Chapter 15 Ageing and Health Breakdown

Melissa Sinfield, Deborah Hatcher, Debra Jackson

When you have completed this chapter you will be able to

• Describe the major physiological systemic changes that accompany ageing and how these play a part in health breakdown;

• Discuss polypharmacy and why older people are vulnerable to it;

• Explain the importance of thorough health assessment in the care of older people; and

• Develop nursing interventions to promote safety and reduce hazards associated with ageing and the use of medications.

INTRODUCTION

THE AGEING POPULATION

Australia and New Zealand, along with the rest of the world, have ageing populations. People are living longer than ever before due to various factors, including improved health services, and scientific and medical developments that have led to improvements in pharmacology as well as other technologies that promote longevity. In addition, increasing consumerism has resulted in an enhanced awareness of the role of diet, exercise and general health maintenance among people in general, including older people. These factors, coupled with a declining birth rate, mean that Australia’s population will continue to age at least until the middle of the century ¹. From a health perspective, people are considered old once they are 65 years and old, old when over 85 years.

The branch of medicine concerned with the elderly is called geriatric medicine, or gerontology. Geriatrics is a word derived from the Greek word geras, meaning old age ². Gerontology is also derived from Greek (geron = old man) and is the umbrella term used to describe the study of ageing and its problems, and encompasses biophysiologic as well as social and psychological aspects². More recently, the term gerontic nursing has become part of the health care lexicon and is a broad term to describe the range of caring acts associated with nursing older people².

Nursing care of the aged, or gerontic nursing is a specialist area of health care and there are many courses available to nurses at postgraduate level. While many older people remain in good health well into old age, health care providers encounter older people in almost all clinical settings. With the exception of paediatrics and midwifery, all clinical areas are seeing increasing numbers of older people. Therefore, despite the status of gerontic nursing as a specialty, the demands of the ageing population require all nurses to have proficiency in gerontic nursing – that is, be cognisant of biophysical, experiential and psychosocial aspects of ageing, and how ageing affects and is affected by disease and its management, including surgical and pharmacological interventions.

This chapter introduces you to some of the major health-related changes that accompany ageing, with a particular focus on applied pharmacology, polypharmacy and health assessment.

SYSTEMIC CHANGES ASSOCIATED WITH AGEING

CARDIOVASCULAR SYSTEM

The cardiovascular system is the system most likely to deteriorate as people age ³. Structural changes may include dilation and increased rigidity of the aorta³^,⁴, fibrosis of the endocardium⁵, left ventricle hypertrophy⁴, and thickening and rigidity of the atrioventicular valves⁵. There may be loss of pacemaker cells and an increase in fibrosis and adipose tissue both in and around the heart⁴^,⁵. Rigidity of the aorta and ventricle walls leads to a decrease in myocardial contractility³. There is a decrease in the amount of blood filling the heart and therefore in the amount that is pumped out with each beat (reduced stroke volume)⁴. In older people, the contraction and relaxation phase of the left ventricle are prolonged, resulting in reduction of the heart’s pumping ability³^,⁴^,⁶ and reduced cardiac output³. There may be calcification of the coronary arteries that impedes blood flow and causes hypertrophy of the left ventricle ⁴.

As people age, changes in the lining of blood vessels frequently occur. The middle layer of the vessel, tunica media, becomes rigid due to the thinning and calcification of the elastin fibres. Fibrosis and an accumulation of fats and lipids lead to atherosclerosis in the inner layer, tunica intima ⁶. Some common examples of health breakdown in the elderly due to age-related changes in the cardiovascular system include atherosclerosis, and hypertension or hypotension.

ENDOCRINE SYSTEM

In the endocrine system, there are many diverse changes that can be attributed to ageing ⁶. Structural changes include fibrosis and atrophy of glands and an increase in nodularity⁴^,⁶. These changes may lead to a decrease in activity, basal metabolic rate, and less thyrotropin secretion and release. There may be a decrease in iodine clearance rates⁴^,⁶, excretion of 17-ketosteroids and thyroid function due to a loss of adrenal function⁶.

Secretion of glucocorticoids, progesterone, androgen, oestrogen and aldosterone are all reduced ⁶. The volume of the pituitary gland decreases⁶, there is atrophy and fibrosis, and a decrease in vascularity, mass and weight. There is increased interstitial fatty tissue in the parathyroid gland⁴. Age-related changes to the pancreas lead to a decrease in glucose tolerance⁴ and insufficient release of insulin by the beta cells leads to a decrease in the older person’s ability to metabolise carbohydrates⁶.

Some examples of health breakdown due to changes in the endocrine system include diabetes mellitus, hyperthyroidism and hypothyroidism.

