Geriatrics Test 1 Flashcards
Gerontology Definition
Is the broad term used to define the study of aging
Geriatrics Definition
Is often used as a generic term relating to older adults, but it specifically refers to the medical care of older adults
Entry Level Gerontology Certification
- Having practiced the equivalent of 2 years full time as a registered nurse
- Having a minimum of 2,000 hours of clinical practice in the specialty area of gerontological nursing within the last 3 years
- Having completed 30 hours of continuing education in gerontological nursing within the last 3 years
Advanced Practice Certification (Geriatrics)
- Advanced practice registered nurse (APRN)
- Gerontological nurse practitioner (GNP)
- Clinical nurse specialist (CNS)
Scope of Nursing Practice
- Defined by state regulation
- Influenced by the complex and multifaceted needs of the population being served
- Depends on the setting in which the nurse practices
Standards of Nursing Practice
- Developed by the nursing profession
- Divided into clinical care and the role of the professional nurse
1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
Standards of Professional Gerontological Nursing Performance
- Quality of care
- Performance appraisal
- Education
- Collegiality
- Ethics
- Collaboration
- Research
- Resource utilization
- Transitions of care
Elder Demographics
- The global share of older people (65 or older) increased from 6% in 1990 to 9% in 2019.
- The percentage of individuals at least 65 years old varies by country because of higher birth rates and shorter life spans in the least developed countries
Centenarians are more likely to be…
The population of centenarians is overwhelmingly female (84%), lower educated, more impoverished, more likely to be widowed, and more disabled as compared with other older cohorts
* The fastest growing segment of the population of U.S. comprises centenarians
Genomics Definition
Is the identification of gene sequences in the DNA
Genetics Definition
Is the study of heredity and the transmission of certain genes through generations
Gender and Older Age
- The older population is predominantly female
- By 2050, women will comprise 54% of the global population aged 65 or older
Health Disparities: African Americans
- In 2018, the medium income of older African American households was estimated to be $47,149, compared with $67,904 among older non-Hispanic white households
- African Americans experience higher rates of diabetes, HTN, and CKD than other Americans
Health Disparities: Hispanic
- The poverty rate in 2017 for Hispanic elders in the United States was nearly twice that of the total older population: 17% compared with 9.2%
- The top five leading causes of death for Hispanic Americans are heart disease, cancer, stroke, diabetes, and chronic lower respiratory diseases
Health Disparities: Asians and Pacific Islanders
- This ethnic group comprises 40 different ethnic groups with varying economic, educational, and health profiles
- Members of this ethnic minority are less likely than U.S. whites to live in nursing homes, and they have a higher life expectancy
- The top five causes of death are heart disease, cancer, stroke, Alzheimer’s disease, and diabetes
Health Disparities: Native Americans and Alaska Natives
- The census group Native American and Alaska Natives comprises 574 nations, tribes, bands, and native villages
- The top five leading causes of death are heart disease, cancer, chronic lower respiratory diseases, diabetes, and stroke
- This population has higher rates of diabetes, HTN, back pain, and vision loss
Health Disparities: Older Foreign-Born Population
- The newly immigrated are those people who are living in the United States who were not U.S. citizens at birth
- Approximately 13.17% of the total U.S. population is foreign-born
- From 2000 to 2017, the number of newly arrived immigrants who are aged 65 and older has roughly tripled, from 2% to 6%
Health Disparities: Living Arrangements
- Globally, 40% of older persons aged 60 years or older live independently, and it is far more common in developed countries
- Older people who live alone are more likely than their married counterparts to live in poverty
- Only 4.5% of older adults live in nursing homes, and 2% live in assisted living facilities
Health Disparities: U.S. Veterans
- In 2015, one out of every two men over 65 years old were veterans
- There are currently three cohorts of older veterans: those who served in WW2, Korean War, and Vietnam
- Some experience PTSD with age
- Changes in military healthcare systems have occurred
Health Disparities: Disabled
- Advances in healthcare have increased the life span of persons with disabilities, including individuals with acquired or congenital disabilities
- According to the U.S. Census, about 85,000 adults over 60 have IDD (intellectual and developmental disabilities), with 1.4 million projected to have IDD by 2030.
