Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Age-Associated Cardiovascular Changes
Definition: Isolated systolic hypertension: systolic blood pressure (BP) >140 mmHg and diastolic BP <90 mmHg.
- Etiology
- Arterial wall thickening and stiffening, decreased compliance
- Left ventricular and atrial hypertrophy
- Sclerosis of atrial and mitral valves
Parameters of Cardiovascular Assessment
- Cardiac assessment: Electrocardiogram (ECG); heart rate, rhythm, murmurs, heart sounds (S4 common, S3 in disease) (Seidel et al., 2003 [Level VI]).
- Assess BP (lying, sitting, standing) and pulse pressure (Kenny, 2003 [Level V]).
- Palpate carotid artery & peripheral pulses for symmetry (Seidel et al., 2003 [Level VI]).
Nursing Care Strategies for Cardiovascular
- Safety precautions for orthostatic hypotension: Avoid prolonged recumbency; rise slowly from lying or sitting position; wait 1 to 2 minutes after position change to stand or transfer (Kenney, 2003 [Level V]). Institute fall prevention strategies. (See the National Guideline Clearinghouse [NGC] summary of the Hartford Institute for Geriatric Nursing guideline Fall Prevention).
- Encourage lifestyle practices to attain a healthy body weight (body mass index [BMI] 18.5 to 24.9 kg/m2) (American Heart Association (AHA) Nutrition Committee et al., 2006 [Level 1]) and normal blood pressure ("Seventh report," 2004 [Level I]); healthful diet (Knoops et al., 2004 [Level II], physical activity (Netz et al., 2005 [Level I]), smoking cessation (U.S. Department of Health and Human Services, "The health consequences," 2004 [Level I]).
Age-Associated Changes in the Pulmonary System
- Etiology
- Decreased respiratory muscle strength; stiffer chest wall with reduced compliance
- Diminished ciliary and macrophage activity, drier mucus membranes. Decreased cough reflex
- Decreased response to hypoxia and hypercapnia
Parameters of Pulmonary Assessment
- Assess respiration rate, rhythm, regularity, volume, depth (Docherty, 2002 [Level I]), exercise capacity (Mahler, Fierro-Carrion, & Baird, 2003 [Level V]). Auscultate breath sounds throughout lung fields (Mick & Ackerman, 2004 [Level V]).
- Inspect thorax, symmetry of chest expansion. Obtain smoking history (Seidel et al., 2003 [Level VI]).
- Monitor secretions, breathing rate during sedation, positioning (Docherty, 2002 [Level I]; Watters, 2002 [Level V]) arterial blood gases, pulse oximetry (Zeleznik, 2003 [Level V]).
- Assess cough, need for suctioning (Smith & Connolly, 2003 [Level V]).
Nursing-Care Strategies
- Maintain patent airways through upright positioning/repositioning (Docherty, 2002 [Level I]), suctioning (Smith & Connolly, 2003 [Level V]), and bronchodilators (National Heart, Lung, and Blood Institute, 1996 [Level I]).
- Provide oxygen as needed (Docherty, 2002 [Level I]).
- Incentive spirometry as indicated, particularly if immobile or declining in function (Dunn, 2004 [Level V]).
- Maintain hydration and mobility (Watters, 2002 [Level V])
- Education on cough enhancement (Dunn, 2004 [Level V]), smoking cessation (U.S. Department of Health and Human Services, 2004 [Level I]).
Age-Associated Changes in the Renal and Genitourinary Systems
- Definitions: Cockroft-Gault Equation: Calculation of creatinine clearance in older adults:
For Men:
Creatinine clearance (mL/min) =
(140 – age in years) X (body weight in kg)
72 X (serum creatinine, mg/dL)
For Women: the calculated value is multiplied by 85% (0.85).
- Etiology
- Decreases in kidney mass, blood flow, glomerular filtration rate (10% decrement/decade after age 30). Decreased drug clearance
- Reduced bladder elasticity, muscle tone, capacity
- Increased post-void residual, nocturnal urine production
- In males, prostate enlargement with risk of benign prostatic hyperplasia (BPH)
Parameters of Renal and Genitourinary Assessment
- Assess renal function (creatinine clearance) (Beck, 1998 [Level V]).
- Assess choice/need/dose of nephrotoxic agents and renally cleared drugs (Beyth & Shorr, 2002 [Level V]). (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Reducing Adverse Drug Events in Older Adults).
- Assess for fluid/electrolyte and acid/base imbalances (Suhayda & Walton, 2002 [Level V]).
- Evaluate nocturnal polyuria (Miller, 2003 [Level V]), urinary incontinence, benign prostatic hypertrophy (BPH). Assess urinary tract infection (UTI) symptoms (Bradway & Yetman, 2002 [Level V]).
- Assess fall risk if nocturnal or urgent voiding (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Fall Prevention).
Nursing Care Strategies
- Monitor nephrotoxic and renally cleared drug levels (Beyth & Shorr, 2002 [Level V]).
- Maintain fluid/electrolyte balance. Minimum 1,500 to 2,500 mL/day from fluids and foods for 50 to 80 kg adults to prevent dehydration (Suhayda & Walton, 2002 [Level I]).
- For nocturnal polyuria: limit fluids in evening, avoid caffeine, use prompted voiding schedule (Miller, 2003 [Level V]).
- Fall prevention for nocturnal or urgent voiding (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Fall Prevention)
Age-Associated Changes in the Oropharyngeal and Gastrointestinal Systems
- Definition: BMI: Healthy: 18.5 to 24.9 kg/m2; overweight: 25 to 29.9 kg/m2; obesity: >30 kg/m2.
