CHAPTER 14. The Geriatric Patient
Jennifer Allen*
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify changes that occur with aging using a systems approach.
2. Describe the demographics of the geriatric patient.
3. Identify potential problems that may occur after a surgical procedure.
4. Discuss the purpose of a preoperative assessment.
5. Identify postoperative priorities in consideration of the physiologic changes that occur with aging.
I. OVERVIEW
A. Geriatric patients present a unique challenge.
B. Physiological changes and pathological conditions mandate utilization of the nursing process.
II. DEFINITION OF GERIATRIC OR OLDER ADULT
A. Age 65 years or older and when one qualifies for retirement income
1. 65 to 74 years: “young-old”
2. 75 to 84 years: “old”
3. 85 years: “old-old”
B. Life expectancy
1. Men: 81 years
2. Women: 84 years
C. Number of older adults in United States is increasing.
1. By 2030, the older population will double to about 72 million people.
a. One in five will be 65 or older.
b. The age group 85 years and older is the fastest growing cohort of the United States population.
c. The 85 and older population is projected to increase from 4.7 million in 2003 to 9.6 million in 2030.
2. Members of minority groups are projected to represent 26.4% of the older population in 2030.
3. More than 2 million Americans celebrated their sixty-fifth birthday in 2003 (5574 per day).
4. Older adults account for one third of all health care costs.
a. Focus is shifting to health promotion and health maintenance.
b. Nurses need to be aware of what health promotion and maintenance practices will benefit the older adult.
c. Recommended health practices
(1) Diet
(2) Exercise
(3) Tobacco cessatation and alcohol reduction
(4) Physical examinations and preventive care
(5) Dental examinations and preventive care
5. There were 50,639 persons aged 100 or more in 2003 (0.17% of total population).
6. Number of centenarians is expected to grow quickly, with estimates of 381,000 by 2030.
D. The Silent Generation, also known as the Veteran Generation (people born before 1946)
1. Comprise 10% of today’s work force
2. Rely on tried and true ways of doing things
3. Core values include:
a. Dedication and sacrifice
b. Hard work
c. Conformity
d. Law and order
e. Respect for authority
f. Patience
g. Duty before reward
h. Adherence to rules
(1) Honor
(a) A keen sense of ethical conduct
(b) One’s word given as a guarantee of performance
4. Veteran generational personality
a. Likes consistency and uniformity
b. Likes things on a grand scale
c. Are conformers
d. Believe in “logic” not “magic”
e. Are disciplined
f. Are past oriented and history absorbers
g. Believe in law and order
E. The Baby Boomers (people born from 1946 though 1964)
1. Comprise approximately 45% of today’s work force and one third of all Americans in 2007
2. Due to size, this group has had and will continue to have a great influence in all areas of society.
3. By 2030, all the baby boomers will be 65 years or older.
4. Unprecedented implications for all areas of society, especially health care
5. There is no typical baby boomer; they are extremely diverse and differ by:
a. As much as 19 birth years
b. Race
c. Culture
d. Socioeconomic status
6. Baby boomers paid their dues and climbed the ladder under the old rules.
7. Core values include:
a. Optimism
b. Team orientation
c. Personal gratification
d. Health and wellness
e. Youth
f. Personal growth
g. Involvement
h. Work
8. Baby Boomer generational personality
a. Dedicated and driven
b. Equate work with self-worth
c. Define themselves through their jobs, achieve identity by work performed
d. Arrive early and leave late
e. Chose profession with intent to make the world a better place
f. Believe you must pay your dues
g. Believe they do not have to grow old and be sedentary
h. Also called the Sandwich Generation, responsible for aging parents while still caring for teenage and college-age children
III. THEORIES OF AGING
A. Biological theories
1. Cellular functioning
2. Stochastic (error) theories
a. Wear and tear theory
b. Cross-linkage theory
c. Free radical theory
(1) Free radical and antioxidants
3. Nonstochastic theories
a. Programed aging theory
b. Gene theory
c. Immunity theory
4. Emerging biological theories
a. Neuroendocrine control or pacemaker theory
b. Caloric restriction (metabolic) theory
B. Sociological theories
1. Role theory
2. Activity theory
3. Disengagement theory
4. Continuity theory
5. Age stratification theory
6. Social exchange theory
7. Modernization theory
C. Psychological theories
1. Jung’s theories of personality
2. Developmental theories of Erikson and Peck
a. Theory of psychosocial development most widely used
b. Emphasis on healthy personality rather than pathologic approach
(1) Stresses rational and adaptive natures of individual
(2) Explains child’s behaviors in mastering developmental tasks
c. Stages of development
(1) Each stage has two components—favorable and unfavorable aspect of conflict.
