Chapter 3 Common Health Problems of Older Adults

Question 1

geriatric syndromes

Answer 1

major health issues associated with late adulthood in community and inpatient settings

Question 2

older adult age ranges

Answer 2

65 to 74 years of age: the young old

• 75 to 84 years of age: the middle old
• 85 to 99 years of age: the old old
• 100 years of age or older: the elite old

Question 3

fastest growing subgroup

Answer 3

is the old old, sometimes referred to as the advanced older-adult population

Question 4

Frailty

Answer 4

geriatric syndrome in which the older adult has unintentional weight loss; weakness and exhaustion; and slowed physical activity, including walking.

Question 5

vast majority of older adults live:

Answer 5

in the community at home, in assisted-living facilities, or in retirement or independent living complexes

Question 6

growing older poulations:

Answer 6

The number of homeless people older than 60 years

men older than 50 years are the fastest growing group of prisoners today

Question 7

experiencing a number of losses

Answer 7

affect a sense of control over their lives

Question 8

failure to perform ADLs lead to:

Answer 8

increase dependence on others and may have a negative effect on morale and life satisfaction.

Question 9

support older adults’ self-esteem and feelings of independence by

Answer 9

encouraging them to maintain as much control as possible over their lives, to participate in decision making, and to perform as many tasks as possible.

Question 10

Health-Protecting Behaviors

Answer 10

• Have yearly influenza vaccinations (preferably after October 1).
• Obtain a pneumococcal vaccination.
• Obtain a shingles vaccination.
• Have a tetanus immunization and get a booster every 10 years.
• Wear seat belts when you are in an automobile.
• Use alcohol in moderation or not at all.
• Avoid smoking; if you do smoke, do not smoke in bed.
• Install and maintain working smoke detectors and/or sprinklers.
• Create a hazard-free environment to prevent falls; eliminate hazards such as scatter rugs and waxed floors.
• Use medications, herbs, and nutritional supplements according to your primary health care provider’s prescription.
• Avoid over-the-counter medications unless your primary health care provider directs you to use them.

Question 11

Health-Enhancing Behaviors

Answer 11

• Have a yearly physical examination; see your primary health care provider more often if health problems occur.
• Reduce dietary fat to not more than 30% of calories; saturated fat should provide less than 10% of your calories.
• Increase your daily dietary intake of complex carbohydrate– and fiber-containing food to five or more servings of fruits and vegetables and six or more servings of grain products.
• Increase calcium intake to between 1000 and 1500 mg daily; take a vitamin D supplement every day if not exposed daily to sunlight.
• Allow at least 10 to 15 minutes of sun exposure two or three times weekly for vitamin D intake; avoid prolonged sun exposure.
• Exercise regularly three to five times a week.
• Manage stress through coping mechanisms that have been successful in the past.
• Get together with people in different settings to socialize.
• Reminisce about your life through reflective discussions or journaling.

Question 12

Common health issues and geriatric syndromes

Answer 12

• Decreased NUTRITION and hydration
• Decreased MOBILITY
• Stress, loss, and coping
• Accidents
• Drug use and misuse
• Inadequate COGNITION
• Substance use
• Elder neglect and abuse

Question 13

vitamins that older adults need more of:

Answer 13

increased dietary intake of calcium and vitamins D, C, and A because aging changes disrupt the ability to store, use, and absorb these substances.

Question 14

change in taste:

Answer 14

Older adults often have less ability to taste sweet and salt than to taste bitter and sour.

Question 15

dental problems:

Answer 15

Tooth loss and poorly fitting dentures from inadequate dental care or calcium loss can also cause the older adult to avoid important nutritious foods.

Question 16

Outcomes of dental problems:

Answer 16

Older people with dentition problems may eat soft, high-calorie foods such as ice cream and mashed potatoes, which lack roughage and fiber.

vitamin deficiencies, constipation, and other problems can result.

Question 17

Constipation

Answer 17

can reduce quality of life for older adults and cause pain, depression, anxiety, and decreased social activities

In some cases it leads to a small or large bowel obstruction

Question 18

constipation risk factors

Answer 18

multiple risk factors, including foods, drugs, and diseases.

