1. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 12: The Critically Ill Older Patient

2. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Normal Aging Extrinsic Aging Specific Individual Factors Intrinsic Aging

3. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Organic Changes With Aging

4. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Conflict with Developmental Tasks Giving up the home to live in an extended- care facility or with adult children Loss of spouse and friends; feeling isolated Decrease in income and increase in medication costs Reaching Developmental Tasks Maintaining a social network Determining meaning of one’s life Contributing to society after retirement Maintaining healthy habits

5. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Age-Related Sensory System Changes Vision Decreased visual acuity and night vision Changes in depth perception Change in perception to blues, greens, and purples Increased eye dryness Hearing Increased cerumen Problems differentiating background noise from sound nearby Problems understanding speech (-f-,-s-, -th-, -ch-, and –sh-)

6. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Age-Related Changes in Smell, Taste, and Touch Smell: decreased ability to distinguish noxious odors (change in appetite; risk for eating bad food; decreased ability to smell smoke) Taste: decreased ability to taste sweet and salty foods –Able to taste bitter and sour foods Touch: decrease in temperature perception and touch sensation

7. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following statements about age-related hearing and equilibrium in the older patient is correct? A. There is an increase in thinner cerumen. B. There is an increase in threshold sensitivity. C. There is a reduction in the ability to understand high- frequency sounds. D. There are changes in the pinna resulting in decreased balance.

8. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. There is a reduction in the ability to understand high- frequency sounds. Rationale: Changes that occur in hearing and equilibrium include a reduction in the ability to hear high-frequency sounds (f, s, th, ch, and sh). There is an increase in thicker cerumen that can block the canal, decreasing the ability to hear. There is a decrease in hearing that affects the threshold sensitivity and ability to comprehend speech. The change in the cochlea can lead to changes in balance.

9. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Skin Changes in the Older Patient Age-Related Changes Skin thins, becomes dry, and loses elasticity Decrease in subcutaneous fat Decrease in sweat glands, risk for hyperthermia Nursing Interventions Assess risk for developing skin breakdown using the Morse Scale. Avoid soap, and use lotion. Support joints when moving patient to prevent tears or shearing actions.

10. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Cardiac Changes in the Older Patient S4 Muscle fibers in the endocardium atrophy Atherosclerosis of blood vessels Left ventricle decreases in compliance Number of pacemaker cells declines Baroreceptors are less sensitive; changes in posture can lead to orthostatic hypotension

11. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Age-Related Changes in the ECG

12. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Respiratory Changes in the Older Patient Decrease in elasticity of lungs and decline in muscle strength Calcification of bony structures to thorax Fewer cilia Decreased PaO2 Few bibasilar crackles due to atelectasis. Ask client to take a deep breath and cough. If the crackles disappear, they are due to aging. If they remain, they are due to pathology.

13. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Renal System Changes in the Older Patient Decrease in number of nephrons: a person loses 1mL/min/year of glomerular filtration rate (GFR) after age 30 –Because of the decline in muscle mass, serum creatinine isn’t the best indicator of renal function. –The GFR is the best indicator. Decrease in renal blood flow (altered excretion of drugs) Decrease in ability to regulate fluids/electrolytes Increase in asymptomatic bacteriuria

14. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Important Nursing Considerations for Older Adults With Urinary Incontinence Always look for underlying causes that can be changed. Provide a toileting schedule when changes cannot be found. Refer the client to a urologist to search for interventions to correct the incontinence. Maintain the client’s dignity; avoid calling protective undergarments “diapers,” etc. Avoid placing a Foley catheter if possible. If catheterization is needed, remove it as soon as possible.

15. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins GI Changes in the Older Patient Decrease in size and number of taste buds Decrease in production of saliva Decrease in size of liver Decrease in GI tract motility Decrease in secretion of hydrochloric acid in the stomach and decrease in mucosal lining of the stomach and GI tract Decrease in absorption of calcium and iron

16. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Age-Related Changes in the Musculoskeletal System Decrease in muscle mass and strength Decrease in bone density Decrease in overall height Changes in joints Changes in gait and posture

17. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Age-Related Changes in the Endocrine System Decrease in hormone production Change in ability to regulate body temperature Decrease in basal metabolic rate Insulin resistance and decreased glucose tolerance Renal tubules become less sensitive to antidiuretic hormone (ADH)

18. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Management of Diabetes in Older Patients A1C < 7%: every 3 months Lipid profile: every year Urine test for microalbuminuria: yearly Dilated eye exam: yearly TSH ECG Dental exam Monitor BP each visit Foot exam: each visit Assess for barriers to treatment (financial, physical, educational)

19. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Reproductive System Changes Older Women Decreased hormones Atrophy of sexual organs Vaginal dryness Breast tissues lose connective tissue and gain adipose tissue Older Men Decrease in seminal fluid and force of ejaculation Prostate hypertrophies –Decreased force of urinary stream –Potential for urinary retention

20. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Age-Related Changes in the Neurological System Atrophy of brain Increase in space inside the cranium Decline in number of neurons Decline in short-term memory Longer reaction time

21. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which statement made by the older adult patient warrants more patient education on sleep hygiene? A. I will nap in the early morning for no longer than 30 minutes. B. I will exercise for 30 minutes before going to bed. C. I will eat most of my daily food intake before dinner. D. I will establish a bedtime ritual.

22. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. I will exercise for 30 minutes before going to bed. Rationale: A person should avoid exercising close to bedtime because the activity would increase the wakefulness cycle. This client needs more patient education regarding spacing activity and sleep. Proper sleep hygiene includes avoiding daytime naps that are longer than 30 minutes. Establishing and maintaining a bedtime ritual and consistent schedule will promote sleep. A person should avoid eating a large meal or drinking caffeine or alcohol before bedtime.

23. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Symptoms of Depression

24. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Drugs That May Cause Depression in the Older Person

25. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Geriatric Depression Scale See Box 12-10.

26. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question An older adult patient with a history of depression is admitted to the ICU to rule out myocardial infarction. The nurse should report which of the following to the cardiologist? A. The patient is taking a beta-blocker. B. The patient is taking a tricyclic antidepressant. C. The patient is taking baby aspirin. D. The patient is taking morphine sulfate.

27. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. The client is taking a tricyclic antidepressant. Rationale: The nurse needs to report that the client is taking a tricyclic antidepressant, which can cause false ECG changes that may appear as myocardial damage. The cardiac enzymes will be used to determine whether the patient has myocardial damage. A tricyclic antidepressant can also place the cardiac patient at risk for ventricular dysrhythmias, which means the drug dosage may need to be reduced or a different drug used. The other meds are part of an acceptable treatment regimen for a client with a MI.

28. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Reversible Causes of Dementia and Delirium

29. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Areas for Potential Abuse or Neglect of the Older Patient Physical abuse Emotional abuse Sexual abuse Neglect and self-neglect Abandonment Financial or material exploitation

30. Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Safe Medication Administration Considerations for the Older Patient Have the patient bring all medications to the visit. Look for medications to avoid according to the Beers criteria, prescription duplication, noncompliance, or potential drug interactions. Assess use of over-the-counter and herbal supplements. Assess alcohol intake. Assess renal and liver function. Assess the patient’s knowledge of medications.