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40 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com

CE2 Continuing Education

HOURS

OVERVIEW: Although people age at different rates, changes to the com- position of the human body are a hallmark of aging. As a result of such changes, disease can present differently in a person over 65 years old than it would in a younger adult or child. This article identifies the critical indicators of underlying conditions, including changes in mental status, loss of function, decrease in appetite, dehydration, falls, pain, dizziness, and incontinence. It also describes the presentation of diseases common to older adults, including depression, infection, cardiac disease, gastroin- testinal disorders, thyroid disease, and type 2 diabetes.

PRESENTATION of ILLNESS in

OLDER ADULTS If you think you know what you’re looking for, think again.

Elaine J. Amella is an associate dean for research and an associate professor at Medical University of South Carolina College of Nursing, Charleston. Contact author: [email protected]. This article is the second in a series that’s supported in part by a grant from the Atlantic Philanthropies to the Gerontological Society of America. Nancy A. Stotts, EdD, RN, FAAN ([email protected]), and Carole E. Deitrich, MS, GNP, RN ([email protected]), are the series editors. The author of this article has no significant ties, financial or otherwise, to any company that might have an interest in the publication of this educational activity.

By Elaine J. Amella, PhD, APRN,BC

O SINGLE, CHRONOLOGICAL TIMETABLE OF HUMAN AGING EXISTS.” This is one conclusion of the Baltimore Longitudinal Study on Aging,

which since 1958 has tracked more than 1,000 people from age 20 to over age 90 in an attempt to define “normal” physiologic human aging.1

Although in most aging people cardiac muscles thicken, arteries stiffen, lung tissues diminish, brain and spinal cord degenerate, kidneys shrink, and bladder muscles weaken, they do so at varying rates in different people. In fact, organs age at different rates within each person; for example, lungs can continue going strong as kidneys begin to fail.

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Taken from Aging in America: The Years Ahead, by photographer Ed Kashi and writer Julie Winokur.

Adding to the confusion is the fact that people over 65 years old (“older adults”) take more med- ications than their younger counterparts; this polypharmacy can lead to a change of mental sta- tus, a symptom that may mistakenly be attributed to old age. In short, to inadequately trained clini- cians, some normal aspects of aging can appear as manifestations of disease while other changes can mask early signs of illness.2 For example, a decreased ability to regulate body temperature puts older adults at higher risk for hypothermia, and it also decreases their ability to promptly respond to pathogens by initiating an inflammatory process (through fever). This can lead to the overtreatment of a relatively healthy person or cause a clinician to miss important clues of an acute disorder requiring treatment.

To differentiate disease from normal aging requires assessment skills developed specifically for the older adult and an understanding of the aging process, as well as an understanding of the factors that produce altered presentations of several ill- nesses in older adults.

HOW THE BODY AGES While it’s been acknowledged that family history, environment, and lifestyle influence aging, there are many theories as to which physiologic changes cause the body to age—and how they do so. While research continues, one fact is incontrovertible: changes in overall body composition are a hallmark of aging.

Alterations in cell replication. One significant change is how cells replicate. Much of what we rec- ognize as aging is governed by changes in cells’ abil- ity to reproduce over a lifetime. Researchers have identified telomeres, the stretches of DNA that pro- tect both ends of chromosomes, as an important factor in human aging. Human cells are thought to divide about 50 to 70 times over a lifetime.3 With each replication, telomeres shorten, allowing chro- mosomes to stay intact. Over time, telomeres shorten until the cell is no longer able to replicate, resulting in cell death, or senescence. While “limited replication or ‘replicative senescence’ is no longer seen as the main issue of ageing—nonetheless, los- ing the ability to divide may well undermine tissues that must produce fresh cells quickly. For instance, it could hamper the immune system’s capacity to respond to novel pathogens and may underlie the slower wound healing of the elderly.”4

Oxidative stress is the damage caused to cellular proteins by free radicals, the toxic compounds released by the metabolism of oxygen and also found in the environment (for example, in smoke and smog). Cigarette smoking, poor diet, and other lifestyle factors can also trigger free-radical activity. Over the course of a lifetime, free radicals bombard

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CASE STUDY What’s causing this patient’s confusion?

Three days after undergoing an open reduction and inter-nal fixation of a fractured hip, 82-year-old Carol Thompson is admitted to the hospital after her daughter found her bruised body crumpled at the bottom of a flight of stairs. Although once very independent, Ms. Thompson is now con- fused and uncooperative. She is pulling at her dressing and unwilling to keep her hip-abduction pillow in place. The social worker recommends placement in a nursing home.

You suspect that something else could be causing Ms. Thompson’s decline. From the chart you learn she fell down poorly lighted stairs and lay there for more than 18 hours before being found. Suspecting a slow bleed into her brain from a subdural hematoma, you wonder if any- one has determined if Ms. Thompson hit her head when she fell. You check her pupils and her major cranial nerves. Because she was dehydrated on admission, she received a large amount of IV fluids. Wondering if she received too much too quickly—perhaps worsening unde- tected heart disease—you check her pulses and blood pressure and note any edema or neck-vein distention. You ask her daughter to bring in her medicine vials, and note that her daily levothyroxine (Synthyroid) was not ordered since admission.

