Geriatric Nursing

-Lecture Outline –
-Introduction to geriatric nursing
-Age-related changes and common medical
problems in the elderly
 Introduction
Aging –
-Showing the effects of time.
-The normal process of time-related change.
-Usually gradual and continuous.
-Begins with birth and continues throughout
life.
Senescence –
-Loss of power of cell division and growth
Geriatrics –
-Medical specialty focusing on the diagnosis
and treatment of diseases in older adults.
-American Nurses Association established the
division of Geriatric Nursing Practice in 1966.
-The goal was to create standards for quality
nursing care for the aged.
-Division of Geriatric Nursing changed name to
Division of Gerontological Nursing Practice in
1976.
-Responsibilities of the gerontological nurse –
-Direct care.
-Management and development of nursing
personnel.
-Evaluation of care and services for the older
adult.
Employment Settings for
Gerontological Nurses
Skilled nursing facilities
-Skilled care provided by nurses
-Retirement communities
Adult day care
-Provides daytime supervision and activities
Residential care facilities
-Previously called rest homes
-Offer supervision and health monitoring
Transitional care units
-Established by acute care hospitals
-Provide subacute care, rehabilitation, and
palliative healthcare services
-Most patients are recuperating from surgery,
major illness, or injuries
-Support services of the acute care facility are
provided
Rehabilitation hospitals or facilities
-Specialized facilities provide subacute care to
patients with complex healthcare needs
-Patients may have head injuries, be
ventilator dependent, or require
rehabilitation after an injury or surgery
Community nursing care
-Visiting nurse service
-Provides skilled care in the home
-Services may include vital signs, education,
wound care, and medication administration
 The Nurse Gerontologist

-Nurse gerontologist provides comprehensive

nursing care to older people.
-Gerontological nurses have specialized
knowledge of the acute and chronic changes
specific to older people.
 Goals of Gerontological Care
-Promoting and maintaining functional status.
-Helping older adults identify and use their
strengths to achieve optimal independence.
 OVERVIEW OF AGING
-Majority of older adults enjoy good health.
-However as many as 20% of adults 65 years of
age and older report a chronic disability.
-Chronic disease is the major cause of disability.
-3 leading causes of death in people ≥ 65
-Heart disease
-Cancer
-Stroke
-People age at different rates.
-An 80 year old patient may be physiologically
younger than a 60 year old patient.
-The organ functional reserve is the safety
margin of organ capacity.
-The difference between maximal organ
capacity and basal function is the organ’s
functional reserve.
-Functional reserve is the safety margin
available to meet additional demands.
-Effects of aging –
-The functional reserve diminishes.
-The ability to handle additional stress
produced by disease, trauma, stress and
surgery diminishes.
-Age-related changes and risk factors may
negatively interfere with patient outcomes.
-Aging is not synonymous with disease.
-The effects of the aging process alone are not
the primary contributors to disability and
disease.
-Many chronic conditions commonly found
among older people can be managed, limited,
and even prevented.
-Chronologic age is not an accurate predictor of
physical condition or behavior
-Physical condition seems to be driven by:
-Lifestyle choices
Exercise
Nutrition
Stress management
-Genetics
-Environment
-The cells of the elderly (regardless of when
they last underwent mitosis) look the same as
young cells.
-However, old cells do not withstand a variety of
challenges quite so well as younger cells.
 Age-related Changes
-The well-being of older people depends on –
-Physical, psychosocial factors
-Mental, socioeconomic factors
-Environmental factors
-As people age, some physiologic changes are
inevitable.
-Older people face unique psycho-social
challenges that can lead to a variety of geriatric
syndromes and issues.
-These in turn can lead to poor health
outcomes, functional decline, frailty, disability
and dependence.
-Total assessment of geriatrics include –
-Evaluation of all major body systems.
-Evaluation of social and mental status.
-Evaluation of the ability of the person to
function independently despite having a
chronic illness/disability.
-People age quite differently and at different
rates.
-Chronologic age is often less predictive of
obvious aging characteristics.
-The body’s ability to maintain homeostasis
becomes increasingly diminished with cellular
aging.
-Organ systems cannot function at full efficiency
because of cellular and tissue deficits.
-With age, cells become less able to replace
themselves.
-A degradation of elastin and collagen causes
connective tissue to become stiffer and less
elastic.
-These changes result in diminished capacity for
organ function and increased vulnerability to
disease and stress.
 Cardiovascular System
-Deposits of the "aging pigment," lipofuscin,
accumulate.
-Connective tissue changes - loss of elasticity
-Loss of Sino-Artrial node cells, slowed
conduction
-Myocyte death without replacement
-Decreased response to beta-receptor
stimulation
-Decreased venous compliance; Veins, like
arteries, stiffen with age
Veins –
-Stiff veins are less able to “buffer” changes in
blood volume
Volume shifts cause exaggerated changes in
cardiac filling pressure
-The veins are a less effective reservoir of
blood in the elderly.
-As a consequence, the elderly are more
sensitive to hypovolemia.
Myocyte death –
-Remaining cells do not divide in adequate
numbers in adulthood
-Cardiac muscle cells die over time
-Remaining cells hypertrophy to compensate
for myocyte death over time
-The hypertrophy in turn exacerbates the
problems with early diastolic filling
-Under normal circumstances, the heart
continues to adequately supply all parts of the
body.
-However, an aging heart may be slightly less
able to tolerate increased workloads.
-Examples of stressors include: illness,
infections, emotional stress, injuries, and
extreme physical exertion.
Blood vessels –
-The aorta becomes thicker, stiffer, and less
flexible. This makes the BP higher resulting in
LV hypertrophy.
-Increased large artery stiffness causes a fall
in DBP, associated with a continual rise in SBP.

