Common Physical Care Problems of the Elderly

NURSING INTERVENTIONS TO PROMOTE MOBILITY

By immediately addressing mobility needs, you can often quickly get the patient back to her former level of activity, and avoid potential complications. The elderly need to be educated about engaging in activity throughout life that will help maintain optimal mobility (Health Promotion Points 40-1). It has been proven that walking 30 minutes a day is very beneficial, but doing this even three times a week is better than not walking at all. Strength training with resistance devices, using free weights or weight machines such as Nautilus, can help prevent muscle wasting, maintain bone density, and improve balance and walking endurance for elders even in their 90s. Dancing, gardening, home maintenance, and swimming can also promote mobility.

Participating in craft activities and arthritis programs can assist with preservation of fine motor movement. Proper treatment for arthritis and osteoporosis will help prevent immobility problems. Estrogen replacement therapy (ERT) and adequate dietary or supplemental calcium and vitamin D in combination with weight-bearing exercise are protective against osteoporosis in women. However, ERT’s potential side effects make its use controversial. Drugs such as alendronate sodium (Fosamax), risedronate sodium (Actonel), ibandronate sodium (Boniva), calcitonin-salmon (Miacalcin), and raloxifene hydrochloride (Evista) can help rebuild bone or stop its loss. Anti-inflammatory drugs such as nabumetone (Relafen) or diclofenac sodium (Voltaren) can also help maintain mobility. Etanercept (Enbrel), an immunomodulator, may be used for those patients with rheumatoid arthritis if they have poor response to other treatment.

The period of confined bed rest during illness needs to be as limited as possible. Merely transferring a patient from the bed to a chair has beneficial effects. Teach the bed rest patient active range-of-motion (ROM) activities and isometric exercises (applying pressure against resistance). An example of isometric exercise is instructing the patient to push into the bed with her hands and attempt to lift her hips, while sitting up in bed. If the patient is incapable of performing these exercises, assist with passive ROM exercises to maintain joint flexibility and help prevent muscle wasting. If the elderly patient is noncommunicative, assess for pain using the guidelines in Chapter 31 prior to attempting a ROM program.

With hospital stays so short, every effort to restore the patient to her maximum mobility potential should begin as soon as possible. When it is medically indicated, ambulate the patient with assistance. Make sure that appropriate assistance devices such as sturdy footwear, eyeglasses, walkers, and canes are brought from home. If the individual is too weak, seek a physical therapy (PT) referral. Such rehabilitative services are essential to promote quality of life for the elderly.

The nursing home setting allows the nurse to monitor and promote mobility over an extended period of time. All patients should be considered for assisted ambulation unless an underlying condition/illness (paralysis, severe cardiac disease) prevents it. The elder who is not ambulated will deteriorate and eventually be unable to walk. Although staff may be reluctant to encourage ambulation of a resident with an unsteady gait, many patients would rather risk a fall than be placed in a wheelchair. You may have to weigh the risk of the elder falling versus the negative effects of prolonged immobility.

PREVENTING FALLS

Falls are one of the most common safety problems for the elderly. Approximately one third of those over 65 years old and one half of those over 80 fall each year. Falls may not always result in serious injury; however, hip fractures are a leading cause of hospitalization and placement in long-term care facilities, with approximately 309,500 hip fractures reported annually (Centers for Disease Control and Prevention, 2006). Falls are the most common cause of traumatic brain injuries and accounted for 46% of falls that are fatal among older adults (Centers for Disease Control and Prevention, 2007).

Once an older person has fallen, there is the fear of falling again. This may cause limitation of activities and increased risk for the harmful effects of immobility. Caregivers and family members may also place restrictions on mobility and limit activities to prevent another fall.

Changes in the elder’s posture, balance, gait, and vision contribute to the risk of a fall (Health Promotion Points 40-2). Environmental factors such as clutter in walking areas, inadequate lighting or glare, improper footwear, and unsafe furnishings such as scatter rugs predispose to falls.

Medications frequently contribute to falls. With each additional medication consumed, the risk of falls is increased. Sedatives, hypnotics, and tranquilizers can decrease alertness and reaction time. Diuretics, antihypertensives, and antihistamines increase the risk of postural (or orthostatic) hypotension (unusually low blood pressure upon standing), which may cause the patient to become light-headed and fall (Safety Alert 40-1).

Most falls occur in the bedroom or bathroom. The home environment should be assessed to see how the patient navigates in these areas during activities of daily living. The patient and family should be educated about risk factors and made aware of measures to avoid falls. If the patient is cognitively impaired, a toileting schedule may be used to discourage self-toileting and a potential fall. Patients who unsafely attempt these actions should not be left unobserved for extended periods of time. The use of a mobility alarm can alert the staff that the patient has attempted to move unassisted.

