Course: Health Assessment�Unit Title: Assessment of the Elderly

Population: Elderly

Dr. Theresa Jones PhD, MSN, BSN, AASN, RN-BC

Developed: June 2018 Copyright Nurses International 2018

Module Goals

Learner Outcome:

• At the completion of these modules the learner will demonstrate knowledge and skills to perform a complete health assessment of an individual.

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Module Objectives

• Outline data collection techniques specific to the care of the elderly
• Differentiate between performing an assessment of a healthy adult and an elderly person.
• Explain how assessment techniques vary across the lifespan.

Medication History

• Prescription medications
• Over the counter medications
• Vitamins and supplements
• Herbal medications
• Topical medications
• Ability and system for taking medications

Substance Abuse

• Tobacco
• Alcohol
• Drugs
• Include prescription opiates, benzodiazepines

Symptom review of common problems

• Insomnia, sleep changes
• Constipation
• Weight loss
• Fatigue
• Preoccupation with bodily functions
• Mood changes
• Cognitive decline

Vital Signs, Height, and Weight

• Elevated BP due to atherosclerosis
• Normal respiratory rates may be elevated
• Decreased normal temp

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• Height: monitor ht, older adults may lose several inches in height

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• Weight: Monitor weight. Ask if there has been more than 5 lbs in the last 2 months, and was the weight loss intentional or unintentional.
• What was the previous years weight?

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What would the nurse do?

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• The nurse is interviewing a client and discovers that the client has had an unintentional weight loss of 15 lbs. over the last two months.
• What questions would help the nurse identify the causative factors related to the weight loss?

Skin and Hair Changes

• Skin loses elasticity, thins, wrinkles and brown colored macules

develop

• Vitiligo (loss of melanocytes) increases with age and telangiectasias may

appear

• Decreased nail growth and nails become thicker
• Decreased thermoregulation due to decreased subcutaneous fat.
• Skin becomes dry and flaky due to decreased function of sweat glands
• Alopecia may occur as well as loss of hair in the axilla and pubic region and

hair on the eyebrows may become coarse.

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Increased risk for pressure ulcers

• This is one of those areas where you shine, NURSES!! Good nursing care PREVENTS pressure ulcers.​
• Monitor the pressure areas by measuring length, width and depth of to gauge of the ulcers​
• Turn the patient every two hours​
• Keep the patient skin clean and dry​
• Place the pillow between the pressure areas to prevent friction and pressure​
• Teach active and passive exercises​
• Use paper tape to secure dressing (avoid skin tears)

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Vision, and Eyes Changes

• Atrophy of periorbital tissue
• Decreased tear production and changes in peripheral vision occur
• Atrophy and yellowing of the conjunctiva
• Slower adaptation to light and color vision declines
• Presbyopia

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Hearing

• Atrophy of external auditory canal
• Drier cerumen
• Thicker tympanic membrane
• Changes in the inner ear: loss of high and low frequency (conductive, sensorineural, mixed hearing loss)
• Presbycusis or generalized hearing loss

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Communication during Assessment

• Visually impaired?​
• Hearing Impaired?​
• Sit or stand at eye level in front of the patient in full view​
• Face the older adult while speaking​
• Do not cover your mouth​
• Provide diffuse, bright non-glare lights​
• Encourage the older adult to use any assistive devices that they may have: glasses, hearing aids

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Interview and History Taking

Assess for sensory deficits that may affect communication

• Hearing: speak clearly, (don’t yell) look directly at patient, patient should wear hearing aids if available.
• Vision: glasses if available

Mental Awareness

• Long term memory, short term memory, allow extra time for answering questions.
• Consider interviewing family/caregivers

What would the nurse do?

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• You are a community nurse performing a preventive health assessment on Chewei, a 77 year old male, well nourished client, who lives alone in a clean, small 3 room house in the local village. As you begin your assessment the client seems to demonstrate cognitive impairment as he does not seem to understand your questions.
• How do you proceed?

Chewei

1. First note that he is well nourished and lives in a clean home, indications that he is likely functioning independently.
2. Do not assume that he has a cognitive deficit, or does not understand
3. First assess for adequate communication. Chewei may be hard of hearing or blind, or both.
4. Establish trust. Chewei maybe refusing to participate in the assessment because he does not trust you or does not understand the reason for the assessment.
5. Once you have completed 1-4, then you can proceed with vital signs and a brief neuro assessment if pt continues to demonstrate a deficit

Head and Neck

• May have changes or limitations in the range of motion
• Prominence of neck vessels, decreased subcutaneous fat and muscle mass
• Decreased sense of smell
• Oral mucosa is drier due to decreased salivary gland activity
• Changes in taste, loss of teeth, dental disease, poor fitting dentures

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Respiratory

• Decreased cough reflex
• Calcification of tracheal cartilage
• Decreased lung elasticity
• Presence of basilar rales that disappear on deep inspiration
• Decrease in endurance of respiratory muscles
• Decreased forced vital capacity

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Cardiac

• Heart normal size if no disease.

