Older Adults and Restorative Care - Article Example

Completed paper AGING Aging is described as the process that reduces the number of healthy cells in the body, therefore, the body loses its ability to respond to a challenge (external or internal stresses) to maintain homeostasis. A. Age related changes The body loses its ability to reproduce some its cells, and as cells are destroyed they are not always replaced. In addition, there is a stiffening of tissues. The loss of cells and stiffening of tissues are our bodies. The maximal physiological capacity of most organ system reduces progressively and irreversibly after 30 years of age. Note: The human life span is about 1100 – 120 years. However, the rate at which body functions declines is not the same in all parts of the body. The age related structural and functional changes in various organs of the body are as follows. 1. Changes at Cellular Level i. A generalized decreases in DNA repair activity occurs in body cells. The connective tissues show an increase in the stiffness of collagen fibers throughout the body and also an increase in the rate of hydrolysis of elastin. ii. There is gradual loss of body cells, being greatest in nerve, muscle, kidney and glands. This accounts for the loss of their function (about 0.6% per year). 2. Loss of Body Reserve. An example of how the body losses reserve with aging is that fasting blood glucose levels remain fairly constant throughout the life of a healthy individual. However, glucose tolerance test shows a loss of response with age. The same holds true for the recovery mechanisms of other systems. 3. Immune Mechanisms. The aging process impairs the immune system, primarily due to decreased effectiveness of cellular immunity, which is crucial for protection against viruses and tumours. This leads to higher incidences of cancer in old age. 4. GIT. An overall decline in the capacity to digest and absorb the nutrients is seen due to atrophy of mucosa of GIT and reduction in enzyme secretions. There is also decrease in the molitity of the GIT. 5. Cardiovascular System. The heart becomes stiffer and less efficient as a pump, while arteries lose elasticity and offer greater resistance to blood flow. This, in turn, decreases blood flow to most organs. 6. Respiratory System. An overall decline of respiratory functions, such as ventilation, exchange of gases as well as regulation of respiration is seen with advancing age. 7. Excretory System. A decrease in number of nephrons and decreased blood flow to kidneys with advancing age makes the kidney less efficient as filter. 8. Endocrine System. In general, number of target cells decreases with decreased sensitivity of receptors to hormones. This results in reduction of physiological response of many of the hormones in the body with the advancing age. 9. Nervous System: i. The aged brain has lost a large percentage of cells in several key neural pathways, therefore, reaction time is longer, learning becomes less efficient and short-term memory becomes less reliable. ii. The function of various neurotransmitters decreases. This is responsible for many old age nervous dysfunctions like Alzheimer’s and Parkinson’s disease. iii. Various special sensations like smell, taste, vision and hearing also decline with age. Important Note: The greatly diminished physiological capacities of each organ system mean that old people are far more apt to die if subjected to such stresses as infection, accidental injury or environmental factors like extreme cold or heat even air pollution. Some of the diseases of aging are heart disease, cancer, arthritis, cataract and allergic disorders. B. Theories of aging Many theories of aging have been postulated through the years. Some of them are: 1. Death Hormone and Limited cell Replication Theory. The production of a death hormone is built into our genes and is released late in life. However, human cells are capable of a limited number of cell divisions and that their potential to replicate decreases with age. 2. Cross- Link Theory. In out cells a large number of smaller molecules have very specific functions, everything works fine as long as every molecule does its job. The ‘cross – linking’ agents can link two or more of these molecules together with strong bonds. When this happens, the molecules can no longer do their work. Cross – linking agents are formed in the body from normal molecules when they are subjected to radiations or air pollution or when normal metabolic reactions are hampered by toxic chemicals like alcohol or heavy metals. 3. Collagen theory. This theory holds that aging is due to cross – linking between collagen molecules and fibrous molecules that support bone, tendon and connective tissue, these collagen molecules then shrink and strangle healthy cells. 4. DNA Damage Theory. It states that aging is due to an accumulation of damage done to the DNA molecule. When damage is done repeatedly and is carried over into new cells, the DNA becomes less efficient. Cross – linking agents (see above), radiation and the lack of necessary building materials for the construction of the DNA during cell divisions are causes of DNA damage. (Proof: Abnormal chromosomes are formed when the animals are exposed to radiation.) Important Note: The body also has a DNA repair mechanism that can restore the DNA to normal if all required conditions are fulfilled. Good nutrition can supply the building materials for the DNA repair mechanism. Junk foods and highly processed foods are low in nucleic acids. 