Question 19

constipation teaching

Answer 19

increase fiber and fluid intake, exercise regularly, and avoid risk factors that contribute to constipation. Older adults should consume 35 to 50 g of fiber each day and drink at least 2 liters a day unless medically contraindicated.

Question 20

factors that influence nutrition

Answer 20

Reduced income, chronic disease, fatigue, and decreased ability to perform ADLs

loneliness

The lack of transportation, the necessity of traveling to obtain such services, and the inability to carry large or heavy groceries prevent some older adults from taking advantage of food programs. Others are too proud to accept free services.

Question 21

nutritional screening

Answer 21

Ask the person about unintentional weight loss or gain, eating habits, appetite, prescribed and OTC drugs, and current health problems. Determine contributing factors

develop and implement a plan of care in collaboration with the registered dietitian, pharmacist, and/or case manager

Question 22

geriatric failure to thrive (GFTT)—

Answer 22

a complex syndrome including under-nutrition, impaired physical functioning, depression, and cognitive impairment

people older than 65 at risk

Question 23

what prevents advanced levels of deterioration

Answer 23

collaborate with the older adult and family to plan referral to his or her primary health care provider for extensive evaluation

Question 24

dehydration can lead to

Answer 24

electrolyte imbalances (especially sodium and potassium) that can cause serious illness or death.

Question 25

fluids for older adults

Answer 25

Teach older adults the importance of drinking 2 liters of water a day plus other fluids as desired. Remind them to avoid excessive caffeine and alcohol because they can cause dehydration.

Question 26

incontinence and dehydration

Answer 26

may actually increase because the urine becomes more concentrated and irritating to the bladder and urinary sphincter.`

Question 27

The major advantages of maintaining appropriate levels of physical activity include:

Answer 27

• Decreased risk for falls
• Increased muscle strength and balance
• Increased MOBILITY
• Increased sleep
• Reduced or maintained weight
• Improved sense of well-being and self-esteem
• Improved longevity
• Reduced risks for diabetes, coronary artery disease, and dementia

Question 28

not homebound

Answer 28

teach the importance of exercise.

Question 29

homebound

Answer 29

focus on functional ability such as performing ADLs.

Question 30

limited MOBILITY

Answer 30

chair exercises are provided.

Question 31

Stress

Answer 31

can speed up the aging process over time, or it can lead to diseases that increase the rate of degeneration. It can also impair the reserve capacity of older adults and lessen their ability to respond and adapt to changes in their environment.

Question 32

Frequent sources of stress and anxiety for the older population include:

Answer 32

• Rapid environmental changes that require immediate reaction
• Changes in lifestyle resulting from retirement or physical incapacity
• Acute or chronic illness
• Loss of significant others
• Financial hardships
• Relocation

Question 33

stress overload

Answer 33

which can result in illness and premature death.

Question 34

Relocation stress syndrome

Answer 34

is the physical and emotional distress that occurs after the person moves from one setting to another.

Question 35

physiologic behaviors

Answer 35

are sleep disturbance and increased physical symptoms such as GI distress.

Question 36

emotional manifestations

Answer 36

are withdrawal, anxiety, anger, and depression.

Question 37

Minimizing the Effects of Relocation Stress in Older Adults

Answer 37

• Provide opportunities for the patient to assist in decision making.
• Carefully explain all procedures and routines to the patient before they occur.
• Ask the family or significant other to provide familiar or special keepsakes to keep at the patient’s bedside (e.g., family picture, favorite hairbrush).
• Reorient the patient frequently to his or her location.
• Ask the patient about his or her expectations during hospitalization or assisted-living or nursing home stay.
• Encourage the patient’s family and friends to visit often.
• Establish a trusting relationship with the patient as early as possible.
• Assess the patient’s usual lifestyle and daily activities, including food likes and dislikes and preferred time for bathing.
• Avoid unnecessary room changes.
• If possible, have a family member, significant other, staff member, or volunteer accompany the patient when leaving the unit for special procedures or therapies.

Question 38

fallophobia

Answer 38

(fear of falling) and avoid leaving their homes.

particularly common for those who have previously fallen and/or have osteoporosis

Question 39

primary cause of decreased MOBILITY and chronic pain in old age

Answer 39

Incapacitating accidents

Question 40

kyphosis

Answer 40

stooped posture

Question 41

presbyopia

Answer 41

(farsightedness that worsens with aging)

may make walking more difficult; the person is less aware of the location of each step

Question 42

reduced sense of touch

Answer 42

decreases the awareness of body orientation

Question 43

Recommendations for Improving Older Adult Driver Safety

Answer 43

• Discuss driving ability with the patient to assess his or her perception.
• Assess physical and mental deficits that could affect driving ability.
• Consult with appropriate primary health care providers to treat health problems that could interfere with driving.
• Suggest community-based transportation options, if available, instead of driving.
• Discuss driving concerns with patients and their families.
• Remind the patient to wear glasses and hearing aids if prescribed.
• Encourage driver-refresher classes, often offered by AARP (formerly the American Association of Retired Persons).
• Consult a certified driving specialist for an on-road driving assessment.
• Encourage avoiding high-risk driving locations or conditions such as busy urban interstates and wet or icy weather conditions.
• Report unsafe drivers to the state department of motor vehicles if they continue to drive.

Question 44

polymedicine

Answer 44

has been used to describe the use of many drugs to treat multiple health problems for older adults.

Question 45

Polypharmacy

Answer 45

is the use of multiple drugs, duplicative drug therapy, high-dosage medications, and drugs prescribed for too long a period of time.

Question 46

what can affect drug absorption from an oral route

Answer 46

include an increase in gastric pH, a decrease in gastric blood flow, and a decrease in GI motility

Question 47

Age-related changes that affect drug distribution

Answer 47

include smaller amounts of total body water, an increased ratio of adipose tissue to lean body mass, a decreased albumin level, and a decreased cardiac output.
Increased adipose tissue

Question 48

Age-related changes affecting metabolism

Answer 48

include a decrease in liver size, a decrease in liver blood flow, and a decrease in serum liver enzyme activity.

Question 49

Age-related changes of the renal system include

Answer 49

decreased renal blood flow and reduced glomerular filtration rate. These changes result in a decreased creatinine clearance and thus a slower excretion time for medications.

Question 50

Monitor these labs when giving medication:

Answer 50

Monitor renal studies, especially serum creatinine and creatinine clearance, when giving drugs to older adults!

Question 51

Common Adverse Drug Events (ADEs) in Older Adults

Answer 51

• Edema
• Severe nausea and vomiting
• Anorexia
• Dehydration
• Dysrhythmias
• Fatigue
• Weakness
• Dizziness
• Syncope
• Urinary retention
• Diarrhea
• Constipation/impaction
• Hypotension
• Acute confusion

Question 52

medication adherence questions

Answer 52

• Do you take five or more prescription medications?
• Do you take herbs, vitamins, other dietary supplements, or OTC medications?
• Do you have your prescriptions filled at more than one pharmacy?
• Is more than one health care practitioner prescribing your medications?
• Do you take your medications more than once a day?
• Do you have trouble opening your medication bottles?
• Do you have poor eyesight or hearing?
• Do you live alone?
• Do you have a hard time remembering to take your medications?

Question 53

Examples of Beers Criteria for Potentially Inappropriate Medication Use in Older Adult

Answer 53

• meperidine (Demerol)
• cyclobenzaprine (Flexeril)
• digoxin (Lanoxin) (Should not exceed 0.125 mg daily except for atrial fibrillation)
• ticlopidine (Ticlid)
• fluoxetine (Prozac)
• amitriptyline (Elavil)
• diazepam (Valium)
• promethazine (Phenergan)
• ketorolac (Toradol)
• short-acting nifedipine (e.g., Procardia)
• ferrous sulfate (Iron) (Should not exceed 325 mg daily)
• chlorpropamide (Diabinese)
• diphenhydramine (Benadryl)