• Cardiac output and strength of contraction may decrease lessening the older person’s activity tolerance.

• Heart rate returns to resting rate more slowly after exertion.

• S4 heart sound is considered normal in older adults.

• Blood vessel elasticity and efficiency decreases

• Sudden emotional and physical stresses may result in cardiac arrhythmias and heart failure.

GI/Hepatic

• More round abdomen, slower intestinal function
• Decrease medication absorption, impaired metabolism of drugs by the liver
• Incidence of colon cancer
• Signs and symptoms include a change in bowel function, rectal bleeding, and weight loss.
• Changes in bowel function may also be associated with changes in diet, exercise, and medications.
• Differentiate gastrointestinal pain from cardiac pain-presentation is very similar

Musculoskeletal, Bone Density

• Muscle mass decreases progressively • Decreased nerve conduction and muscle tone diminishes speed, strength, resistance to fatigue, reaction time, and coordination.
• Predisposed to fractures including vertebral compression fractures because bones become more fragile.
• Osteoporosis leads to a loss of total bone mass.
• Osteoarthritic changes in the joints can be observed and note any surgical scars from joint replacement surgeries.

Female Reproductive and Genitourinary

• Relaxed ligament support of breasts and involution of breast ductal tissue
• The vulva atrophies due to decreases in estrogen and reduced vascularity. Labia becomes atrophied and flattened, and the clitoris is a potential site for cancerous lesions.

• Vagina becomes drier and dyspareunia (difficult or painful intercourse) is also a common occurrence.

• The cervix and uterus decrease in size and the fallopian tubes and ovaries atrophy.

• Ovulation and estrogen production cease and prolapse of the uterus can occur in older females, especially those who have had multiple pregnancies.

• Inquire about voiding patterns and changes, bladder control, urinary incontinence, frequency and urgency.

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Male Reproductive and Genitourinary

• Penis and testes decrease in size and firmness of the testes decrease.

• Decreased testosterone

• Decreased sperm production

• Erection takes longer

• Urinary frequency, nocturia, dribbling, and problems with starting and stopping stream.

• Benign Prostatic Hyperplasia

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Central Nervous System

• Decreased brain size and weight, myelin in the white matter
• Decreased sensation in peripheral nerves
• Increased reaction time, and slowed information processing and memory retrieval
• Decreased reflex with increased nerve conduction rate.​
• Decreased ability of the hypothalamus to regulate body temp.​
• Decreased sense of balance or equilibrium.​
• Decrease sensitivity & sensation.​
• Irregular sleep stages.​
• Decreased motor coordination response.

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Sundowner syndrome

• Sundowning is a symptom associate with dementia and Alzheimer's​
• Also known as “late-day confusion.” ​
• Dementia patients: confusion and agitation may get worse in the late afternoon and evening. ​
• Symptoms much less pronounced earlier in the day.

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Assessing Hydration Status in the Elderly

• Difficult to assess due to physiologic changes
• Reduced skin turgor due to collagen changes and decreased subcutaneous

fat, evaluate skin turgor over sternal region

• Dry tongue from mouth breathing and decreased salivary gland activity
• Eyes sunken due to decreased periorbital fat
• Decreased urine output, tachycardia, and mental status changes are late signs in this population

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During your assessment USE

• Signs and symptoms are diminished in older adults.​
• Historically, researchers established normal lab values and symptoms based on YOUNGER populations.​
• Classic signs and symptoms of disease are often absent, blunted or atypical in the elderly.​
• Especially in the event of UTI’s, Pneumonia, and MI.

For example: UTIs in the Elderly​...

• May present with no other symptom, except Confusion.​
• Incontinence may be a sign of UTI.​
• Elevation of body temperature within normal limits.​
• Classic symptoms of fever, dysuria, frequency and urgency are often ABSENT.​
• Many elderly people do not drink enough water, and are usually somewhat dehydrated, which places them at risk for UTI.​
• Does your elderly patient have foley catheter for more than 3 days? If so, they are at high risk for UTI. (Rowe & Mehta, 2013)

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Pneumonia in the Elderly​

• Atypical presentation may include confusion with decreased appetite.​
• Tachycardia​
• Tachypnea​
• Feeling tired, increased fatigue​
• Fever, cough and chest pain may be absent.

