GASTRO INTESTINAL ISSUES OF OLDER ADULTS

GIT – Comprised of those organs necessary for digestion absorption and storage of vital nutrients and vitamins.

I. GIT System changes in the older adult
1.) Mouth dryness caused by decreased salivation.
2.) Retraction of Gingiva
3.) Shrinkage and fibrosis of root pulp
4.) Loss of bone density in alveolar bridge
5.) Loss of papillae on tongue, atrophied tasted buds
6.) Decreased esophageal motility, relaxed lower sphincter
7.) Weak gag reflex
8.) Reduced stomach emptying and motility
9.) Decreased secretion of hydrochloric acid
10.) Poor absorption of vitamins and minerals
11.) Atrophy of small and large intestines
12.) Reduction of peristaltic activity

A.) Gastritis and Ulcers
1. Def.: inflammatory change and erosion in the stomach’s mucus membrane.
2. Etiology : drug-induced ulcers resulting from increased acidity common in older adults (iron, aspirin, no steroids, anti-inflammatory medications), psychological stress, alcohol, disease processes
3. Incidence: both gastric and duodenal ulcers occur in the older adult, but gastric ulcers are more common, men are more prone to peptic ulcer disease.
4. Typical Clinical Presentation – epigastric pain, malaise, anorexia, emesis, wt. Loss, melena, anemia
5. Diagnostic Tests – stools for occult blood, GI series and endoscopy.

6. Nursing Management
a.) Assessment: vital signs, stool for occult blood, pain location, stress level, alcohol intake
b.) Nursing Diagnosis:
1.) Pain related to ulceration of stomach mucosa
2.) Knowledge Deficit related to self-care

c.) Interventions
1). Medical
a). Medications as ordered
b.) Relief of symptoms (antispasmodics)
c.) Dietary modifications (fiber rich, bland diet)
d.) Antacids to reduce acidity
e.) Stress reductions

3.) Nursing
a.) Report abnormal findings promptly, especially BP decrease, and pulse increase; blood in vomitus or stool
b.) Observe stool for occult blood, epigastric pain, monitor medications
c.) Reassurance
d.) Adequate rest
e.) Observation for constipation/diarrhea
f.) Diet, medication monitoring
g.) Stress reduction/ lifestyle modification

Evaluation
1.) Client will be free of pain
2.) No GI bleed will occur
3.) Ulcerations will diminish in size

B. Constipation – decrease in the frequency from the usual bowel elimination pattern or the onset of difficulty in defecating.
I. Etiology in the older adult
1. decreased physical activity and mobility leading to slower transit time
2. Decreased abdominal musculature
3. Chronic illness – prolonged bed rest
4. Prescription and non-prescription drugs I.e. anticholinergics, NSAIDS, iron preparation, analgesics, antidepressants, antacids w/ aluminum or calcium, diuretics
5. Poor toileting habits by ignoring urge or not allowing adequate time or privacy
6. Dietary factors – inadequate fluid intake; lack of interest in eating
7. Inappropriate or prolonged use of laxatives and enemas
8. Pathological conditions
a.) Diverticuloses
b.) Tumors
c.) Hemorrhoids
d.) Depression
e.) Dehydration

II. Clinical Presentation
1. Change in defecating pattern
2. Anorexia
3. Straining to defecate
4. Complaints of abdominal or rectal fullness
5. Abdominal distention with dullness to percussion
6. Fecal impaction

III. Management
a.) Assessment – refer to clinical presentation for objective cues, address history of causes
b.) Nursing diagnosis
a.) Abdominal pain
b.) Altered, patterns of bowel elimination
c.) Interventions
1.) Routine toileting schedule, encourage to sit 15-30 minutes, avoid straining
2.) Respond to urge to defecate
3.) Daily physical exercise, passive and active range of motion in the bed ridden
4.) Minimum daily fluid intake of 1500-2000 cc
5.) Discourage routine use of laxatives, enemas and suppositories
6.) Respond appropriately to client’s definition of constipation, explaining normal colonic physiology and emphasizing that daily defecation is not essential and less than daily defecations are normal for older adults.
7.) Address to environmental needs to promote mobility and functions.
8.) Appropriate and short term use pf pharmaceutical agents in the lowest effective dose. Bulk forming agents, laxatives, stool softness, stimulants and enemas.




