Assisting in Geriatrics
Learning Objectives
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Apply critical thinking skills in performing the patient assessment and patient care.
3. Discuss the impact of a growing aging population on society.
4. Identify the stereotypes and myths associated with aging.
5. Role-play the effect of the sensorimotor changes of aging.
6. Explain the changes in the anatomy and physiology of the body systems caused by aging.
7. Summarize the major diseases and disorders faced by older patients.
8. Describe various screening tools for dementia, depression, and malnutrition.
9. Explain the effect of aging on sleep.
10. Differentiate among independent, assisted, and skilled nursing facilities.
11. Summarize the role of the medical assistant in caring for aging patients.
12. Determine the principles of effective communication with older adults.
13. Identify legal and ethical issues associated with aging patients.
Vocabulary
collagen (kah′-luh-jen) The protein that forms the inelastic fibers of tendons, ligaments, and fascia.
costal Pertaining to the ribs.
decubitus ulcers Sores or ulcers that develop over a bony prominence as the result of ischemia from prolonged pressure; also called bed sores.
elastin An essential part of elastic connective tissue; when moist, it is flexible and elastic.
lacrimation (la-krihm-a′-shun) The secretion or discharge of tears.
Scenario
Bill Novelli, CMA (AAMA), works for Dr. Sara Kennedy, a primary care physician in a small town close to where he grew up. Although patients of all ages are seen in the practice, most patients are age 65 or older. Bill has learned to recognize the unique communication needs of aging individuals and the importance of using family and community resources to maintain optimum health in this special population.
While studying this chapter, think about the following questions:
• Do myths about aging and stereotypes about aging people negatively affect older individuals?
• How is Alzheimer’s disease diagnosed and what are the stages of its development?
• Why is depression so common in aging individuals and how is it diagnosed and treated?
• How can the medical assistant most effectively communicate with an older person?
• Why is the use of community resources such an important factor in the care of aging people?
According to the Administration on Aging, an agency of the U.S. Department of Health and Humans Services, the aging population—those age 65 or older—numbered more than 40 million in 2011. By 2030 almost 1 of every 5 Americans (about 72 million people) will be 65 years or older. The fastest growing segment of the U.S. population are those age 85 or older.
The average life expectancy of an individual who reaches age 65 is an additional 18.7 years (20 years for women, 17.1 years for men). A child born in 2010 has a projected life expectancy of 80.8 years, more than 30 years longer than a child born in 1900. Older women outnumber older men; 22.9 million women are older than age 65, as are 17.4 million men. About 30% of older people who live outside of institutions live alone; half of women over age 75 live alone. More than half a million grandparents over the age of 65 are the primary caregivers for their grandchildren who live with them. Most older people have at least one chronic medical condition, and many have multiple conditions. Hypertension, arthritis, heart disease, cancer, and diabetes are the health problems most commonly seen in the elderly, and a significant number also suffer from strokes, asthma, emphysema and chronic bronchitis.
What does all this mean to those who have chosen careers in healthcare? As the aging population expands, it will affect all aspects of society. One area in particular will be these individuals’ increased use of health services. To provide better services to the aging patient, the medical assistant must understand the aging process, which includes the physical and sensory changes with which older people must cope (Procedure 48-1). This knowledge enables medical assistants to recognize the special needs of the aged and to develop therapeutic management and communication skills that can help them effectively care for the older patient. Ongoing research and education about the aging process have dispelled many of the old stereotypes.
Aging is a complex physiologic, psychological, and social process. Old age is not an illness but a normal life process that people experience in different ways. Lack of exercise, poor nutrition, substance abuse, continual stress, and air pollutants all are factors that cause a person to show the effects of aging decades earlier than someone who has practiced healthy living habits.
As people age, changes occur in their physical appearance and abilities, along with sensory changes in vision, hearing, taste, and smell. These changes do not occur at the same time in everyone; however, sensorimotor changes can have a profound effect on the individual’s ability to interact with his or her environment.
Changes in Anatomy and Physiology
The aging process brings about changes in all of the body’s systems. Table 48-1 summarizes these changes and what can be done to promote healthy aging.