Health Disparities: Prisoners
- As of 2016, 38,000 inmates over the age of 65 were in federal and state prisons
- Because of the stressors related to incarceration, as well as increased likelihood of an unhealthy lifestyle preceding incarceration, prisoners 50-55 experience physical and mental changes normally associated with free-world citizens at least 10 years older (“they age faster”)
Leading Cause of Death for Older Adults in the United States
Heart disease
Changes in Medicare over the last decade:
- An initial wellness examination that includes prevention counseling
- Annual wellness visits
- Smoking cessation (no longer limited to those who have an illness caused by or complicated by tobacco use
- Comprehensive health programs that include complementary and alternative practices, developed for cardiac rehabilitation
- Screening and intensive behavioral therapy for obesity
- Depression screening in a primary care setting that can provide follow-up and referral
- Alcohol misuse counseling sessions, up to four per year, in a primary care setting with a qualified provider
- Elimination of all deductibles and copayments for prevention services to enhance access
Physical Health: Nutrition
- Older adults are vulnerable to both obesity and malnutrition
- Social isolation, dental problems, medical disease, and medication contribute to malnourishment
- Blue zones show a correlation in lifestyle habits and diet among the most concentrated areas of centenarians (Mediterranean diet)
Physical Health: Dietary Implications for Older Adults
- Low fat, low cholesterol, and low sodium diets are suggested
- Highly restricted diets can lead to deficient dietary intake and malnutrition
Emotional Health
- Physical and mental health are connected
- Depression (experiencing loss)
- Dependency
- Quality of life and wellness
Intellectual Health
- The ability to think, learn, process, and utilize memory clearly
- Alzheimer’s disease
- Dementia
Vocational Health
- More older adults cannot financially support themselves with retirement savings, making the role of employment increasingly significant
- Older adults may choose re-engagement over retirement through voluntary opportunities, cohousing, participation in senior centers, or intergenerational programming
Baby Boomers
- Baby boomers began turning 65 in 2011
- This cohort of older adults is the:
1. Longest lived
2. Best educated
3. Healthiest
4. Most engaged
5. Largest cohort of retirees
Spiritual Health
Life Review: an autobiographical effort preserved in print, by tape recording, or on videotape
Health Behavior Change
- The processes underlying the learning of new health behaviors
- Popular theories
- Cognitive theory
- Stages of change - Education paired with empowerment theory
- Health promotion interventions must be individualized
Green House
- Revolution in long term care
- First constructed in Tupelo, MS
- Looks life surrounding homes in the neighborhood
- 10 residents have private room and bath with shared areas for cooking and socializing, and a garden
- Promotes autonomy
Primary Prevention
Designed to prevent disease from occurring
Secondary Prevention
Early detection and management of disease
Tertiary Prevention
Management of clinical diseases to prevent them from progressing and to avoid complications
U.S. Preventative Services Task Force (USPSTF)
USPSTF endorsement:
- Level A: highly recommended
- Level B: recommended
- Level C: recommended for some
- Level D: not recommended
- Level I: insufficient data for recommendation
The Focus of Health Promotion Efforts
Recommended by Health People 2030 and USPSTF:
1. Physical activity
2. Nutrition
3. Tobacco use
4. Health screening
5. Injury prevention
6. Preventative medications and immunizations
7. Caregiver support
Physical Activity
- Functional decline is partly attributable to physical inactivity
- Moderate activity
- 30 minutes of brisk walking 5 or more days per week - Barriers to physical activity
- Lack of access to safe areas to exercise, pain, fatigue, and impairment in sensory function and mobility - Nursing plays a part in promoting physical activity
- Goal setting
- Planning
- Follow up
Signs of Poor Nutrition in Older Adults
- BMI under 21
- Weight gain or loss
- Albumin < 3.4 g/dL
- Cholesterol < 160 mg/dL
- Hgb < 12 g/dL
- Serum transferrin < 180
Safety and Older Adults
- Falls are the leading cause of unintentional injury death in older adults in the U.S.
