As We Age: Common Health and Safety Concerns of the Elderly

Many of us assume that disease is part of the normal aging process. It is not. Aging is not a process of decline; it is a process of becoming, of continuing to meet life's challenges and of growing into a complete human being. The second half of life brings many changes: new career, retirement, widowhood, a new home, an "empty nest." Many of these changes bring new freedom and opportunities. Others may present problems, many of which can be addressed if we plan for them.

Our hope is that we are assisting you in the study of gerontology. Gerontology is the study of all aspects of aging. Geriatrics, on the other hand, is the study of the diseases of aging. We want you to be aware of normal gerontologic changes, and on guard regarding abnormal changes which may require geriatric intervention.

Everyone Is Aging

Everyone wants a long and healthy life. So, what do we typically find when we look to see how healthy elders have lived their lives? In his book Taking Care of Today and Tomorrow, George J. Pfeiffer noted that people who live in areas with especially long life expectancy have the following characteristics; apart from hereditary or genetic influences (we cannot choose our parents or grandparents, but their life expectancy influences ours):

• Dietary and Nutritional factors - diets tend to be low in animal fats and high in vegetables and whole grains.

• Moderate Consumption of Alcohol - some alcohol is consumed, although alcoholism is uncommon.

• Physical Activity Throughout Life - a good deal of physical activity is done.

• Sexual Activity Continues in Later Years - sexually active and free to express themselves in this way.

• Social Involvement - respected and valued and remain involved in community life.

• Physical Environment - challenging and free from pollutants.

In general, the lessons are clear. Regular physical activity, a balanced diet, maintaining a healthy weight, social involvement, moderate or no drinking, and no smoking (one of the most important ways to improve longevity), can significantly decelerate the aging process. Factors such as physical exercise, diet and cessation of harmful habits can be addressed at any age. You can speak with your doctor about developing a plan to exercise and diet in a manner that is healthy for you.

Aging may, nonetheless, result in a decline in one's ability to perform functions (activities). It is, for example, unusual (but not unheard of) to see an eighty year old go skydiving. Still, we should not confuse declining physical strength and dexterity with health and safety concerns that can be addressed to improve an elder's quality of life. Health, for older adults, can be defined as the ability to function at the individual's highest potential despite the presence of age-related changes and risk factors.

The normal aging process is summarized as follows:

• As individuals age, they become more diverse, not more alike.

• Age related changes develop in each individual in a unique way.

• Normal aging and disease are separate factors.

• Normal aging includes both gains and losses and does not necessarily indicate decline.

• Most older adults successfully adapt to the aging process.

Common Ways that the Body Ages

Normal Aging Changes in the Skin

Our skin is our largest organ and it is important because it protects everything inside. We experience changes in skin condition as part of the normal aging process. The rate of change is unique to each individual. Within the skin, collagen production slows, and elastin (the substance that enables skin to snap back into place) has a bit less spring. Dead skin cells do not shed as quickly and turnover of new skin cells may decrease slightly. These changes begin as we reach early adulthood and continue throughout our lifetime; the signs of aging are typically not visible for decades. The signs of aging are:

• Fine wrinkles

• Thin and transparent skin

• Loss of underlying fat, leading to hollowed cheeks and eye sockets as well as noticeable loss of firmness on the hands and neck

• Bones shrink away from the skin due to bone loss, which causes sagging skin

• Dry skin that may itch

• Inability to sweat sufficiently to cool the skin

• Graying hair that eventually turns white

• Hair loss

• Unwanted hair

• Nail plate thins, the half moons disappear, and ridges develops

Genes control how quickly the normal aging process unfolds. For example, some individuals notice those first gray hairs in their 20s; others do not see graying until their 40s. Fragile skin can also be caused by medications and by disease.

Changes in skin condition can impact comfort. For example, an older person may be more sensitive to cold and heat. They may also be more susceptible to pain. Among the safety concerns associated with fragile skin are skin tears, bruising and blood loss following an accident.

Other changes to our skin include:

• Reduced blood flow to the skin causing wounds to heal slower is another symptom of aging.

• As people grow older, veins dilate, causing the blood vessels near the skin surface to become more prominent.

• Blood vessels become more fragile in the elderly, increasing the risk of large bruises and skin tears.

• Blood supply to the legs is reduced, causing cold feet and increasing the risk of blood clots and pressure ulcers for elders.

• Symptoms such as sensitivity to pressure decreases as the body ages.

• It is common for Melanin production to decrease and cause hair to turn gray with age.

