bonnie m. wivell, ms, rn, cns chapter 6: review of the aging of physiological systems

Bonnie M. Wivell, MS, RN, CNS

Chapter 6: Review of the Aging of Physiological Systems

Heart chambers enlarge Thickening of heart walls

◦ Especially left ventricle◦ Decreased flexibility

Increase in heart weight Myocardial cells enlarge

◦ Men- decreased number of myocardial cells Heart muscle loses efficiency Reduced cardiac output under physiologic

stressors

Arteries◦ Dilate and stiffen◦ Reduced elasticity◦ Atherosclerosis

Increased peripheral resistance◦ Hypertension◦ Positional hypotension

Decreased stimulation of the baroreceptors leads to impaired sympathetic nerve response and resistance in peripheral vessels

Heart Valves◦ Calcium deposits accrue leading to stenosis

Murmurs◦ Asymptomatic

Blood Pressure◦ Systolic ↑ ◦ Diastolic ↓

Pulse◦ At rest vs. activity

Alveoli◦ Flatter, shallow, decreased surface area◦ Decreased number of capillaries per alveolus◦ Impaired passage of oxygen from alveoli to the

blood Lung

◦ Decreased elastic recoil◦ Total lung capacity (total vol lungs can expand

during inspiration) remains unchanged◦ Vital capacity (max amt of air expelled with

exhalation) decreases◦ Lower lobes have lesser air flow hence decrease

gas exchange

Chest wall◦ Stiffer reducing the ability to expand and contract◦ Loss of rib elasticity – calcification of cartilage◦ Kyphosis, arthritis of costavertebral joints and

increased rigidity of the thoracic cavity Increased anteroposterior diameter Flattening of the diaphragm

Respiratory Infection◦ 25% of all deaths >85 years

Chronic Obstructive Pulmonary Disease◦ Chronic bronchitis, chronic obstructive bronchitis,

emphysema◦ Environmental irritants cause increased mucous◦ Alveoli always inflated become fibrous◦ Excessive cardiac workload as heart tries to

compensate Pneumonia

◦ Lung inflammation secondary to infection◦ Pneumococcal

Mouth◦ Teeth less sensitive and more brittle

Loss is not a normal part of aging Dentures

◦ Difficult to chew with no teeth and atrophy of muscles and jaw bones

◦ Salivary glands Same amount as young Dry mouth secondary to medication

◦ Less acute taste sensation Increased risk for aspiration, indigestion,

constipation

Esophagus & Pharynx◦ Normal until 80 years of age◦ Stiffening◦ Absent gag reflex in 40% of healthy older adults◦ Dysphagia◦ Reflux/Heartburn – longer duration of episodes

Stomach ◦ Gastric acid changes

Decline in gastric defense mechanisms Increased potential for mucosal injury

Small intestines◦ Decreased acid production and motility

disturbances can lead to bacterial overgrowth causing malabsorption and malnutrition

◦ Vit A ↑◦ Vitamin D, calcium, zinc ↓◦ B1, B12, C, Iron unchanged

Gastrointestinal System Large Intestine

◦ Medications can affect motility◦ Endocrine and neurological changes affect motility

Large intestine loses nerve connections in the smooth muscle of the colon, increasing colonic transit time

Liver◦ Decreased size and blood flow◦ Drug clearance can be affected but highly variable

Gallbladder◦ Slower emptying rate so less bile secreted when food

is digested◦ Increased bile volume can lead to gallstones

Pancreas◦ Decreases in weight◦ Some histological changes such as fibrosis and cell

atrophy

Kidneys◦ Shrink in length and weight◦ Decreased glomeruli by 30-40%◦ Size and number of nephrons decrease◦ Decreased renal blood flow◦ Glomerular filtration rate decreased

Disease, medications can make this worse Elimination of waste and toxins declines Accumulation of harmful substances such as uric

acid and meds in the body Impaired sodium regulation can occur

Bladder◦ Reduced capacity due to decreased size◦ Develops fibrous matter in wall reducing

stretching capacity and contractility◦ Decreased filling capacity ◦ Ability to withhold voiding declines◦ Increased incidence of detrusor overactivity◦ Urinary frequency, urgency, nocturia

Incontinence is not a normal part of aging

Overall atrophy, including external structures Uterus tips backwards Vagina becomes shorter and narrower Loss of mucosal layers, decreased lubrication pH increases, more alkaline

◦ More infection, vaginitis Menopause

◦ Estrogen depletion◦ Average of 51 years (45-55 yo)◦ Hot flashes, mood disturbance, weight gain, vaginal

dryness, bladder infections, loss of sex drive, fatigue, insomnia, cognitive decline, hair loss, backaches, joint pain

Pelvic muscles atrophy causing decreased support of pelvic organs

Reduction in testosterone and sperm count Erectile dysfunction

◦ Increased amount of time to achieve erection◦ Need more stimulation to maintain the erection◦ Less intense orgasms and ejaculation◦ Decreased ejaculatory volume◦ Longer refractory period