TABLE 48-1
System Changes with Aging and Measures to Promote Health
| BODY SYSTEM | AGE-RELATED CHANGES | HEALTH PROMOTION |
| Cardiovascular system | Arteriosclerosis and atherosclerotic plaque buildup reduces blood flow to major organs; 50% of the aging population have hypertension; CVD is the number one killer of women and men in their 60s. | Regular exercise; weight control; diet rich in fruits, vegetables, and whole grains; cholesterol, blood glucose monitoring |
| Central nervous system | Brain shrinks by 10% between ages 30 and 90; takes longer to learn new material; attention span and language remain the same; signs and symptoms may be caused by depression, vascular disease, and drug reactions. | Aerobic exercise to increase blood flow to CNS; maintaining mental activities (e.g., reading, interacting with others) |
| Endocrine system | After age 50, women have a sharp decline in estrogen; men have a more gradual decline in testosterone. | Possible hormone replacement therapy or natural soy supplements |
| Gastrointestinal system | Decline in gastric juices and enzymes by age 60; decreased peristalsis with increased constipation; some nutrients are not absorbed as well. | High-fiber diet and adequate fluid intake; regular exercise to prevent constipation |
| Musculoskeletal system | Muscle mass decreases; tendency to gain weight; gradual loss of bone density; deterioration of joint cartilage. | Strength training to increase muscle mass; stretching to remain limber; exercise; vitamin D and calcium supplements |
| Pulmonary system | At age 55 the lungs become less elastic and the chest wall gradually stiffens, making oxygenation more difficult. | Quit smoking; regular aerobic exercise |
| Sensory organs | Hearing is intact through the mid-50s but declines by 25% by age 80; oral problems are common; skin thins and loses elasticity; presbyopia after age 40; cataracts common after age 60. | Avoid exposure to loud noise, use of hearing aids; good dental hygiene; prevention of sun damage to the skin; annual eye examinations; diet rich in dark green, leafy vegetables to prevent cataracts and macular degeneration |
| Urinary system | Kidneys become less efficient; bladder muscles weaken; one third of seniors experience incontinence; prostate enlargement is common. | Pelvic exercises, drugs, or surgery for incontinence; annual PSA with digital rectal exam monitoring for men |
| Sexuality | Men: Impotence is not a symptom of normal aging; men over age 50 may have some altered function. Women: Menopause causes vaginal narrowing and dryness, resulting in painful intercourse. | Men: Maintenance of cardiovascular health with exercise, weight control, no smoking, diabetes management Women: Use of vaginal lubricants or estrogen cream |
CNS, Central nervous system; CVD, cardiovascular disease; PSA, prostate-specific antigen.
Cardiovascular System
Cardiovascular disease is the most frequent cause of illness and disability in the aging population, and congestive heart failure (CHF) is the most common reason for hospitalization. Age-related changes occur in the cardiovascular system, but disease and lifestyle habits such as lack of exercise, poor diet, and stress contribute to these changes. Heart disease is ranked as the leading cause of death among men and women; therefore, proper management of cardiovascular disease can help maintain the health of an aging population and reduce mortality rates.
The aging process causes structural changes in the heart. Myocardial cells enlarge, and deposits of fat and connective tissue increase; these combine to make the myocardial wall stiffer and to lengthen the amount of time needed for the relaxation phase of the cardiac cycle. As a result, cardiac output declines, making aging people more susceptible to CHF. The reduction in cardiac output leads to pooling of blood in the legs, cold extremities, and edema (Table 48-2). In addition, the heart cannot respond as quickly or as forcefully to an increased workload, so exercise, sudden movements, and changes in position can result in dizziness and loss of balance. Aging also brings with it an increase in blood pressure, requiring the heart to work harder to pump blood into the systemic circulation. Hypertension increases the workload of the left ventricle, and this may result in hypertrophy of the chamber and weakening of the myocardial wall. The valves of the heart tend to thicken and become more rigid, making it more difficult for blood to circulate through the cardiopulmonary vessels. With these cardiovascular problems, arrhythmias become more common.