Question 54

medication assessment

Answer 54

• Obtain a list of all medications taken on a regular and as-needed basis; include OTC and prescribed drugs, herbs, and nutritional supplements. If a list is not available, ask the older adult or family to gather all ointments, pills, lotions, eyedrops, inhalers, injectable solutions, vitamins, minerals, herbs, and other OTC medications and place into a bag for review.
• Highlight all medications that are part of the Beers criteria; highlight any medication for which the indication for its use is not clear, is inappropriate, or could be discontinued (e.g., duplicative drug).
• Collaborate with the older adult, family, pharmacist, and primary health care provider if appropriate to determine the need for medication changes. Suggest once-a-day dosing if possible.
• Give older adults verbal and written information (at the appropriate reading level) regarding any change or new medication prescribed.
• Promote adherence to the drug therapy regimen exactly as prescribed; remind older adults to check with their primary care provider if they want to change their regimen or add an OTC medication or natural product (nutritional or herbal supplement, or probiotic).
• Encourage lifestyle changes and other nonpharmacologic interventions to help manage or prevent health problems.
• Remind older adults not to share or borrow medications.

Question 55

legally competent

Answer 55

• 18 years of age or older
• Pregnant or a married minor
• A legally emancipated (free) minor who is self-supporting
• Not declared incompetent by a court of law

Question 56

guardian

Answer 56

is appointed to make health care decisions

Question 57

clinically competent

Answer 57

if he or she is legally competent and can make clinical decisions.

Question 58

most helpful interventions to prevent cognitive changes in older adults.

Answer 58

Cognitive training (e.g., learning a new skill), physical activity, social engagement, and NUTRITION

Question 59

3Ds

Answer 59

depression, delirium, and dementia

Question 60

Depression

Answer 60

is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations. It can be primary or secondary and can range from mild to severe or major.

Question 61

primary depression

Answer 61

is thought to result from a lack of the neurotransmitters norepinephrine and serotonin in the brain.

Question 62

Secondary depression

Answer 62

sometimes called situational depression, can result when there is a sudden change in the person’s life such as an illness or loss.

Question 63

Geriatric Depression Scale—Short Form (GDS-SF)

Answer 63

is a valid and reliable screening tool and is available in multiple languages.

Question 64

Without diagnosis and treatment, depression can result in:

Answer 64

• Worsening of medical conditions
• Risk for physical illness
• Alcoholism and drug use
• Increased pain and disability
• Delayed recovery from illness
• Suicide

Question 65

Older adults with depression

Answer 65

may have early-morning insomnia, excessive daytime sleeping, poor appetite, a lack of energy, and an unwillingness to participate in social and recreational activities.

Question 66

primary treatment for depression

Answer 66

usually includes drug therapy and psychotherapy

Question 67

Tricyclic antidepressants should not be used for older adults because:

Answer 67

anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence.

Question 68

Dementia

Answer 68

is a broad term used for a syndrome that involves a slowly progressive cognitive decline, sometimes referred to as chronic confusion.

Question 69

Delirium

Answer 69

is characterized by the patient’s inattentiveness, disorganized thinking, and altered level of consciousness

Question 70

Hyperactive

Answer 70

patients may try to climb out of bed or become agitated, restless, and aggressive.

Question 71

Hypoactive

Answer 71

patients are quiet, apathetic, lethargic, unaware, and withdrawn. They often move very slowly and stare.

Question 72

Mixed delirium

Answer 72

patients have a combination of hyperactive and hypoactive manifestations.

Question 73

Some of the many factors that can cause delirium are:

Answer 73

• Drug therapy (especially anticholinergics, opioids, and psychoactive drugs)
• Fluid and electrolyte imbalances
• Infections, especially urinary tract, pneumonia, and sepsis
• Fecal impaction or severe diarrhea
• Surgery (especially fracture hip repair and post-transplant)
• Metabolic problems such as hypoglycemia
• Neurologic disorders such as tumors
• Circulatory, renal, and pulmonary disorders
• Nutritional deficiencies
• Hypoxemia (decreased arterial oxygen level)
• Mechanical ventilation
• Relocation
• Major loss
• Critical care setting

Question 74

Delirium screening tools

Answer 74

Confusion Assessment Method (CAM), Delirium Index (DI), NEECHAM Confusion Scale, and Mini-Cog.

