrease some of the symptoms of urge incontinence (detrusor instability), their side effects (dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate choices for the elderly. Various surgical procedures are also used to man-age urinary incontinence, particularly stress urinary incontinence.

 

Detrusor hyperactivity with impaired contractility is a type of urge incontinence that is seen predominantly in the elderly pop-ulation. In this variation of urge incontinence, the patient has ab-solutely no warning that he or she is about to lose urine. When toileted, the patient often voids only a small volume of urine or none at all, then experiences a large volume of incontinence after leaving the bathroom. The nursing staff should be familiar with this form of incontinence and should not show disapproval to the patient. Many patients with dementia suffer from this type of in-continence because both incontinence and dementia are a result of dysfunction in similar areas of the brain. Prompted, timed voiding can be of assistance to these individuals, although clean intermittent catheterization is the preferred management.

ACQUIRED IMMUNODEFICIENCY SYNDROME IN OLDER ADULTS

 

Acquired immunodeficiency syndrome (AIDS) is no longer only a disease of young people. It is increasingly recognized that AIDS does not spare the older segment of society. According to a report of the Centers for Disease Control and Prevention, between 1981 to 1989, more than 10% of all AIDS patients nationwide were 50 years of age or older at the time of diagnosis, and about 3%were age 60 years or older. In that report, male homosexual contact and blood transfusions were the predominant modes oftransmission among older patients. Transmission by contaminated blood products has declined in recent years, so the predominant mode of transmission in older people now is through sexual contact. The most common AIDS-indicator disease inthe older person is Pneumocystis carinii pneumonia. Wasting syndrome and HIV encephalopathy are also common in olde HIV-infected people. Survival time is significantly shorter in older patients than in younger patients with AIDS (Ory &Mack, 1998).

 

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