• Females develop facial and upper lip hair related to lower hormonal levels as they age.

• It is normal for all body hair to thin as part of the aging process.

• Fingernail and toenail growth slows with aging and nails may become brittle and develop ridges.

Normal Aging Changes in the Musculoskeletal System

Older adults experience alterations in posture, changes in range of motion, and slowed movement. These changes account for many of the characteristics normally associated with old age.

• Normally muscle elasticity and mass diminishes with aging, causing decreases in strength, endurance, reaction time, and coordination amongst the elderly.

• As the body ages, bones lose minerals, making them brittle and susceptible to fractures.

• Muscle wasting occurs and regeneration of muscle tissue is slowed.

• Muscles of the arms and legs become thin and flabby.

• Skeletal instability and shrinkage of discs in the spine are common as the body ages, causing increased risk of injury and less flexibility of the spine.

• Spinal curvature develops and becomes visible with aging.

• Degenerative joint changes cause stiffness, pain, and limited range of motion with aging.

Osteoporosis affects 25% of women older than 60 years of age. The loss of bone mass and bone strength which results leads to broken hips, arms, legs, and back injuries. Adding calcium to the diet, regular exercise, avoidance of alcohol, avoidance of smoking and estrogen replacement (for women) are key prevention strategies.

Normal Aging Changes in the Cardiovascular System

The cardiovascular system loses efficiency, but many older adults compensate for this because they require less oxygen at rest and during exercise. Nonetheless, a high incidence of cardiovascular disease in the elder population makes it difficult to distinguish between normal age related changes and changes due to sickness.

• Cardiac muscle strength is diminished.

• Heart valves become thickened and more rigid.

• These changes affect cardiac output and recovery time shrinks; heart rate takes longer to return to normal after exercise.

• A slowed heart rate is normal in older adults, which causes a slowing of the pulse and less efficient circulation, increasing the risk of blood clots with age.

• Blood flow to all organs decreases with aging. The brain receives more blood than other organs, but mental changes may occur as a result of reduced oxygenation; however, mental confusion is not a normal part of the aging process.

• Elasticity of arteries decreases as part of the aging process. Fatty build-up on artery walls causes reduced blood flow to the body and increased blood pressure.

One treatment methodology, used in response to strokes, transient ischemic attacks (also called TIA or "mini-strokes"), and blood clots is blood thinner (often Coumadin). The use of blood thinners should be monitored by a health care professional because they increase the risk of injury due to blood loss following a fall or other injury. Sometimes blood loss may be internal and is not apparent.

Normal Aging Changes in the Respiratory System

Respiratory function typically changes so gradually that most older adults compensate well for these changes.

• The rib cage becomes rigid as cartilage calcifies.

• The thoracic spine may shorten, and osteoporosis may cause a stooped posture, decreasing active lung space and limiting thoracic movement.

• Lung capacity decreases as part of the aging process.

• Less effective coughs increase the risk of pneumonia and lung infections with age.

• With aging, alveoli in the lungs thicken, causing less effective oxygen exchange.

Normal Aging Changes in the Gastrointestinal System

Changes in the gastrointestinal (GI) system often cause great concern for older adults. Many of these changes are not life threatening. Indigestion, constipation and anorexia are common GI problems that affect functional status.

• Tooth enamel thins with normal aging.

• Saliva production decreases, and incidences of periodontal disease increase with aging.

• It is normal for taste buds to diminish with aging, beginning with those that perceive sweetness and saltiness. Seniors or nursing home residents may complain that they cannot taste their food, and they may use condiments more often than before.

• The gag reflex is less effective as people age, greatly increasing the risk of choking.

• With aging, esophageal peristalsis slows and sphincters in the digestive system are less effective; this causes delayed entry of food into the stomach, increased risk of choking, and increased heartburn.

• As people age, gastric emptying slows, causing food to remain in the stomach longer.

• Peristalsis and nerve sensation slows in the large intestine, increasing the incidence of constipation with aging.

• It is common for the liver size to decrease once a person is over the age of 70.

• Normal aging includes the decrease of liver enzymes, making it more difficult to detoxify chemicals taken into the body; also causing a slower metabolism of medications in the elderly.

• Aging means the gallbladder empties less efficiently. Bile thickens, cholesterol content increases; incidence of gallstones increases.

Poor dietary habits contribute to many diseases that occur in older persons. Chronic diseases, such as heart disease and cancer, can be slowed and for some people prevented by eating a healthy diet, avoiding obesity and decreasing the amount of fat intake.

