Constance M. Smith, PhD, RN, Valerie T. Cotter, MSN, CRNP, FAANP
Evidence-Based Content - Updated July 2012
Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. These protocols were revised and tested in NICHE hospitals. The text is available here.
The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:
To identify anatomical and physiological changes, which are attributed to the normal aging process.
Age-associated changes are most pronounced in advanced age of 85 years or older, may alter the older person’s response to illness, show great variability among individuals, are often impacted by genetic and long-term lifestyle factors, and commonly involve a decline in functional reserve with reduced response to stressors.
Gerontological changes are important in nursing assessment and care because they can adversely affect health and functionality and require therapeutic strategies; must be differentiated from pathological processes to allow development of appropriate interventions; predispose to disease, thus emphasizing the need for risk evaluation of the older adult; and can interact reciprocally with illness, resulting in altered disease presentation, response to treatment, and outcomes.
A. Definition(s): Isolated systolic hypertension: systolic BP >140 mm Hg and diastolic BP <90 mm Hg.
1. Arterial wall thickening and stiffening, decreased compliance.
2. Left ventricular and atrial hypertrophy. Sclerosis of atrial and mitral valves.
3. Strong arterial pulses, diminished peripheral pulses, cool extremities.
1. Decreased cardiac reserve.a. At rest: No change in heart rate, cardiac output.
b. Under physiological stress and exercise: Decreased maximal heart rate and cardiac output, resulting in fatigue, shortness of breath, slow recovery from tachycardia.c. Risk of isolated systolic hypertension; inflamed varicosities.
d. Risk of arrhythmias, postural and diuretic-induced hypotension. May cause syncope.
D. Parameters of Cardiovascular Assessment
1. Cardiac assessment: ECG; heart rate, rhythm, murmurs, heart sounds (S4 common, S3 in disease). Palpate carotid artery & peripheral pulses for symmetry.1
2. Assess BP (lying, sitting, standing) and pulse pressure. 2
1. Decreased respiratory muscle strength; stiffer chest wall with reduced compliance.
2. Diminished ciliary & macrophage activity, drier mucus membranes. Decreased cough reflex.
3. Decreased response to hypoxia and hypercapnia.
1. Reduced pulmonary functional reserve.
a. At rest: No change.
b. With exertion: Dyspnea, decreased exercise tolerance.
2. Decreased respiratory excursion and chest/lung expansion with less effective exhalation. Respiratory rate 12-24 breaths per minute.
3. Decreased cough and mucus/foreign matter clearance.
4. Increased risk of infection and bronchospasm with airway obstruction.
C. Parameters of Pulmonary Assessment
2. Inspect thorax appearance, symmetry of chest expansion. Obtain smoking history.
4. Assess cough, need for suctioning.7
D. Nursing-Care Strategies
3. Incentive spirometry as indicated, particularly if immobile or declining in function. 8
4. Education on cough enhancement, 8 smoking cessation. 9
To determine renal function (GFR):
Cockroft-Gault equation: Calculation of creatinine clearance in older adults 10:
For Women, the calculated value is multiplied by 85% (0.85).
MDRD: see National Kidney Disease Education Program calculator.11
1. Decreases in kidney mass, blood flow, GFR (10% decrement/decade after age 30). Decreased drug clearance.
2. Reduced bladder elasticity, muscle tone, capacity.
3. Increased postvoid residual, nocturnal urine production.
4. In males, prostate enlargement with risk of BPH.
1. Reduced renal functional reserve; risk of renal complications in illness.
2. Risk of nephrotoxic injury and adverse reactions from drugs.
3. Risk of volume overload (in heart failure), dehydration, hyponatremia (with thiazide diuretics), hypernatremia (associated with fever), hyperkalemia (with potassium-sparing diuretics). Reduced excretion of acid load.
4. Increased risk of urinary urgency, incontinence (not a normal finding), urinary tract infection, nocturnal polyuria. Potential for falls.
