Neurological System

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Chapter 25

Endocrine Function

There is decreased estrogen production in women (menopause), decreased testosterone production in men (andropause), decreased adrenal function (adrenopause), and decreased growth hormone (GH)–insulin-like growth factor (IGF) (somatopause).

Neuroendocrine Aging

Endocrine system uses a delicate balance of chemical messengers in the bloodstream to maintain homeostasis and regulate mood, growth, organ function, metabolism, nutrition, and sexual activity.

Clinical manifestations due to the imbalance include decreased bone remodeling, decreased lean muscle mass, increased adipose tissue, compromised skin integrity, impaired insulin signaling, and impaired immune response.

Endocrine Physiology in Older Adults

Decline in biosynthesis and balance of sex hormones with aging

Both genders may experience hot flashes, night sweats, depression, and sexual dysfunction in response to declines in androgen or estrogen.

Laboratory values—luteinizing hormone and testosterone in men; follicle-stimulating hormone and estrogen in women determine endocrine decline.

Andropause and Menopause

Menopausal and postmenopausal hormone replacement (HR) practices continue to change based on larger, more rigorous research studies.

Although many clinicians continue to prescribe hormone replacements, the benefit must outweigh the risks of developing adverse events.

Menopause

Age-related decreases in mineralocorticoids, glucocorticoids, and androgenic hormones manifest changes in body composition, skeletal mass, muscle strength, body weight, and metabolism.

Age-related decreases in DHEA and norepinephrine can produce fluid and electrolyte imbalances; impair glucose, protein, and fat metabolisms; and impair immune and inflammatory responses.

Adrenopause

Somatotropin (growth hormone), an anabolic protein, is secreted from the hypothalamus–pituitary axis and influences many age-related changes.

Somatopause

Multifactorial syndrome of aging due to chronic low inflammation, and is characterized by central obesity, elevated triglycerides, reduced high-density lipoprotein (HDL) cholesterol, hypertension, and/or hyperglycemia

Primary risk factors for the syndrome are abdominal obesity, insulin resistance, physical inactivity, and hormonal imbalance.

Metabolic Syndrome–Diabetes Continuum Pathophysiology

When three of the following five criteria are met:

Obesity (waist circumference >40 inches in men or >35 inches in women)

Blood pressure >130/85 mm Hg

Fasting plasma glucose >100 mg dL

Triglyceride >150 mg dL

HDL cholesterol >40 mg dL in men or <50 mg dL in women

Metabolic Syndrome: Diagnosis

Primary therapeutic objectives: reduction of risk factors for diabetes and atherosclerotic disease

Therapeutic lifestyles changes

Nutritional management watch—low-saturated fats, trans fat, cholesterol, and simple sugars

Drug therapy for elevations in blood pressure, low-density lipoprotein cholesterol (LDL-C), and hyperglycemia

Metabolic Syndrome: Medical Management

Patients with metabolic syndrome have a fivefold increased risk.

Hyperglycemia is caused by impaired carbohydrate metabolism, changes in pulsatile insulin release, and resistance to insulin-mediated glucose disposal.

Signs and symptoms: polydipsia, polyphagia, and polyuria, fatigue, blurred vision, weight change (gain or loss), and infections

Type 2 Diabetes Mellitus (T2DM) Pathophysiology

Goal for A1C in healthy older population—<7.5%; in frail, older adults with comorbidities—≤8%

Includes risk reduction: cessation of smoking, controlling hypertension, managing dyslipidemia, promoting exercise, and aspirin therapy

Metformin along with lifestyle modification, or other drugs in combination and insulin if A1C is >9%, fasting plasma glucose is >250 mg/dL, random glucose is consistently >300 mg/dL, or ketonuria is present

Type 2 Diabetes Mellitus Medical Management

Review of past medical, surgical, and family history

Current medications

Self-care abilities or restrictions, self-monitoring of blood glucose levels

Current weight measurement and recent patterns of loss or gain

Food and fluid balance; hyperglycemia may produce subtle symptoms in older adults

Urinary assessment

Current living conditions

T2DM: Assessment and Diagnosis (1 of 2)

Evaluate for the presence of bowel incontinence, constipation, and diarrhea.

Assess ability to learn and knowledge of T2DM.

Assess memory and mood.

Assess for neurologic symptoms.

Assess patient’s skin condition.

Assess circulation, blood pressure (BP) lying, and sitting.

Can you name six nursing diagnoses?

T2DM: Assessment and Diagnosis (2 of 2)

Inadequate or excessive nutrition resulting from decreased functional capacity, altered taste, and deficient knowledge

Decreased tissue perfusion, peripheral, resulting from decreased or interrupted arterial flow

Reduced sexual expression resulting from metabolic alterations

Inadequate coping resulting from metabolic alteration or feelings of distress

Need for health teaching resulting from diabetes self-management and skills

Potential for reduced skin integrity resulting from impaired circulation

The patient will do the following:

Follow the plan of care by taking action on the basis of professional advice

Show evidence of successful individual coping

Demonstrate increased knowledge of the ADA diet

Demonstrate understanding of drug administration

Maintain peripheral circulation

Demonstrate foot care regimen

Verbalize satisfaction with the degree of sexual functioning

T2DM: Planning and Expected Outcome

Education

Diet

Insulin and oral hypoglycemic drugs

Emergency identification

Blood glucose monitoring

Exercise

Lifestyle changes

Sick day management

Skin alterations and wound infections

T2DM: Intervention

Evaluate the effectiveness of care plan by frequently measuring achievement of established specific outcomes.