Changes in Urinary Elimination
1.) The excretory function of the kidney diminishes with age.
2.) With age, the number of functioning nephrons decreases to some degree, thus impairing the kidney’s filtering abilities.
3.) The muscle tone of the bladder decreases with aging. This decrease the amount of urine it can hold. Complaints of urinary urgency and urinary frequency are common.
4.) In men, these changes are often due to an enlarge prostate gland and in women to weakened muscles supporting the bladder or weakness of the urethral sphincter.
5.) Retention of residual urine predisposes the elderly adult to bladder infections.
6.) Incontinence is a common problem for many older people. Bladder incontinence means the inability to control urination. Bowel incontinence means the inability to control bowel movements

Incontinence is not a “normal” consequence of aging
Women over the age of 60 have 2x the incidence as men
Without proper assessment, incontinence often leads to premature institutionalization
Social isolation and depression can accompany the embarrassment of incontinence.

II. Assessment
a) Identify contributing factors presence of acute and chronic illness, tumors, brain and spinal cord injuries; pharmaceuticals
b.) Environmental assessment
c.) Physical examination
d.) Laboratory work-ups

III. Interventions for urinary incontinence
A.) Behavioral techniques
1.) Bladder training for urges & stress incontinence.
2.) Habit training or timed voiding for urge incontinence.
3.) Kegel exercises (pelvic floor)
4.) Maintain fluid intake at 1500 cc or more before evening hours; limit caffeine products to breakfast and lunch hours.
5.) Modify environment for functional incontinence including adequate lighting, toilet w/in easy reach, portable commode if necessary, alteration of clothing with wide openings in slacks and easy closure.

B.) Pharmaceutical agents i.e. Anticholinergics, alpha-adrenergic agonists.
C.) Surgical intervention – should not be overlooked.
D.) Others

1.) Intermittent self-catheterization is appropriate measure to manage acute and chronic urinary retention.
2.) Indwelling catheter limited to 2-4 weeks.
3.) Absorbent pads and garments offer thorough evaluation.

SENSORIMOTOR STIMULATION

I. Age-Related Changes
- Occur slowly, bringing with them a decrease inactivity and function. Most older adults can continue to adopt and function in their usual environment.

1. Vision
1. Presbyopia – “farsightedness” – loss of range of accommodation for new vision
a.) Onset: often the age of 40 years
b.) Cause: loss of flexibility of the lens
c.) Corrective lenses assist individual to maintain visual function

2. Cataracts
a.) Clouding of the opacity of the lens of the eye
b.) Almost all of the individuals over the age of 65 will have some type of cataract formations
c.) Major causes of legal blindness
d.) Diabetes Mellitus and hypoparathyroidism increase risk of cataracts

3. Decreased Lacrimations
a.) “Dry eye”
b.) Interventions: Artificial lubrication; eliminate secondary infections caused by rubbing eyes

4. Senile Muscular Degeneration (SMD)
a.) Loss of central vision
b.) Individuals needs reassurance and assistance to learn to use peripheral vision
c.) No definitive, effective treatment
5. Glaucoma
a.) Often asymptomatic
b.) Occurs more frequently in African-Americans
c.) All individuals over age 40 years should have routine eye examinations that test for glaucoma (tonometry).
d.) Primary chronic open-angle glaucoma takes time to develop and individuals may not be aware of any vision changes, associated with diabetes.
e.) Primary acute-closed angle glaucoma is acute in nature; characterized by painful episodes and marked decrease in vision.