(2) Progression to next stage depends on resolution of conflict.
(3) Conflict never mastered completely—remains a recurrent problem throughout life.
d. Stage VIII relates to the older adult.
(1) Ego integrity versus despair stage (stage VIII)
(a) Old age
(b) Results from satisfaction with life and acceptance of what has been
(c) Despair is a result of remorse for what might have been.
(d) Ego integrity results in renunciation and wisdom and concern with life in the face of death.
(e) Process achieved through introspection
e. Peck expanded on the original work of Erikson.
(1) Identification of discrete tasks of late life
(2) Achievement of tasks will result in ego integrity.
(3) Tasks represent a movement toward Erikson’s final stage.
3. Maslow’s Hierarchy of Human Needs
a. Focuses on attributes or characteristics that contribute to healthy personality development
b. Concerned with uniqueness and potential of individuals
(1) Humans motivated by two need systems
(a) Basic
(i) Food, water, and shelter
(b) Growth needs—internally motivated and reinforced
(i) Beauty
(ii) Self-fulfillment
(2) Needs arranged in a hierarchy
(a) Lower-level needs assume dominance.
(b) When one level need is satisfied, the next becomes predominant.
(c) Theory does not address developmental stages or shaping of human behaviors.
IV. PHYSIOLOGIC CHANGES OF AGING: CHANGES IN BOTH STRUCTURE AND FUNCTION
A. Changes that occur with aging are not incidental, they are expected.
1. Changes begin the moment life begins.
2. Changes become more apparent in the fifth or sixth decade.
3. In seventh and eighth decades, physiologic changes are significant and no longer deniable.
4. Changes in aging are predictable, but not the exact time they occur.
5. The timing and degree of aging is affected by heredity, environment, and health maintenance.
B. Functional age is impacted by:
1. Chronic disease processes
2. Personal attitudes and outlook
3. Family and friends network
C. Nervous system
1. Divided in two systems
a. Central nervous system (CNS)
(1) Consists of brain and spinal cord
b. Peripheral nervous system
(1) Consists of cranial nerves and spinal nerves
(2) Includes the somatic nervous system and the autonomic nervous system
c. Many functions occur at an unconscious level.
d. Other activities are done at a conscious level.
2. Neurogenic atrophy and reduction of peripheral nerve fibers
a. Decreased blood flow and CNS activity
(1) Causing slower reaction times
(2) Reduced ability to cope with body stressors
(3) Diminished ability to respond to demands on cardiovascular systems
(4) Prolonged emergence from pharmacologic interventions (e.g., benzodiazepines) and decreased pain perception
b. Decreased cognitive function
(1) Loss of memory and decreased understanding
(2) Lengthening of learning speed
(3) Higher risk of confusion
(4) Short attention span
(5) Decreased sensory abilities
(a) Impaired hearing acuity
(i) Men especially lose high-frequency sounds.
(ii) Deafness
(iii) Decrease in acoustic acuity
(b) Vestibular changes may also alter balance and/or cause vertigo.
(c) Visual precision is reduced.
(i) Lenses fail (as in cataracts).
(ii) Glaucoma
(d) Decreased tactile perception
(e) Acuity of smell diminished
(i) May impair hygiene
(6) Postoperative cognitive dysfunction in the elderly may persist at least 3 months after otherwise uncomplicated surgery.
c. Homeostatic mechanism slows, altering sympathetic and parasympathetic responsiveness.
(1) Decreased sensitivity to baroreceptors
(2) Change in thermoregulation
(a) Affected by autonomic impairment
(b) Changes to skin and blood vessels
(c) Impaired by many chronic medications
(d) Elderly vulnerable to heat stroke and hypothermia
d. Compromised perfusion caused by arteriosclerotic changes
(1) Increased incidence of organic brain syndrome
(2) Increased incidence of cerebrovascular accidents (strokes)
(3) Increased incidence of microemboli
(4) Decreased cerebral blood flow
(5) Decreased cerebral metabolic oxygen consumption
(6) Decreased CNS activity
3. Common disorders
a. Cerebral arteriosclerosis
b. Cerebral vascular accident
c. Parkinson’s disease
d. Dementia
e. Alzheimer’s disease
4. Nursing implications
a. Allow additional time to assimilate information and give responses.
b. Prepare for possible increased length of stay in ambulatory surgery.
c. Encourage use of sensory aids.
(1) Hearing aids
(2) Visual aids
(a) Glasses
(b) Contacts
(c) Magnifying glass
d. Include family member or responsible adult in instructions.
e. Verbal communication
(1) Face patient when speaking.
(2) Raise speaking volume, not pitch.
(3) Speak slowly and clearly.
f. Observe for prolonged or toxic effects of drugs.
(1) Encourage lower doses.
g. Safety measures
(1) Handrails
(2) Other assistive devices
(a) Canes, walkers, nonslip shower chairs
(3) Nonskid footwear
(4) Physical support by caretaker
(5) Observation
D. Respiratory system
1. Includes the nose, pharynx, larynx, trachea, bronchi, bronchioles, alveolar ducts, and alveoli
a. Provides for ventilation and gas exchange
b. Facilitates transfer of oxygen into and removal of carbon dioxide from the blood
c. Depends on the musculoskeletal system and CNS to function
2. Airway
a. Edentia
(1) Impacts patency of airway
(2) Creates difficulty in intubation
b. Decreased bone mass of jaw
3. Anatomic changes
a. Increased anteroposterior diameter
b. Progressive flattening and decreased muscle strength of diaphragm
c. Increased chest wall rigidity
(1) Arthritic changes in rib cage
d. Reduction in alveolar surface
e. Narrowing of intervertebral disks
(1) Reduces total lung capacity by 10%
f. Loss of skeletal muscle mass, leading to wasting of diaphragm and skeletal muscles
g. Loss of teeth changes jaw structure, leading to difficult airway maintenance.
4. Physiologic changes
a. Reduction in pulmonary elasticity
b. Decreased chest wall mobility
c. Loss of alveolar septa, leading to air trapping
d. Decreased pulmonary compliance
e. Increased airway resistance
f. Decreased cough and gag reflex, leading to risk of aspiration
g. Ventilation and perfusion alterations develop.
(1) Decreased tidal volume
(2) Decreased vital capacity
(3) Decreased inspiratory reserve
(4) Decreased cardiac output
(5) Decreased aerobic capacity
(6) Increased dead space
(7) Decreased oxygen and carbon dioxide exchange
(8) Decreased oxygen content of blood
(a) Pa o2 = 100 − (0.4 × Age in years) = mm Hg
(b) For example, in an 80 year old: Pa o2 = 100 − (0.4 × 80) = 68 mm Hg (vs normal Pa o2 of 100 mm Hg)
h. Environmental changes impact the respiratory system.
(1) Smoke
(2) Dust
(a) Air pollution
5. Common disorders
a. Chronic obstructive pulmonary disease (COPD)
b. Influenza
c. Pneumonia
d. Tuberculosis
e. Lung cancer
6. Nursing considerations
a. Airway
(1) Assess airway constantly.
(2) Protect unconscious airway.
(a) Suction oropharynx as needed.
(b) Support and position.
(3) Provide appropriate airways and oxygen delivery supplies.
(4) Inserting dentures can help support the airway.
b. Secretions and effective cough
(1) Position
(a) With head elevated when possible
(b) To maximize chest expansion
(2) Encourage coughing and deep breathing.