Normal Aging Changes in the Genitourinary System

Changes in the genitourinary system affect voiding and sexual performance. A common misperception is that incontinence and decreased sexual function are part of normal aging. This misperception often causes older adults to delay seeking treatment.

• Rate of filtration decreases with aging, causing it to be more difficult to process drugs.

• Physical ability to conserve sodium diminishes in the elderly.

• Bladder capacity decreases as we age, increasing the frequency of urination; however, incontinence is not a normal consequence of aging and is often related to infection or neglect.

• Kidney function increases when lying down, causing increased trips to the bathroom at night which is a normal aging change.

• A weakened bladder and perineal muscles will cause inadequate emptying of the bladder for the elderly.

• With aging, an enlarged prostate gland in males will cause an increase in the frequency of urination, dribbling, or complete urinary obstruction; urine residual results in and greatly increases the risk of infection.

Normal Aging Changes in the Neurological System

Age related changes in the nervous system affect all body systems and involve vascular response, mobility, coordination, visual activity and cognitive ability. Most misconceptions about normal aging involve the nervous system. For example, one of those misconceptions is that mental decline or "senility" is inevitable with aging.

• With aging, decreased blood flow and reduced oxygenation to the brain causes slower transmission of nerve impulses. This change causes the elderly to need additional time for motor and sensory tasks involving speed, balance, coordination, and fine motor activities (buttoning buttons, opening bottles, etc.).

• Deterioration in nerve terminals that provide data to the brain about body movement and position occur with aging, which results in balance and coordination problems in the elderly.

• It is common for the lens in eyes to become less elastic with age, making it more difficult to see in dim lighting or when switching between spatial distances.

• Cataracts are a common symptom of aging.

• Lenses in the eyes turn yellow in color, causing distorted color perception with aging.

• As the body ages, accommodation of pupil size decreases, so the eyes take longer to adjust to changes in lighting.

• Consistency of fluid within the eye changes with aging, causing blurred vision in the elderly.

• With aging, it is normal for decreased secretions and tears in eyes, causing dryness and itching.

• Neurons in ears decrease with aging, and the blood supply diminishes in the body. Aging changes may cause hearing difficulty.

• Ability to sense pressure, temperature and pain diminish with age.

Normal Aging Changes in the Endocrine System

• Delayed release of insulin by beta cells in the pancreas causes increase the blood sugar and incidence of diabetes with aging.

• A normal symptom of aging is a slower metabolism rate, which can cause weight gain and obesity in some seniors.

Chronic Diseases and Conditions

Beyond the normal aging process, we must consider chronic diseases. More than 80% of older adults experience at least one chronic disease condition and as many as 50% report three chronic disease conditions. This dynamic increase the importance of good communication with your health care provider because many of these conditions can be addressed. Regardless of age, the goal for health promotion is to assist older adults in reaching an optimal state of health.

The most common chronic disease conditions for older adults include arthritis, hypertension, heart conditions, hearing impairments, poly-pharmacy (too many medications) and dementia. Another issue we need to consider is chronic pain. These conditions are not part of the normal aging process. They can result in increased instances of hospitalization and premature admission to a long-term care facility such as a nursing home. Persons who experience chronic disease conditions should discuss them with a health care provider.

Chronic Conditions Associated with Aging

Arthritis (49%)

Hypertension (37%)

Hearing impairments (32%)

Heart disease (30%)

Cataracts and sinusitis (17%)

Orthopedic impairments (16%)

Alzheimer's disease

Dementia (as distinguished from delirium, see Appendix A) is an organic brain disorder that causes changes in cognitive and affective functions. Alzheimer's Disease is the most common type of dementia and afflicts several million Americans. It begins gradually, but over a period of years leads to severe loss of memory and other mental abilities.

It is important to seek medical attention when confusion, personality change, disorientation or significant memory lapses are noticed since there may be treatable causes for such symptoms.

Many medical centers now offer multi-disciplinary geriatric assessment teams. It may be worthwhile to arrange such an assessment since it is estimated that up to 25 percent of all diagnoses of Alzheimer's Disease are incorrect. Immediate medical assessment is particularly recommended when the change in function is sudden rather than gradual. There is, however, no cure at present for Alzheimer's. Treatment may reduce agitation or relieve depression, and a supportive, structured environment can make life easier for the patient and his/her caregiver. There are support groups for caregivers in many communities; social support is of great importance for both the caregiver and the victim of this disease.

