Physiological basis of the care of the elderly client

1. Physiological basis of the care of the elderly client The Integument; Sensation: Hearing, Vision, Taste, Touch

2. Patient scenario • You are assigned to care for MX, an 87 year old obese (264 lbs) woman. • She arose from a sitting position and experienced severe low back pain 3 weeks ago. • Diagnosis: herniated disks L4-5 and L5-S1. • She states her legs feel like “noodles” and she can’t feel them very well. • Her temperature has increased from 98.2 to 100.6.

3. Informal evaluation What additional information do you need? • Subjective information • Objective information • Psychosocial information

4. Normal functions of the skin • Regulation of body fluids—prevent loss from deeper layers • Regulation of temperature—blood vessels in dermis • Regulation of immune function—prevent microbe invasion • Production of vitamin D activated by UV light • Sensory reception—detect touch, pressure, temperature, pain

5. Structure of the skin

6. What the skin does with age…. • Fine and coarse wrinkles • Rough, leathery texture • Mottled hyperpigmentation • Telangiectasia (dilated red splotches) • Actinic keratoses • Facial expression • Body image

7. Normal changes of aging • Pigmentation changes—photoaging • Decrease in eccrine (total body), apocrine (armpits, genital, areolar, anal), sebaceous glands → dry skin • Decrease in number of blood vessels • Loss of eyelid elasticity • Decreased elastin, wrinkling • Adipose tissue redistributes to waist & hips

8. Normal changes of aging • Changes in pigmentation • Decreased melanocytes with decreased photoprotection • Delayed wound healing • Onychomycosis common • Decreased touch receptors, corresponding slowing of reflexes and pain sensation

9. Specific changes in epidermis • Contains less moisture • Epidermal mitosis slows, healing takes longer • Manufacture of vitamin D less efficient

10. Sidebar: What Vitamin D Does! • Vitamin D promotes anti-inflammatory actions systemically to reduce the risk of coronary heart disease • Vitamin D level is inversely correlated with coronary artery calcification • Vitamin D promotes absorption of calcium and phosphorus by bone

11. Risks of age related changes in skin

12. Facilitating integumentary health • Avoid drying of the skin in the elderly! • Promote skin nutrition and hydration through bath oils, lotions and massage • Vitamins and vitamin supplements • Avoid excessive bathing • Early treatment of pruritis

13. Specific changes in the dermis • Elastin decreases in quality but increases in quantity leading to wrinkles • Vascularity decreases • Capillaries become thinner and more easily damaged • Decline in touch and pressure sensations

14. Specific changes in the subcutaneous layer • Subcutaneous tissue thinner in the face, neck, hands and lower legs • More visible veins • Fat distribution more obvious in abdomen and thighs in women, the abdomen in men

15. Changes in hair and nails • Gray or white hair • Hair becomes more coarse and thin • Gradual loss of pubic and axillary hair • Facial hair in women • Ear and nose hair in men • Hair loss, men > women • Nails duller, yellow or grey • Nail growth slows • Longitudinal striations

16. Changes in eccrine and apocrine glands • Decreased sweating and thermoregulation • Amount of sebum decreases, causing less water in stratum corneum resulting in xerosis

17. Pruritis • Most common dermatologic complaint in the elderly • Drying of the skin by any means • Diabetes, atherosclerosis, hyperthyroidism, urea, liver disease, cancer, pernicious anemia, some psychiatric diseases • Problem: traumatizing scratching

18. Treatment—pruritis • Bath oils, massage • Moisturizing lotions • ZnO2 may be applied topically

19. Damage due to sun • Photoaging—long-term UVR damage • Exposed areas of the face, neck, arms, and hands • Freckling, loss of elasticity, damaged blood vessels, weathered appearance • May result in actinic keratosis, a precancerous lesion

20. Sun protection • Avoid tanning and sunburn • Sunscreen daily, SPF 30 • Moisturize • Protective clothing • Protective accessories that block UV rays: umbrellas, sunglasses, window shades and car window tints

21. Sun sensitizing drugs • Antibiotics: Doxycycline, tetracycline, quinolones • Antidepressants: tricyclic antidepressants • Antihistamines: diphenhydramine • Nonsteroidalanti-inflammatories: ibuprofen • Diuretics: furosemide, hydrolorothiazide • Antihypertensives: Cardizem, diltiazem • Cholesterol drugs: simvastatin, lovastatin • Hypoglycemics: glipizide, glyburide • Sulfonamides: sulfadiazine, sulfamethoxazole

22. Actinic keratosis • Most common precancerous lesion • More common in men • 1 in 1000 will progress to skin cancer (usually squamous cell carcinoma) within 1 year • Ill-defined border • Back of hands, face, forearm, V of neck, nose, ears, bald scalp

23. Skin cancer—major types • Basal cell carcinoma—waxy, pigmented, may be erythematous, papular or scaly macular • Squamous cell carcinoma— firm to hard, erythematous, nodular or ulcerated nodular, especially on dorsum of hands, forearms and face