D. Parameters of Renal and Genitourinary Assessment
B. Assess choice/need/dose of nephrotoxic agents and renally cleared drugs.14(see topic Reducing Adverse Drug Events).
C. Assess for fluid/electrolyte and acid/base imbalances. 15
D. Evaluate nocturnal polyuria, urinary incontinence, BPH. 13 Assess UTI symptoms (see Atypical Presentation of Disease section).
E. Assess fall risk if nocturnal or urgent voiding (see topic, Preventing Falls in Acute Care)
E. Nursing-Care Strategies
A. Monitor nephrotoxic and renally cleared drug levels. 14
B. Maintain fluid/electrolyte balance. Minimum 1,500-2,500 mL/day from fluids and foods for 50- to 80-kg adults to prevent dehydration. 15
C. For nocturnal polyuria: limit fluids in evening, avoid caffeine, use prompted voiding schedule. 13
D. Fall prevention for nocturnal or urgent voiding (see topic Preventing Falls in Acute Care)
BMI: Healthy, 18.5–24.9 kg/m2; overweight: 25–29.9 kg/m2; obesity, 30 kg/m2 or greater.
1. Decreases in strength of muscles of mastication, taste, and thirst perception.
2. Decreased gastric motility with delayed emptying.
3. Atrophy of protective mucosa.
4. Malabsorption of carbohydrates, vitamins B12 and D, folic acid, calcium.
5. Impaired sensation to defecate.
6. Reduced hepatic reserve. Decreased metabolism of drugs.
1. Risk of chewing impairment, fluid/electrolyte imbalances, poor nutrition.
2. Gastric changes: altered drug absorption, increased risk of GERD, maldigestion, NSAID-induced ulcers.
3. Constipation not a normal finding. Risk of fecal incontinence with disease (not in healthy aging).
4. Stable liver function tests. Risk of adverse drug reactions.
D. Parameters of Oropharyngeal and Gastrointestinal Assessment
1. Assess abdomen, bowel sounds.
2. Assess oral cavity (see topic Oral Health Care); chewing and swallowing capacity, dysphagia (coughing, choking with food/fluid intake). 17If aspiration, assess lungs (rales) for infection and typical/atypical symptoms. 1819 (See Atypical Presentation of Disease section.)
3. Monitor weight, calculate BMI, compare to standards.20, Determine dietary intake, compare to nutritional guidelines. 21,22,23(Ref 21; 22; 23); (see topic Nutrition).
4. Assess for GERD; constipation and fecal incontinence; fecal impaction by digital examination of rectum or palpation of abdomen.
E. Nursing-Care Strategies
1. Monitor drug levels and liver function tests if on medications metabolized by liver. Assess nutritional indicators. 22,23
2. Educate on lifestyle modifications and over-the-counter (OTC) medications for GERD.
3. Educate on normal bowel frequency, diet, exercise, recommended laxatives. Encourage mobility, provide laxatives if on constipating medications. 24
4. Encourage participation in community-based nutrition programs;23 educate on healthful diets. 21
Sarcopenia: Decline in muscle mass and strength associated with aging.
1. Sarcopenia with increased weakness and poor exercise tolerance.
2. Lean body mass replaced by fat with redistribution of fat.
3. Bone loss in women and men after peak mass at 30 to 35 years.
4. Decreased ligament and tendon strength. Intervertebral disc degeneration. Articular cartilage erosion. Changes in stature with kyphosis, height reduction.
1. Sarcopenia: increased risk of disability, falls, unstable gait.
2. Risk of osteopenia and osteoporosis.
3. Limited ROM, joint instability, risk of osteoarthritis.
D. Nursing-Care Strategies
2. Pain medication to enhance functionality (see topic Pain). Implement strategies to prevent falls (see topics Preventing Falls in Acute Care, Physical Restraints and Side Rails in Acute and Critical Care Settings: Legal, Ethical and Practice Issues).
1. Decrease in neurons and neurotransmitters.
2. Modifications in cerebral dendrites, glial support cells, synapses.
3. Compromised thermoregulation.
1. Impairments in general muscle strength; deep-tendon reflexes; nerve conduction velocity. Slowed motor skills and potential deficits in balance and coordination.