Ms. Thompson’s surgery was complicated and lasted longer than expected; she did not receive a transfusion. You wonder if she might still be recovering from the anes- thesia and check to see if hemoglobin and hematocrit lev- els were checked postoperatively; they were tested only on day one. Despite pressurized devices and the use of anti- coagulant, you consider that she might have had a small stroke or other vascular insult. Finally, you wonder about pain management. Not only is Ms. Thompson recovering from major surgery, but she also has significant arthritis. Could her pain be adequately treated with the opioid anal- gesic ordered? You check her vital signs, perform a neuro- logic examination, assess for delirium using the Confusion Assessment Method, note her comfort level using the Checklist of Nonverbal Pain Indicators, examine her oral mucosa and conjunctiva for paleness, and review her med- ication record using the Beers Criteria for Potentially Inappropriate Medication Use in the Elderly.

In consultation with the orthopedic surgeon and the nurse practitioner managing her care, you arrange for the levothyroxine to be restarted, blood work to be drawn, and a change in pain medication to a sustained-release and breakthrough morphine agent. You also ask her daughter to meet with health care providers to discuss a longer hospital stay—until the medical issues causing this possible delirium can be addressed. You arrange for her daughter to visit outside of visiting hours and you remind her to bring in her mother’s eyeglasses.

Ms. Thompson’s delirium begins to lift in about 24 hours. Within 48 hours, she is participating with her treat- ment plan and looking forward to returning home.

cells, eventually causing cell mutation and senes- cence; as a result, oxidative stress has been recog- nized as a factor in the pathogenesis of cancer and heart disease. A link to the general decline in physi- ologic functioning that occurs with age has also been hypothesized.5

INDICATORS Early recognition of indicators of underlying health problems, including change in mental status, falls, dehydration, decrease in appetite, pain, loss of func- tion, dizziness, and incontinence, can mean an oppor- tunity to initiate treatment while recovery is still possible.6 (These problems aren’t inherent to aging.)

An in-depth examination is required to determine cause, especially because some indicators have both physiologic and psychological origins. (See Aging of the Body’s Systems, page TK.) Key to providing appropriate treatment to older adults is establishing a baseline that goes beyond the usual history and physical parameters to examine mental, functional, nutritional, and social-support status. A history that

contains information about the health of siblings, partners, and children can provide clues to family history, environment, and lifestyle. Baseline informa- tion should be gathered upon admission to a facility, and whenever the patient’s condition changes. Community-dwelling older adults should be assessed at least once a year. More frequent evalua- tions are warranted for patients with chronic prob- lems, such as memory loss or joint disease.

Change in mental status is a common harbinger of disease, drug toxicity, or psychological trauma in older adults. The primary causes of delirium and acute states of confusion are adverse effects from medication, drug–drug interactions, or toxic levels of medication in the blood.7 Whenever older patients are unable to focus their thoughts or expe- rience a sudden change in mental status (occurring over one day, a few days, or even weeks), the nurse should suspect medication toxicity. This is especially important when the patient has recently received anesthesia or new medications. The assumption that older adults are normally confused is incorrect

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MED SURGE With age, the body’s reaction to medication changes.

For Groucho Marx, old age was not a subject of rever-ence. “Anyone can get old,” he said. “All you have to do is live long enough.” Of course, a clinician knows what a comedian doesn’t: living “long enough” these days usu- ally entails a medication regimen—and with this comes a high risk of adverse drug events and drug–drug interac- tions. The fact is, even in otherwise healthy older adults, changes in body composition influence the absorption, dis- tribution, and clearance of medications.30

Absorption. According to Williams, “In older persons, absorption is generally complete, just slower. In addition to age-related changes, common medical conditions such as heart failure may reduce the rate and extent of absorption.”30

Distribution. As people age, they lose lean body mass gain and adipose tissue gain. Because there is less fluid available, water-soluble medications can reach toxic levels more quickly. Furthermore, the increase in adipose tissue means that fat-soluble drugs (predominantly the psychotrop- ics) are absorbed into these less well-vascularized fat stores, and it takes longer for the drug to reach a therapeutic level (as well as longer for them to be excreted from the system). Vigilant monitoring is required with potentially nephrotoxic medications, including antimicrobials, cardiovascular agents, H2-antagonists, oral hypoglycemics (especially the sulfonylureas), and nonsteroidal antiinflammatory agents.

Protein malnutrition is common in underweight and obese older adults. This means that there are fewer binding sites for protein-binding drugs such as warfarin (Coumadin and others) or phenytoin (Dilantin and others); causing more “free” drug

to circulate and putting the patient at greater risk for adverse effects such as bleeding or confusion. Protein malnutrition is determined by using prealbumin level less than 15 mg/dL, serum albumin level less than 3.2 g/dL, total lymphocyte count less than 1500 � mm3, transferrin level less than 200 mg/dL, and serum cholesterol level less than160 mg/dL.31

Clearance. With decrease in kidney and liver function- ing, clearance and excretion of drugs also takes longer. The nurse needs to closely monitor serum protein level (normal range 5.5 to 9.0 g/dL) and albumin level (normal range 3.5 to 5.5 g/dL), as well as renal and liver functions to help the older patient avoid toxicity or undertreatment.32

Assessing kidney function and drug toxicity. Measures of serum creatinine, used to assess excretion for many drugs, are related to muscle mass and thus aren’t a good measure of kidney functioning in a frail individual or one who has lost muscle mass due to immobility. Contact the physician or pharmacist if there’s any doubt regarding the nephrotoxicity of the drug, and use the Cockcroft–Gault formula to calculate the creatinine clearance (see Cockcroft–Gault Equation for Calculating Creatinine Clearance, page TK). Creatinine clearance, a measure of the glomerular filtration rate, is a valuable way to note decline in kidney function in older adults. Accepted clearances are published for each drug, but the nurse should be especially concerned in patients with a clearance of less than 50 mL/min, which is indicative of a prerenal state.33 The pharmacist should be consulted about the need for dose adjustment, and monitoring of renal func- tion should continue.