-Baroreceptors (stabilize BP during

movement/activity) become less sensitive
with aging……
 -This may contribute to the relatively
common finding of orthostatic hypotension.
-A slight increase in the size of the heart,
especially the left ventricle, is common.
-The heart wall thickens, so the amount of
blood that the chamber can hold may actually
decrease.
-The heart may fill more slowly.
 Hematologic Changes
-A decrease in total body water is observed with
aging. Blood volume therefore decreases.
-The number of red blood cells are reduced, but
not significantly.
-Most of the white blood cells stay at the same
levels, but lymphocytes decrease in number and
effectiveness.
-Overall, cell counts and parameters in the
peripheral blood are not significantly different
from in young adult life.
-However, the cellularity of the bone marrow
decreases moderately.
 Age and the Immune System
-The efficiency of the immune system declines
with age, but this is variable among persons.
-Nonspecific defenses become less effective
-The ability of the body to make antibodies
diminishes.
-Autoimmune disorders are increased in older
adults.
-The thymus gland (which produces hormones
that activate T cells) atrophies throughout life.
-The peripheral T-cells proliferate much less
exuberantly in old age.
-The result …..
-Common infections are often more severe
with slower recovery and decreased chances
of developing adequate immunity.
 Observed Changes in the Lungs
-The number of cilia & their level of activity is
reduced.
-Glandular cells in large airways are reduced.
-Decreased number of nerve endings in larynx.
-The cough reflex is blunted thus decreasing the
effectiveness of cough.
-Decreased levels of secretory IgA in nose &
lungs  decreased ability to neutralize viruses.
-The number of alveoli do not change
significantly.
-The number of functional alveoli decreases as
the alveolar walls become thin, the alveoli
enlarge, are less elastic.
-Decreased elasticity of the lungs may be due to
collagen cross-linking.
-The loss of elasticity accounts for "senile
hyperinflation“.
-The FEV1 drops by 30 mL/year during your
adult life
-VC is diminished by about 20%
-RV increases by about 50%
-Combine less functional alveoli with slightly
thickened capillaries  decreased surface area
available for O2-CO2 exchange  lower O2 to
supply vital organs, especially in setting of acute
respiratory illness.
-The respiratory muscles lose strength &
endurance.
-There is increased stiffness of chest wall (i.e.,
decreased compliance).
-Pulmonary vasculature becomes less elastic,
pulmonary artery thickens & enlarges 
increased resistance to blood flow in lungs 
increased pulmonary artery pressure.
 Observed Changes in the Kidney
-Renal blood vessels become smaller & thicker
reducing renal blood flow.
-Kidney size decreases by 20-30% by age 90.
-Decreased GFR. Typically begins to decline at
about age 40.
-By age 75 GFR may be about 50% less than
young adult.
-Current research shows that this is not true for
all elders, however.
-There is a decline in the number of renal
tubular cells, an increase in tubular diverticula,
& a thickening of the tubular walls  decreased
ability to concentrate urine & clear drugs from
the body.
-Overall kidney function, however, remains
normal unless there is excessive stress on the
system.
 Observed Changes in the Urinary Bladder
-The muscular ureters, urethra, & bladder lose
tone & elasticity. The bladder may retain urine.
This causes incomplete emptying.
-Decline in bladder capacity  less urine can be
stored in the bladder.
This causes more frequent urination.
The warning period between the urge and
actual urination is shortened or lost as one
ages.
 Observed Changes in the Musculoskeletal
System
Muscles
-Sarcopenia (↓ muscle mass & contractile
force) occurs with age.
-Sarcopenia is associated with increased
fatigue & risk of falling (so may compromise
ADLs).
-Sarcopenia affects all muscles including;
respiratory muscles (↓ efficiency of
breathing) & GI tract (constipation).
-Bone/Tendons/Ligaments
-Gradual loss of bone mass (bone resorption >
bone formation) starting around age 30s.
-Decreased water content in cartilage
-Decreased water in the cartilage of the
intervertebral discs results in a ↓ in
compressibility and flexibility. This may be
one reason for loss of height.
-Decreased water content of tendons &
ligaments contributing to ↓ mobility.
 Observed Changes in the GI Tract
-Basal and maximal stomach acid production
diminish sharply in old age.
At the same time, the mucosa thins.
-Decline in number of gastric cells  decreased
production HCL (an acidic environment is
necessary for the release of vitamin B12 from
food sources).
-Decrease in amount of pancreatic enzymes
without appreciable changes in fat, CHO, or
protein digestion.
-Diminished gastric and pancreatic enzymes
result in a hindrance to the absorption of other
nutrients (iron, calcium, and folic acid).
-Hepatic blood flow, size and weight decrease
with age.
-Overall function, however, is preserved, but
may be less efficient in the setting of drug