- Nurses should provide a full multifactorial fall risk assessment if the adult:
- Has experienced more than one fall
- Has had an injury requiring medical care
- Has difficulty with walking and/or balance
Polypharmacy and Medication Errors
- Older adults are 12% of the U.S. population but use about 1/3 of all prescription and OTC drugs
- Increased numbers of medications carry increased risks
- Beer’s Criteria for Potentially Inappropriate Medications in Older Adults
- Screening Tool of Older Persons’ Prescriptions (STOPP)
- Screening Tool to Alert to Right Treatment (START)
Immunizations
- Flu (annual for age 65+)
- Pneumococcal pneumonia (one time for 65+)
- Tetanus and diphtheria (booster every 10 years for all older adults)
- Herpes zoster (one time for age 60+)
- COVID-19
Important Screenings for Older Adults
- Mental health
- Alcohol abuse
- Drug use
- Elder abuse and neglect
- Heart and vascular disease
- Stroke
- Thyroid disease
- Osteoporosis
- Vision and hearing
- Prostate cancer
- Breast cancer
- Colorectal cancer
Aging Process
- Aging processes that occur in one physiological system can directly or indirectly influence other physiological systems
- Physiological aging is an extremely individual process, and how the body ages is greatly affected by a person’s genetic makeup, health behaviors, and availability of resources
Aging Changes in the Cardiovascular Structure (Cardiac Aging)
- Enlargement of heart chambers and coronary cells
- Ages arteries become extended and twisted
- All four cardiac valves increase in circumference
- SA node demonstrates some fibrosis
- Loss of pacemaker cells
Vascular (cardio) Aging
- Arterial walls thicken with variable levels of arterial thickness occurring depending on differential changes in elastin and collagen levels
- When large arteries dilate and stiffen, this leads to HTN
- Peripheral arteries can also show increased stiffness due to accumulating mineral (calcium), lipid, and collagen residues.
- Arteries stiffen due to alterations in elastin and collagen, arterioles undergo atrophy, affecting their ability to expand with pressure alterations
Autonomic Nervous System Aging Effects on the Cardiovascular System
- Orthostatic hypotension
- Norepinephrine concentrations increase
- Impaired sympathetic nerve response and resistance in peripheral vessels
How does the autonomic nervous system affect orthostatic hypotension?
- Changes related to orthostatic hypotension include decreased reaction of the entire system, both myocardial and vascular, to beta-adrenergic stimulus as well as reduced baroreflex activity relating to an imbalance in neuroendocrine control
- These changes in the baroreflex activity can lead to impaired sympathetic nerve response and resistance in peripheral vessels. As a result, blood pressure becomes unstable, and hypotension may result.
Aging of the Respiratory System
- Decline in chest wall ability (stiffens which decreases the ease with which the thoracic cavity can expand)
- Decline in elastic recoil of the lung (results in unexpired air remaining in the lungs, and consequentially, during the next inhalation, less air can be inspired)
- Decline in respiratory muscle strength
- Alveoli become flatter and shallower, and there is a decrease in the amount of tissue dividing individual alveoli
Changes in Respiratory Measures
As a results of physiological changes with the lungs, the respiratory system is less able to provide sufficient gas exchange to meet the body’s demand for oxygen, particularly at times of maximum physical exertion.