5. Free Radical Theory (Most Acceptable). It states the aging is due to the damaging effect of free radicals on living tissues. 6. Metabolic Products Theory. The accumulation of oxidation products in our cells makes us tired. Some of these metabolic products can form free radicals and cross – linking agents. Our body needs rest (in the form of sleep) to get rid of these products, called body’s cleansing mechanism and return to a state of equilibrium. Important Note: For the cleansing mechanism to work properly, we most have adequate nutrition, a sufficient amount of bodily fluid and a normal BMR. Drinking a glass of water and taking a light meal before retiring is, therefore, an advisable measure. A full stomach interferes with the BMR and may also prevent good sexual functioning. 7. Stress Theory. This theory states that the body and the cells can tolerate a certain amount of stress. The point at which stress changes into distress differs form one individual to another. Distress can affect the rate of cell division, hormone levels and many other functions. Important Note: A healthier body is more resistant to distress than a sick or fragile one. That is why good healthy practices (exercise and hygiene) and nutrition are so important. 8. Immunologic Theory. Lifespan decreases have been associated with a number of factors that can hamper immune responses, such as cigarette smoking, obesity and distress. This theory states that aging is due to decreasing immunological functions with age. Our immune system has two major types of cells, the B – cells and T – cells. The T – cells, when pass through the thymus, become ‘killer’ cells and can destroy microorganisms and cancer cells. While the B – cells deactivate the chemicals that are produced by these cancer cells. As the thymus shrinks with age, the effectiveness of the T – cells also decreases. Many nutrients have been associated with increasing immune functions, that include: vitamins A,C,E, folic acid and minerals like selenium, zinc, calcium and magnesium. 9. Cybernetic Theory. This theory suggests that aging is due to an increasing loss of control by the nervous system over all functions of the body. The neuroendocrines, from the hypothalamus to the pituitary and the thyroid, trigger the release of many hormones that control the functioning of the body. An imbalance of certain neurotransmitters (specially serotonin, nor-epinephrine and dopamine), in the neuroendocrines is a result of the aging process. Note: In the synthesis of neurotransmitters in the brain, nutrients and polyunsaturated fatty acids play key roles. C. Factors that will Delay Aging If we can control the rate of deleterious reactions that impair the stability of living system, we can control the aging process. Some of the important factors that increase life span will also delay aging. The factors are: 1. Not Smoking Cigarettes. Cigarette smoking causes increase formation of free radicals. Note: Cigarette smoking is the largest avoidable cancer and heart disease risk factor. 2. Maintaining Normal Weight. Eating low-fat nutritious foods instead of high-fat junk foods can save a person from 900 to 1500 calories per day. This is equivalent to 0.5- 1 kg per week. The calorie-restricted diets are enriched with vitamins and minerals, therefore, calorie restriction acts at very fundamental level to genuinely slow the aging process. Important Note: Calorie-restricted individuals act younger, look younger and, by objective physiological standards of aging, actually are younger. However, many discomforts of calorie restriction are: sleeplessness, hunger, aggression and anxiety. 3. Regular Exercise: i. Exercise is an absolute for the prevention of heart disease, diabetes and blood sugar disorders. ii. Exercise is one of the most important and healthful way of relieving stress. It can also eliminate depression. People who suffer from depression also age faster and look older. Eliminating depression is, therefore, an established anti-aging procedure. iii. When we exercise, the main source of energy is the burning of glucose. B-complex group of vitamins are important to burn glucose effectively. Stress in general increases the need for the vitamin B-complex. That is why the B-complex group of vitamins are termed the stress vitamins. 