2. Decreased temperature sensitivity. Blunted or absent fever response.
3. Slowed speed of cognitive processing. Some cognitive decline is common but not universal. Most memory functions adequate for normal life.
4. Increased risk of sleep disorders, delirium, neurodegenerative diseases.
C. Parameters of Nervous System and Cognition Assessments
1. Assess, with periodic reassessment, baseline functional status. 29 (See topics Assessment of Function and Preventing Falls in Acute Care). During acute illness, monitor functional status and delirium. (see topic Delirium: Prevention, Early Recognition, and Treatment).
4. Assess temperature during illness or surgery. 33
D. Nursing-Care Strategies
1. Institute fall preventions strategies (See topic Preventing Falls in Acute Care).
3. Recommend behavioral interventions for sleep disorders.
B. Nursing Care Strategies
1. Follow CDC immunization recommendations for pneumococcal infections, seasonal, influenza,zoster,tetanus, hepatitis for the older adult 1838.
1. Diseases especially infections may manifest with atypical symptoms in older adults.
2.Symptoms/signs often subtle include nonspecific declines in function or mental status, decreased appetite, incontinence, falls 16, fatigue 39, exacerbation of chronic illness 18.
B. Parameters of Disease Assessment
1. Note any change from baseline in function, mental status, behavior, appetite, chronic illness 18.
2. Assess fever; Determine baseline and monitor for changes; 2–2.4 °F (1.1–1.3 °C) above baseline 16. Oral temperatures above 99 °F (37.2 °C) or greater also indicate fever18.
3. Note typical and atypical symptoms of pneumococcal pneumonia 161941, tuberculosis 33,influenza16,UTI16,, peritonitis 39,, and GERD 42.
A. Older adult will experience successful aging through appropriate lifestyle practices and health care.
B. Health care provider will
1. Identify normative changes in aging and differentiate these from pathological processes.
2. Develop interventions to correct for adverse effects associated with aging.
C. Institution will
1. Develop programs to promote successful aging.
D. Will provide staff education on age-related changes in health.
Follow-up Monitoring of Condition
A. Continue to reassess effectiveness of interventions.
B. Incorporate continuous quality improvement criteria into existing programs.
9. U.S. Department of Health and Human Services (2004b). The health consequences of smoking: A report of the Surgeon General. Retrieved April 13, 2007, from http://www.cdc.gov/tobacco/data?statistics/sgr/sgr?2004. Evidence Level I.
10. Péquignot, R., Belmin, J., Chauvelier, S., Gaubert, J.Y., Konrat, C., Duron, E., & Hanon, O. (2009). Renal function in older hospital patients is more accurately estimated using the Cockcroft-Gault formula than the modification diet in renal disease formula. Journal of the American Geriatrics Society, 57(9), 1638-1643. Evidence Level II.
11. National Kidney Disease Education Program. (2009). Health professionals: GFR MDRD calculators for adults (conventional units). Retrieved from http://www.nkdep.nih.gov/professionals/gfr_calculators/orig_con.htm/. Evidence Level I.
13. Miller, M. (2009). Disorders of fluid balance. In S. Studenski, K.P. High, & S. Asthana (Eds.), Hazzard's geriatric medicine and gerontology (6th ed., pp. 1047-1058) New York, NY, McGraw-Hill. Evidence Level V.
18. High, K.P. (2009). Infection in the elderly. In J.B. Halter, J.G. Ouslander, M.E. Tinetti, S. Studenski, K.P. High, & S. Asthana (Eds.), Hazzard's geriatric medicine and gerontology (6th ed., pp. 1507-1515). New York, NY: McGraw-Hill. Evidence Level V.
19. Bartlett, J.G., Dowell, S.F., Mandell, L.A., File, T.M., Jr., Musher, D.M., & Fine, M.J. (2000). Practice guidelines for the management of community-acquired pneumonia in adults. Infectious Diseases Society of America. Clinical Infectious Diseases, 31(2), 347-382. Evidence Level I.