- Decreased vital capacity (the maximum amount of air that can be expelled following a maximum inspiration)
- Increase in residual volume
- Decrease in forced expiratory volume (amount of air that can be forcefully expelled in 1 minute)
Age Related Pathologies of the Respiratory System
- COPD
- Pneumonia
Aging Changes: Mouth
- changes in taste
- teeth changes
- difficulty chewing (musculature)
Aging Changes: Esophagus
- changes in upper esophageal sphincter pressure
- increased time for the upper esophageal sphincter to relax
- decreased intensity of esophageal contractions
- muscle changes that affect swallowing
Aging Changes: Stomach
Pepsin, bicarbonate, and sodium ion secretions and prostaglandin content do show age-related decline. These secretion changes cause a decline in gastric defense mechanisms and create an increased potential for mucosal injury in the stomach.
Aging Changes: Small Intestine
No age related changes
Aging Changes: Large Intestine
- A loss of enteric or intestinal neurons and nerve connections to the smooth muscle in the colon occurs
- The rectum shows an age related increase in fibrous tissue
- The external anal sphincter shows an age-related decrease in motor neurons responsible for sphincter to control
Aging Changes: Liver
- The liver’s size as well as its blood flow and perfusion can decrease by 30-40%.
- Hepatocytes undergo structural changes
- Decreased drug clearance in the older population can occur due to the declines in liver size and blood flow as well as age related changes in the kidneys, but this is highly variable among individuals
Aging Changes: Gallbladder
- Declines in emptying rates so that less bile is secreted when food is digested
- Increased bile volume can lead to gallstones (more common in women)
- Bile ducts tend to widen with age, allowing potential gallstones to pass through more easily; however, the duct near the opening of the small intestine becomes narrower, trapping the gallstones and leading to abnormal changes
Aging Changes: Pancreas
- The pancreas decreases in weight with age but this has not affect on its function due to the large reserve capacity of the pancreas
Urinary Structural Changes with Age
- Kidneys
- Bladder
- Ureters and urethra
Aging Changes: Kidneys
- The kidneys shrink in length and weight
- The number of glomeruli decreases by as much as 30-40% by age 90 due to glomerulosclerosis
- Size and number of nephrons decrease
- Blood flow to kidneys decreases due to vascular changes
- GFR declines
- Renal tubules decrease in number and length
** Despite age-related changes, the kidneys contain a large reserve capacity, and functional abilities remain relatively stable unless stressed
Aging Changes: Bladder
- Bladder decreases in size and develops fibrous matter in the bladder wall, changing its overall stretching capacity and contractility
- Filling capacity declines
- The ability to withhold voiding declines
Aging Changes: Ureters and Urethra
- With age, both the length of the urethra and the pressure needed to close off the urethra decline in women
- The urethra thins with age, and striated muscle that controls sphincters also thins and weakens
Urinary Functional Changes with Age
- Urination
- GFR
- Homeostasis changes
- Hormone changes
Aging Changes: Urination
- Amount of urine expelled decreases, which increases with amount of post-void residual
- decreased ability to concentrate and dilute urine, which leads to electrolyte imbalance
- Urine osmolality reaches only half that in a younger adult, leading to increased water loss
- Increase in nocturia
Aging Changes: GFR
- The equation used to calculate GFR can be used to predict renal disease, but it may not reflect the usual aging process. As a result, use of the equation can lead to medication underdosing in healthy older adults and overdosing in compromised older adults
Aging Changes: Homeostasis Changes
During times of stress, kidneys may not function optimally
- Decrease in the ability to regulate sodium concentration
- Decrease in ability to maintain balance of sodium and potassium and conserve water during times of stress
- Acid/base homeostasis is relatively stable during aging but younger people do it more efficiently
Aging Changes: Hormone Changes
- Plasma renin and aldosterone concentration levels decline with age