Question 75

Excessive substance use (both alcohol and illicit drugs)

Answer 75

increases the risk for falls and other accidents; affects mood and COGNITION; and leads to complications of chronic diseases

Question 76

neglect

Answer 76

can occur when a caregiver fails to provide for an older adult’s basic needs such as food, clothing, medications, or assistance with ADLs.

Question 77

Physical abuse

Answer 77

is the use of physical force that results in bodily injury, especially in the “bathing suit” zone (abdomen, buttocks, genital area, upper thighs)

Question 78

Financial abuse

Answer 78

occurs when the older adult’s property or resources are mismanaged or misused

Question 79

Emotional abuse

Answer 79

is the intentional use of threats, humiliation, intimidation, and isolation toward older adults.

Question 80

signs of abuse

Answer 80

such as bruises in clusters or regular patterns; burns, commonly to the buttocks or the soles of the feet; unusual hair loss; or multiple injuries, especially fractures.

Question 81

Neglect may be manifested by

Answer 81

pressure injuries, contractures, dehydration or malnutrition, urine burns, excessive body odor, and listlessness.

Question 82

The older adult should be referred to the appropriate service when there is:

Answer 82

• Evidence of mistreatment without sufficient clinical explanation
• Report by an older adult of being abused or neglected
• A belief by the health care professional that there is a high risk for or probable abuse, neglect, abandonment, or exploitation

Question 83

Fulmer SPICES

Answer 83

• Sleep disorders
• Problems with eating or feeding
• Incontinence
• Confusion
• Evidence of falls
• Skin breakdown

Question 84

nutritional screenings on the first day of patient admission

Answer 84

including a thorough nutritional history and weight, height, and body mass index (BMI)

Question 85

Urinary and bowel ELIMINATION issues

Answer 85

Place the patient on a toileting schedule or a bowel or bladder training program

Question 86

prevent acute confusion:

Answer 86

avoiding multiple drugs and promoting adequate sleep

Question 87

fall

Answer 87

is an unintentional change in body position that results in the patient’s body coming to rest on the floor or ground.

Question 88

Falls: The Joint Commission’s National Patient Safety Goals (NPSGs)

Answer 88

require that all inpatient health care settings use admission and daily fall risk assessment tools and a fall reduction program for patients who are at high risk.

Question 89

Falls- Assess for the presence of these risk factors:

Answer 89

• History of falls
• Advanced age (>80 years)
• Multiple illnesses
• Generalized weakness or decreased mobility
• Gait and postural instability
• Disorientation or confusion
• Use of drugs that can cause increased confusion, mobility limitations, or orthostatic hypotension
• Urinary incontinence
• Communication impairments
• Major visual impairment or visual impairment without correction
• Alcohol or other substance use
• Location of patient’s room away from the nurses’ station (in the hospital or nursing home)
• Change of shift or mealtime (in the hospital or nursing home)

Question 90

Implement these nursing interventions for all patients, regardless of risk:

Answer 90

• Monitor the patient’s activities and behavior as often as possible, preferably every 30 to 60 minutes.
• Teach the patient and family about the fall prevention program to become safety partners.
• Remind the patient to call for help before getting out of bed or a chair.
• Help the patient get out of bed or a chair if needed; lock all equipment such as beds and wheelchairs before transferring patients.
• Teach patients to use the grab bars when walking in the hall without assistive devices or when using the bathroom.
• Provide or remind the patient to use a walker or cane for ambulating if needed; teach him or her how to use these devices.
• Remind the patient to wear eyeglasses or a hearing aid if needed.
• Help the incontinent patient to toilet every 1 to 2 hours.
• Clean up spills immediately.
• Arrange the furniture in the patient’s room or hallway to eliminate clutter or obstacles that could contribute to a fall.
• Provide adequate lighting at all times, especially at night.
• Observe for side effects and toxic effects of drug therapy.
• Orient the patient to the environment.
• Keep the call light and patient care articles within reach; ensure that the patient can use the call light.
• Place the bed in the lowest position with the brakes locked.
• Place objects that the patient needs within reach.
• Ensure that adequate handrails are present in the patient’s room, bathroom, and hall.
• Have the physical therapist assess the patient for mobility and safety.