A. Auditory: because hearing loss is gradual and progressive, many learn to compensate by lip-reading and positioning themselves advantageously, often individuals limit conversation to assist with “guessing” which can lead in turn to isolation.
1. Presbycusis
a.) Inability to hear high-frequency sounds
b.) Inability to understand the spoken word
2. Cerumen
a.) Secreted in smaller amounts as one ages, but with more keratin, making it more difficult to remove.
b.) If not removed, can cause difficulty with hearing.

B. Smell
2.) Changes can be caused by disease, smoking and environment

C. Taste
1.) Changes include periodontal disease, gingivitis, tooth loss, decreased saliva secretions. Atrophic changes of the tongue can lead to decreased ability to taste.
2.) Sweet taste remains consistent, while salt taste diminishes with aging.

D. Touch
1.) Influenced by physical, as well as psychological and socio cultural issues.
2.) Decreased reaction time.



II. Sensory Stimulations – An important aspect of nursing care, it can be used to maintain as individual’s orientation.
A.) Sight
1.) Provide adequate lighting
2.) Offer large print books, playing cards.
3.) Face the client when speaking with him or her
4.) Do not cover mouth, smoke, or chew gum when speaking
5.) Allow TV or Radio
6.) Make sure eyeglasses, contact lenses are clean and worn
7.) Color-code doors
8.) Place telephone within reach
9.) Announce presence when entering the room
10.) In a new setting, tell client where the furniture is located and allow client to become oriented while you are present.
11.) Do not change client’s schedule without telling him or her.
12.) Explain to the client how his or her meal tray is arranged so he or she can feed himself or herself.
13.) Select clothes with large pockets so client can keep personal items there without losing them.

B.) Hearing
1.) Clean out ear wax
2.) If client has a hearing aid, make sure it is used.
3.) Explain extraneous noises.
4.) Speak at a moderate rate of speed.
5.) Make sure client can see your mouth.
6.) Inform client if topic of conversation changes.
7.) Always speak into client’s “good ear”.
8.) Keep pad and pencil near.

C.) Smell
1.) Encourage client to smell food
2.) After bathing, apply lotions and cologne.
3.) Encourage client to keep clean.
4.) Provide opportunities to use pleasant odors.
5.) Install smoke detectors.

D.) Taste
1.) Give consideration to special diets.
2.) Give client a choice of foods.
3.) Arrange food on a tray so it appears attractive
4.) Check food to be sure it is served at the correct temperature.
5.) Encourage oral hygiene before and after meals.

E.) Touch
1.) Offer back rubs with lotions
2.) Touch hands or arms when speaking to the client.
3.) Allow client to touch.

F.) Speech
1.) Utilize YES & NO signals, such as nodding or shaking head.
2.) Have picture word-cards available.
3.) Be alert to facial expressions, pointing, touching.
4.) Have pen and paper available for writing.

Neurological and Alzheimer ’s disease
The nervous system in the adult is composed of
1.) CNS
a.) Brain – Cognition, memory, behavior
b.) Spinal Cord – Communication with the brain, coordinates-reflexes and sensory activity.
2.) Peripheral Nervous System

Normal Physiologic changes in the elderly
A.) 1.) Small decrease in brain wt. And volume (7-8%)
2.) Loss of large neurons in selective cortical and sub cortical structures.
3.) Neurochemical changes includes decreased activity of catecholamine synthesis, enzymes
4.) Dec. amts. Of neurotransmitter.

B.) Age-Associated Memory Changes
1.) Forget specific details and names of people, but will remember these later
2.) General awareness of memory impairment.
3.) Able to learn new material but may have difficulty with information retrieval.
4.) Memory impairment does not impair daily functioning.