GASTROINTESTINAL SYSTEM

Problems associated with the gastrointestinal system are common in older people ⁷. Changes in function include decreased gastric emptying and increased gastric pH⁸, decreased peristaltic action of the oesophagus, reduction in the production of ptyalin, hydrochloric acid and pepsin and a tendency for faulty absorption of vitamins B₁, B₁₂, K, calcium and iron⁹. Many older people experience poor appetite¹⁰; which may be due to a reduction in taste bud acuity and a decline in their ability to detect sweet and salty food¹⁰. Older people can also experience problems with their dentition⁶ which decreases their ability to enjoy eating. Impaired swallowing increases with age¹¹ and has been attributed to decreased salivation to moisten food⁵^,⁶. This may also be due to medications such as antihistamines and antidepressants that have anticholinergic effects¹¹. Their gag reflex may be diminished resulting in dysphagia⁶ and nearly half the people aged over 80 years have diverticulitis due to weakening of the intestinal wall¹². Other physiological changes include a tendency to constipation or faecal incontinence. The latter is caused by loss of muscle tone of the internal sphincter of the large intestine and diminished awareness of a forthcoming bowel evacuation⁹.

GENITOURINARY SYSTEM

A number of structural changes of the genitourinary system occur as people age. Within the kidneys, renal mass ⁴^,⁶, renal tissue growth, renal blood flow and glomerular filtration rate decrease and creatinine clearance falls with age⁶. Tubular reabsorption and renal concentrating ability decline, resulting in less efficient tubular exchange of substances, conservation of water and sodium and antidiuretic hormone secretion. Adaptive mechanisms to maintain blood volume and extracellular fluid composition are impaired as people get older and plasma renin and plasma aldosterone levels decrease ⁴. In the bladder, smooth muscle is replaced by fibrous connective tissue, the muscles weaken and bladder capacity decreases⁴^,⁶. There may also be loss of striated muscle in the external urethral sphincter and decrease in closing pressure⁴. Older people may experience decrease in the force of the flow of urine⁴^,⁶, difficulty in bladder emptying and delay in micturition reflex³^,⁴^,⁶.

In older men, fibrosis of seminiferous tubules can occur, as well as reduced fluid retaining capacity in the seminal vesicles ⁶, and erections may be slower and more difficult to maintain⁴. The prostate enlarges with age³^,⁵ and testosterone production may be reduced⁶. In ageing women, a decrease in eostrogen levels weakens the skeletal pelvic floor muscles and urethra smooth muscle³^,⁵. There may be atrophy of the vulva, cervix, uterus, fallopian tubes and labia, and the vagina may atrophy and shorten with thinning of the mucous lining and loss of elasticity⁶.

INTEGUMENTARY SYSTEM

The older person’s skin differs significantly from the skin of a younger person ¹³. Reduction in skeletal muscle mass and subcutaneous fat leads to loose, wrinkled and fragile skin⁸. Skin elasticity is reduced¹² and the time taken for an older person’s wounds to heal is usually longer due to reduction in epidermal turnover and repair¹⁴. Sweat and oil secreting glands atrophy and the older persons’ skin loses its ability to retain moisture and is likely to become dry and scaly¹⁵. Cellular changes can range from uneven pigmentation¹⁶ through to the development of malignant melanoma¹⁴. Nearly half the people aged 65–75 years of age have at least one significant skin problem, and the majority of people over 75 have between one and four disorders¹². These include pruritis (severe itching), lentigos (liver spots), eczema, purpura, seborrheic keratoses¹², fungal infections and other skin disorders such as scabies and herpes zoster¹⁷.

MUSCULOSKELETAL SYSTEM

As a consequence of the ageing process, there is decreased bone and muscle mass, and muscle weakness ⁶. Older people’s bones become brittle due to reduction in calcium absorption⁶ and because the rate of bone reabsorption is greater than the rate of new bone formation⁴^,⁵. The number of skeletal muscle fibres decreases with age³^,⁴^,⁵^,⁶ and there can often be atrophy and decrease in muscle fibre size³^,⁴^,⁶. Older people may experience a decrease in height due to a loss of bone mass in the vertebrae and thinning of the intervertebral discs⁴^,⁵^,⁶. Joints may become enlarged⁶ and tendons and ligaments can shrink and harden, resulting in reduction of joint mobility³. In addition, synovial fluid in the joints can become more viscous and membranes more fibrotic⁶. Reflexes become slower, largely due to shrinkage of muscles and tendons⁴.

Age-related alterations to the musculoskeletal system can lead to changed appearance and slower movements in the older person ⁴. As a consequence of these changes, their movement is often more cautious, they may experience difficulty maintaining their balance ³, and can be prone to falls⁶. Three examples of health breakdown due to changes in the musculoskeletal system are osteoporosis, osteoarthritis and fractures.

NERVOUS SYSTEM

Nervous system changes attributed to ageing are diminished brain weight ¹⁸, and a reduction in the size and density of neurones¹⁹. The number of synapses is reduced, as well as the concentration of neurotransmitters⁷^,¹⁹. As the body ages, there may be an accumulation of neurofibrillary tangles and neuritic plaques associated with dementia²⁰, and cognitive function can diminish, although this varies widely between individuals²¹. It is important to remember that one way in which older people’s cognitive function can be maintained is by presenting them with interesting and challenging learning activities¹⁵. Alterations in normal sleep patterns can occur with age, and the older person may experience increased wakefulness and arousal from sleep⁸. Some examples of health breakdown associated with the ageing nervous system are dementia, delirium, depression, insomnia, epilepsy and Parkinson’s disease¹⁷.

RESPIRATORY SYSTEM

Respiratory function is affected by advancing age ¹⁴. Hardening of the airways and supportive tissue can occur, and degeneration of the bronchi, reduction in the elasticity and mobility of intercostal cartilage, and reduction in the strength and elasticity of the respiratory muscles are common⁹. Pulmonary function tests are likely to reveal a decrease in vital capacity and reduction in forced expiratory volume⁸. Older people may be unable to take deep breaths, have decreased cough reflex and dry mucous membranes⁴. Respiratory disorders common in the elderly are asthma, chronic obstructive pulmonary disease, pneumonia and influenza¹⁷.

SENSORY SYSTEM

As people age, the acuity of the five senses, hearing, sight, smell, taste and touch, tends to diminish ⁷.

• Hearing: By age 65, one person in three has some hearing loss; by age 75, the incidence is one person in two ¹⁵. Age-related hearing deficits include increased sensitivity to loud sounds, tinnitus, increased effort required to recognise speech²²; impaired sound localisation²³ and presbycusis can lead to hearing loss for high-frequency sounds⁶^,²⁴. Conduction deafness is common in older people; they hear outside sounds as muffled and their own voice may seem louder. Hearing loss may lead to the older person experiencing social isolation¹⁵.

• Sight: Older people’s eyesight is often diminished, their pupils are smaller ²⁵ compared to younger people and their eye lens tends to lose elasticity resulting in a reduction in the accommodation capacity of the lens²⁵. There is a decreased ability to adjust to darkness and glare, a reduction in peripheral vision⁷, and an inability to focus on near objects²⁶. There is a decrease in retinal image quality, a decline in contrast sensitivity, and difficulties in distinguishing between the colours, blue and green²⁷^,²⁸. They may also experience a reduction in tear production⁷^,⁸^,¹⁵.

Disorders associated with the ageing eye are macular degeneration ²⁷, which can lead to loss of central vision and difficulty seeing detail, and diabetic retinopathy, which may result in loss of parts of the visual field, blurring and patchiness of vision. Glaucoma often produces a loss of peripheral vision²⁴, and cataracts result in blurred vision, sensitivity to bright light and changes in colour vision¹⁵. Vision impairment can impact negatively on the older person’s ability to interact with others, and may lead to functional difficulties, loss of independence, social isolation, loneliness and decreased quality of life ²⁷.

• Smell: The sense of smell diminishes with advancing age due to reduction in the cells of the olfactory bulb in the brain and in the number of sensory cells in the nasal lining ⁹^,¹⁵.

• Taste: Atrophy of the tastebuds and decline in their number results in a reduction in the efficacy of the tastebuds ⁹. Older people frequently have decreased ability to detect sweet and salty foods¹⁰.

• Touch: Peripheral neuropathy is common in the elderly ²⁹ and leads to overall reduction in touch sensation.

PHARMACOLOGY

Pharmacokinetics may be affected in older people and this is due to systemic changes affecting drug absorption, distribution, metabolism and excretion (see Table 15.1). Altered pharmacokinetics are attributable to age-related changes, such as decreased cellular activity, reduced blood flow to major organs, decreased renal and hepatic function, reduced gastric motility, decreased muscle activity, and altered homeostatic responses³⁰.

Table 15.1 PHYSIOLOGICAL CHANGES OF AGEING AND PHARMACOLOGICAL IMPLICATIONS

Older people are vulnerable to polypharmacy³¹^,³², a phenomenon that has been linked to health problems as diverse as constipation³³ and delirium³⁴. There are various definitions of polypharmacy. Galbraith, Bullock and Manius³⁵ state that it is ‘the excessive or unnecessary use of medications’. Patel³⁶ takes a different view and defines it as the use of multiple medications by an individual that can cause drug-to-drug interactions, and links it to the presence of multiple disease processes. Older people tend to have more health problems both in number and complexity than younger people³⁷, and so have legitimate reasons for increased drug use.