The nurse should positively reinforce effective diabetes management strategies.

If a patient does not comply with management strategies, situation needs to be reassessed so that adaptations can be made.

Document assessments.

T2DM: Evaluation

The nurse is caring for an older adult with type 2 diabetes mellitus. While reviewing his labs, the nurse notes if the patient has metabolic syndrome. Which of the following labs are consistent with this syndrome? (Select all that apply.)

FBS 150 mg/dL

HDL 32 mg/dL

Triglyceride 120 mg/dL

HgbA1C 7.2%

Quick Quiz!

ANS: A, B

Answer to Quick Quiz

Involves hypersecretion of thyroid hormones, enlarged thyroid gland

Low or suppressed TSH level

Subclinical hyperthyroidism: asymptomatic patient has suppressed serum TSH level with normal thyroxine (T4) and T3 levels; associated atrial fibrillation and decreased bone mineral density

Thyroid storm: life-threatening syndrome—fever, severe tachycardia, altered mental status, dehydration, and irritability

Hyperthyroidism Pathophysiology

Classic geriatric presentation—tachycardia, fatigue, tremors, and nervousness

Enlarged, palpable goiter present in 60% of older adults with hyperthyroidism.

Most common complication is atrial fibrillation.

Hyperthyroidism Signs and Symptoms

Treatment: antithyroid drugs and radioactive iodine

Rarely is surgical intervention required due to the risk of surgery to older adults

Adjunctive treatment—with beta-adrenergic blockers, can slow the heart rate of tachycardia

Hyperthyroidism Medical Management

Hypofunctioning endocrine state that results from inadequate thyroid hormone

Diagnosis is based on sensitive, reliable assays of serum TSH and T4 levels.

Elevation of serum TSH level

Primary hypothyroidism—hypofunctioning of the thyroid

Secondary hypothyroidism—nonfunctional anterior pituitary gland

Tertiary hypothyroidism—defect in the hypothalamus

Hypothyroidism Pathophysiology

Almost all cases of hypothyroidism in older adults are subclinical, inconspicuous, and progress slowly toward thyroid failure.

Symptoms often attributed to old age: fatigue, cold intolerance, weight gain, muscle cramps, paresthesias, and confusion

Hypothyroidism Signs and Symptoms

Treatment for hypothyroidism includes pure synthetic thyroxine (e.g., levothyroxine).

Usual starting dose is at 25 mcgs per day. The drug is increased every 4–6 weeks until the serum levels of T4 and TSH are within the normal range.

Hypothyroidism Medical Management

Six times more frequently in women

Characterized by low bone mass leading to fragile, easy-to-break bones

Low bone mass from failure to reach peak bone mass as a young adult, increased bone resorption, or decreased bone formation

50%–80% of peak bone mass is genetically determined.

Diagnosed by dual x-ray absorptiometry (DEXA) of the proximal femur and lumbar spine

Primary Osteoporosis Pathophysiology

Spontaneous fractures are those caused by minimum trauma, loss of height, dorsal kyphosis, chronic back pain.

History of fractures after 40 years old, family history of osteoporosis, cigarette smoking, and low body mass index have been shown to correlate strongly with osteoporosis.

Primary Osteoporosis Signs and Symptoms

Calcium 500–1000 mg/day and vitamin D least 400 IU/day

Weight-bearing and muscle-strengthening exercises add minimally to bone density, but help posture, balance, and reduce falls.

Estrogens, bisphosphonates, selective estrogen receptor modulators, and calcitonin are used in antiresorptive therapy based on risk profile.

Primary Osteoporosis Medical Management

Erectile dysfunction (ED) and female sexual dysfunction (FSD) have garnered increased interest and research dollars in recent

FSD remains ill defined, even though a relatively high rate of sexual dysfunction exists among postmenopausal women due to low desire, vaginal dryness, or inability to reach orgasm.

Sexual Dysfunction

ED is persistent inability to achieve or sustain an erection firm enough for sexual intercourse and penetration.

FSD is a sexual arousal disorder due to menopause and declining estrogen produces a thin and dry vaginal vault which causes decline in sexual arousal, pain during intercourse.

Neuroendocrine physiologic impairments interfere with the normal female sexual response.

Sexual Dysfunction Signs and Symptoms

Pharmacological—phosphodiesterase type 5 inhibitors and alprostadil

Nonpharmacological—counseling, lifestyle modifications, vacuum constriction devices, and performing regular erection exercises

Surgery

FSD Tx—watchful waiting, dose reduction of causative drugs, testosterone replacement, sensate focus psychotherapy, and prescription of bupropion, buspirone, or sildenafil

Sexual Dysfunction Medical Management