Presence of these signs point to a diagnosis of delir- ium and warrant a complete diagnostic assessment.

Falls don’t necessarily imply a change in condi- tion; however, the circumstances of a fall should be investigated to determine whether the cause was environmental or health related. In short, a new onset of falls should always be seen as a symptom of illness until proven otherwise. Falls should be considered within the context of the following com- plex problems: • cardiac—syncope, orthostasis, cardiac arrhythmias • musculoskeletal—poor posture, osteoporosis,

loss of strength • neurologic—poor balance and gait, vertigo, and

dizziness • change in mental status—a slow intracranial

hemorrhage • sensory—loss of vision or hearing, poorly lighted

areas • functional—general weakness • continence—slipped on urine, hurrying to bath-

room • psychological—fear of falling, unusual limitation

of activities In determining the details of the fall, ask: Did the

person black out or feel dizzy prior to the fall? Could he have hit his head when he fell? Was he wearing eyeglasses or a hearing aid, if needed? While numerous assessments should be done, sev- eral are critical: complete a baseline mental status examination; question the patient about dizziness (see “Dizziness,” below); assess orthostasis through lying, seated, and standing blood pressure; check heart rate and electrocardiogram for possible atrial fibrillation; and complete a neurologic assessment— especially noting possible changes related to stroke and head trauma.10

Assessment for poor balance and gait can be accomplished with the timed up-and-go test: ask the patient to rise out of chair, walk 10 feet, turn around, return to the chair, and sit down.11 (Remain close in case the patient begins to fall.) Look for shuffling gait, lack of arm swing, unequal shoulder or hip height (which can indicate spinal deformity or leg shortening), the ability to turn without support, and the ability to stand and sit in a controlled fashion. The timed up-and-go test should be accomplished in 20 seconds or less. Further referral is indicated if the

and may cause clinicians to miss one of the most important symptoms of undiagnosed illness.

Delirium. In addition to medications, other pri- mary causes of delirium include dehydration, hypoxia, metabolic disturbances, untreated anemia, nutritional deficiencies, and infection (especially those of the respiratory and urinary tracts).8

Secondary causes include untreated thyroid disease, vitamin deficiency (especially B12), and decreased sensory input from loss of vision or hearing. Patients who are unable to see or hear others are often disorientated. When necessary, eyeglasses and hearing aids are a simple intervention.

When possible, familiar routines and care can help reorient patients to new environments. For the older adult, sudden location changes—for example, a move from a nursing home to a hospital—can be confusing and trigger delirium.

If caught in time, delirium can be reversible. At minimum, assessment should include the following three questions that are part of the Confusion Assessment Method:

1. Did the confusion happen rather quickly—for example, since admission or the onset of illness— and are there times during the day when the person is more confused than at other times?

2. Is this person easily distracted and inattentive to tasks or conversations?

3. Does the person have an altered level of con- sciousness—is he overly alert, groggy, or stuporous?9

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TRY THIS A resource for geriatric tools.

Several types of assessments are needed to determineif changes in a patient’s health are due to a change in health status or to normal aging. Yet while numerous assessment tools exist, few have been either developed for or modified to meet the norms of aging. An excellent resource for nurses working with older adults is the “Try This” series, sponsored by the Hartford Institute for Geriatric Nursing. Available both in print and on the Internet (at www.geronurseonline.org, this series is focused on assessing common problems and symptoms in older adults. Through “Try This,” nurses can gain access to a wide variety of resources, including the Beers Criteria for Potentially Inappropriate Medication Use in the Elderly and tools used to assess mental status or confusion (the Mini Mental State Examination or the Confusion Assessment Method), pain or discomfort (Checklist of Nonverbal Pain Indicators), and falling (Fall Risk Assessment). In addition to providing the tool, “Try This” provides directions for administration and guid- ance on the interpretation of results.

Want to discuss what you’ve read in this article or other issues related to nurses caring for older adults? Go to www.nursingcenter.com/ajnolderadults to participate in a discussion forum with the series authors and editors.

patient takes more than 30 seconds to complete the task.

Medications should be reviewed and special note taken of psychoactive drugs (especially sedatives), drugs that lower blood pressure, and those that cause hypoxia or hypoglycemia. People with dementia or delirium are 50% more likely to fall and thus need careful assessment and monitoring.12

Those who fall will fall again until the cause is diag- nosed and corrected.

Dehydration is common in older adults because decreased muscle mass means that they have less free water, the extracellular water that predomi- nates in muscle tissue. Additionally, the thirst response is blunted with age—this can result in inadequate fluid intake.13 Chronic dehydration is more likely to occur in older adults, especially those who are unable to hold a glass steadily, such as nursing home patients or those with dementia.

