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CONSIDER: NORMAL AGING CHANGES

OVERVIEW
The process of normal aging in the absence of disease is accompanied by a myriad of changes in body systems. Many of these alterations, show great variability among individuals, are often impacted by genetics and long-term lifestyle factors, and involve decline in functional reserve with a reduced response to stressors.

The clinical presentation of these anatomical and physiological alterations is of critical importance in nursing assessment and care of the older adult. Normal age-associated changes must be differentiated from pathological processes in order to develop appropriate interventions. Normal changes can adversely impact health and functionality and require corrective strategies to adapt to the changes. Further, aging and illness can interact reciprocally, resulting in altered presentation of illness and response to treatment, as well as outcomes.

Outlined in the assessment screening section are age-related changes for each organ system, followed by clinical implications with associated risks, nursing assessment, and care strategies.

DEFINITION
Aging changes: anatomical and physiological changes that are attributed to aging. These changes may alter the elderly person's response to illness.

ASSESMENT/SCREENING TOOLS

Aging Changes and Implications Assessment and Care Strategies
Cardiovascular System
Aging changes
  • Left ventricle hypertrophy
  • Decreased force of contraction, contractile efficiency, stroke volume
  • Decreased baroreceptor sensitivity and beta adrenergic response
  • Arterial stiffening and all thickening, decreased compliance
  • Decreased O2 uptake by tissues
Implications
  • Decreased cardiac reserve & output
  • Slow recovery from tachycardia
  • Fatigue, SOB
  • Increased premature or ectopic beats
  • Risk of valvular dysfunction & systolic murmurs, conduction abnormalities
  • Risk of postural & diuretic-induced hypotension
  • Strong arterial pulses, diminished peripheral pulses;cool extremities
  • Risk of inflamed varicosities
Assessment
  • Assess BP (lying, sitting, standing) & pulse pressure
  • Cardiac assessment: rate/rhythm/heart sounds
    -note altered landmarks, distant heart sounds, extra heart sounds (S3 in CHF)
  • Palpate cartoid artery, peripheral pulses for symmetry
  • Monitor heart rate and rhythm, note irregularity, ECG
  • Assess for dyspnea with exertion, exercise intolerance
Care strategies
  • Referral for irregularities in heart rhythm, decreased or asymmetry of pulses
  • Safety precautions for orthostatic hypotension
    - Rise slowly from lying or sitting position
    -Wait 1-2 minutes after position change to stand or transfer
    -Monitor for overt signs of hypotension: change in sensorium/mental status, dizziness, orthostasis -Institute Fall prevention strategies (See Falls Topic)
Respiratory System
Aging changes
  • Decreased response to hypoxia & hypercarbia/li>
  • Diminished ciliary & macrophage activity
  • Increased airway reactivity
  • Decreased muscle strength & endurance
  • Drier mucus membranes
  • Decreased alveolar function, vascularization, elastic recoil
  • Thorax & vertebrae rigid

Implications
  • Decreased cough, deep-clearance
  • Risk of infection & bronchospasm (airway obstruction)
  • Altered pulmonary function - lower maximal expiratory flow (FEV, FEV1/FVC1
    - increased residual volume
    - reduced vital capacity
    - unchanged total lung capacity
  • Dyspnea after exertion, decreased exercise tolerance
  • PO2, SpO2 decreased. Decreased capacity to maintain acid-base balance
  • Respiratory rate12-24
  • Decreased respiratory excursion & chest/lung expansion with less effective exhalation
  • Diminished breath sounds at lung bases - risk of atelectasis
Assessment
  • Respirations - rate, pattern, breath sounds throughout lung fields
  • Note thorax appearance, chest expansion
  • Assess cough, deep breathing, exercise capacity
  • Monitor arterial blood gases, pulse oximetry
  • Monitor secretions, sedation, positioning which can reduce ventilation/oxygenation