Female Reproductive Aging
- Neuroendocrine function
- Female system changes
- Ovaries
- Uterus
- Vagina - Menopause
Aging Changes: Female Neuroendocrine Function
- FSH levels begin increasing before menopause occurs and continue to increase throughout and after menopause
- Estradiol levels increase right before and while transitioning into menopause and then drastically decrease during menopause
Aging Changes: Ovaries
- Ovaries atrophy to such a small size that they can become impalpable during an examination
Aging Changes: Uterus
- Age related decreases in uterine thickening during menstrual cycles occur as the result of decreased estrogen and progesterone levels. This results in decreased menstrual flow
- Decreased ligaments weaken with age and allow uterus to tilt or fall out of position
- Decreases in size postmenopause
Aging Changes: Vagina
- Becomes shorter and narrower
- Vaginal walls thin and weaken
- Loss of lubrication
- pH shifts from an acidic environment to a more alkaline
Male Reproductive Aging
- Neuroendocrine changes
- Male system changes
- Testes
- Glands
- Penis
- Andropause
- Decline and eventual deficiency in testosterone levels significant enough to cause clinical symptoms
Aging Changes: Male Neuroendocrine Function
- Increases in FSH and LH levels
- Decreases both serum and bioavailable testosterone levels
- Decline in interstitial cell function
** As testosterone levels decline in older males, the amount estrogen remains stable, leading to a decline in the testosterone-to-estrogen ratio
Aging Changes: Testes
- Decrease in both size and weight
- Leydig cells decrease in number but not structure
- Seminiferous tubules show thinning of the walls and narrowing of lumen, known as sclerosis
- Although a decline in sperm production occurs in older males, the production never ceases, so the older male remains fertile
Aging Changes: Penis
- Fibrous changes in erectile tissues
The Aging Brain
- Overall structural changes
- Neuron changes
- Vascular changes
- Plaques and tangles
- Free radicals
- Neurotransmitter changes
- Neuroendocrine changes
Overall Structural Changes in the Brain
- Brain decreases in size and weight
- Ventricles enlarge (may explain some loss of brain volume)
- Gyri (raised ridges on the surface of the brain) shrink
- Sulci (grooves between the gyri) become wider
Aging Changes: Brain Neuron Changes
Approximately 10% of all neocortical neurons are lost over the lifespan in both sexes
Aging Changes: Vascular Changes in the Brain
- Cerebral blood flow decreases, by an average of 20%
- Decreased glucose utilization and metabolic rate of oxygen in the brain
Aging Changes: Plaques and Tangles
- Neurofibrillary tangles and beta-amyloid plaques are considered hallmarks of AD, but both also can be found in older individuals without evidence of dementia
Aging Changes: Neurotransmitter Changes in the Brain
- Cholinergic
- Dopaminergic
- Monoaminergic
- Amino acid transmitters
Aging Changes: Spinal Cord Cells
Overall, the number of spinal cord cells remains stable until around age 60 and then declines thereafter
Aging Changes: Nerve Conduction
- The aging spine may narrow due to pressure on the spinal cord resulting from bone overgrowth
- Because of narrowing, axons decrease and can eventually cause changes in sensation
The Aging Peripheral Nervous System
** The peripheral nervous system contains approximately 100 billion nerve cells
1. Sensory neurons (function declines; alters reflexes and voluntary actions)
2. Somatic motor neurons (decrease in number; leads to muscle degeneration and weakness)
3. Autonomic motor neurons (decline in function; leads to problems with orthostatic hypotension and thermoregulation)
4. Injury responsiveness (decrease in reparative properties)
Aging Changes: Hypothalamus and Pituitary Gland
- Growth hormone decreases
- Vasopressin (AKA antidiuretic hormone, ADH) increases
Aging Changes: Thyroid Gland
- T3 and T4 decrease
- TSH increases
Aging Changes: Parathyroid Gland
It is thought that with age, PTH may have a decreased ability to stimulate production of active vitamin D by the kidneys and/or that active vitamin D may be impaired in its ability to stimulate intestinal absorption of calcium
Aging Changes: Pineal Gland
- Melatonin levels decline
Aging Changes: Adrenal Glands
- Adrenal cortex
- Glucocorticoids (no changes in cortisol)