C.) No clinically significant changes in behavior or personality.
Some diseases affecting the CNS in the elderly include:
a.) Cerebral vascular accident (CVA)/Stroke – is a disease of circulatory system which affects brain function.
It is caused by a blood clot or bleeding in the brain which destroys brain tissue.
A stroke often affects the part of the brain controlling movements may cause paralysis on one side – Hemiplegia
Strokes can also affect speech centers and the client may have aphasia.

b.) Parkinson’s Disease
Cause the resident to have tremors or shaking; stiff, rigid muscles; a shuffling gait; and gen. Weakness.
Medication often helps ease some of these problems.

c.) Alzheimer’s – Type Dementia
1. Dementia – a set of symptoms which reflect a progressive deterioration in intellect and/or behavior, causing impairment in an individual’s ability to function in everyday life. There are over 70 progressive , irreversible disorders that cause dementia.
2. Alzheimer ’s disease (AD) – A progressive neurological disease that affects one’s ability to think, remember reason, judge, concentrate and perform day-to-day activities. It also affects one’s personality, language and behavior; approximately 66% of all dementias are Alzheimer ’s disease.

Management:
a.) Medical – Tacrine Hydrochloride is the only drug approved by the FDA for the treatment of AD.
b.) Nursing – Main goal is to help the client feel safe, comfortable, in control pleased, satisfied and able to experience the highest possible physical, emotional, intellectual and social functioning for as long as possible.

Psychosocial Development – A number of theories explain psychosocial aging.
1.) Disengagement Theory – Aging involves mutual withdrawal (disengagement) between the older person and others in the elderly person’s environment.
2.) Activity theory – The best way to age is to stay active physically and mentally
3.) Continuity Theory - People maintain their values, habits and behavior in old age.

Peck proposes the developmental tasks of the older adult as follows:
1.) Adjusting to decreasing physical strength and health.
2.) Adjusting to retirement and reduced income.
3.) Adjusting to the death of one’s spouse.
4.) Establishing an explicit affiliation with one’s age group.
5.) Meeting social and civic obligations.
6.) Establishing satisfactory living arrangements.
7.) Establishing satisfactory relationships with adult children.
8.) Finding meaning in life.



Gerontology – is the process including biologic, psychologic, and sociologic factors.

Geriatrics – is the term for the medical specialty that addresses the diagnosis and treatment of the physical problems of the elderly person.

Nursing practice that focuses on the care of the elderly requires basic nursing knowledge of skills combined with specialized knowledge of the diverse need of the aging population.

Category
Age 60-74 = the young old
Age 75-84 = the middle old
Age 85- older = the old old

Scientist have postulated theories of why people age. Biologic theories of aging are either extrinsic or intrinsic
Extrinsic theory – encompasses factors in the environment i.e. wear and tear theory
Intrinsic theory – address factors within the body e.g. free radical theory,
Genetic theory, immune theory.

Physical Changes of Aging
Integumentary System
Decreased vascularity of the dermis – skin becomes paler, loses its elasticity, slower wound healing.
ß melanin production – pallor; makes skin prone to skin cancer
ß Sebaceous and sweet glands function – causes dryness of the skin Þ itching; tolerance to extreme cold and warm climate.
ß collagen and SC fat - ß elasticity
ß thickness of the epidermis
Thinning of hair – due to ß vascularity of the tissue layer that produces hair follicle, loss of hair color is due to a decrease in the # of functioning melanocytes.
Decrease rate of the hair growth
Thickening of connective tissue – causes finger nails and toe nails to become thickened and brittle.

Body temp. - body temp. is lower in the elderly adult because of a decrease in the metabolic rate. It’s not uncommon for an elderly adult to have a 350C (950F) in the early morning as N base line.

Intolerance to cold Þ due to ß (diminished)
Shivering reflex and low metabolic rate.

Intolerance to heat Þ sluggish sweating and circulatory mechanism.

Basic Nursing Care

Protect your client from exposure to sun and elements; wind, cold, or rain.
-Use sun block or sunscreen at all times.
Reduce pressure on body parts at all times changing the position of your client frequently, as often as every 2 hours. (Use of special pads i.e. egg crate cushion)
Keep the client’s body as clean and dry as possible esp. if the client is incontinent. Use a disposable bed protector to make cleaning easier.
Keep linens wrinkle free, smooth and dry at all times. Do not let the client lie on catheters or any type of tubing.
Be alert to the effects that medication have on the skin.
Encourage good eating habits and the adequate intake of fluids.