Elderly patients need to be moved slowly out of bed to prevent possible orthostatic hypotension. Elastic support stockings may help prevent or lessen such hypotension. They should use appropriate footwear. A gait belt should be used until independent ambulation is established. Assistance devices, such as a cane or walker that can provide a wider base of support and increase stability, may be needed.

The call bell should be readily available to the patient who is in bed, in a chair, or in the bathroom. Beds should be in the low position with brakes engaged, unless a caregiver is at the bedside. Bells should be answered promptly to avoid unsafe attempts to stand or walk. Health care team members need to remember to keep walking paths clear, adjust lighting, and wipe up spills from the floor as soon as they are noticed.

Protective devices should be used only when there is a documented reason and only after the patient or her guardian has given permission, and they are ordered by the physician. This includes vest or waist devices, safety belts, and geri-chairs. Federal Omnibus Budget Reconciliation Act (OBRA) regulations are very specific about when and what types of devices are permissible. Check the guidelines at your place of employment and follow policy.

Both the patient and significant others need to be taught about hazards in the home and how to prevent falls in the home. If the individual is being discharged from the hospital and lives alone, a referral may be made for a member of the health care team to assess the home for potential safety hazards. Family members and significant others need to be encouraged to make regular visits to the elder’s home to check for unsafe conditions (Health Promotion Points 40-3).

Discourage the elderly from climbing a ladder or standing on a chair to reach high places. If a person needs to reach a high area, a stepstool with a broad base of support should be used. If balance is unsteady, the individual should be instructed not to reach for objects above head level. Devices to assist with reaching can be purchased to avoid the temptation to reach overhead.

URINARY INCONTINENCE

Incontinence is one of the most common reasons that elder adults are institutionalized. Families who cope with other health problems are often unable to deal with incontinence. Embarrassment, social withdrawal, depression, and low self-esteem are common for the elderly patient who is incontinent.

Urinary incontinence is not a normal consequence of aging. Incontinence can be the result of an acute condition or a chronic problem. Approximately 30% of community-dwelling elders and more than 50% of nursing home residents are incontinent of urine (Palmer & Newman, 2004). Causes and treatment of incontinence are presented in Chapter 29. Temporary incontinence may develop as a result of an acute illness. If the patient is assisted to regain continence as soon as the acute episode is over, permanent incontinence can often be avoided. An underlying cause should always be sought when incontinence occurs. Bowel incontinence is not as common a problem and is covered in Chapter 30.

CONSTIPATION AND FECAL IMPACTION

Constipation is a common problem among the elderly. Many older people believe anything other than a daily bowel movement is abnormal. Before deciding whether constipation is a problem, assess the frequency, amount, and consistency of stools as well as the possible contributing factors addressed in Chapter 30.

Fecal impaction can rapidly develop in the ill elder who, while on bed rest, is receiving pain medication and not eating a normal diet. Signs and symptoms may include abdominal cramping or rectal pain, abdominal distention, the passing of small amounts of liquid stool, and loss of appetite. Digital examination of the rectum often reveals a mass (Safety Alert 40-2). You need to check whether a physician’s order is required at your employing institution before performing this procedure.

NURSING INTERVENTIONS FOR NUTRITIONAL SUPPORT

Meals can be made more enjoyable for the patient in a long-term care setting by serving the food in an attractive manner and by making the environment as pleasant as possible. Assess for social problems such as annoying table company, and then appropriately address the issue. A nutritionist can assist in determining the nutritional needs of the institutionalized patient. A liquid dietary supplement may be necessary to help the elderly patient meet dietary needs. Tube feedings and parenteral feedings may have to be used if attempts at oral feedings fail. Patients with dysphagia (difficulty swallowing) are at high risk for developing a nutritional deficit. These patients need to sit upright or in a high Fowler’s position and be fed very small amounts to avoid aspiration. Liquids may need to be thickened. The chin should be tucked when swallowing. The patient should remain in an upright position for 45 to 60 minutes after eating. Providing a stress-free environment is essential because stress can make dysphagia more pronounced.

VISION DEFICITS

Age-related eye changes can be debilitating if they are not recognized and corrected, and may result in a severe limitation of the patient’s overall independence. Visual accommodation (the ability to focus on near and far objects) decreases with age as a result of weakening of the muscles that control the lens. Beginning in their 40s, most people need bifocals or reading glasses to correct presbyopia (age-related decreased ability to focus on near objects) and to compensate for loss in accommodation.