(3) Ensure reflexes have returned before administering oral fluids.
c. Oxygenation
(1) Monitor oxygen saturation (e.g., pulse oximeter).
(2) Support with oxygen as necessary.
d. Pain
(1) Alleviate pain.
(2) Use anxiety- and stress-reduction tactics.
E. Cardiovascular system
1. Comprises the heart, blood, blood vessels, and the lymphatics
a. Transports oxygen- and nutrient-enriched blood to the organs
b. Transports waste products to the excretory organs
2. Cardiovascular disease is the leading cause of death of older adults in the United States.
3. Most changes are caused by arteriosclerotic changes.
a. Loss of large artery elasticity
(1) Coronary
(2) Aorta
(3) Carotid
(4) Iliac
(5) Femoral
(6) Popliteal
(7) Renal
b. Decreased organ perfusion and decreased compensatory regulation from loss of elasticity
c. Vessel fragility
d. Increase in systolic blood pressure
4. Loss of tissue elasticity
a. Organ perfusion decreases
(1) Myocardium
(2) Decreases optimal regulation of all body systems
b. Peripheral circulation impaired
(1) Lowers tolerances to stress response (heart workload increases)
(2) Along with decreased collagen, increases difficulty of venipuncture
(a) Aging collagen makes tough “rolling” veins.
(b) Loss of elasticity is likely to cause bleeding around site during and after venipuncture.
(3) Higher risk for bruising
(4) Increases peripheral vascular resistance
(a) Restricts left ventricular ejection
(b) Promotes cardiac hypertrophy
(5) Potential for orthostatic hypotension
c. Increased susceptibility to clotting disorders
(1) Stroke
(2) Thrombosis
(3) Embolism
5. Cardiac conduction system
a. Decreased heart rate
(1) Resulting from increased parasympathetic activity
(2) Resulting from degenerative changes in conduction system
b. Dysrhythmias and blocks occur more frequently.
c. Can lead to CNS changes
d. Myocardial changes
(1) Left ventricular hypertrophy
(2) Increased myocardial irritability, leading to dysrhythmias
(3) Fibrosis of endocardial lining, leading to endocardial thickening and rigidity, decreased contractility
(4) Calcification of valves, leading to valve incompetence
6. Altered hemodynamics
a. Pump effectiveness diminishes because of atrophy of myocardial fibers.
b. Decrease in cardiac output (1% per year after 30 years of age)
c. Slower circulation time
d. Prolonged onset of action and clearing times for drugs
e. Increased blood pressure
f. Systolic blood pressure increases with aging, reflecting development of poorly compliant arterial walls.
g. Heart rate decreases, suggesting increase in activity of parasympathetic nervous system.
h. Slowed circulation time, leading to slower onset of drug effects
i. Decreased cardiac reserve; stressors
(1) Fever
(2) Tachycardia
(3) Exertion
(4) Anxiety
(5) Hypoxemia
(6) Pain
7. Orthostatic hypotension
a. Decreased blood vessel tone, leading to peripheral pooling of blood, increased risk for deep vein thrombosis
b. Baroreceptor failure
c. Medications (most common cause)
(1) Antihypertensives
(2) Diuretics
(3) Tricyclic antidepressants
(4) Phenothiazines
(5) Alcohol
d. Decreased tolerance to volume changes
8. Common disorders
a. Coronary artery disease
b. Coronary valve disease
c. Congestive heart failure
d. Peripheral vascular disease
9. Nursing considerations
a. Observe responses to medications.
(1) Allow adequate time for response before repeating.
(2) Use lower range of medication dosage and encourage team to use lower dosages.
b. Monitor for cardiac inadequacy.
(1) Lungs
(a) Provide adequate oxygenation.
(i) Encourage deep breathing.
(ii) Watch for fluid overload while ensuring adequate hydration.
(2) Heart
(a) Assess heart sounds.
(b) Cardiac monitoring for arrhythmias
(c) Assess lung sounds.
(d) Avoid extremes of blood pressure.
(i) Watch for orthostatic changes.
(e) Encourage slow position changes.
(f) Vascular considerations
(i) Gentle venipunctures
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