Question 91

For patients at a high risk for falls:

Answer 91

• Implement all assessments and interventions listed previously.
• Relocate the patient for best visibility and supervision.
• Encourage family members or significant other to stay with the patient.
• Collaborate with other members of the health care team, especially the rehabilitative services.
• Use technologic devices such as mattress sensor pads and chair alarms to alert staff to patients getting out of bed.
• Use low beds or futon-type beds to prevent injury if the patient is at risk for falling out of bed.

Question 92

nocturia

Answer 92

(urination at night)

Question 93

restraint

Answer 93

is any device or drug that prevents the patient from moving freely and must be prescribed by a health care provider.

Question 94

Using Restraint Alternatives

Answer 94

• If the patient is acutely confused, reorient him or her to reality as often as possible.
• If the patient has dementia, use validation to reaffirm his or her feelings and concerns.
• Check the patient often, at least every hour.
• If the patient pulls tubes and lines, cover them with roller gauze or another protective device; be sure that IV insertion sites are visible for assessment.
• Keep the patient busy with an activity, pillow or apron, puzzle, or art project.
• Provide soft, calming music.
• Place the patient in an area where he or she can be supervised. (If the patient is agitated, do not place him or her in a noisy area.)
• Turn off the television if the patient is agitated.
• Ask a family member or friend to stay with the patient at night.
• Help the patient to toilet every 2 to 3 hours, including during the night.
• Be sure that the patient’s needs for food, fluids, and comfort are met.
• If agency policy allows, provide the patient with a pet visit.
• Provide familiar objects or cherished items that the patient can touch.
• Document the use of all alternative interventions.
• If a restraint is applied, use the least restrictive device (e.g., mitts rather than wrist restraints, a roller belt rather than a vest).

Question 95

Chemical restraints

Answer 95

• Antipsychotic drugs
• Antianxiety drugs
• Antidepressant drugs
• Sedative-hypnotic drugs

Question 96

Closely monitor older adults receiving antipsychotics for adverse drug events (ADEs). Assess patients for:

Answer 96

• Anticholinergic effects, the most common problem, causing constipation, dry mouth, and urinary retention
• Orthostatic hypotension, which increases the patient’s risk for falls and fractures
• Parkinsonism, including tremors, bradycardia, and a shuffling gait
• Restlessness and the inability to stay still in any one position
• Hyperglycemia and diabetes mellitus, which occur more with drugs such as risperidone (Risperdal) and quetiapine (Seroquel)

Question 97

program to prevent agency-associated pressure injuries

Answer 97

• Nutritional support
• Avoidance of skin injury from friction or shearing forces
• Repositioning and support surfaces
• A plan to increase MOBILITY and activity level when appropriate
• Skin cleaning and use of moisture barriers

Question 98

assessment tool for pressure sores

Answer 98

the Braden Scale for Predicting Pressure Sore Risk

Question 99

pressure sore prevention

Answer 99

Frequent turning

Assess the skin every 8 hours for reddened areas that do not blanch. Remind UAP to keep the skin clean and dry. Use pressure-relieving mattresses and avoid briefs or absorbent pads that can cause skin irritation and excess moisture.

Question 100

discharge information

Answer 100

The system should include follow-up phone calls after discharge to home and having one case manager to coordinate care during and after the transition from the inpatient agency to home. A home care nurse or other health care professional can serve as a “health coach” to ensure understanding of discharge instructions, consistent follow-up appointments, and a designated emergency contact for the patient and family. Discharge instructions should be easy to read, in large print, and accurate.