4. Overall Good Nutrition. The life span increase attributable to high-quality nutrition is anywhere from 10 to 20 years. Older adults in the acute care setting need special attention to help them adjust to the acute care environment and to meet their basic needs for comfort, safety, nutrition/hydration, and skin integrity. The acute care setting poses increased risk for adverse events such as delirium, dehydration, malnutrition, nosocomial infections, urinary incontinence, and falls. The risk for delirium is increased when hospitalized older adults experience immobilization, infection, dehydration, pain, and hypoxia. Multiple medications and multiple medical diagnoses are also risk factors for delirium. Nonmedical causes of delirium include placement in unfamiliar surroundings, separation from supportive family members, and stress. Impaired vision or hearing contributes to confusion and interferes with attempts to reorient the older adult. When the prevention of delirium fails, interventions begin with treatment of the cause. Supportive interventions include encouraging family visits, providing memory cues (clocks, calendars, name tags) and compensating for sensory deficits. Reality orientation techniques may be useful. Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests. The risk for dehydration and malnutrition is also increased when older adults are unable to reach beverages or to feed themselves while in bed or connected to medical equipment. Interventions include getting the client out of bed, providing beverages and snacks frequently, and including favorite foods and beverages in the diet plan. The increased risk for nosocomial infections in older adults is related to age-related reductions in immune system response. The use of indwelling urinary catheters accounts for 80% of nosocomial urinary tract infections. Other nosocomial infections include surgical site infection, pneumonia, and bloodstream infections. Prevention begins with hand hygiene and measures to minimize the risk of infection from procedures. Prevention also includes measures to increase the older adult’s resistance to infection. Older adults in acute care settings are also at risk for becoming incontinent of urine (transient incontinence). Causes of transient urinary incontinence include delirium, untreated urinary tract infection, excessive urine production, medications, restricted mobility, and constipation or impaction. Interventions for transient urinary incontinence are geared to correcting contributing factors. The interventions may include an individualized plan to provide voiding opportunities and modification of the environment to improve access to the toilet. Indwelling urinary catheters should be avoided if possible. Measures to prevent skin breakdown should be used. The increased risk for skin breakdown and the development of pressure ulcers is related to changes in aging skin and to situations that arise in the acute care setting such as immobility, incontinence, and malnutrition. The key points in the prevention of skin breakdown are avoiding pressure, reducing shear forces and friction, providing skin care and moisture management, and providing nutritional support. Older adults in the acute care setting are at risk for falling and sustaining injuries. Many of the falls occur as the older adult gets out of bed without assistance. Sedating medications may increase unsteadiness. Medications causing orthostatic hypotension may also increase the risk for falls because of the blood pressure drop when the older adult gets out of a bed or chair. The increase in urine output from diuretics increases the risk for falling by increasing the number of attempts to get out of bed to void. Attempts to get out of bed when physically restrained may lead to injury when the older adult becomes entangled in the restraint. Equipment such as wires from monitors, intravenous tubing, urinary catheters, and other medical devices become obstacles to safe ambulation. Impaired vision may prevent the older adult from seeing tripping hazards such as trash cans. Confused older who may try to get out of bed although weak, unsteady, or drowsy may benefit from reality orientation or the presence of family members and friends. Interventions to reduce the risk for falling include assistance with ambulation, strengthening exercises, medication monitoring, assistance with toileting, and removal of tripping hazards. Older Adults and Restorative Care Restorative care refers to two types of ongoing care. The first type of restorative care continues the convalescence from acute illness or surgery that began in the acute care setting. The second type of restorative care addresses chronic conditions that affect day-to-day functioning. Both types of restorative care take place in private homes and in long-term care settings. Interventions during convalescence from acute illness or surgery are directed toward regaining or improving the prior level of independence in ADLs (Activities of Daily Living). Interventions that began in the acute care setting should be continued and later modified as convalescence progresses. To achieve this continuation, the acute care setting’s discharge in formation should include information on the ongoing interventions (e.g. exercise routines, wound care routines, medication schedules, vital sign monitoring, and blood glucose monitoring). Interventions should also address the restoration of interpersonal relationships and activities at either their previous level or at the level desired by the older adult. When restorative care addresses chronic conditions, the goals of care include stabilizing the chronic condition, promoting health, and promoting independence in activities of daily living. Interventions to stabilize the chronic condition may