Benign prostatic hyperplasia (BPH)◦ Prostate around urethra at base of bladder◦ Enlargement◦ Urinary retention◦ Increased frequency, discomfort with urination,

bladder and kidney infections, erectile and ejaculatory dysfunction

Andropause Androgen deficiency; occurs gradually and doesn’t

occur in all males Low libido Decreased energy, strength, and stamina Increased irritability Cognitive changes ED Osteopenia/osteoporosis Breast enlargement Decreased muscle mass Shrinkage of testes Increased fat deposition

Decreased size and weight of brain◦ Ventricle size increases◦ Loss of neurons◦ Increased subdural space – risk of chronic

hematoma Personality remains consistent with that of

earlier years in the absence of disease Learning ability/attention span/memory

changes◦ Acetylcholine decreases ◦ Loss of acetylcholine pronounced in Alzheimer’s

Nervous System Motor dysfunction due to decreased dopamine

receptors◦ Parkinson’s

Sleep changes/depression◦ Norepinephrine and serotonin decreases

Decreased cerebral blood flow Plaques and tangles are hallmarks of Alzheimer’s

disease Spine

◦ Narrowing◦ Changes in sensation◦ Degenerative disease

Thyroid◦ Decreased activity◦ Decreased metabolic rate

Pineal gland◦ Decreased melatonin◦ Sleep patterns

Glucose Intolerance◦ Decreased tissue sensitivity to circulating insulin◦ Delayed and insufficient release of insulin◦ Reduced ability to metabolize glucose

Sarcopenia: reduction in muscle mass◦ Functional disability and frailty

Osteoarthritis◦ Most common, affects weight bearing joints from years

of wear, loss of cartilage, increased bone matrix, decreased joint mobility

Rheumatoid arthritis◦ Immune

Osteoporosis◦ Reduction in bone quantity and strength

Tendons shrink and harden Increased risk of fractures

Touch◦ Mechanoreceptors ◦ Inability to acknowledge that an object is touching

or applying pressure to the skin◦ Decrease in ability to identify where the touch or

pressure is occurring◦ Inability to distinguish how many objects are

touching the skin◦ Decreased ability to identify objects just by touch◦ Proprioception

Safety issues?

Smell◦ Decreased ability to smell◦ Decreased odor detection◦ Inability to identify smells◦ Affects sense of taste

Safety issues? Affects on life?

Taste◦ Chemoreceptors◦ Hypogeusia = decrease in taste◦ Medication, smoking, disease, infections, poor

oral health◦ Food poisoning and malnutrition of concern


Vision Presbyopia Narrowing of visual field Impaired color discrimination (blue/yellow) Decreased night vision Diseases, not normal aging process

◦ Cataracts, glaucoma, macular degeneration, diabetic retinopathy


Hearing Presbycusis

◦ Age related hearing loss Most common of all sensory deficits Safety issues? Affects on life?

Decreased elasticity Thinning Increased dryness Fragile Wrinkles Decreased blood flow

◦ Cooler skin Subcutaneous layer increases around hips

and belly

Hair◦ Thinning, loss, gray

Nails◦ Slower growth, thinner, more brittle

Glands◦ Decreased sweating


Depressed immune response T-cell activity declines

◦ Fewer naïve T-cells so respond slower to new antigens

Increased potential for infection Reactivation of dormant viruses

◦ Varicella zoster, mycobacterium tuberculosis Vaccinations good for this age but body

responds slower

No significant changes with ages, unless disease mediated

Hct and Hgb unchanged Anemia

◦ Due to other disease processes, medications

Lower normal body temperature◦ 96.9 degrees F - 98.9 degrees F

Reduced ability to respond to cold temperatures

Differences in response to heat

Chapter 7: Assessment of the Older Adult

Bonnie M. Wivell, MS, RN, CNS

Activities of Daily Living◦ Katz – distinguished between independence and

dependence in certain skills◦ Barthel Index – measures functional levels of

self-care and mobility◦ Refined ADL Assessment Scale – task

segmentation◦ Functional Independence measure (FIM) – used

in rehab◦ Eating, dressing, bathing/washing, grooming,

walking/ambulation, ascending/descending stairs, communication, transferring, toileting

IADLs: more complex than ADL ◦ Lawton and Brody in 1969◦ Telephone, taking medications, shopping,

finances, preparing meals, laundry, housekeeping, yardwork, home maintenance, transportation, recreation

Family and patient history Chest pain Medications (include OTC and herbs) Sources of stress Vital signs Heart sounds Other tests prn: CBC, Lytes, ECG, Echo,