During acute dehydration, which may result from vomiting, diarrhea, or fever, which may cause metabolic rates to increase, the kidneys do not con- centrate urine; older adults are then at risk for fur- ther dehydration. Noting basic parameters as orthostatic hypotension, dryness of the oral mem- branes, poor skin turgor, and urine color and amount, as well as checking for elevated serum sodium (above 145 mEq/L) and osmolarity (outside the range of 280 to 300 mOsm/kg), can alert the nurse to further action.

Decrease in appetite or early satiety is not always classic anorexia but may mean other problems are fomenting.14 In older adults, worsening of heart fail- ure and early-onset pneumonia can present with this symptom before any other.

Pain can change markedly with age. Like younger adults, older adults experience both acute and chronic pain. However, the two groups may use dif- ferent words to describe their pain (for example, older adults may complain of “aches” or “discom- fort”) and older adults may have difficulty pinpoint- ing the exact origin of pain, especially if it occurs below the waist and is reported as “crampy.”

Furthermore, people with chronic pain may have dif- ficulty evaluating their pain on the common 0-to-10 scale in which 0 means no pain. Commonly used tools for assessing pain in older adults include the visual analog scale, the verbal descriptor scale, and the Wong–Baker FACES Pain Rating Scale.15

In people with dementia, special attention must be paid to nonverbal cues. For example, someone with dementia who is unable to ask for analgesia may express pain by grimacing, moaning, crying out, or resisting a caregiver’s attempts to move the patient’s body. Additionally, peripheral and sensori- motor neuropathy may cause people with diabetes to be unaware of trauma to the extremities. Thus, in both these populations, careful and frequent exam- ination of all vague complaints of pain is necessary.

Such examination may entail a review of the patient’s history and records for potential causes of pain, an assessment of current pain, and a review of all medications in the patient’s regimen. The patient’s beliefs about use of pain medication should be examined—especially myths about addiction— and the patient’s family should be contacted for fur- ther information.16

Loss of functional ability can be significant in active people and in those with extremely limited mobility. Fatigue and decline in activity may signal anemia, thyroid disease, infection, or cardiovascular or pulmonary insufficiency. While numerous assess- ments exist to test ability, both the Katz Index of Activities of Daily Living and the Barthel Index were developed specifically for older adults. However, the most effective way to monitor func- tion is to establish a baseline by observing the patient as he performs his usual routines and then assess function regularly, especially during a decline in health. Timely referral to rehabilitation programs may allow older adults to regain prior capacity— before the onset of permanent decline.

Dizziness is a common complaint. As people age, they are more likely to report sensations such as vertigo, lightheadedness, disequilibrium, or a vague sense of dizziness. Careful questioning about

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COCKCROFT–GAULT EQUATION FOR CALCULATING CREATININE CLEARANCE Creatinine clearance* � (140 � age) � weight (kg)

serum creatinine (mg/dL) � 72 (� 0.85 for women)

* Special considerations: For patients over 90 years old, use age 90. For obese patients, use the ideal body weight:

Men = 50 kg � 2.3 kg for every inch over 5 feet Women = 45.5 kg � 2.3 kg for over every inch over 5 feet

Cockcroft DW, Gault MH. Nephron 1976;16(1):31- 41

Nursing assessments include checking for irregular pulses, measuring orthostatic blood pressure, reviewing the patient’s most recent electrocardio- gram, and asking about hearing loss or ringing in the ears. Neurologic assessments are also required. Note balance as the patient walks heel to toe, observing if he begins to fall to one side or grabs on to objects for stability. Note his ability to perceive position (for example, can he close his eyes and still correctly detect direction as the nurse moves his big toe up and down?). Watch for swaying when the patient is standing with his eyes closed. Finally, measure

the circumstances surrounding the episode is required: Was the patient getting up suddenly, lean- ing his head backward, sitting still, or moving? Questioning about the sensation itself is also important: Did the patient perceive the room spin- ning? Was he faint or woozy? Was he unsteady or off balance?

Dizziness can be a symptom of anemia, arrhyth- mia, depression, infection, ear disease, acute myocar- dial infarction, eye problems, stroke, cerebral tumors, vasovagal response, or cerumen impaction in the ear. It can also be a sign of drug toxicity.17

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TABLE 1. AGING OF THE BODY’S SYSTEMS Body System Physiologic Changes Expected Signs or Symptoms

Skin • Loss of subcutaneous tissue and thinning of dermis

• Underlying tissue more fragile; inabili- ty to respond to heat or cold quickly; proneness to heat stroke; loss of mois- ture; wrinkling

Sensory • Loss of lid elasticity • Ocular changes in cornea, iris, pupil,

lens • Auditory canal narrows • Calcification of ossicles • Changes in organ of Corti • Olfactory bulb and cells decrease

• Eyelids drop or turn inward • Increased astigmatism; need for more

light; glare problematic; need for eye- glasses

• Cataracts • Increased cerumen • Hearing loss • Impaired sound transmission, tinnitus • Inability to discriminate odors

Cardiovascular • Decreased stress response • Stiffer valves • Conductivity altered • Vessels less elastic