24. Education regarding skin cancers • Those who have had one nonmelanoma skin cancer is at risk for future skin cancers • Any suspicious lesion should be biopsied • Risk for skin cancer associated with total amount of time spent in the sun • Basal cell rarely metastasizes • Squamous cell can metastasize

25. Skin tears • Occur easily in frail elderly • Classification • Category 1: linear or flap type without tissue loss • Category 2: partial tissue loss • Category 3: full thickness tissue loss

26. Risk factors for decubitus ulcers • Fragile skin that damages easily • Poor nutritional status • Reduced sensations of: pressure and pain • Elderly have more frequent encounters with conditions that contribute to skin breakdown

27. Lab indicators of pressure ulcer risk • Serum albumin—indicator of protein stores • 3.5-5.0 g/dl is normal • Prealbumin—indicator of protein deficiency • >15 mg/dl is normal • Lymphocyte count—indicator of protein malnutrition • 2000-3500 µL is normal

28. Pressure ulcers • Can develop on any part of the body • Caused by tissue anoxia and ischemia • Most common sites: Sacrum (most distal portion of spine) Greater trochanter (head of femur) Ischialtuberosities (protuberance of proximal hip)

29. Use of the Braden scale Risk of developing pressure ulcers based on evaluation of six areas: • Sensory perception • Moisture • Activity • Mobility • Nutrition • Friction and shear

30. Example of Braden Scale Form

31. Preventing Pressure ulcers Prevention is based on 6 areas of Evaluation: • Avoid unrelieved pressure • Encourage activity • Turn every hour • Pillow • Flotation pad • Encourage outside activities • Avoid shearing forces

32. Skin health promotion and recovery requires: • High protein, vitamin rich diet • Good skin care • Bath oils and lotions • Keep skin dry • Massage bony prominences • Range of motion at least daily

33. Stage 1—signs/symptoms • Persistent redness (erythema or hyperemia) • Ischemia (erythema with edema and induration) • Skin is still intact • Erythema does not blanch when pressure applied

34. Stage 2—signs and symptoms • Partial skin thickness loss • Appearance of an abrasion, a blister, a shallow ulcer

35. Stage 3—signs and symptoms • Full skin thickness loss • Subcutaneous tissue is exposed • Appearance of deep ulcer • May or may not be undermining of surrounding tissue

36. Stage 4—signs and symptoms • Full skin thickness loss • Subcutaneous tissue loss • Muscle and or bone is lost • Deep ulceration • May be accompanied by: •Necrosis •Sinus tract formation •Exudate •Infection

37. Interventions • Hyperemia—relieve pressure, use of adhesive foam • Ischemia—skin protectant solutions, clean with normal saline at least daily if skin broken • Necrosis—transparent dressing permeable to oxygen and water vapor, irrigate thoroughly, topical antibiotics • Ulceration—debridement is required

38. Principles of pressure ulcer healing • Debridement of nonviable (necrotic) tissue • Keep wound clean • Dress to keep moist wound bed • Prevent and treat infection

39. Cellulitis • Occurs when one or more types of bacteria enter through a break in the skin • Most common types of bacterial causes of cellulitis • Streptococcus • Staphylococcus • MRSA is increasing • The most common location is the lower leg

40. Age related changes of the eye • Skin surrounding eye becomes thinner • Eyelid musculature decreases • Ectropion • Entropion • Decreased visual acuity, color discrimination • Atrophy of lacrimal glands • Increase intraocular pressure (IOP) • Arcussenilis

41. Light sensitivity

42. Common visual impairments • Macula absorbs excess blue and UV light, promoting visual acuity. Macular degeneration affects central vision and visual acuity • Cataracts—clouding of the lens covering the eye • Glaucoma--⇧IOP causes optic nerve damage

43. Risks for macular degeneration • Age > 50 years • Cigarette smoking • Family history of macular degeneration • Increased exposure to UV light • Caucasian • Light colored eyes • Hypertension or cardiovascular disease • Lack of dietary antioxidants and zinc

44. Macular degeneration

45. Risks for cataracts • Increased age • Smoking and alcohol • Obesity • Diabetes, hyperlipidemia, hypertension • Eye trauma • Exposure to sun • Long term use of corticosteroid medications • Caucasian race

46. Cataracts

47. Risks for glaucoma • Increased IOP • Age > 60 years • Family history of glaucoma • Myopia, diabetes, hypertension, migraines • African American ancestry

48. Glaucoma

49. Medications that can affect vision in the elderly • Β-blockers → bradycardia, CHF, syncope, bronchospasm (Timoptic, Betagan) • Adrenergics → palpitations, hypertension, tremor (Lopidine) • Miotics/cholinesterase inhibitors → bronchospasm, N/V, abdominal pain (pilocarpine) • Carbonic anhydrase inhibitors → renal failure, hypokalemia, diarrhea (Trusopt, Azopt)

50. Hearing changes • Hearing impairments and loss affect communication and desire to interact • Cerumen tends to be drier, harder • Pruritis of canal is common • Most hearing changes are attributable to exposure to loud sounds