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Acute Myocardial Infarction

• Change in behavior​
• Sudden onset of dyspnea with anxiety and confusion.​
• Weakness​
• Nausea and/or stomach pain​
• Classic symptoms of crushing chest pain and diaphoresis are often ABSENT.

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What would the nurse do?

• 82 year old Glenda and her 22 year old grandaughter Katara have been out at a community fair for several hours on a hot summer day. While walking 4 miles home from the fair, both Glenda and Katara become weak and nauseated. As they are in your neighborhood, they stop at your home and ask you for help
• How would your assessment differ between Glenda and Katara? Which patient would you assess first?
• What are your primary concerns with Glenda? With Katara?
• How do theirs risks differ based on age?

Glenda and Katara: Assess Glenda first

Risks based on age: Glenda is at higher risk for heart attack and stroke. Katara is of child bearing age and maybe pregnant.

Both are at risk for dehydration, although Glenda is likely at higher risk of dehydration simply due to age.

Primary concerns: Assess Glenda first as you must evaluate for heart attack and stroke. As women do not always have chest pain to indicate heart attack, you may need to call for emergency help for Glenda.

Assess Katara and inquire about pregnancy and assess for dehydration. Katara is at extremely low risk for heart attack or stroke.

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Psychosocial assessment of the Elderly

• RETIREMENT​
• ROLE CHANGES
• LONELINESS​
• DEPRESSION AND SUICIDE: see resource sheet, Preventing Suicide in Older Adults: ​
• http://www.mentalhealthamerica.net/preventing-suicide-older-adults

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Don’t forget to screen for depression and suicide

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Suicide screening in the Elderly (SAMHSA, 2012)

• There are several important risk factors for suicide in older adults. These include, among others:
• Depression
• Prior suicide attempts
• Marked feelings of hopelessness
• Co-morbid general medical conditions that significantly limit functioning or life expectancy
• Pain and declining role function (e.g., loss of independence or sense of purpose)

Continued next slide

Suicide screening in the Elderly (SAMHSA, 2012)

Continued

• Social isolation
• Family discord or losses (e.g., recent death of a loved one)
• Inflexible personality or marked difficulty adapting to change
• Access to lethal means (e.g., firearms)
• Alcohol or medication misuse or abuse
• Impulsivity in the context of cognitive impairment

“Suicide attempts are often more lethal in older adults than in younger adults. Older people who attempt suicide are often more frail, more isolated, more likely to have a plan, and are more determined than younger adults” (SAMHSA, 2012)

Glossary

• Atherosclerosis: fat and plaque deposits on the inner artery walls.
• Alopecia: scalp hair loss.
• Vitiligo:is a condition in which the skin loses its pigment cells (melanocytes).
• Telangiectasias: visible, bright red, fine dilated blood vessels.
• Presbyopia: the lens loses it’s elasticity which decreases the ability to see close objects.

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• Conductive hearing loss: interrupted transmission of sound waves through the outer and middle ear structures.
• Sensorineural hearing loss: results from damage to the inner ear, the auditory nerve, or the hearing center in the brain.
• Mixed hearing loss: combination of conductive and sensorineural hearing loss.

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Additional learning resources

Decoster, L., Van Puyvelde, K., Mohile, S., Wedding, U., Basso, U., Colloca, G., ... & Kimmick, G. (2014). Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations. Annals of Oncology, 26(2), 288-300.

Jarvis, C. (2011). Physical examination & health assessment (6th ed.). St. Louis, MO: Elsevier

Pilotto, A., Cella, A., Pilotto, A., Daragjati, J., Veronese, N., Musacchio, C., ... & Panza, F. (2017). Three decades of comprehensive geriatric assessment: evidence coming from different healthcare settings and specific clinical conditions. Journal of the American Medical Directors Association, 18(2), 192-e1.

SAMHSA (2012). Older Americans Behavioral Health Issue Brief 4: Preventing Suicide in Older Adults. https://acl.gov/sites/default/files/programs/2016-11/Issue%20Brief%204%20Preventing%20Suicide.pdf

Stanley, S., & Laugharne, J. (2014). The impact of lifestyle factors on the physical health of people with a mental illness.

Graphic and/or Photo Citations

Image:

https://www.tes.com/lessons/efmfNPiCGghoCg/atherosclerosis

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