Multi-Infarct Dementia

This is the second major form of dementia, which is caused by multiple strokes. Blockage of a large artery can result in massive brain damage, while minor strokes invoking small arteries and blood vessels may leave little or no observable signs. The cumulative effect of minor strokes may produce a dementia. This type of dementia often occurs in stages, and medical treatment of underlying causes such as high blood pressure can slow or halt the erosion of function.

Depression

Depression is defined as a period lasting at least two weeks in which a person loses interest and pleasure in the events that usually engage him or her. Depressive illness often lasts for years and afflicts some 15 percent of older persons. Symptoms include: 1) A pervasive feeling of sadness, hopelessness and irritability; 2) Weight loss caused by loss of appetite; 3) sleep loss; 4) decreased ability to concentrate; 5) lassitude or loss of energy.

Commonly used medications such as diazepam and flurazepam, barbiturates, reserpine, betablockers, and cortisol, can cause depression. Alcoholism and illness can also bring on depression. Many elderly people suffer losses, whether physical, social, or financial, which can cause sadness or depression.

Most depressions are likely to lift within a year or more, and medical intervention can clear them up in approximately a month. Physical activity and psychotherapy can also assist the process.

Note that severe depression can result in behavior similar to that of an Alzheimer's victim, and can lead to such a diagnosis. Likewise, the Alzheimer's patient, when treated for a depression, can exhibit improved mental function.

Arthritis

This is a common problem in later life. Arthritis refers to a number of rheumatic diseases, inflammation of the joints or the tissues around them. Osteoarthritis is characterized by pain and stiffness in the large weight-bearing joints and in the joints of the fingers. It occurs twice as often in women, but in most cases it is not a very serious problem. It usually responds to aspirin or other anti-inflammatory drugs. Exercise can be very helpful in combating osteoarthritis, except when there is severe pain or constant inflammation. Joint replacement is now becoming a common procedure, and often brings great relief from pain and increased mobility.

Rheumatoid Arthritis

This form of arthritis is not as common, but is more severe in its effects. Joints become very painful and swollen. Fatigue and weight loss can occur, and 50 percent of those who have this ailment develop joint deformities over time. It can also affect the lungs, spleen, skin or heart. It first appears about age 30-40 and is much more prevalent among women than men. The drugs used to treat rheumatoid arthritis may be more potent than for other forms of arthritis and may take some time to provide relief.

Heart Disease

Coronary heart disease affects more than five million Americans, with one and a half million persons in the U.S. suffering a heart attack each year. While over one-third of such attacks are fatal, mortality rates have been steadily declining in recent years due to improved prevention and better therapies. This disease occurs when the blood vessels supplying blood to the heart become blocked. If an artery is partially blocked, blood flow is reduced and produces chest pain called angina. Underlying heart disease is atherosclerosis, a condition in which fatty deposits build up over time in the inner walls of arteries. When a blood clot builds up on one of these plaques (fatty deposits) a heart attack can occur. High blood pressure, high blood cholesterol, and smoking are contributing factors to heart disease which can be controlled.

High Blood Pressure

About one fourth of Americans have high blood pressure that requires medical attention. This disease can run in families. It can develop silently with no symptoms, but it can be life threatening. Early detection is, therefore, important, and blood pressure checkups are readily available, often at no cost at health fairs, senior centers, etc. Adults should have a blood pressure checkup at least once a year. The process is simple and quickly administered by a health care worker (a cuff with a gauge attached is wrapped around the arms and inflated, then the pressure is slowly released).

Dietary change to control weight, reduced alcohol intake, exercise, stress management, and medications, can all help make the prognosis good. In untreated cases, there is increased likelihood of stroke, heart attack, congestive heart failure or kidney failure. Once the disease occurs, prevention of recurrence must be maintained throughout life.

Stroke

A stroke involves a sudden interruption of blood flow to a part of the brain. It can result in impaired memory and thought, speech and behavior, and sensory loss. A stroke can result in paralysis or weakness, usually on one side of the body. Many people (up to one third of victims) die after the first stroke. This is the third leading cause of death. Strokes are more common among men.

Treatments include drugs, and physical, occupational, and speech therapy. Aspirin can diminish the chances of future strokes, and one third of victims achieve a full recovery. More than 50 percent of stroke patients recover enough to carry on independently. Others may require constant care. Families should be encouraged to participate actively in rehabilitation efforts for a significant period, since recovery may occur in stages and a particular stage may continue for some time.