- Etiology
- Decreases in strength of muscles of mastication, taste, and thirst perception.
- Decreased gastric motility with delayed emptying. Atrophy of protective mucosa.
- Malabsorption of carbohydrates, vitamins B12 and D, folic acid, calcium.
- Impaired sensation to defecate.
- Reduced hepatic reserve. Decreased metabolism of drugs.
Parameters of Oropharyngeal and Gastrointestinal Assessment
- Assess abdomen, bowel sounds (Edwards, 2002 [Level V]).
- Assess oral cavity (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline
Managing Oral Hydration); chewing and swallowing capacity, dysphagia (coughing, choking with food/fluid intake) (Shaker & Staff, 2001 [Level V]). If aspiration, assess lungs (rales) for infection and typical/atypical symptoms (Bartlett et al., 2000 [Level I]; Kelley, 2002 [Level V]).
- Monitor weight, calculate BMI, compare to standards (AHA Nutrition Committee et al., 2006 [Level I]). Determine dietary intake, compare to nutritional guidelines. (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Nutrition).
- Assess for gastroesophageal reflux disease (GERD) (Edwards, 2002 [Level V]), constipation and fecal incontinence; fecal impaction by digital examination of rectum or palpation of abdomen (Tariq, 2004 [Level V]).
Nursing-Care Strategies
- Monitor drug levels and liver function tests if on medications metabolized by liver. Assess nutritional indicators (McGee & Jensen, 2000 [Level V]).
- Educate on lifestyle modifications and over-the-counter (OTC) medications for GERD (Edwards, 2002 [Level V]).
- Educate on normal bowel frequency, diet, exercise, recommended laxatives. Encourage mobility, provide laxatives if on constipating medications (Harari, 2003 [Level V]).
- Encourage participation in community-based nutrition programs (Krassie & Roberts, 2001 [Level V]); educate on healthful diets (U.S. Department of Health and Human Services, 2000, 2005 [both Level I]).
Age-Associated Changes in the Musculoskeletal System
Definition: Sarcopenia: Decline in muscle mass and strength associated with aging.
- Etiology
- Sarcopenia with increased weakness and poor exercise tolerance.
- Lean body mass replaced by fat with redistribution of fat.
- Bone loss in women and men after peak mass at 30 to 35 years.
- Decreased ligament and tendon strength. Intervertebral disc degeneration. Articular cartilage erosion. Changes in stature with kyphosis, height reduction.
Nursing-Care Strategies
- Encourage physical activity through health education and goal setting (Conn et al., 2003 [Level I]; Conn, Valentine, & Cooper, 2002 [Level I]) to maintain function (Fielding et al., 2002 [Level II]; Netz et al., 2005 [Level I]).
- Pain medication to enhance functionality (see the NGC summary of the Hartford Institute for Geriatric Nursing guideline Pain Management). Implement strategies to prevent falls (Carter, Kannus, & Khan, 2001 [Level I] ). (See the NGC summaries of the Hartford Institute for Geriatric Nursing guidelines Fall Prevention.
- Prevent osteoporosis by adequate daily intake of calcium and vitamin D (USDHHS, "Bone health," 2004 [Level I]), physical exercise, smoking cessation (USDHHS, 2004 The health consequences of smoking: [Level I]; U.S. Preventive Services Task Force (USPSTF), 1996 [Level I]). Advise routine bone-mineral density screening (USPSTF, 2002 [Level I]).
Age-Associated Changes in the Nervous System and Cognition
- Etiology
- Decrease in neurons and neurotransmitters.
- Modifications in cerebral dendrites, glial support cells, synapses.
- Compromised thermoregulation.
Parameters of Nervous System and Cognition Assessments
- Assess, with periodic reassessment, baseline functional status (Craft, Cholerton, & Reger, 2003 [Level V]). (See the NGC summaries of the Hartford Institute for Geriatric Nursing guidelines Assessment of Function and Fall Prevention). During acute illness, monitor functional status and delirium. (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Delirium: Prevention, Early Recognition, and Treatment).
- Evaluate, with periodic reassessment, baseline cognition (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Assessing Cognitive Function) and sleep disorders (Floyd, 2002 [Level I]). (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Excessive Sleepiness).
- Assess impact of age-related changes on level of safety and attentiveness in daily tasks (e.g., driving) (Henry et al., 2004 [Level I]; Park, O'Connell, & Thomson, 2003 [Level I]).
- Assess temperature during illness or surgery (Abrass, 2003 [Level V]). Monitor atypical symptoms of infection, absent fever.
Nursing-Care Strategies
- Institute fall preventions strategies (See the NGC summary of the Hartford Institute for Geriatric Nursing guideline Fall Prevention).
- To maintain cognitive function, encourage lifestyle practices of regular physical exercise (Colcombe & Kramer, 2003 [Level I]), intellectual stimulation (Mattson, 2003 [Level V]), and healthful diet ("Seventh report," 2004 [Level I]).
- Recommend reaction time training and safe driving courses to improve safety (Craft Cholerton, & Reger, 2003 [Level V]).
- Recommend behavioral interventions for sleep disorders (Irwin, Cole, & Nicassio, 2006 [Level I]).
Follow-up Monitoring of Condition
- Continue to reassess effectiveness of interventions.
- Incorporate continuous quality improvement criteria into existing programs.
Definitions:
Levels of Evidence
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