Care strategies
  • Maintain patent airway through repositioning, suctioning, bronchodilators
  • Prevention of respiratory infections with pulmonary
  • Incentive spriometry as indicated, particularly if unable to ambulate or decline in function
  • Education on cough enhancement, avoidance of environmental contaminants, smoking cessation
  • Maintain hydration and mobility
  • Provide oxygen as needed
Genitourinary System
Aging changes
For kidney
  • Decreased functional reserve when water/salt overload/deficit
  • Decreased blood flow, oxygenation, glomerular filtration rate (often < 50%, measured by creatinine clearance)
  • Tubule degeneration
    - Reduced response to vasopressin
    - Impaired capacity to dilute, concentrate, acidify urine; impaired sodium regulation
  • Reduced bladder elasticity, muscle tone, capacity
  • Weakend urinary sphincter
  • Decreased or delayed perception of voiding signal
  • Increased nocturnal urine production
  • In males, benign prostatic hypertrophy
Implications
  • Risk of renal complications in illness; susceptibility to acute ischemic renal failure & embolism
  • Risk of dehydration, volume overload, hyperkalemia (with potassium-sparing diuretics), hyponatremia (with thiazide diuretics), hypernatremia (with NSAIDs). See addendum
  • Reduced excretion of acid load
  • Risk of postural hypotension
  • Decreased drug clearance
  • Risk of nephrotoxic injury by drugs
  • In bladder, increased post-void residual urine
  • Risk of urinary tract infection (UTI), incontinence (not a normal finding) (See Urinary Incontinence Topic)
  • Nocturnal polyuria- risk for falls
  • In males, risk of urinary hesitancy dribbling, frequency, incontinence (BPH)
Assessment
  • Assess renal function, particularly in acute/chronic illness
  • Monitor blood pressure (orthostatic)
  • Assess for dehydration, volume overload, electrolyte imbalances, proteinuria- See addendum at end of table
  • Determine source of fluid/electrolyte imbalance, monitor laboratory data
  • Assess choice/dose/need for nephrotoxic agents (e.g., aminoglycoside antibiotics, radiocontrast dye) and renally excreted medications (See Medication Topic)
  • Palpable bladder after voiding due to retention
  • Assess for urinary incontinence, UTI
  • Assess for abnormal urine stream, urinary retention with BPH
  • Assess fall risk in nocturnal or urgent voiding

Care strategies
  • Maintain hydration, baseline fluid/electrolyte balance. Prepare for fluid/electrolyte correction as indicated
  • Monitor drug levels of renally cleared medications
  • Calculate creatinine clearance - see addendum
  • Monitor for normal renal function: constant serum creatinine level to baseline
  • Safety precautions in nocturnal or urgent voiding & postural hypotension, institute fall prevention strategies
  • Referral to incontinence specialists with follow-up for incontinence management
  • Referral to renal or urology as indicated
  • Caution providers regarding medications that increase urinary retention in BPH, renal toxic drugs (See Medication Topic)
  • See addendum at end of table for signs and symptoms of dehydration, UTI, electrolyte imbalances (See Atypical Presentation Topic
Gastrointestinal System
Aging changes
  • Decreased thirst perception
  • Decreased esophageal motility & lower esophageal sphincter pressure
  • Decreased stomach motility; mucosal atrophy
  • Decreased small intestine motility, villi, digestive enzyme secretion
  • Decreased large intestine blood flow, motility, defecation sensation
  • Decreased liver size, blood flow, enzymatic metabolism of drugs; increased biliary lipids