• Diminished cardiac output • Diastolic murmurs • More ectopic beats; less ability to

respond to changes in blood pressure • Poorer perfusion to vital organs with

resulting hypoxia; varicosities; peripher- al pulses not always palpable

Pulmonary • Enlargement and rigidity of chest wall • Airway collapse

• Poorer expansion with less efficient exchange; shallower breathing; less effective cough

• Oxygen exchange less efficient espe- cially under stress

Gastrointestinal • Increase in occurrence of hiatal hernia and decrease in intraabdominal strength

• Reduced gastric acid • Slower neural transmission • Weakening of intestinal walls

• Reflux • Peptic ulcers • Vitamin deficiency • Constipation and incontinence • Diverticulosis

extraocular movements by asking the patient to watch as you slowly outline the letter “H,” noting any rapid back-and-forth eye movements as he fol- lows your hand.

Incontinence isn’t unique to older adults, but new-onset urinary incontinence should always be investigated. In older adults incontinence often occurs as a result of a urinary tract infection, limited mobility, or metabolic problems such as hyper- glycemia or hypercalcemia. Other causes include the use of medications such as diuretics or sedatives, the latter of which can inhibit the person’s ability to rec-

ognize the need to use the toilet and slow his move- ment toward the bathroom. While many techniques can be used to rehabilitate people with urge or stress urinary incontinence or urinary retention, these reversible causes must be investigated first.18 A dip stick urine test to look for the presence of the nitrites and blood usually found during infection can provide excellent clues for further workup.19

PRESENTATION OF DISEASE Infection. It is believed that immunity deteriorates with age as a result of decreasing T lymphocyte

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Ebersole P. Age-related changes. In: Ebersole P, et al., editors. Toward healthy aging. Human needs and nursing responses. Philadelphia: Mosby; 2004. p. 74-80.

Renal • Decrease in blood flow, glomeruli, renin, and filtration

• Increased creatinine clearance; loss of ability to concentrate urine and conserve water; poor response to stress

Musculoskeletal • Shrinking vertebral discs, loss of bone mass • Muscle atrophy

• Loss of height by 1.5 to 3 in.; fracture more common

• Decrease in strength and stamina; atrophy

Neurologic • Diminished stage 3–4 (deep) sleep • Decreased proprioception • Altered pain sensation • Tactile sense decreases • Sleep disorders, especially in different

environments (hospital)

• Difficulty in changing position or achieving balance

• Decreased perception of pain • Loss of sensation in extremities

Immune • Decrease in thymus mass and production

• Increase in immunoglobulins

• Decline in cell-mediated immunity; reac- tivation of disease (tuberculosis, herpes)

• Autoimmune response not associated with disease

Endocrine • Loss of sensitivity to insulin • Diminished sex hormones

• Blood glucose does not return to normal as quickly

• Benign prostatic hyperplasia; testicular firmness; vaginal dryness and atrophy; longer time to orgasm

Body System Physiologic Changes Expected Signs or Symptoms

function.20 With age, the thymus gland decreases in size and function. As a result, the effectiveness of the T lymphocyte response to antigens decreases. Rates of infection rise steadily with age, and mor- tality rates are sometimes two to three times higher for the same diseases seen in younger people. There is also an increase in certain cancers and autoim- mune diseases with aging. Because of lower basal metabolic rates, older adults have lower core tem- peratures. Thus, a patient with a normal tempera- ture or a low-grade fever may actually be experiencing a significant temperature hike. Additionally, with age, the body’s ability to trigger an inflammatory response to pathogens slows, making temperature an imprecise measure of the severity of infection. When assessing for infection, it’s critical to have an accurate baseline temperature and to note any recent changes such as confusion or decreased activity.

Presentation. Because the symptoms of infections change with age—for example, fever and chills are replaced with confusion or decreased functional ability—they often go undetected in older adults until the infection has reached an acute stage. Additionally, many older adults who use non- steroidal antiinflammatory drugs for painful muscu- loskeletal conditions have their inflammatory response altered, so at intake nurses should always question patients about recent use of antipyretic medications. The following list describes possible presentations of the infections most commonly occurring in older adults: • pneumonia—increased respiratory rate with

decreased appetite and functioning • urinary tract infections—incontinence, increased

confusion and falls Skin infections are often missed in older adults,

who may be difficult to undress or move from a wheelchair. Cellulitis can occur in people with vas- cular disease; early signs may be missed in people with chronic dependent edema.

Alterations in gastrointestinal status have many causes, including low-level dehydration, slower peristalsis, chronic neuromuscular disease, or even lack of mobility related to osteoarthritis (which can make the older adult prone to constipation). Other causes of gastrointestinal distress may present in the older adult as follows: • Upper or lower GI bleeding may present insidi-

ously with signs of dehydration and crampy abdominal pain that’s difficult to localize.

• GI obstruction can present without the usual boardlike abdomen, but instead with cramps, dehydration, stringy stool or diarrhea, and vague complaints of feeling unwell.

• Diverticulosis may present with diffuse pain and a low-grade temperature that signal inflamma- tion, infection, or even perforation.

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TIPS FOR NURSES BY HEALTH CARE SETTING Hospital nurses

• Confusion is not inevitable. Look for neurologic events or new medication.

• Many hospitalized older adults suffer from chronic dehydration accelerated by acute illness.