20. American Heart Association Nutrition Committee, Lichenstein, A.H., Appel, L.J., Brands, M., Carnethon, M., Daniels, S.,...Wylie-Rosett, J. (2006). Diet and lifestyle recommendations revision 2006: A scientific statement from the American Heart Association Nutrition Committee. Circulation, 114(1), 82-96. Evidence Level I.
23. Visvanathan, R., & Chapman, I.M. (2009). Undernutrition and anorexia in the older person. Gastroenterology Clinics of North America, 38(3), 393-409. Evidence Level V.
25. Conn, V. S., Minor, M. A., Burks, K. J., Rantz, M. J., & Pomeroy, S. H. (2003). Integrative review of physical activity intervention research with aging adults. Journal of the American Geriatrics Society, 51(8), 1159–1168. Evidence Level I.
26. Netz, Y., Wu, M. J., Becker, B. J., & Tenenbaum, G. (2005). Physical activity and psychological well-being in advanced age: A meta-analysis of intervention studies. Psychology & Aging, 20(2), 272–284. Evidence Level I.
27. U.S. Department of Health and Human Services. (2004b). Bone health and osteoporosis: A report of the Surgeon General. Retrieved February 13, 2007, from http://www.surgeongeneral.gov/library/bonehealth. Evidence Level I.
28. Agency for Healthcare Research & Quality. (2010). Guide to clinical preventive services, 2010-2011: Recommendations of the U.S. preventive services task force. AHRQ Publication No. 10-05145. Rockville, MD. Retrieved from http://www.ahrq.gov/clinic/pocketgd1011/
29. Craft, S., Cholerton, B., & Reger, M. (2009). Aging and cognition: What is normal? In W. R. Hazzard, J. P. Blass, J. B. Halter, J. G. Ouslander, & M. E. Tinetti (Eds.), Principles of geriatric medicine and gerontology (pp. 1355–1372).NY: McGraw-Hill. Evidence Level V.
32. Park, H. L., O’Connell, J. E., & Thomson, R. G. (2003). A systematic review of cognitive decline in the general elderly population. International Journal of Geriatric Psychiatry, 18(12), 1121–1134. Evidence Level I.
33. Kuchel, G.A. (2009). Aging and homeostatic regulation. In J.B. Halter, J.G. Ouslander, M.E. Tinetti, S. Studenski, K.P. High, & S. Asthana (Eds.), Hazzard's geriatric medicine and gerontology (6th ed., pp. 621-629). New York, NY: McGraw-Hill. Evidence Level V.
35. Mattson, M. (2009). Cellular and neurochemical aspects of the aging human brain. In J.B. Halter, J.G. Ouslander, M.E. Tinetti, S. Studenski, K.P. High, & S. Asthana (Eds.), Hazzard's geriatric medicine and gerontology (6th ed., pp. 739-750). New York, NY: McGraw-Hill. Evidence Level V.
36. Joint National Committee (2004). Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Retrieved August 31, 2006, from http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm. Evidence Level I.
37. Hunt, K.J., Walsh, B.M., Voegeli, D., & Roberts, H.C. (2010). Inflammation in aging part I: Physiology and immunological mechanisms. Biological Research for Nursing, 11(3), 245-252. Evidence Level V.
38. Centers for Disease Control and Prevention. (2010). Recommendations and guidelines: Adult immunization schedule. Retrieved from www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#hcp/. Evidence Level I.
39. Hall, K.E. (2002). Aging and neural control of the GI tract. II. Neural control of the aging gut: Can an old dog learn new tricks? American Journal of Physiology. Gastrointestinal and Liver Physiology, 283(4), G827-G832. Evidence Level V.
42. Hall, K.E. (2009). Effect of aging on gastrointestinal function. In J.B. Halter, J.G. Ouslander, M.E. Tinetti, S. Studenski, K.P. High, & S. Asthana (Eds.), Hazzard's geriatric medicine and gerontology (6th ed., pp. 1059-1064). New York, NY: McGraw-Hill. Evidence Level V.
Last updated - July 2012
These protocols were revised and tested in NICHE hospitals.