focus on regulation or prevention. An example of a regulatory intervention is the monitoring of blood glucose levels in diabetes. An example of prevention is a smoking cessation program for the older adult with chronic obstructive pulmonary disease. Health promotion for older adults, as addressed in this chapter, applies to all older adults. Health promotion interventions should occur in all health care settings. For example, nurse-directed programs in long-term care have improved ambulation, reversed urinary incontinence, and reduced confusion. Interventions to promote independence in ADLs address physical ability, cognitive ability, and safety. The physical ability to perform ADLs requires strength, flexibility, and balance. Accommodation must be made for impairments of vision, hearing, and touch. The cognitive ability to perform ADLs requires the ability to recognize, judge, and remember. Cognitive impairments, such as Alzheimer’s disease, may interfere with safe performance of ADLs, although the older adult is still physically capable of the activities. Interventions to promote independence in ADLs adapt these requirements to the needs and lifestyle of the older adult. Safety is always considered be cause it is not enough to be able to perform any of the ADLs. The older adult should be able to perform the ADLs with only an amount of risk that is acceptable to the older adult. Beyond the basic activities of daily living, the older adult’s ability to perform instrumental activities of daily living (IADLs) must be assessed and appropriate interventions implemented. Instrumental activities of daily living are tasks such as using a telephone, preparing meals, shopping, doing laundry, cleaning the home or apartment, and driving an automobile. To remain living independently at home or in an apartment, older adults must be able to perform IADLs, be able to purchase services by outside workers, or have a supportive network of family and friends who assist with these tasks. Restorative care measures focus on activities to prevent improve, reduce, or eliminate problems. Priorities of care are established, client goals and expected outcomes are determined, and appropriate interventions are selected. This is done with the older adult’s participation so that the interventions are understood and conflicts in approaches or priorities can be avoided. Consideration by the nurse of the older adult’s lifetime experiences, as well as the values and sociocultural patterns developed, serves as the basis for planning individual care. When the older adult’s cognitive status prevents participation in health care dedsions, the family must be included. Family and friends are rich sources of data because they knew the older adult before the impairment. Frequently, they can provide explanations for the older adult’s behaviors and suggest methods of management. Thoughtful assessment and planning leads to goals of care that consider the influence of normal aging changes, facilitate an optimal level of comfort and coping, and promote independence in self-care activities. Key concepts The number of older adults, especially the number of older adults over age 85, is increasing. Because nurses’ attitudes toward older adults influence the quality of care, those attitudes should be based on accurate information about older adults, rather than myths and stereotypes. The biological and psychosocial theories of aging offer possible explanations for the changes seen in aging, but every older adult is a unique individual who ages in a unique way. The physical changes that accompany aging are considered to be normal, not pathological, although they may predispose the older adult to disease. Cognitive impairment is not normal in older adults and requires assessment and intervention. Areas affected by psychosocial changes of aging include retirement, social isolation, change in housing death, and sexuality. Cognitive impairment includes acute, potentially reversible disorders and chronic, irreversible, progressive disorders. Nursing interventions for psychosocial concerns include therapeutic communication, touch, reality orientation, validation therapy, reminiscence, and interventions to improve body image. The leading causes of death in the older population are heart disease, cancer, stroke, lung disease, accidents/falls, diabetes, kidney disease, and liver disease. Health promotion recommendations for older adults include good nutrition, regular exercise, smoking cessation, measures to reduce the risk for falls, and measures to reduce adverse medication reactions. Acute care settings place older adults at risk for delirium, dehydration, malnutrition, nosocomial infections, urinary incontinence, and falls. Restorative nursing interventions, whether accomplished in the older adult’s home or in long-term care institutions, stabilize chronic conditions, promote health, and promote independence in basic and instrumental activities of daily living. PHARMACOLOGIC ASPECTS OF AGING Older people use more medications than does any other age group although they comprise only 12.6% of the total population, they use 30% of all prescribed medications and 40% of all over the counter