• Not all older adults have high fevers with infection. Other symptoms can include increased respiratory rate, falls, incontinence, or confusion.

Nursing home nurses • Pain is undertreated in older adults with dementia.

Look for nonverbal cues such as grimacing or resistance to care.

• Decline in functional ability (even minor declines, such as the inability to sit upright in a chair) may be a signal of new illness.

• Residents with less muscle mass—both the frail and the obese—are at much higher risk for toxicity from protein-binding drugs such as phenytoin (Dilantin and others) and warfarin (Coumadin and others).

Ambulatory care nurses • Complaints of fatigue or decreased ability to do

usual activities may be signs of anemia, thyroid problems, depression, or neurologic and cardiac problems.

• Severe gastrointestinal problems in older adults don’t always present with the acute symptoms seen in younger patients. Ask about constipation, crampy sensations, and changes in bowel habits.

• Older adults reporting increased dyspnea and confu- sion, especially those with a cardiac history, should be sent to the ED; these are the most common presen- tation of myocardial infarction in this population.

• Depression is common among older adults with chronic illnesses. Watch for lack of interest in for- mer activities, significant personal losses, or changes in role or home life.

Home care nurses • Falls should be investigated further, focusing on

balance, gait, and neurologic issues. • Older adults being treated for late-stage heart dis-

ease should be monitored for loss of appetite as an early symptom of impending failure.

• Drug–drug interactions in older patients who are seeing more than one provider and taking multiple medications are common. Watch for signs.

Assessment. When assessing for alterations in gastrointestinal status, first observe the contour of the abdomen, looking for old scars that might indi- cate adhesions. Then, using the stethoscope, listen in all four abdominal quadrants for the presence of bowel sounds. Percussion of the abdomen helps nurses determine whether the bowel is filled with feces or air. Special attention should be paid to any bruits or masses in older adults with poorly con- trolled hypertension; these may signal an abdominal aortic aneurysm and should be confirmed with an ultrasound or computed tomographic (CT) scan. Finally, light followed by deep palpation will help isolate painful areas, determine the existence of masses, and identify distention of the bladder. A patient’s report of blood in the stool or changes in stool color may be unreliable since the patient may be unable to clearly see the toilet contents.

Appendicitis. Although often considered a dis- ease of young adulthood, appendicitis also occurs in older adults. The rate of morbidity and mortality with appendicitis increases with age from 1% in the general population to 70% in older adults.21 Among older adults, appendicitis is often misdiagnosed as bowel obstruction and surgical treatment is delayed, resulting in a higher rate of perforation. The four classic symptoms—right lower-quadrant pain, ele- vated white blood counts, fever, and anorexia—are still present and quite predictive but are often missed because health care providers may not sus- pect appendicitis in older patients. Thorough abdominal examination, blood work, careful evalu- ation of reports of pain and decline in appetite, and evaluation using abdominal and pelvic CT scans can reduce the potentially devastating effects.

Cardiac disease. In the most acute insult, myocardial infarction, the classic symptom is not crushing chest pain and diaphoresis, but sudden onset of dyspnea often accompanied by anxiety and confusion. Recognition of these signs and symp- toms can result in early detection and treatment. The damaged heart muscle is unable to adequately perfuse, which causes associated symptoms such as confusion (caused by decreased cerebral profusion) or a drop in urine output (caused by decreased renal perfusion). The absence of ischemic pain is particu- larly evident among persons with long-standing angina and those with poorly controlled diabetes.

Heart failure. The beginning signs of worsening heart failure may be hard to detect in an inactive older adult with dependent edema. Often, the only changes noted may be a decreased appetite, weight gain of 2 to 3 lbs., and complaints of poor sleep. Teaching patients and caregivers these simple signs could ensure appropriate treatment and help patients to avoid future hospitalizations.

Nurses need to be cautious about the aggressive administration of IV fluids delivered to people with

heart disease and long-standing, poorly controlled hypertension; they may be at high risk for heart fail- ure. Aggressive treatment is required for those iden- tified as high risk. Critical observations include sudden onset of confusion or increased anxiety, increase in respiratory rate, widening pulse pres- sure, weight change from baseline, overwhelming fatigue, and anorexia.

Type 2 diabetes. As blood glucose rises, the older adult may not experience the three Ps: polyuria, polydipsia, and polyphagia. Instead, the patient is more likely to become dehydrated, confused, develop incontinence related to glycosuria, and later develop a wasting disorder with weight loss instead of gain. Confusion is an early symptom of hypo- glycemia. If older adults are treated with certain oral hypoglycemic agents that stimulate insulin pro- duction (such as sustained-release glipizide [Glucotrol XL and others]), their risk for acute hypoglycemia increases because they are less able to create and store glycogen for transformation to blood glucose when blood levels drop. This is espe- cially problematic if the person lives alone and has no one to remind him to eat during illness or other times of stress. The American Diabetes Association recommends that people in the following categories be screened for diabetes: those with a family history of the disease; those with a body mass index greater than 25; those with hypertension or elevated lipids; members of high-risk racial or ethnic groups such as African Americans, Latinos, Native Americans, Asian Americans, or Pacific Islanders; and those with a history of vascular disease with a fasting plasma glucose level of greater than 126 mg/dL.22

Thyroid disease. Fatigue and tremor, two of the most common symptoms of thyroid problems, may be missed or absent in old age. The gland itself may be hard to palpate as it slips lower and deeper into the neck. Instead, hyperthyroidism presenting in old age is often seen with new onset atrial fibrillation, weight loss, proximal muscle weakness, and confu-

[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 49

THE ABSENCE OF ISCHEMIC PAIN IS

PARTICULARLY EVIDENT AMONG

PERSONS WITH LONG-STANDING

ANGINA AND THOSE WITH POORLY

CONTROLLED DIABETES.