Hayes ³⁷ asserts that polypharmacy accounts for 30% of hospital admissions of older people. It is of vital importance therefore that clinicians have an awareness of existing medication intake before prescribing or administering a new agent. In some situations, an individual’s health status is such that a risk/benefit analysis will support the introduction of a new agent, despite any known hazards associated with concurrent use of certain agents. The responsibility then is on clinical staff to be aware of the nature of the possible reactions, and to monitor older people closely and regularly for any evidence of the presence of adverse reactions.

Many pharmaceutical agents have adverse affects that may compromise the general health of older people and it is important that nurses maintain a sound knowledge of the adverse reactions of commonly prescribed drugs. Consider oral health as an example; many prescribed drugs have the potential to cause xerostomia (dry mouth), reduced salivary secretion, ulceration and/or discolouration of the oral mucosa, oral pain and swelling, oral infections and altered taste sensations ³¹. Any or all of these adverse affects have the capacity to contribute to difficulties with appetite and food intake, and, therefore, compromise nutritional status. Sometimes, additional medications are prescribed to treat adverse reactions or iatrogenic disease.

Certain social factors are identified as influencing older persons’ adherence to drug regimens. Older people are more likely than other age groups to be on a fixed income, and this can mean that affording prescribed medication might be difficult at times. Older people also have high usage of over-the-counter medications such as laxatives and analgesics, and this may increase the likelihood of adverse reactions and drug interactions ³⁰.

Case study

Mrs Joy Anderson, 75, lives at home with her husband of 50 years. She is 155 cm tall and weighs 49 kg. Over the past five years, her husband, Reg, has had three right cerebral vascular accidents (CVAs), which have resulted in him experiencing significant left-sided weakness, difficulty with walking, eating and grasping objects. Sometimes, Mr Anderson has urinary incontinence at night. The Andersons have three adult children, two sons and a daughter. Their daughter, who lives close by, is in daily contact with her parents by telephone and visits every second day. Both sons are in contact with their parents approximately weekly.

Mrs Anderson finds the responsibilities of caring for her chronically ill husband very stressful and has had trouble sleeping. She says that she has no trouble falling asleep, but then wakes up a few hours later and is unable to settle back to sleep. Twelve months ago, a sedative was prescribed by her doctor. She finds that it is sometimes effective. Mrs Anderson has been taking the same antihypertensive medication for the past five years. Her general practitioner checks her blood pressure at every visit and though Mrs Anderson did not know the latest reading, she said the doctor was happy with it. Lately, Mrs Anderson has lost interest in eating and often cannot be bothered to cook a meal for herself and her husband.

At her daughter’s insistence, Mrs Anderson has agreed to a fortnightly community home-care visitor who cleans the house and does the heavy laundry. The home-care visitor also takes Mr and Mrs Anderson to medical appointments and to do their shopping.

Over the past three weeks, Mrs Anderson has been experiencing frequency of urine and dysuria. Early one morning, as she rushed to the toilet, she tripped on a floor mat and fell heavily on her right hip. Unable to get up, she was forced to lie on the floor until her daughter arrived later that morning, by which time she had been lying on the floor for nearly three hours.

Mrs Anderson was transported to the emergency department of the local hospital where a physical examination revealed that she had pain on passive motion of her right hip and shortening and external rotation of her right leg. During the initial examination, Mrs Anderson described how her urinary frequency had, she believed, caused her to fall the previous night. A urine sample obtained from Mrs Anderson was noted to have a strong odour and was dark in colour. A ward urinalysis revealed leucocytes, protein and blood. A mid-stream specimen of urine (MSU) was collected and sent to the laboratory for analysis.

An anteroposterior (AP) X-ray of the pelvis confirms a diagnosis of a fracture to the right intracapsular femoral neck. An intravenous line was inserted, intravenous fluids commenced, an indwelling urinary catheter inserted, and Mrs Anderson was nil-by-mouth in preparation for surgery later that morning. The results of the MSU indicated a diagnosis of cystitis and Mrs Anderson was prescribed a course of intravenous antibiotics.

Mrs Anderson’s daughter contacted her brothers to discuss their father’s care while their mother was hospitalised. The siblings agreed that their father should spend one week at each of their homes, during which time they would investigate the possibility of nursing home respite care for their father. Mr Anderson was furious when his children informed him of the arrangements they had made and refused to leave his home. He shouted at them that he could manage very well, with the assistance of his daughter and the fortnightly home-care visitor, while his wife was in hospital.

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