The lens of the eye may yellow with age, causing a decline in color perception in the elderly. Because the iris has decreased ability to respond to light changes, the elder may experience difficulty adjusting from light to dark.

As the blood supply to the retina decreases, depth perception, peripheral vision, and night vision decrease. Any loss of peripheral vision should be further evaluated to rule out glaucoma. Glaucoma, a common disorder of the aging eye, is the accumulation of fluids inside the eye that exert pressure on the optic nerve, eventually causing blindness. It is often asymptomatic and a frequent cause of preventable blindness.

Frequently the elderly develop cataracts, a clouding of the lens. Cataracts occur to some extent in almost all elders, especially those with diabetes. Perhaps the most debilitating eye disorder is age-related macular degeneration, in which the elderly person gradually loses acute, central, and color vision. Unfortunately, there is no proven effective way to halt this disorder (Complementary & Alternative Therapies 40-1). Many medications, especially maintenance drugs such as oral hypoglycemics and thyroid replacement hormones, can affect vision. Thus a careful assessment of the patient’s medications, as discussed later in this chapter, is imperative.

HEARING DEFICIT

The inability to hear high-frequency sounds usually begins to become noticeable by late middle age. Presbycusis is the inability to hear high-pitched sounds and the inability to hear spoken words. This problem is often intensified with the presence of background noise. Tinnitus, or ringing in the ears, may also cause a further loss of hearing.

Presbycusis is commonly exacerbated by cerumen (earwax) accumulation. Removal of a wax impaction can make a significant difference in the elder’s hearing ability. It is of utmost importance to assess frequently if cerumen is contributing to the hearing loss. Products such as Debrox (carbamide peroxide) are effective in wax removal and can be periodically continued at home.

Hearing loss can lead to ongoing frustration and embarrassment for the individual. The person with a hearing deficit may complain of others mumbling, as well as have a reduced tolerance for loud noises. She may pretend to hear, when she really does not understand what has been communicated. This becomes an important concern when attempting to communicate about health-related issues. Hearing should be checked periodically.

NURSING INTERVENTIONS FOR POLYPHARMACY

A thorough medication history is the initial step in preventing polypharmacy. A comprehensive assessment can help maintain a therapeutic medication regimen, identify educational needs, eliminate unnecessary medications, and reduce the risk of adverse drug reactions (Nursing Care Plan 40-1). Specifically, questions should be asked that provide information about the patient’s current prescriptions, OTC drugs, and any vitamins and herbal preparations being taken. Ask the patient to bring a bag with all the drugs she takes at home. Assessment data should also include the patient’s current administration schedule, knowledge about her medications, medication-related problems, noncompliance problems, frequency of physician visits, sensory deficits, mental and physical disabilities, ability to purchase and obtain medication, and the use of alcohol and caffeine. Ideally, a pharmacist or physician should address these questions. However, the nurse should be prepared to assess the patient’s drug history initially as well as continue to gather information so that a therapeutic medication regimen may be maintained.

In a long-term care facility, it is imperative to assess continually the number of medications, side effects, and the necessity for each being administered to avoid a potentially dangerous situation (Assignment Considerations 40-1).

You should attempt to reduce the complexity of the medication regimen by improving self-medication practices. Developing a drug reminder system and a schedule that is appropriate or compatible with the individual’s lifestyle can help decrease confusion and increase compliance. A referral to a home health nurse can provide for monitoring of compliance at home. A frequently used medication reminder system is the daily/weekly pill container that is available at pharmacies. A homemade egg carton container may be substituted for the elder affected with arthritic hands. Other reminder tactics can include the use of check-off systems, calendars, color- or symbol-coded medication bottles, an alarm clock, or a voice-mail system. The use of cueing with daily events such as brushing teeth can also be helpful to promote compliance.

1. Prevention of mobility problems in the elderly can be addressed by encouraging: (Select all that apply.)

    

2. Factors that may contribute to falls in the elderly are: (Select all that apply.)

    

3. One of the most common reasons that elder adults are placed in long-term care facilities is:

4. Dietary substances that help prevent constipation include: (Select all that apply.)

    

5. Dietary recommendations for the elderly include:

    

6. The elder with a sensory impairment as a result of the aging process may:

7. Measures to try to prevent the development of macular degeneration include:

8. Drug toxicity occurs more easily in the elderly due to: (Select all that apply.)

    

9. Drug use assessment to identify concerns related to polypharmacy should include:

10. The condition most likely to cause a vision loss in the elderly is ________________________________. (Fill in the blank.)

CRITICAL THINKING ACTIVITIES ? Read each clinical scenario and discuss the questions with your classmates.