- Mineralocorticoids (decrease in aldosterone)
- Adrenal sex hormones (DHEA decreases) - Adrenal Medulla (decrease in epinephrine)
Aging Changes: Pancreas
- Blood glucose levels
- Glucose intolerance (tolerance declines)
- Insulin secretion (little to no change)
- Insulin resistance (increases)
- Glucose counterregulation (impaired)
Confounding Factors of the Glucose Intolerance of Aging
- Adiposity (increase in adipose tissue in intraabdominal region; decrease lean body mass)
- Physical activity (decreased insulin action due to decline in functional mobility)
- Diet (diminished dietary carbohydrate intake)
- Polypharmacy (meds affecting glucose metabolism)
Drugs that Affect Glucose Metabolism
- Beta blockers
- Calcium channel blockers
- Glucocorticoids
- Alcohol
- Nicotine
- Caffeine
Aging of the Skeletal Muscle
- Sarcopenia (reduction in muscle mass)
- Changes in muscle fibers (loss in number of both fast twitch and slow twitch fibers)
- Loss of motor units
- Hormonal influences (hormones promote buildup of muscle, and older adults have less hormone production)
- Protein synthesis (no change)
- Nutritional factors (food intake declines)
Aging of Bones
- Bone loss (estrogen deficiency)
- Bone type (cortical and trebecular bone decreases)
- Bone strength (due to increased porosity and loss of collagen)
Age-Related Disease and Injury of the Bone
- Osteoporosis
- Bone fractures
- Joint types and problems
- Osteoarthritis
Aging Changes: Touch
The ability to touch and distinguish texture and sensation tends to decline with age because of a decrease in the number and alteration in the structural integrity of touch receptors
Aging Changes: Smell
The chemical senses of smell and taste work together and influence each other as a functional entity
- Age related olfactory changes
Aging Changes: Taste
- Taste, or gustation, and the chemoreceptors for taste are located in approximately 10,000 taste buds found mostly on the tongue
- Age related gustation changes
Aging Changes: Vision
- The eyes monitor objects and conditions around the body, continually sending sensory messages to the brain, such as the body can elicit appropriate responses to the outside environment
- Changes in eye structure
- Changes in visual function
- Age related eye diseases (cataracts, glaucoma, macular degeneration, diabetic retinopathy)
Aging Changes: Hearing
- Vestibular system (decline in hair cells, ganglion cells, and sensory nerve fibers)
- Hearing mechanism
- Hearing loss (alteration and the decline in threshold sensitivity, the ability to hear high frequency sounds, and the ability to discern speech) (presbycusis most common)
The Aging Skin
- The greatest changes in aging skin are seen in the dermis
- There is a general thinning of the dermal layer, with loss of thickness averaging 20% in older persons
- Estrogen and aging skin (less estrogen means loss of elasticity)
Aging Changes: Hair
- Germination centers that produce hair follicles undergo changes and may, in fact, be destroyed
- The hair on older men’s eyebrows and inside their ears may become longer and coarser
- Women may develop unwanted facial hair
- Hair graying
Aging Changes: Nails
- The linear growth of nails decreases with age
- Nails become thinner, drier, and more brittle
- Nails become more flat or concave instead of convex
Aging Changes: Skin Glands
- Number of sweat glands decreases
- Efficiency declines and less sweat is produced, results in impaired thermoregulation
- Sebaceous glands do not decrease in number, however, the size and the activity of the glands do decrease
- Decreased sebaceous gland function leads to increased dryness, roughness, and itchiness
The Immune System
- Innate immunity
- Acquired immunity
- Autoimmunity
The Hematopoietic System
- Hematopoiesis
- Blood cells
- Erythrocytes
- Leukocytes
- Thrombocytes
Stem Cells and Aging
- Proliferative capacity of stem cells
- CD34+ progenitor stem cells
- Age related changes in the cytokine network
Anemia and Aging
- Anemia is a condition in which a deficiency in the number of erythrocytes or the amount of hemoglobin they contain limits the exchange of oxygen and carbon dioxide between the blood and tissues
- If anemia is diagnosed in older adults, there is almost always another comorbid medical condition present and underlying the anemia