Cancer

Almost one million persons develop cancer each year in the U.S. The disease tends to occur more often later in life (75 percent of all cases are diagnosed after age 55, 50 percent after age 65). There are many forms of cancer and its course can vary a lot depending on the type of cancer and when it is discovered.

Smoking is the single greatest cause of death from cancer. Dietary changes, such as limiting alcohol intake, eating low fat and high fiber food, fruits and vegetables, and maintaining fitness, can reduce the likelihood of developing cancer. Breast cancer is the most common form of cancer among women; early detection greatly contributes to the chance of full recovery.

Prostate cancer is the second most common form of cancer among men, after lung cancer. Enlarged prostate is common among older men and produces some of the same symptoms as colon cancer. New surgical techniques preserve sexual function. The incidence of colorectal cancer in the last five feet of the digestive tract or in the rectum has increased in this country, but survival rates are improving. Lung cancer is a major cause of death and is often associated with heavy smoking.

Cataracts

A cataract is a cloudy or opaque area in the lens of the eye which can interfere with vision if it grows large or dense enough. About 45 percent of individuals over age 75 show signs of cataracts, which may occur in one or both eyes. Cataracts can impair the ability to read or drive, and can cause serious impairment of vision if treatment does not occur. Slowly growing cataracts may not require surgery for many years. However, cataract surgery is now a routine intervention, which can normally be carried out on an outpatient basis.

Diabetes

Adult onset diabetes usually occurs after age 40; about 10 million persons in the U.S. have diabetes. Adult onset diabetes is closely linked to excess weight, and the risk grows with the level and duration of obesity. Those who are overweight or who have a family history of diabetes should have their blood glucose level checked every five years and every two years after age 65. Diet and exercise programs can help many. However, in patients with insulin-dependent diabetes mellitus, injections, drugs, and ongoing monitoring of blood sugar levels are necessary.

Obstructive Lung Disease

There are two closely related disorders, Emphysema and Chronic Bronchitis, which by damaging lung structures impair the capacity to bring in oxygen and expel carbon dioxide. The victim feels at first short of breath and later starved for air. Most sufferers are current or former smokers, and the more smoking one does the higher the chances of getting the disease. Obstructive lung disease worsens slowly, taking up to twenty years to develop fully, so most serious cases tend to occur after age 65. To reduce lung damage, quit smoking, avoid exposure to dust, air pollution, fumes and persons with respiratory infections. Breathing exercises, general fitness exercises, and medication can improve air flow.

Urinary Incontinence

Urinary incontinence is not part of the normal aging process. It is a sign that there is an underlying problem. Common causes of bladder control problems include infections, nerve damage from diabetes or stroke, heart problems, medications, and depression. Urinary stress incontinence can result during sudden increases in abdominal pressure; when you sneeze, cough, or exercise.

After menopause, women may develop bladder control problems. As their periods end, the body stops making estrogen, and estrogen, in addition to its other functions, helps keep the lining of the bladder and urethra healthy. Lack of estrogen can cause the bladder control muscles to weaken and may lead to incontinence.

Types of urinary incontinence

• Stress: Leakage of small amounts of urine during physical movement like laughing hard, lifting, coughing, or sneezing.

• Urge: Loss of urine with a sense of urgency or spasm-like feeling.

• Functional: Untimely urination because of physical disability, external obstacles, or problems in thinking or communicating that prevent a person from reaching a toilet, such as a broken hip or being unaware where bathroom in mall is.

• Overflow: Unexpected leakage of small amounts of urine because of a full bladder.

• Transient: Leakage that occurs temporarily because of a condition that will pass, like an infection or medication

Treatments vary depending on the cause of the incontinence. For women, hormone therapy addresses the decrease in estrogen, but may not be the answer for everyone. Other treatment options include limiting diuretics such as caffeine and alcohol, practicing Kegel exercises (an isometric program to help strengthen the pelvic floor muscles), retraining the bladder.

It has also been suggested that weight reduction and exercise may help prevent or reduce the likelihood of developing urinary incontinence. Your health care professional may suggest other courses of action including medications, biofeedback, electrical stimulation or surgery (e.g., to reposition or support a sagging bladder).

What Caregivers Can Do to Help

The most important thing to remember is that the basic needs of older adults are no different than those of a younger person. Basic needs, in addition to food and shelter, are central to the life experience and must be met for an older person to remain healthy.

First, each person must know that they are loved, wanted and needed. This may seem touchy-feely at first glance, but it relates to mental outlook, an absence of depression and the presence of motivation to work on prevention. When a person loses the will to go on, everything falls by the way-side and health will decline.

Second, though the world of an aging person may become much narrower, the individual must continue to be socially involved. Companionship is important. As a person becomes older, they may feel they are of no use. They may not be able to work or some-times may not even be able to care for themselves. Creating social opportunities is important. Including elders in family gatherings is one way to accomplish this. Another might be encouraging elders to record, either on audio tape or in writing, their memories, the family history, stories and values which can then be passed on to younger generations.

Third, elders need to feel useful. Meaningful activities that encourage self-sufficiency should be encouraged. Finally, older people need to be recognized for the positive things they are able to do. We all want to be accepted as we are.

Before you can improve your relationship with an aging family member, loved one or friend, you need to acknowledge your feelings about their aging process. Once you understand your own reactions to aging, you can begin to understand how and why the older person reacts the way they do. With this information, you can begin to make the changes necessary to improve your relationship with them.

Try to remember to build on the older person's strengths. Be available to the older person and listen when they express feelings of loss. Be honest with your aging family member, loved one or friend. Saying what you feel or think means sharing your inner thoughts in a constructive way. This can be a little risky, but it shows that you trust and respect them and the role they play in your relationship.

Unhealthy Conditions

Pressure Sores

Pressure plus time can result in a pressure sore. Pressure sores (also called bedsores; decubitus ulcers; trophic ulcers) should be addressed when they occur. Pressure sores occur where there is loss of blood flow and ulceration of tissues (ischemic necrosis: tissue death due to loss of blood supply) overlying a bony prominence that has been subjected to prolonged pressure against an external object (e.g., bed, wheelchair, cast, splint).

Pressure sores occur most often in patients with diminished or absent sensation or who are debilitated, emaciated, paralyzed, or long bedridden. Tissues over the sacrum, ischia, greater trochanters, external malleoli, and heels are especially susceptible; other sites may be involved depending on the patient's position. Pressure sores can also affect muscle and bone.

Pressure sores are categorized by "stages." A stage 1 pressure sore is a red spot on the skin and a stage 2 pressure ulcer is slightly worse. These sores often respond to massage if treated. Stage 3 pressure ulcers involve broken skin and stage 4 pressure ulcers are those which have reached through tissue to the bone. Stage 3 and Stage 4 pressure ulcers are serious conditions requiring medical attention. If left untreated, they will worsen, may become infected and may result in amputation of the affected limb.

Prevention is the best treatment for pressure ulcers. Most people do this naturally by moving around. For bedfast individuals who need assistance moving, they should be moved every two hours. They should be kept clean. Diet should be monitored. A well-balanced diet, high in protein, is important. There is some evidence that supplemental vitamin C and zinc help healing.

Dehydration

Dehydration in the elderly occurs when a person does not have the necessary fluid content in their body to perform normal and crucial bodily functions. Most body systems and organs are severely affected by water deprivation. Dehydration can be especially harmful in the elderly and can harm more quickly than starvation. A 10 percent loss of body fluids is serious. A 20 percent loss in bodily fluids can result in death.

Dehydration can be prevented by following these guidelines.

• Make sure an elder drinks at least 6 cups of fluid each day.

• If an elder has diarrhea, vomiting, bleeding, edema, infections, bedsores, increased activity levels, fever, increased exposure to warm environments, or is taking diuretics, he or she needs to increase their intake of fluids to prevent dehydration. Important Note: This does not apply to people with heart and renal conditions who are on a doctor ordered "fluid restriction." In this case, consult with the doctor for detailed fluid instructions.

Unhealthy Weight Loss

Persistent weight loss is not normal and can lead to multiple complications. Weight loss accompanied by changes in protein and vitamin intake causes complications throughout the body.

It is best to be proactive and to take weight loss seriously. Elders with malnutrition may develop:

• reduced muscle mass

• personality and behavior changes

• weakness

• fatigue, advancing to complete exhaustion

• depression

• weakened immune system

• apathy and lack of initiative

• increased risk of pressure sores

• increased risk of falls

• death

Signs and symptoms of weight loss due to malnutrition include:

• loss of appetite

• dull, dry or thinning hair

• red, swollen gums and lips; the corners of the mouth may be cracked

• dry mouth with fissures

• red or purple, inflamed tongue, smooth in appearance.

Care for the Dying

Death is normal. When facing death, individuals differ in what they consider important (e.g., some consider quantity of life more important than quality; some accept pain or disfigurement more readily than others). The individual's preferences are paramount, and care must be planned accordingly. Some older adults find an appropriate time and way to bring life to a satisfying close; others do not.