Because the complaints of younger and older adults may be different, it’s important to use an instrument specific to assessing depression in older adults. One such instrument is the Geriatric Depression Scale, which is available at www. hartfordign.org/resources/education/tryThis.html. Depression scales developed specifically for older adults don’t focus on somatic complaints or fatigue, as these may be manifestations of chronic illness. Older adults often present with confusion, lack of interest in life, or unwillingness to participate in the examination (providing answers such as “Why are you bothering me?”). Asking the questions, “Are you sad or blue?” and “Have you stopped doing things that once gave you pleasure?” are simple screening questions to detect depression. Nurses must ask specifically about plans for self-harm when self-destructive thoughts are stated. ▼

REFERENCES 1. National Institute on Aging. Research for a new age. 1993.

http://www.niapublications.org/ pubs/research/index.asp. 2. Ebersole P. Age-related changes. In: Ebersole P, et al., editors.

Toward healthy aging. Human needs and nursing responses. Philadelphia: Mosby; 2004. p. 79-108.

3. Siegel L. Are telomeres the key to aging and cancer? 2004. http://gslc.genetics.utah.edu/ features/telomeres.

4. Tilley A. Ageing. An overview. 2002. http://www. ibmsscience.org/general/ageing.htm.

5. Sohal RS. Role of oxidative stress and protein oxidation in the aging process. Free Radic Biol Med 2002;33(1):37-44.

6. Flacker JM. What is a geriatric syndrome anyway? J Am Geriatr Soc 2003;51(4):574-6.

7. Gleason OC. Delirium. Am Fam Physician 2003;67(5): 1027-34.

8. Foreman MD, et al. Delirium in elderly patients: an overview of the state of the science. J Gerontol Nurs 2001;27(4):12-20.

9. Inouye SK, et al. Clarifying confusion: the confusion assess- ment method. A new method for detection of delirium. Ann Intern Med 1990;113(12):941-8.

10. Resnick. Preventing falls in acute care. In: Mezey M, et al., editors. Geriatric nursing protocols for best practice. New York: Springer; 2003. p. 141-64.

11. Bischoff HA, et al. Identifying a cut-off point for normal mobility: a comparison of the timed ‘up and go’ test in com- munity-dwelling and institutionalised elderly women. Age Ageing 2003;32(3):315-20.

12. Nowalk MP, et al. A randomized trial of exercise programs among older individuals living in two long-term care facili- ties: the FallsFREE program. J Am Geriatr Soc 2001;49(7):859-65.

13. Hodgkinson B, et al. Maintaining oral hydration in older adults: a systematic review. Int J Nurs Pract 2003;9(3):S19-28.

14. van Staveren WA, et al. Regulation of appetite in frail per- sons. Clin Geriatr Med 2002;18(4):675-84.

15. Herr K. Chronic pain: challenges and assessment strategies. J Gerontol Nurs 2002;28(1):20-7; quiz 54-5.

16. Horgas A, McLennon S. Pain management. In: Ebersole P, et al., editors. Toward healthy aging. Human needs and nursing responses. Philadelphia: Mosby; 2004. p. 229-50.

sion, while hypothyroidism may have few, if any, symptoms.23 Many older adults have subclinical thyroid disease and may suffer cardiac disease and osteoporosis before treatment is initiated; nurses should carefully assess complaints of fatigue in all older adults.

Assessment. To assess endocrine problems, the thyroid can be palpated in the neck as the trachea is stabilized and the person is asked to turn his head. Thyroid stimulating hormone remains the preferred indicator of thyroid disease (the normal range for adults is 0.4 to 4 µIU/mL) and needs to be closely monitored in older adults taking amiodarone (Cardarone and others) for heart disease.24

Depression is the most commonly occurring men- tal health problem for older adults, especially in those with chronic illness and those living in institu- tions.25 As the rate of suicides is highest in older white men, early assessment and treatment of depression is paramount.26 However, many older adults avoid complaining of feeling sad or depressed, which can make it difficult for health care practition- ers to recognize this problem in their patients.27

Additionally, the societal expectation that older adults are tired, complain, and have little interest in life may disguise the most common symptoms of depression: fatigue, somatic symptoms that don’t seem to have an origin in pathology, and a decrease in activities the person formerly enjoyed. Failure to recognize that most older adults find satisfaction and joy in life can deprive patients of treatment that could vastly improve the quality of their lives.