overload.
-Decreased tone in stomach and intestines
result in slower peristalsis  constipation.
 Observed Neurologic Changes
-There is neuronal loss in the brain throughout
life (amount & location varies)
-Loss is chiefly gray matter not white matter
-However, many neurons have ↑ dendrite
growth which may partially compensate for
neuronal loss in some areas of the brain.
-Slowed neuronal transmission
-Changes in sleep cycle: takes longer to fall
asleep, total time spent sleeping is less than
their younger years.
-Awakenings throughout the night, increase in
frequency of daytime naps
-Sense of smell markedly decreases
-The lens of the eye loses fluid and becomes
less flexible, making it more difficult to focus at
the near range.
-Dry eyes.
 Observed Skin Changes - Epidermis
-The number of epidermal cells decreases by
10% per decade and they divide more slowly
making the skin less able to repair itself quickly.
-Epidermal cells become thinner making the
skin look noticeably thinner.
-Changes in the epidermis allows more fluid to
escape the skin.
-The fat cells get smaller
This leads to more noticeable wrinkles and
sagging
 Age-Related Changes in the Reproductive
System
Women
-The “climacteric” occurs (defined as the period
during which the reproductive capacity
decreases (i.e., ovarian failure) then finally
stops = loss of estrogen & progesterone; FSH
and LH ↑↑). This is also described as the
transition from perimenopause (~age 40s) to
menopause.
-Thinning and graying of pubic hair
-Ovaries and uterus decreases in size and
weight
-Skin is less elastic + loss of glandular tissue
gives breasts a sagging appearance.
-Hot flashes (can cause sleep deprivation if they
occur at night), sweats, irritability, depression,
headaches, myalgias.
-Sexual desire is variable. The symptoms are
typically present for about 5 years
-Atrophy of vaginal tissues due to low estrogen
levels = thinning & dryness occurs.
Men
-Testosterone decreases, testes become softer
and smaller.
-Erections are less firm and often require direct
stimulation to retain rigidity.
-Though fewer viable sperm are produced and
their motility decreases, men continue to
produce enough viable sperm to fertilize ova
well into older age.
-Less seminal fluid may be ejaculated
-They may not experience orgasms every time
they have sex
-The prostate gland enlarges; this often results
in compression of the urethra which may inhibit
the flow of urine.
Successful Aging - Homeostasis less efficient,
but still present
 AGING AND DISEASE
-Aging is associated with increase in incidence
and severity of disease.
-Factors predispose individuals to functional
losses later in life
Summary of clinical manifestations of aging
Neuromuscular function
-loss of neurons,atropy of neuronal
dendrites,impaired synaptic connections
-decline in motor strength,slowed reaction
time,diminished reflexes
-decrease in proprioceptor function that
controls balance
Cardiovascular function
-increased stiffness of blood vessels
-decreased responsiveness to
catecholamines
-decrease in exercise heart rate
-decrease in diastolic relaxation
Immune function
-altered function of helper T-cells
-diminished immune response
Immune function
-altered function of helper T-cells
-diminished immune response
Stature and musculoskeletal changes
-decrease in height
-loss of bone mass
-decrease in muscle strength
-skeletal bone loss
Integumentary function
-thin dry skin
-decreased sebum and sweat
-thick and brittle nails
-sparse, grey hair
Special senses
-decrease in visual acuity
-hearing loss
-decline in sense of smell
Respiratory function
-progressive loss of elastic recoil in lungs
and chest wall
-decrease in PO2
Gastrointestinal function
-dental problems
-dry mouth
-mucosal atrophy
-constipation
Renal function
-decrease in functional glomeruli
-decline in renal blood flow
-decrease in GFR
-decrease in urine concentration ability
Genitourinary function
-decreased bladder capacity, incomplete
emptying
-increased incidence of incontinence
-decreased serum testerone levels in man
-increased vaginal dryness in women
-decreased sexual response
 REST AND SLEEP
-A person spends 1/3 of his life in sleep
-Sleep is time for cell growth& repair
-Elderly need 5-7 hrs at night

Importance of Rest and sleep in elderly

-Conserve energy
-Provide organ respite (rest)
-Restore the mental alertness& neurological
efficiency
-Relieve tension
-Emerge feeling of well being
Factors affecting sleeping
patterns
-Age related changes in sleep patterns
-Internal factors
-External factors
 Nursing measures adopted to promote sleep
-Engage in exercise program
-Avoid exercise within 3-4 hours of bedtime.
-Spend time out door in the sunlight each day but avoid
period between 12 to 3pm sunshine exposure.
-Engage in relaxing activities near bedtime.
-Avoid tobacco at bedtime
-Avoid drinking any caffeinated beverages before mid
afternoon.
-Limit fluid intake after the dinner hour if nocturia is a
problem.
-Limit daytime naps to 30 minutes or less.
-Avoid using the bed for watching TV, writing bills, and
reading.
The end