Exercise stress test

Family and patient history Shortness of breath – describe Medications History of smoking Air pollutant exposure Coughing Energy level Sitting up at night to help breathing Check lung sounds, posture Possible tests: sputum, lung function,

chest x-ray

History Oral cavity

◦ own teeth◦ hygiene◦ dentures well-fitting

Diet◦ Appetite, vomiting, stomach pain, changes in

stooling Appetite

◦ Decreased body weight◦ Risk for injury, less energy, psychological

changes

Nausea, vomiting, indigestion◦ note that c/o indigestion unrelieved by antacids

may indicate heart-related problems in older adults

Usual bowel patterns◦ Constipation (check fluids, activity, positioning,

timing, meds) Medications Possible tests: barium enema, GI series,

stool specimens, sigmoidoscopy, colonoscopy

History Pre-existing diseases such as diabetes or

hypertension associated with renal failure UA Incontinence

◦ Type: stress, urge, functional, overfow◦ Frequency◦ Nocturia◦ Voluntary flow◦ Use of pads

History Significant other, Spouse, Partner,

Widowed Number of children Present problems Changes in function Erectile dysfunction (males) or

dyspareunia (females) Chronic illnesses Medications that can interfere with sexual

function or libido

Neurological Function Patient and family history History of seizures Medications Reflexes Balance Sleep patterns Cognition Communication

Speech Memory Energy level Motor and sensory function Neuro checks

◦ Vital signs ◦ PERRLA◦ Grip strength◦ Orientation◦ Cranial Nerves

Patient and family history ROM Daily activities Signs of arthritis

◦ Pain◦ Joints affected◦ Inhibits daily activities◦ Medications used◦ Other pain relief methods used and their

effectiveness

Posture Devices for mobility Postmenopausal

◦ Risk for osteoporosis The Up and Go Test

Five senses Vision

◦ Presbyopia◦ Signs of common problems

macular degeneration cataracts glaucoma

Hearing◦ History of recent hearing loss

presbycusis cerumen impaction foreign body

◦ Hearing aids used

Taste Smell

◦ Taste and smell connected◦ Ask about satisfaction with how things smell

and taste Touch

◦ Any changes in sensation

Patient and family history Present skin conditions/complaints

◦ Rashes◦ Itching◦ Dryness◦ Breakdown

Braden risk assessment scale (pg. 501-502)◦ Bruising◦ Skin tears

Nutrition Weight Circulation

Color Hydration Circulation Intactness Wounds Also check hair and nails

◦ Brittleness◦ Dryness◦ Thickness◦ Texture

Patient or family history of disease◦ Esp. diabetes and thyroid problems

Changes in weight and appetite Fatigue Vision problems Slow wound healing Gastrointestinal problems

Signs of diabetes◦ Polyphagia, polydipsia and polyuria

Signs of hypothyroidism◦ Skin changes, sensitivity to cold, fatigue, weight

gain, constipation Diagnostic tests as needed

◦ Glucose testing, thyroid screening and/or panel

Check for signs of anemia◦ Esp. iron deficiency – skin color, food choices

Lab tests: CBC, Hct, HGB History of infection Takes vaccines for flu or pneumonia HIV/AIDS – sexual assessment

Attention, memory, language, visual-spatial skills, orientation◦ Mini Mental State Examination (MMSE)◦ Mini-Cog: 3 item recall and clock drawing

Signs of dementia Social abilities

◦Giving and receiving attention◦Participating in conversation◦Appreciating humor◦Helping others

Quality of life◦Attitude, beliefs, and feelings about aging and

mental health Depression

◦ Geriatric Depression Scale (pg. 250)◦ Persistence of symptoms

Social support◦ Family, friends, neighbours, church

Living arrangements Resources Insurance Finances Independence and need for assistance Potential for isolation

Spirituality Religion Worship practices Religious artefacts Spiritual leader/advisor Check for signs of spiritual distress

Ten Principles of Comprehensive Assessment:

1. The cornerstone of an individualized plan of care for an older adult is a comprehensive assessment.

2. Comprehensive assessment takes into account age-related changes, age-associated diseases, heredity and lifestyle.

3. Nurses are members of the health care team, contributing to and drawing from the health team to enhance the assessment process.

4. Comprehensive assessment is not a neutral process.

5. Ideally, the older adult is the best source of information to assess his or her health. When this is not possible, family members or caregivers are acceptable and secondary sources of information. When the older adult cannot self-report, physical performance measures may provide additional information.

6. Comprehensive assessment should first emphasize “ability” and second, should address disability. Appropriate interventions to maintain and enhance ability, and to improve or compensate for disability should follow from a comprehensive assessment.

7. Task performance and task capacity are two difference perspectives. Some assessment tools ask “Do you dress without help?’ (performance) while others ask, “Can you dress without help?” (capacity). Asking about capacity will result in answers that emphasize ability.

8. Assessment of older adults who have cognitive limitations may require “task segmentation” or the breaking down of tasks into smaller steps.

9. Some assessment tools or parts of assessment tools may be more or less applicable depending on the setting, that is, community, acute care or long-term care settings.

10. In comprehensive assessment, it is important to explore the meaning and implications of health status from the older adult’s perspective. For example, the same changes in visual acuity for two older adults may have quite different meanings and implications for everyday life.

bonnie m. wivell, ms, rn, cns chapter 6: review of the aging of physiological systems

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