TABLE 48-2
Normal Changes in Cardiac Output with Age
| AGE | BLOOD PUMPED BY RESTING HEART (quarts/min) | MAXIMUM HEARTBEAT DURING EXERCISE (beats/min) |
| 30 | 3.6 | 200 |
| 40 | 3.4 | 182 |
| 50 | 3.2 | 171 |
| 60 | 2.9 | 159 |
| 70 | 2.6 | 150 |
From the American Heart Association. Accessed 7/20/2012. Available at www.americanheart.org.
Aging causes the walls of the veins to weaken and stretch. This damages the valves, especially in the veins of the legs, where the walls are subject to greater pressure as blood struggles to return to the heart against the force of gravity. As a result, edema and varicose veins of the lower extremities are common in the elderly, increasing the risk of phlebitis and the formation of thrombi in the deep veins, or deep vein thrombosis (DVT).
Arteriosclerosis is considered part of the aging process. The vessel walls thicken and become less elastic as a result of the calcification and buildup of connective tissue. In addition, the artery’s ability to dilate and contract diminishes. To maintain an adequate blood supply throughout the body, the heart must work harder to overcome the resistance caused by stiffened vessels. Older adults have a higher incidence of orthostatic hypotension. The clinical criterion for alterations in blood pressure from sitting to standing is a drop of more than 20 mm Hg in the systolic pressure or more than 10 mm Hg in the diastolic pressure when the position is changed. Such a decrease typically is caused by a drop in the volume of circulating blood, and it can be an important diagnostic sign in aging patients. The physician may have the medical assistant take orthostatic blood pressures as part of the routine intake protocol for aging patients.
Endocrine System
Hormonal changes that occur with aging are related to a general decrease in hormone production combined with changes in tissue receptor binding. The most common endocrine system disorder seen in aging patients is diabetes mellitus (DM) type 2. As a person ages, insulin production by the beta cells in the pancreas decreases and insulin resistance at the tissue level increases. According to the National Institutes of Health, more than half of the 16 million Americans diagnosed with diabetes type 2 are over age 65. Elderly patients with diabetes are at increased risk of developing vascular disease, including renal disorders, retinopathy, neuropathy, myocardial ischemia, angina, myocardial infarction, cerebrovascular accidents, and peripheral vascular disease, such as lower extremity ulcers.
Older patients do not always experience the classic symptoms of diabetes, which are polyuria, polydipsia, and polyphagia. They may show a variety of problems, including unexplained weight loss, slow wound healing, recurrent bacterial or fungal infections, changes in mental state, cataracts, macular disease, muscle weakness and pain, angina, foot ulcers, and uremia. The range of symptoms is due to the insidious onset of diabetes in older people, who may have gradually developing hyperglycemia for years before diagnosis.
The treatment protocol for aging patients with diabetes is the same as for other age groups; however, special consideration must be given to the patient’s ability to understand and comply with the therapeutic plan. In addition, because the person may have other health problems that are being treated with medications, an aging patient newly diagnosed with diabetes may face a complicated treatment regimen that requires explicit instruction and continual follow-up in the ambulatory care setting.
The medical assistant must be aware of any sensory abnormalities, such as diminished vision or problems with fine motor skills, which may interfere with the patient’s ability to follow treatment guidelines. Teaching and treatment plans must be adapted to meet the individual needs of each patient.
Gastrointestinal System
Age-related changes in the gastrointestinal system begin in the mouth with dental problems, a decrease in the number of taste buds and the production of saliva, and a diminishing sense of smell. Older people generally find eating less pleasurable, have a reduced appetite, and are unable to chew and lubricate their food as well as younger people; this makes dysphagia (difficulty swallowing) a common age-related problem. Aging also brings a decrease in the production of hydrochloric acid, which affects the digestion of calcium and iron. Secretion of intrinsic factor, a protein that is needed for the absorption of vitamin B12, also declines, which affects the function of the nervous system and the formation of red blood cells, resulting in excessive fatigue. It is not unusual for aging patients to be seen in the physician’s office regularly for vitamin B12 injections.