Some dying persons benefit from curative, rehabilitative, or preventive care. For others, however, supportive care is the only realistic choice. Good care of the dying involves more than discontinuing unwarranted treatment; it includes developing a care plan that accounts for the elder's goals and the limits imposed by illness. A good hospice program can assist the elder and his or her family in this process.

References

• Dispelling the Myths of Aging, http://www.umext.maine.edu/onlinepubs/htmpubs/4209.htm.

• P. Gerstein, Delirium, Dementia, and Amnesia, http://www.emedicine.com/emerg/topic345.htm.

• Aging Skin: Blemishes and Non-melanoma Skin Cancers, http://adam.about.com/reports/000020.htm.

• G. Craig, Update on Gerontology, http://learn.sdstate.edu/nursing/Gerontology.html.

Appendix A: Delirium versus Dementia

Although confusion and/or disorientation can be signs of both Delirium and Dementia, these conditions are different. Delirium is an acute confusional state. It is potentially reversible. Dementia is not. Delirium usually occurs over a period of days to months. Dementia is slow and insidious. It progresses slowly over months to years.

Delirium can result from any of the following:

• Infections

Bronchopneumonia - An acute respiratory / lung infection confined to an individual bronchus and the lung tissue it supports. Signs and symptoms include fever, pain with breathing, coughing (usually productive).

Local skin lesions - Rashes, wounds, pressure areas.

Diverticular abscesses - An infection within the colon. Signs and symptoms include fever and abdominal pain.

Bacterial endocarditis - An infection in the lining of the heart, bacterial in origin. Signs and symptoms include fever, night sweats, fatigue, malaise, weight loss, chills, joint aches and pains.

Urinary Tract Infections (UTI) - A urinary tract infection is often characterized by foul smelling, concentrated, dark-colored urine that may be milky or cloudy (healthy urine is clear to pale yellow with mild odor). There may also be blood or pink tinge to the urine. The person with a UTI will frequently complain of burning, stinging or pain just before, during or just after voiding. There are often complaints of urgency (suddenly having to urinate) and frequency (urinating all the time). UTIs are common while a person has a foley catheter, or shortly after a foley catheter is removed, during periods of immobility, decreased fluid intake, or when incontinent (unable to control bowels or bladder) and meticulous perineal hygiene is not provided.

• Neurologic factors

CNS affecting drugs. - Drugs that effect the central nervous system (CNS):

Barbiturates, i.e.: Phenobarbital, Seconal, Nambutal.

Sedatives, i.e.: Chloral Hydrate, Dalmane, Halcion, and Ambien.

Tranquilizers, i.e.: Ativan, Valium, Xanax.

Cerebral arteriosclerosis - Hard plaques lining the inside of the blood vessels within the brain. This causes decreased blood flow to the brain. There are few signs and symptoms if any, until affected blood vessel is occluded. Reduced blood flow can cause the symptoms of a Transient Ischemic Attack (TIA) which are temporary changes in level of cognitive function. Full occlusion leads to stroke.

Stroke - Also known as a Cerebral Vascular Accident (CVA). Some modern textbooks may refer to this as a Brain Attack or Brain Infarct. Signs and symptoms vary depending on the part of the brain affected. Sensory, motor and / or processing abilities can be affected.

Brain tumor - Signs and symptoms vary depending on the location of the tumor. Mild to severe headache. Slowly progressive weakness on one side, convulsions, visual changes, inability to speak, vomiting, other mental changes.

Subdural hematoma - A bubble filled with blood within the confines of the skull. As the blood filled bubble increases in size, it causes pressure to bare on the brain. Signs and symptoms: recent trauma is usually part of history. Mild to severe headache. Slowly progressive weakness on one side, convulsions, visual changes, inability to speak, vomiting, other mental changes. Fluctuating changes in level of consciousness.

Epilepsy - A recurring disorder of cerebral function. It is characterized by changes in: level of consciousness, motor activity, sensory phenomena, caused by sudden excessive electrical activity in the brain.

• Cardiorespiratory (heart and lungs) factors

Myocardial Infarction (MI) - Also known as a heart attack. Death of heart muscle tissue. Signs and symptoms include: deep, substernal visceral pain often described as aching or pressure, often with radiation to the back, jaw or left arm. It feels like angina, but is unrelieved with nitroglycerin or rest.

Congestive Heart Failure (CHF) - This is a state where the heart does not beat efficiently. The primary cause of CHF is a MI in the past. Symptoms include: shortness of breath, difficulty breathing, frothy sputum, swelling in the legs, ankles and/or feet, fatigue.