Implications
  • Risk of dehydration, electrolyte imbalances, poor nutritional intake
  • Risk of dysphagia, hiatal hernia, aspiration
  • Delayed emptying of stomach with risk of maldigestion
  • Gastroesophageal Reflux Disease (GERD)
  • Constipation, flatulence common
  • Risk of fecal impaction
  • Risk of adverse drug reactions due to slowed liver metabolism
  • Decreased absorption of fat, carbohydrate, protein, vitamin B12, iron, folate, calcium, and vitamin D with risk of anemia, osteoporosis, malnutrition
  • In mouth, risk of gingivitis, tooth loss with chewing impairment
Assessment
  • Assess abdomen (note smaller liver), bowel sounds
  • Monitor weight, dietary intake, elimination patterns, fluid intake
  • Assess dentition, chewing & swallowing abilities, eating habits/nutrition
  • Assess lungs for basilar crackles, infection from aspiration
  • Evaluate poor food intake
Care strategies
  • 3 day calorie count, consultation with dietician for poor intake/unplanned weight loss. (See Mealtime Difficulties Topic)
  • Monitor drug levels and liver function tests if on medications metabolized in liver; electrolytes, BUN/creatinine, albumin (nutritional indicator and if low effects drug levels like digoxin)
  • Monitor for signs of dysphagia, coughing or choking with solids/liquids. Speech &/or swallowing evaluation as indicated
  • Monitor for signs of aspiration particularly if decline in function/weakness; GERD
  • Monitor nutrition/diet intake, fluid intake, elimination particularly if immobile. Maintain mobility.
  • Provide laxatives if on constipating medications, e.g., narcotics
Musculoskelatal System
Aging changes
  • Narrowed intervertebral disks
  • Decreased bone mass
  • Lean body mass replaced by fat with redistribution of fat
  • Decrease in muscle mass & regeneration of muscle fibers
  • Increased latency/contraction time of muscle
  • Increased hip/knee flexion
  • Tendon & ligament stiffening
  • In joints, articular cartilage erosion; increased bone overgrowth & calcium deposits

Implications
  • Giat & balance instability common
  • Risk of osteoporosis & fractures, osteoarthritis
  • Decreased total body water & intercellular/interstitial fluid
  • Decreased muscle strength & agility; slowed reflexes and reaction time-fall risk
  • Decreased endurance
  • Joint stiffness with decreased mobility
  • Risk of injury, pain on ROM, joint subluxation, crepitus
Assessment

Care strategies
  • Maintain maximal function, encourage/provide active or passive ROM
  • Assess for pain and provide pain medication to enhance functionality
  • Demonstrate/encourage muscle strengthening exercises
  • Referrals to physical/occupational therapy
  • Fall risk interventions, avoid restraints. (See Falls Topic and Restraints Topic)
Nervous System & Cognition
Aging changes

  • In CNS, decrease in neurons, brain size, neurotransmitters
  • Slowed nerve impulse conduction. Decreased peripheral nerve function

Implications
  • Risk of poor balance, postural hypotension, falls, injury
  • Decreased proprioception; potential for extrapyramidal Parkinson-like gait
  • Ischemic paresthesia in extremities common
  • Slowed thought processing, response to stimuli, reflexes.
  • Risk of mild cognitive impairment, delirium in acute illness (See Delirium topic)
Assessment

Care strategies
  • Monitor for delirium during acute illness
  • Institute fall prevention strategies (See Falls Topic)
  • Rise slowly from lying, sitting positions; wait 1-2 minuted prior to transfer
Addendum
Dehydration symptoms
: orthostatic hypotension, weight loss, tachycardia, hyperthermia, weakness, nausea, anorexia, oliguria, dry mucus membranes & skin, poor skin turgor, increased thirst

Volume overload symptoms: weight gain >2%, I >O, bounding pulse, tachycardia, increased BP & CVP, distended neck/peripheral veins, crackles, dyspnea, SOB, confusion

Hyponatremia (serum sodium < 135 mEq/L) symptoms: hypotension, tachycardia, hyperthermia, nausea, malaise, lethargy, somnolence, confusion, poor skin turgor, increased thirst, muscle twitching, abdominal cramps, headache, seizure, coma, elevated BUN & Hct

Hypernatremia (serum sodium > 148 mEq/L) symptoms: orthostatic hypotension; increased thirst; poor skin turgor; dry mucus membranes; weight loss; oliguria; lethargy; hyperthermia; elevated BUN, Hct, creatinine

Hyperkalemia (serum potassium > 5.0 mEq/L) symptoms: diarrhea, cardiac arrhythmias/arrest, ECG abnormalities, irritability, apathy, confusion, muscle weakness, loss of reflexes, paresthesias

Calculation of creatinine clearance in elderly:
For Men
Creatinine clearance (ml/min) =

140 - age (years) X body weight (kg)
72 X serum creatinine (mg/dL)

For women above x 85% (0.85)

Urinary tract infection symptoms: dysuria, flank or suprapubic pain, hematuria, urinary frequency/urgency, cloudy/malodorous urine, anorexia, confusion, nocturia, enuresis

See Atypical Presentation Topic

 

Last updated - January 2005