PHYSICAL HEALTH PROBLEMS IN OLDER POPULATIONS

Although the problems may have developed slowly, the onset of symptoms is often acute.
Furthermore, the presenting symptoms may appear in other body systems before becoming
apparent in the affected system. The term “frail” is used to describe those elders who are at
highest risk for adverse health outcomes or geriatric syndromes. There are no standard clinical
criteria for frailty. According to the most widely agreed on definition, frail people are those who
are most vulnerable to significant problems because they meet one or more of the following
conditions:

• Being 85 years of age or older

• Being unable to perform IADLs or ADLs independently
• Suffering from multiple chronic diseases

As with specific illnesses, geriatric syndromes are never a normal consequence of aging.
Early intervention can prevent further complications and help to maximize the quality of life for
many older people.

Impaired Mobility
The causes of decreased mobility are many and varied. Common causes are Parkinson’s disease,
diabetic neuropathy, cardiovascular compromise, osteoarthritis, osteoporosis, and sensory
deficits. Environmental barriers and iatrogenic factors are also significant. Elderly patients
should be encouraged to stay as active as possible to avoid the downward spiral of immobility.
During illness, bed rest should be kept to a minimum, because even brief periods of bed rest
quickly lead to deconditioning and, consequently, to a wide range of complications. When bed
rest cannot be avoided, the patient should perform active range-of-motion and strengthening
exercises with the unaffected extremities, and the nurse should perform passive range-of-motion
exercises on the affected extremities. Frequent position changes help offset the hazards of
immobility. Both the staff and the patient’s family can assist in maintaining the current level of
mobility.
Dizziness
Older people frequently seek help for dizziness, which presents a particular challenge because
there are so many possible internal and external causes. For many, the problem is further
complicated because of an inability to differentiate between the true dizziness (a sensation of
disorientation in relation to position) and vertigo (a spinning sensation). Other similar sensations
include near-syncope and disequilibrium. The causes for these sensations range in severity from
minor, as in a buildup of ear wax, to severe, as in dysfunction of the cerebral cortex, cerebellum,
brain stem, proprioceptive receptors, or the vestibular system. Even a minor reversible cause,
such as an ear wax impaction, can result in a loss of balance and a subsequent fall and injury.
Because of the many predisposing factors, nurses should seek to identify potentially treatable
factors related to the dizziness. This impairment reduction strategy may reduce the vulnerability
of older persons to injury.
Falls and Falling
Falling is a common and preventable source of mortality and
morbidity in older adults. As the major cause of trauma in the elderly, falls are not often fatal but
do threaten health and the quality of life. Normal and pathologic consequences of aging that
contribute to increased falls include visual changes such as loss of depth perception,
susceptibility to glare, loss of visual acuity, and difficulty in light accommodation. Neurologic
changes include loss of balance, dizziness, loss of position sense, and delayed reaction time
cardiovascular changes may result in cerebral hypoxia and postural hypotension. Cognitive
changes include confusion, loss of judgment, and impulsive behavior. Musculoskeletal changes
include altered posture and decreased muscle strength. Use of many medications, medication
interactions, and alcohol precipitate falls by causing drowsiness, incoordination, and postural
hypotension. Osteoporosis-related fractures can have a negative effect on the individual’s ability
to maintain an independent living arrangement. Overall, elderly women who fall sustain a greater
degree of injury than do elderly men. The most common fracture occurring from a fall is hip
fracture resulting from the combined comorbidities of osteoporosis and the condition or situation
that provoked the fall. Studies have shown that elderly people who fall experience a greater
decline in their ability to perform ADLs and social activities, have a greater chance of being
institutionalized, and use more health care services than elderly people who do not fall. In
institutionalized elderly people, restraints in the form of physical modalities (lap belts; geriatric
chairs; vest, waist, and jacket restraints) and chemical modalities (medications) are known to
precipitate many of the injuries they were meant to prevent. Documented injuries and deaths
resulting from these restraints include strangulation, vascular and neurologic damage, pressure
ulcers, skin tears, fractures, increased confusion, and significant emotional trauma. The time
required to supervise restrained patients adequately is better used addressing the unmet need that
provoked the behavior that resulted in the use of restraint. Because of the overwhelming negative
consequences of restraint use, the accrediting agencies of nursing homes and acute care facilities
now maintain stringent guidelines concerning their use.

Urinary Incontinence

Urinary incontinence can be acute, developing during an illness, or it can develop chronically
over a period of years. The older patient often does not report this very common problem unless
specifically asked. Transient causes may be attributed to delirium and dehydration; restricted
mobility and restraints; inflammation, infection, and impaction; and pharmaceuticals and
polyuria (use the acronym DRIP to remember them). Once identified, the causative factor can be
eliminated. Established incontinence may be a result of neurologic or structural abnormalities.
The pelvic floor serves as the supporting mechanism or “hammock” for the bladder, uterus, and
rectum. It may have become weakened as a result of pregnancy, labor and delivery, prior pelvic
surgeries, or work that required prolonged standing or lifting. Dysfunction of the pelvic floor can
be greatly improved with Kegel exercises. Other measures that help prevent episodes of
incontinence include having quick access to toilet facilities and wearing clothing that can be
unfastened easily. The patient with this problem should be urged to seek help from appropriate
health personnel, because incontinence can be as emotionally devastating as it is physically
debilitating. Nurses who specialize in behavioral approaches to urinary incontinence
management are particularly successful in assisting an individual either to regain continence or
to significantly improve the level of continence. Although medications such as anticholinergics
may decrease some of the symptoms of urge incontinence (detrusor instability), their side effects
(dry mouth, slowed gastrointestinal motility, and confusion) may make them inappropriate
choices for the elderly. Various surgical procedures are also used to manage urinary
incontinence, particularly stress urinary incontinence. Detrusor hyperactivity with impaired
contractility is a type of urge incontinence that is seen predominantly in the elderly population.
In this variation of urge incontinence, the patient has absolutely no warning that he or she is
about to lose urine. When toileted, the patient often voids only a small volume of urine or none at
all, then experiences a large volume of incontinence after leaving the bathroom. The nursing staff
should be familiar with this form of incontinence and should not show disapproval to the patient.
Many patients with dementia suffer from this type of incontinence because both incontinence
and dementia are a result of dysfunction in similar areas of the brain. Prompted, timed voiding
can be of assistance to these individuals, although clean intermittent catheterization is the
preferred management. -