Food passes more quickly through the small intestine, resulting in poorer absorption of vitamins and minerals. Peristalsis in the colon decreases, making aging patients more susceptible to constipation and diverticular disease. Poor eating habits, a reduced fluid intake, and some medications (e.g., antidepressants, diuretics, antacids containing aluminum or calcium, and medications for Parkinson’s disease) also contribute to constipation. The liver decreases in size and weight after age 70. It is still able to perform vital functions, but more time is required to metabolize drugs and alcohol. All of these factors combine to increase the potential for adverse drug reactions in older adults.
Aging individuals have a higher incidence of several gastrointestinal system diseases, such as gastroesophageal reflux disease (GERD), peptic ulcers, diverticulosis (related to lack of dietary fiber and constipation), cholelithiasis, and colorectal cancer. Dietary counseling and annual screenings should be part of the routine care of aging patients.
Integumentary System
The skin is the body’s first line of protection against infection, and it also is responsible for preventing the loss of body fluid and regulating body temperature. Changes in the appearance and function of the integumentary system usually are caused by a combination of ordinary age-related changes and environmental factors, especially the amount of sun exposure over time. Exposure to ultraviolet light from the sun frequently is the cause of wrinkles, age spots, blotches, and leathery, dry, loose skin, all of which are associated with aging. Changes caused by the ultraviolet light from the sun or by the normal aging process can affect all three layers of the skin: the epidermis, dermis, and subcutaneous tissue.
The cells in the epidermis reproduce more slowly as people age, and this slower regeneration causes the skin to appear thinner. The skin becomes more prone to tearing and blistering. The risk of infections increases, the healing process takes longer, and older people are more susceptible to bruising. Because the skin can be easily torn, it is important to be very careful when performing phlebotomy or covering a wound on an older patient. Vitamin D synthesis, a major function of the epidermis, significantly declines in aged skin, and a decrease in the number of melanocytes increases photosensitivity.
The dermis loses 20% of its mass during the aging process, resulting in the paper-thin or transparent skin seen in older adults. The number of collagen cells in the dermis also declines with age, causing the skin to sag and wrinkle. Because both sweat and sebaceous glands decrease in number, aging people have difficulty tolerating higher temperatures because they perspire less. At the same time, the blood supply to the dermis decreases; this makes it difficult to regulate the body temperature and leads to an increased susceptibility to both hypothermia and heat stroke in aging individuals. Any situation in which an older adult would be exposed to extremes of cold or heat should be avoided. Make sure a blanket is available in the examining room if the air conditioning is on. Ask the person if he or she is too cold or too hot and take the necessary steps to make the patient feel more comfortable.
Atrophy of the subcutaneous layer increases the skin’s susceptibility to trauma, so patients bruise much more easily. The skin is denied natural lubrication, and dry skin is one of the most common complaints among older people. In addition, fat deposits increase in the abdomen in men and in the abdomen and thighs in women as they age.
Suggestions that might help older people prevent and treat dry skin include:
• Using a room humidifier to moisten the air
• Bathing less frequently and using warm rather than hot water
• Using a mild soap or cleansing cream (e.g., Aveeno, Basis, or Dove)
• Wearing protective clothing in cold weather
Pain receptors are distributed throughout the skin. Because of age-related changes in the receptors, older people have a higher pain threshold. They may not notice a cut or burn as quickly as a younger person would, so a more serious burn may occur before it is noticed. In addition, wound healing becomes a problem because of decreased blood flow to dermal tissues.
Other changes occur in the skin’s appendages. Hair changes in color, growth, and distribution. Hair grays because of the decreased rate of melanin production and the replacement of pigmented hair with nonpigmented hair. Women lose hair on the trunk and have increased facial hair. Although alopecia (male balding) is caused by an inherited trait, aging also causes hair loss. Hair on the eyebrows, nose, and ears becomes coarser and longer in men. The nails of older people take longer to grow and are more brittle. Nails, particularly toenails, thicken as a result of trauma or nutritional deficiencies. It is not unusual for nails to split, making them more susceptible to fungal infections.
Seborrheic keratoses, usually referred to as “age spots,” are one of the most common benign skin disorders found in the aging population. They appear as waxy, greasy papules that vary from tan to dark brown (Figure 48-1) and typically are found in areas of sun exposure, such as the trunk, back, face, neck, extremities, and scalp. They are not dangerous but may be removed for cosmetic purposes.
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