Assessment. Kurlowicz recommends screening for depression in the following high-risk groups: alcohol or substance abusers; people with dementia, stroke, cancer, arthritis, hip fracture, myocardial infarction, chronic lung disease, or Parkinson dis- ease; those suffering from functional disability, espe- cially new onset; widows or widowers; caregivers; and those who are isolated or lacking social sup- port.28 Furthermore, certain medications, especially digitalis (Digoxin and others), propranolol (Inderal and others), and benzodiazepines, are associated with depression.29

50 AJN ▼ October 2004 ▼ Vol. 104, No. 10 http://www.nursingcenter.com

Complete the CE test for this article by using the mail-in form available in this issue or visit NursingCenter.com’s “CE Connection” to take the test and find other CE activities and “My CE Planner.”

THE 8TH ANNUAL NURSES IMPROVING CARE FOR HEALTHSYSTEM ELDERS LEADERSHIP CONFERENCE January 31 to February 1, 2005

Marriot Financial Center Hotel, New York City

For more information, visit www.nicheprogram.org.

17. Eaton DA, Roland PS. Dizziness in the older adult, part 1. Evaluation and general treatment strategies. Geriatrics 2003;58(4):28-30, 3-6.

18. Wyman JF. Treatment of urinary incontinence in men and older women: the evidence shows the efficacy of a variety of techniques. Am J Nurs 2003;(Suppl):26-35.

19. Thurlow KL. Infections in the elderly: part 2. Emerg Med Serv 2002;31(4):44.

20. Aspinall R. Age-related changes in the function of T cells. Microsc Res Tech 2003;62(6):508-13.

21. Storm-Dickerson TL, Horattas MC. What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 2003;185(3):198-201.

22. Standards of medical care in diabetes. Diabetes Care 2004;27(Suppl 1):S15-35.

23. Margolius S, Reed R. Thyroid disease. In: Ham R, et al., editors. Primary care geriatrics. A care-based approach. St. Louis, MO: Mosby; 2002. p. 517-24.

24. Demers LM, Spencer CA. Laboratory medicine practice guidelines: laboratory support for the diagnosis and moni- toring of thyroid disease. Clin Endocrinol (Oxf) 2003;58(2):138-40.

25. Birrer RB, Vemuri SP. Depression in later life: a diagnostic and therapeutic challenge. Am Fam Physician 2004;69(10):2375-82.

26. Chima F. Elderly suicidality. Human behavior and social environment perspective. J Human Behav Soc Environ 2002;6(4):21-6.

27. Nelson J, Battista D. Diagnosis and treatment of late-life depression. Clin Nurse Spec 2002:69-71.

28. Kurlowicz L. Depression in older adults. In: Mezey M, et al., editors. Geriatric nursing protocols for best practice. New York: Springer; 2003. p. 185-205

29. Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 2003;58(3):249-65.

30. Willlams CM. Using medications appropriately in older adults. Am Fam Physician 2002;66(10):1917-24.

31. Family Practice Notebook. Lab markers of malnutrition. 2000. http://www.fpnotebook.com/ PHA48.htm.

32. Payne K. Total serum protein. 2004. http://my.webmd.com/ hw/health_guide_atoz/ hw43614.asp.

33. Veterans Health Administration, Department of Defense. VHA/DoD clinical practice guideline for the management of chronic kidney disease and pre-ESRD in the primary care setting. Washington, DC: Department of Veterans’ Affairs; 2001.

[email protected] AJN ▼ October 2004 ▼ Vol. 104, No. 10 51

GENERAL PURPOSE: To present registered professional nurses with an overview of the aging process and the factors that produce altered presentations of sev- eral illnesses in older adults.

LEARNING OBJECTIVES: After reading this article and taking the test on the next page, you will be able to • discuss the pathophysiology of the aging

process and the ways it predisposes older adults to illness.

• describe the assessment process for older adults, as well as the possible causes of abnormal findings.

• list specific examples of the altered presentation of common disorders in older adults.

To earn continuing education (CE) credit, follow these instructions:

1. After reading this article, darken the appropriate boxes (numbers 1–17) on the answer card between pages TK and TK (or a photocopy). Each question has only one correct answer. 2. Complete the registration information (Box A) and help us evaluate this offering (Box C).* 3. Send the card with your registration fee to: Continuing Education Department, Lippincott Williams & Wilkins, 333 Seventh Avenue, 19th Floor, New York, NY 10001. 4. Your registration fee for this offering is $13.95. If you take two or more tests in any nursing journal published by Lippincott Williams & Wilkins and send in your answers to all tests together, you may deduct $0.75 from the price of each test.

Within six weeks after Lippincott Williams & Wilkins receives your answer card, you’ll be notified of your test results. A passing score for this test is 12 correct answers (77%). If you pass, Lippincott Williams & Wilkins will send you a CE certificate indicating the number of contact hours you’ve earned. If you fail, Lippincott Williams & Wilkins gives you the option of taking the test again at no additional cost. All answer cards for this test on Presentation of Illness in Older Adults must be received by October 31, 2006.

This continuing education activity for 2 contact hours is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing nursing educa- tion (CNE) by the American Nurses Credentialing Center’s Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 00012278, category A). This activity is also provider approved by the California Board of Registered Nursing, provider number CEP11749 for 2 contact hours. Lippincott Williams & Wilkins is also an approved provider of CNE in Alabama, Florida, and Iowa, and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continu- ing education requirements as Type 1. *In accordance with Iowa Board of Nursing administrative rules governing grievances, a copy of your evaluation of this CNE offering may be submitted to the Iowa Board of Nursing.

CE2 Continuing Education

HOURS