medications. Medications have improved the health and well-being of older people by alleviating symptoms of discomfort, treating chronic illnesses, and curing infectious processes. Problems commonly occur, however, because of medication use (polypharmacy), and noncompliance. Combinations of prescription medications and some over-the-counter medications further complicate the problem. Any medication is capable of altering nutritional status, which, in the elderly, may already be compromised by a marginal diet or by chronic disease and its treatment. Medications can depress the appetite, cause nausea and vomiting, irritate the stomach, cause constipation or diarrhea, and decrease absorption of nutrients. In addition, they can alter electrolyte balance and carbohydrate and fat metabolism. A few examples of medications capable of altering the nutritional status are antacids, which produce thiamine deficiency. Cathartics, which diminish absorption, antibiotics and phenytoin, which reduce utilization of folic acid, and phenothiazines, estrogens, and corticosteroids, which increase food intake and cause weight gain. ALTERED PHARMACOKINETICS Pharmacokinetics is the study of the actions of medications in the body, including the processes of absorption, distribution, metabolism, and excretion. Variability in these processes in older people is caused, in part, by a reduced capacity of the liver and kidneys to metabolize and excrete the medications and by lowered efficiency of the circulatory and nervous systems in coping with the effect of certain medications. Many medications and their metabolites are excreted by the kidney. With advanced age, body weight, total body water, lean body mass, and plasma albumin (protein) all decrease, while body fat increases. Consequently, agents that are highly protein-bound have fewer binding sites and higher pharmacologic activity, whereas fat soluble agents have more binding sites, and therefore enhanced storage and delayed elimination. NURSING IMPLICATIONS The nurse administering medications to older must be aware of the following. Medications removed from the body primarily by renal excretion remain in the body for a longer time in people with decreased renal function. Often dosages must be reduced, because over dosage and medication toxicity t usual therapeutic dosages are common. Medications with a narrow safety margin (e.g. digitalis glycosides) must be administered cautiously. A decline in cardiac output may decrease the delivery rate to the target organ or storage tissue. The circulatory and central nervous systems of older people are less able to cope with the effects of certain medications, even when blood levels are normal. Idiosyncratic or unusual responses to medications may manifest as toxic reactions and complications. As a result of a slowing metabolism, medication levels may increase in the tissues and plasma, leading to prolonged medication action. Many elderly people have multiple medical problems that require treatment with one or more medications. The possibility of interactions between medications is further magnified if the older person is also taking one or more over-the-counter medications. A high-fiber diet and the use of psyllium (Metamucil) or other laxatives may accelerate gastrointestinal transport and reduce absorption of medications taken concurrently. If, for any reason, a patient is not dependable about taking medication, the nurse must be sure that the pill or capsule is actually swallowed and not retained between the cheeks and the gums or teeth. Teaching self administration of medication requires asking the hpatient questions and requesting return demonstrations to ensure that learning has occurred. Sensory and memory losses, as well as decreased manual dexterity, can affect the patient’s ability to carry out instructions properly, and the teaching plan will need to be adjusted to meet each patient’s needs. The following steps taken by the nurse can help the patient to manage his or her medications and improve compliance. Explain the action, side effects, and dosage of each medication. Write out the medication schedule. Encourage the use of standard containers without safety lids (if there are no children in the household). Suggest the use of a multiple day multiple dose medication dispenser to help patients adhere to the medication schedule. Destroy old, unused medications. Review the medication schedule periodically. Discourage the use of over-the-counter medications and herbal agents without consulting a health professional. Encourage the patient to take all medications, including over-the-counter medications, with him or her regularly when visiting the primary health care provider. References: 1)Journal of Clinical Nursing. 10(6):721-729, November 2001. SCHUURMANS, MARIEKE J. PhD, RN; DUURSMA, SIJMEN A. MD, PhD; SHORTRIDGE-BAGGETT, LILLIE M. EdD, RN, FAAN 2) Protein-Energy Undernutrition Among Elderly Hospitalized Patients A Prospective Study Dennis H. Sullivan, MD; Suzy Sun, BA; Robert C. Walls, PhD JAMA. 1999;281:2013-2019. 3) American Journal of Nursing: June 1999 - Volume 99 - Issue 6 - pp 24J-24P 4) Geriatric Nursing, Volume 18, Issue 6, Pages 250-254 J.Maklebust Read More