Pulmonary embolism - This is when a blood clot that is traveling through the body lodges in the lungs. Symptoms include: shortness of breath, pain or difficulty breathing, frothy/blood-tinged sputum.

Respiratory failure - The lungs stop functioning.

Acute hemorrhage - Active bleeding. Usually a significant quantity.

• Endocrine and metabolic conditions

Hypothyroid - The thyroid gland does not produce sufficient thyroid hormone. Symptoms include weight gain; dry, lackluster skin and hair; depressed muscular activity, goiter (enlarged thyroid in throat, bulging eyes).

Hyper/Hypoglycemia - Alterations in blood sugar.*

Hyperglycemia: Increase in thirst, hunger and urine output, with decrease in weight.

Hypoglycemia: Sweating, nervousness, tremulous, faintness, palpitations, confusion, and blurry vision.

*If the individual is a known diabetic, s/he may have a blood glucose monitor. If so, test the individual's blood sugar.

Hyperparathyroid - Excessive secretion of parathormone. Signs and symptoms include: constipation, loss of appetite, nausea and vomiting with abdominal pain.

Elevated Blood Urea Nitrogen (BUN) - This is often associated with decreased kidney function.

• Electrolyte imbalances

Dehydration - Often caused by vomiting, lavage/suctioning, diuretic therapy, diarrhea with insufficient intake to replace loss. Evident by increased thirst, dry skin, mucous membranes. Lack of eye moisture. Sudden weight loss.

Renal failure - Evident by changes in urine output (quantity or quality). Dry, itchy skin. Sometimes crystals form on skin.

Hypercalcemia - Increase in calcium levels. Can be seen with thyroid changes. Signs and symptoms include: constipation, loss of appetite, nausea and vomiting with abdominal pain. May lead to heart rhythm changes.

• Nutritional Factors

Cachexia - A state of ill health, malnutrition and wasting.

B12 deficiency - Signs and symptoms include: pins and needles numbness, leg stiffness, unsteady gait, lethargy and fatigue.

Thiamine deficiency - Signs and symptoms include: fatigue, irritation, poor memory, sleep disturbances, precordial (in front of the heart) pain, loss of appetite, abdominal discomfort and constipation.

• Environmental factors

Decreased sensory input. - Due to decreased visual (seeing), auditory (hearing), gustatory (taste), olfactory (smell), or tactile (touch), interaction with the environment. This is frequently seen in the elderly in institutional environments such as nursing homes.

Sensory overload. - Due to increased visual (seeing), auditory (hearing), gustatory (taste), olfactory (smell), or tactile (touch), interaction with the environment. This is frequently seen in the elderly in institutional environments such as high care units in hospitals.

Sudden isolation. - Can be the result of institutionalization or the illness or death of a "best friend."

• Other factors

Anesthetics - After surgery, recovery from anesthetics can be prolonged and require up to a week or more.

Trauma - The stress of any injury.

Tissue anoxia - Loss of oxygen to a tissue. Can be from an infarct.

Gangrene - Death of tissue due to severe infection. Associated with the loss of limbs as well as internal organs.

Digitalis toxicity - Digitalis is use in the treatment of congestive heart failure, atrial fibrillation and flutter and tachycardia (rapid heart beat). Signs and symptoms include: fatigue, generalized muscle weakness, agitation, hallucinations, arrhythmias, "yellow-green" halos around visual images, blurry vision, loss of appetite, nausea.

Stress - Stress affects your endocrine system and your nervous system. These powerful chemicals, called hormones, affect levels of chemicals, biochemicals and fluids within your body. The assist in regulating blood pressure, blood sugar, blood chemistry, how much you sweat, body temperature, how fast your metabolism is.

Multiple problems - The more problems that are occurring, the more likely and the more significant the delirium may be.

This list is not all conclusive. The only way to determine if your loved one's cognitive loss is reversible is to have him / her evaluated by a licensed physician, knowledgeable in the needs of the geriatric person.

Caution: The information in this Memorandum is NOT designed to be health care advice. Solomon, Steiner & Peck, Ltd., is NOT a health care provider, nor are we trained to make a health diagnosis or prescribe treatment. Our purpose here is to educate you so you can identify issues and talk with your doctor more effectively. For more information about specific conditions discussed in this Memorandum, we suggest that you review the Merck Manual of Geriatrics. It can be purchased at many bookstores and is also available online at http://www.merck.com/mrkshared/mmg/contents.jsp.