Introduction

This unit is unique in that the primary objective is to present practical, concise information of clinical relevance for the beginning practitioner that is not covered elsewhere. The focus is on 12 significant problems and concerns associated with the older adult (falls, use of restraints, thermoregulation, sleep disturbance, skin breakdown, polypharmacy, specific types of hearing changes, age-related macular degeneration, incontinence, sexual neglect, caregiver burden, warning signs of poor nutrition).

The unit begins with health assessment of the older adult, system by system, highlighting the most common changes associated with the aging process; it ends with several functional rating scales to assist in management of care in the home or community.

  1. Health assessment of the older adult
    1. Skin
      1. Decrease in elasticity-wrinkles and lines, dryness.
      2. Loss of fullness-sagging.
      3. Generalized loss of adipose and muscle tissue-wasting appearance.
      4. Decrease of adipose tissue on extremities, redistributed to hips and abdomen in middle age.
      5. Bony prominences become visible.
      6. Excessive pigmentation-age spots.
      7. Dry skin and deterioration of nerve fibers and sensory endings-pruritus.
      8. Decreased blood flow-pallor and biotchiness.
      9. Overgrowth of epidermal tissue-lesions (some benign, some premalignant, some malignant).
    2. Nails:
      1. Dry, brittle.
      2. Increased susceptibility to fungal infections.
      3. Decreased growth rate.
      4. Toenails thick, difficult to cut.
    3. Hair:
      1. Loss of pigment-graying, white.
      2. Decreased density of hair follicles-thinning of hair.
      3. Decreased blood flow to skin and decreased estrogen production-baldness.
        1. Hair distribution: thin on scalp, axilla, pubic area, upper and lower extremities.
        2. Decreased facial hair in men.
      4. Decreased estrogen production-increased facial (chin, upper lip) hair in women.
    4. Eyes:
      1. Loss of soluble protein with loss of lens transparency-development of cataracts.
      2. Decrease in pupil size limits amount of light entering the eye-elderly need more light
      3. Decreased pupil reactivity-decrease in rate of light changes to which a person can readily adapt.
      4. Decreased accommodation to darkness and dim light-diminished night vision.
      5. Loss of orbital fat-sunken appearance.
      6. Blink reflex-slowed.
      7. Eyelids-loose.
      8. Visual acuity-diminished.
      9. Peripheral vision-diminished.
      10. Visual fields-diminished.
      11. Lens accommodation-decreased; requires corrective lenses.
      12. Presbyopia-lens may lose ability to become convex enough to accommodate to nearby objects; starts at age 40 (farsightedness).
      13. Color of iris-fades.
      14. Conjunctiva-thins, looks yellow.
      15. Increased intraocular pressure -> glaucoma.
    5. Ears:
      1. Changes in cochlea-decrease in average pitch of sound.
      2. Hearing loss-greater in left ear than right; greater in higher frequencies than in lower.
      3. Tympanic membrane-atrophied, thickened-hearing loss.
      4. Presbycusis-progressive loss of hearing in old age.
    6. Mouth:
      1. Dental caries.
      2. Poor-fitting dentures.
      3. Cancer of the mouth-increased risk.
      4. Decrease in taste buds-inability to taste sweet/salty foods.
      5. Olfactory bulb atrophies decreased ability to smell.
    7. Cardiovascular:
      1. Lack of elasticity of vessels-increased resistance to blood flow; decreased diameter of arteries-increased blood pressure.
      2. Atherosclerotic plaques-thrombosis.
      3. Valves become sclerotic, less pliable reduced filling and emptying.
      4. Diastolic murmurs heard at base of heart.
      5. Loss of elasticity, decreased contractility-decreased cardiac output.
      6. Changes in the coronary arteries-pooling of blood in systemic veins and shortness of breath-reduced pumping action of the heart.
      7. Disturbance of the autonomic nervous system-dysrhythmias.
      8. Extremities-arteriosclerotic changes-weaker pedal pulses, colder extremities, mottled color.
    8. Respiratory:
      1. Efficiency reduced with age.
      2. Greater residual air in lungs after expiration.
      3. Decreased vital capacity.
      4. Weaker expiratory muscles-decreased capacity to cough.
      5. Decreased ciliary activity-stasis of secretions-susceptibility to infections.
      6. Oxygen debt in the muscles-dyspnea on exertion.
      7. Reduced chest wall compliance.
    9. Breasts:
      1. Atrophy.
      2. Cancer risk-increased with age.
    10. Gastrointestinal:
      1. Lack of intrinsic factor-pernicious anemia.
      2. Gastric motility-decreased.
      3. Esophageal peristalsis-decreased.
      4. Hiatal hernia-increased incidence.
      5. Digestive enzymes-gradual decrease of ptyalin (which converts starch), pepsin and trypsin (which digest protein), lipase (fatsplitting enzyme).
      6. Absorption-decreased.
      7. Improper diet-constipation.
    11. Endocrine:
      1. Basal metabolism rate lowered-decreased temperature.
      2. Cold intolerance.
      3. Women: decreased ovarian function-increased gonadotropins.
      4. Decreased renal sensitivity to ADH-unable to concentrate urine as effectively as younger persons.
      5. Decreased clearance of blood glucose after meals-elevated postprandial blood glucose.
      6. Risk of diabetes mellitus increases with age.
    12. Urinary:
      1. Renal function-impaired due to poor perfusion.
      2. Filtration-impaired due to reduction in number of functioning nephrons.
      3. Urgency and frequency: men-often due to prostatic hyperplasia; women-due to perineal muscle weakness.
      4. Nocturia-both men and women.
      5. Urinary tract infection-increased incidence.
      6. Incontinence-especially with dementia.
    13. Musculoskeletal:
      1. Muscle mass-decreased.
      2. Bony prominences-increased.
      3. Demineralization of bone.
      4. Narrowing of intervertebral space-shortening of trunk.
      5. Posture-normal; some kyphosis.
      6. Range of motion-limited.
      7. Osteoarthritis-related to extensive physical activities and joint use.
      8. Gait-altered.
      9. Osteoporosis related to menopause, immobilization, elevated levels of cortisone.
      10. Calcium, phosphorus, and vitamin D decreased.
    14. Neurological:
      1. Voluntary, automatic reflexes-slowed.
      2. Sleep pattern-changes.
      3. Mental acuity-changes.
      4. Sensory interpretation and movement-changes.
      5. Pain perception-diminished.
      6. Dexterity and agility-lessened.
      7. Reaction time-slowed.
      8. Memory-past more vivid than recent memory.
      9. Depression.
      10. Alzheimer’s disease.
    15. Sexuality:
      1. Women:
        1. Estrogen production-decreased with menopause.
        2. Breasts atrophy.
        3. Vaginal secretions-reduced lubricants.
        4. Sexuality-drive continues; sexual activity declines.
      2. Men:
        1. Testosterone production-decreased.
        2. Testes-decrease in size; decreased sperm count.
        3. Libido and sexual satisfaction-no changes.