GENITOUNRINARY SYSTEM

DEFINITION:

In anatomy, the genitourinary system or urogenital system is the organ system of

the reproductive organs and the urinary system. These are grouped together
because of their proximity to each other, their common embryological origin and
the use of common pathways, like the male urethra.

CHANGES:
A number of changes in the genitourinary system occur as the body ages. Look
at these changes.

a.

Even without kidney disease, aging causes the kidneys to lose some of their

ability to concentrate urine. With aging, progressively more water is needed to excr
ete
the same amount of waste. Therefore, it
is necessary for older persons to drink more
water than young people. Older people eliminate larger amounts of urine (polyuria)
even at night (nocturia).
b. Beginning at about age 40, there is
a decrease in the number and size of the
nephrons. Often, more than 50 percent of the nephrons are lost before age 80.
c. There may be an increase in blood urea nitrogen (BUN) without serious
symptoms.
d. The elderly are more susceptible than young people to infections of the
urinary system.
e.
Childbearing may have caused damage to the musculature of the pelvic floor.
Years later, this damage may cause urinary tract problems.
f.

Enlargement of the prostate, common in older men, may cause obstruction

and back pressure in the ureters and kidneys. If
an enlarged prostate condition is
untreated, it will cause permanent damage to the kidneys.
g. Age changes may predispose a person to incontinence, but age changes do
not cause a person to
be incontinent. Most elderly persons (60 percent of those

residing in nursing homes and up to

90 percent of those living independently) have no
incontinence.

COMMON DISORDERS:
Prostatitis has traditionally been divided into four clinical categories: acute bacterial
prostatitis, chronic bacterial prostatitis, non-bacterial prostatitis and prostatodynia.
Only 5 to 10 percent of prostatitis cases have a bacterial etiology.

MANAGEMENT:
Prostatitis treatments vary depending on the underlying cause. They can include:

Antibiotics. This is the most commonly prescribed treatment for prostatitis.

Your doctor will base the choice of medication on the type of bacteria that may be
causing your infection. If you have severe symptoms, you may need intravenous
(IV) antibiotics. You'll likely need to take oral antibiotics for four to six weeks, but
may need longer treatment for chronic or recurring prostatitis. Take all of the
prescribed drugs as directed even if you're feeling better. Otherwise, treatment may
not work. