Immobility

Immobility is a common presentation of illness in the elderly and is considered one of the major syndromes in geriatrics. It is estimated that after 65 years, 18% of people have problems with mobility without assistance, and from age 75 over half have difficulty leaving the house. 

I think i can say that all young society view the elderly as slow people who have a very passive lifestyle and they used to hinder. I include myself in those people because Who has not had to advance an old man in a hurry? Everyone grow older and the energy that young people have, it is going to decrease litle by litle to the point that if you suffer from a chronic illness, it can leave you  disabled for the rest of your life

Persons who are chronically ill, aged, or disabled are particularly susceptible to the adverse effects of prolonged bed rest, immobilization, and inactivity. After prolonged immobility, there are changes in various organs and systems also tend to perpetuate the syndrome. The most important affected systems are cardiovascular and musculoskeletal.

Immboility impact on the prognosis of the immobilized elderly can be more relevant than the disease itself, may appear even after short periods of bed rest. Some of the problems that the immobility produces are: 

1. Contractures
2. Pressure Ulcers
3. Thromboembolism
4. Dehidration
5. Constipatio
6. Incontinence
7. Hypothermia/Hyperthermia
8. Sleep Disorders or Insomnia
9. Dyspnea 
10. Hypotension

How we can see, the immbility its a serius problem that we must to control this problem in order to prevent any complication.

Basic needs in the elderly: Nutrition Needs

Nutrition plays an important role in health maintenance, rehabilitation, and prevention  and control of disease.  An understanding of the nutritional needs of older adults is essential to providing good nursing care. Good eating habits throught life promote physical wellness and mental well-being and an inadequate nutrition can result in serious problems such as malnutrition which can contribute to the development of osteoporosis and skin ulcers. In addition can complicate existing conditions such as cardiovascular disease and diabetes mellitus

When we talk about nutrition in the elderly, we must show the inadequate supply due to physical changes, for example:

• Reduction in saliva flow and tendency to Dry mouth (xerostomia).
• Thinning and atrophy of the gums, missing teeth, dental replacement.
• Loss of mandibular muscle strength
• Decreased taste buds
• Dysphagia (difficulty swallowing solids or liquids) due to altered swallowing mechanism.
• Less competition sphincter that separates the esophagus from the stomach.
• Less acid secretion and atrophy of the overlying mucosa. They also make slower movements propulsion food into the small and gastric emptying (digestions slow and difficult).

As a result of changes in body composition and generally, the decline in physical activity, older people should take less calories compared to earlier stages of his life; because otherwise, progressively tend to get fat. In addition, due to his unhealthy diet, they used to have nutritional deficit. I have looked at the internet and i have found that many european studies say that vitamin D, B12, folic acid and zinc. 

As far as I´m concerned the nutricion is an importan factor in the health and it is really easy to change. So if we want that the elderly  have a good health we have to start controling him nutrition. 

But How can we control it? In my opinion, we can found many types of  questionnaires but i prefer the "Mini Nutritional Assessment" (MNA). I do not why i prefer this one, maybe is because i think that it is the most complete.  It is s a questionnaire designed specifically to assess the nutritional status of the elderly population about the anthropometric (weight, height ...), general assessment (lifestyle, medication and mobility), dietary assessment and subjective assessment (self-rated health and nutrition).

We can found this questionnaire here: http://www.mna-elderly.com/default.html

Bibliography

• Hoffmann G. Maintaining Fluid Balance and Meeting Nutrition Needs. Basic Geriatric Nursing 5th Edition. Missouri: Elsevier; 2012. p 102-130. 

• Estrella M. Nutrición en el anciano. 2012 November 22; Madrid, Spain. Available from: http://www.seen.es/docs/apartados/456/nutricion-anciano2012.pdf

• Morales I. Nutrición en el anciano sano. Clínica Universidad de Navarra. 2011 February 06. Available from: http://www.cun.es/area-salud/salud/nutricion-salud/nutricion-anciano-sano

Pain in the elderly

According to the Medline database PAIN is:

 "An unpleasant sensation induced by noxious stimuli which are detected by NERVE ENDINGS of NOCICEPTIVE NEURONS".

But thanks to advances in medicine, nowaday this feeling can be defeated, although in the elderly some factors can make more dificult this objective:

1.  Elderly use to be less attended  in the field of health in general due to health is really expensive and resources are limited so research focuses on youth.
2. The cost / benefit ratio is worse in the elderly.
3. Communication problems
4. More time needed

In addition, a lot of people think that elderly trend to complain more than other kind of adults but we can not generalize. During my interships i have found all kind of patient, from patients who go to the emergency for a headache to patients that having a four-stage cancer had not gone to the doctor before. So we have to teach society how to use well the health resources that we have and we should not ignore to patient who complains of pain.

Although we can found many kind of pain, the characteristic of pain in the elderly is that it tends to be chronic. Many studies show that chronic pain its about from 50% in communitary field to 80% in nursing home. It is really easy and cheap give a solution to this kind of pain, even WHO proposed a analgesic staircase limited to a small number of drugs which you can manage pain in 80% of patients in an outpatient.

So, from my point of view and with all this in mind, everybody will be old one day and i suppose that none want to have any kind of pain. For this reason health should not leave out so much the elderly because everybody want to grow old having a good health

Bibliography

• FMC. Dolor crónico en el anciano. Formación médica continuada en atención primaria. 2011 September ; 18:9-23. Available from: http://www.elsevierinstituciones.com/ei/ctl_servlet?_f=1012&id_articulo=90027137&idinst=16

• Ribera J. El dolor en el anciano. Servicio de Geriatría. Hospital Clínico San Carlos. Madrid . 2007 ; 207(4):155-7. Available from: http://www.elsevier.es/sites/default/files/elsevier/pdf/65/65v207n04a13101842pdf001.pdf

Theories of aging

This week we have speak about some theories of aging in class and  i would like to mention two of them particulary. One biologic theorie which is called the programmed theory and one psychosocial theorie which is called the activity theory. 

Programmed theory 

This theory said mainly that mamals are genetically programmed, we have a "biologic clock" that regulates growth and development. So life expectancy is predetermined, with cells programmed to divide a certain number of times. This functional changes in the cells cause aging. 

I am not totally agree with this theory, because maybe is too simply. From my point of view this theory do not consider some important aspects such as might be the life style, the place where her life, the economy, all the diseases that a person can have during all her life and which can reduce the expectance of life etc..

I mean, Do you think that people who have obesity, smoke and drink or they have been a cancer, can live more than people who have a good life style (having a good diet, doing excercise, not having bad habits like smoking or alcohol...)? All this only because her "biologic clock" said  this is the end.  

But on the other hand, i agree in same cases, when a healty elderly dies without any reason, this theory can have the answer saying that her cell numer were finished.

Activity theory     

This theory is one of my favorites because in my opinion, if everyone did moderate exercise and had a proper diet, in other words, if people followed a proper life style, the life expectancy would increase a lot and many of illness that we know (above all cardiovascular diseases) it will greatly reduce. 
The activity theory proposes that activity (mental and physical both) is necessary for successful aging.  An active life helps maintain functioning well into old age so having a "busy life" we reduce the propability of suffer any kind of mental or physical disease like alzehimer. We can find a lot of 

We can find numerous studies that confirm this theory, for example, the study carried out by Buchman AS et al evidence that physical frailty in old age is associated with Alzheimer in older persons. 
In conclusion, if you want to have a healthy life remember, you only have to practice moderate exerecice and eat healthy in order to come up with the best possible health to the old age.

Bibliography 

• Buchman AS, Schneider JA, Leurgans S,et al. Physical frailty in older persons is associated with Alzheimer disease pathology. Neurology. 2008 August 12; 71(7): 499–504. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676981/

• Libertini G. Empirical evidence for various evolutionary hypotheses on species demonstrating increasing mortality with increasing chronological age in the wild. The Scientific World Journal 2008; 8:182-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18301820

• Nauert PhD, R. Mental, Physical, Social Activity Help Maintain Brain. Psych Central [serial on the Internet] 2012 [Retrieved on April 14, 2013]. Available from: http://psychcentral.com/news/2012/04/30/mental-physical-social-activity-help-maintain-brain/38024.html

• The Cochrane library. [Data base on the Internet]. Oxford: Cochrane editorial-unit; 1999  [updated 2012 May 16; cited 2013 Apr 14]. Physical Activity and exercise for health and well being of older people (Cochrane Review).  Available from: http://www.thecochranelibrary.com/details/collection/2043267/Physical-activity-and-exercise-for-health-and-well-being-of-older-people.html

Global geriatric assessment

On internet you can find many definitions about what is the global geriatric asssesment. 

In short words, it is a complex interdisciplinary diagnostic which allows us to detect the physical, functional, psychological and social problems in the elderly in order to develop an intervention and long-term monitoringof problems. In addition to optimizing resources and getting a better independence.

But the global geriatric asssesment is really big so i am going to divide this point in five:

• Phisical assesment
• Funccional assesment
• Mental and social assesment
• Afective assesment

 Phisical/ clinical assessment

In my opinion is one of the most important because the patient's physical condition will determinate the activities that the pationt is going to be able to do. In addition the phisical problems are easier to treat than mental problems. I mean, heal an ulcer is easier to treat the alzheimer. Although this does not mean that the other reviews are not important. 

A good clinical assessment must consist of:

Anamnesis which appear 

• Personal history,
• Review of systems and symptoms, which leads us to the detection of large geriatric syndromes
• Complete drug history and update in order to detect possible symptoms and signs related to side effects
• Nutritional history

Physical examination: of course we can´t  fully explore all patients but we can teach them about  potential problems that could have and warn us that if it happens. Initial physical examination that if we do as nurses is to observe the physical, personal care, grooming .. and then take vital signs (temerperatura, blood pressure, heart rate and respiratory and oxygen saturation

Laboratory tests:  which, although must send by the doctor, we need to know because if we suspect any disease, we should talk to the doctor in order toasks for the test. Some of them are: hemogram, glucose, electrocardiogram, mantoux thorax x.-ray...

Functional assessment

Is the process responsible for getting information about the ability of the elderly to perform their normal life. But How can we do that? Easy, we only have to use scales. But which is the best scale? well, depens what we want to review. For example, if we have to review how the elderly does the basic activities of daily living we can use:

• Katz Index of independence in activities of daily living
• Barthel Index
• Plutchik's Life Style Index

On the other hand, if we want  to review how the elderly does the instrumental activities of daily living, we can use:

• Lawton and Brody Index

Mental and social assesment

Up till now i have talked about the "physical part" so now is turn to the psychological part which is very important too. I think that helping to treat these patients is the most complicated labor in which you must be really patience. I prefer to help in physical than in mental problems, although I know that both are important. Even if I thought for a moment I would say that the mental part is much more important than physical because what I prefer? -Having a bad appearance but have a good memory and ability to ration or having a good physical appearance but not even remember my name?

Returning to the mental and social assesment, we can divide this in two parts:

• Mental assesment: It is important to pay attention to the cognitive and affective parts, both parties are very fragile in the elderly.

 However, while the elderly are cared for by the family, is still common to find elders with severe cognitive impairment whose family has never detected memory problems. Therefore, regardless of what tell the family and the patient, it is useful to make a small mental examination to reveal any problem at this level. In order to do this, we can turn to some index like: the Short Portable Mental Status Questionnaire of Pfiffer, Mini-mental State Examination of Folstein or cognitive mini-exam of lobo.

• Social assement: allows us to know the relationship between the old man and his environment. although it is a function of the social worker, the nurse should record all relevant data which affecting to the patient.

Afective assesment

In respect of affection, we can mention two psquiatric disorder very common which affect to elderly population are depression and anxiety.

1. Depression: People over age 65 , depressions is a problem for as many as 1% to 9% of community-dwelling eldery, 10% to 26% or more of long-term care residents, and 11% to 46% of hospitalized older adults. But only 1 in 6 elderly who suffer forom depression is teated. Depression may be related to a wide range of factors, including loss of independence or loved ones or increased medical problem. 
2. Anxiety: is an emotional state of discomfort and aprhensión disproportionate to the stimulus that triggers it. In the elderly is more common as a symptom of anxiety as a disease and has repercussions on the life, cognitive performance and worsening depression

In order to appreciate  the affective sphere, we can use a lot of scales but the most important is The Geriatric Depression Scale (Yesavage scale).

Bibliography

• Hoffmann G. Health Assessment of Older Adults. Basic Geriatric Nursing 5th Edition. Missouri: Elsevier; 2012. p 151-166. 

• Redin J. Comprehensive geriatric assessment (I). Evaluation of the geriatric patient and the concept of fragility. Servicio de Geriatria del Hospital de Navarra [cited 10 de Apr 2013]. Available from: http://www.cfnavarra.es/salud/anales/textos/vol22/suple1/suple5.html

• Shelkey M, Mason V, Wallace M. Katz Index of Independence in Activities of Daily Living (ADL). The Hartford Institute for Geriatric Nursing. 2012 ; (2):1-2. Available from: http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf

• Barthel D. Barthel Index. University of Dundee. 1999. Available from: http://www.dundee.ac.uk/medther/Stroke/Scales/barthel.htm

• Graf C. The Lawton Instrumental Activities of Daily Living (IADL) Scale. The Hartford Institute for Geriatric Nursing. 2013 ; (23):1-2. Available from: http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf

• Pfeiffer E. The short portable mental status questionnaire (SPMSQ). Standfor School of Medicine . 2010. Available from: http://geriatrics.stanford.edu/culturemed/overview/assessment/downloads/spmsq_tool.pdf

• Folstein M, Folstein S, McHugh P. Folstein Mini-Mental State Exam. utmb Health. 1975. Available from: http://www.utmb.edu/psychology/Folstein%20Mini.pdf

• Sherry A A. The Geriatric Depression Scale (GDS). The Hartford Institute for Geriatric Nursing. 2012 ; (4):1-2. Available from: http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf

Speaking with the elderly

Introducction

In the old age there is a development of communication and language, because it extends the general world knowledge and you have more contents and experiences to communicate. But while in normal aging, there are difficulties of lexical access, syntactic processing difficulties and speech organization. This problems seem to be caused by a loss of efficiency in processing.

In addition the physiological changes that occurs hinder the conversation with them. Mainly changes in vision and hearing. If a person can´t look well or he can´t hear very well, the most of sensory signals which are important (warning look in his eyes, the eye contact, body in care), never perceive. But communication problems are not only influenced by phyisiological changes, communication is going to be influenced by society, enviroment, culture, family, loneliness...

With this in mind, if we look at it from the point of view of health, the communication difficulties mean dificulties to establish therapeutic relationships too. From my point of view, the proffesional should work in order to communicate clearly and using other sensory channels to communicate clearly and effectively

Some tips that come to mind that we can do to improve communication are:

• Doing shorts and frequently interviews 
• Being near to the elderly and speaking loudly and slowly 
• Giving him time to respond
• Subsequently request information to the family or primary caregiver to complete and contrast information

Here are two videos that I found it quite interesting and funny in which appear more advice

Bibliography

Rabadán O, Pereiro A, Facal D. Comunicación y lenguaje en la vejez. Portal Mayores. 2006 October 23; (67):1-20. Available from: http://www.imsersomayores.csic.es/documentos/documentos/juncos-comunicacion-01.pdf

Martilla R. Características de la comunicación en el anciano. Terapia ocupacional. 2000 September. Available from: http://www.terapia-ocupacional.com/articulos/Caracteristicas-Comunicacion-Anciano.shtml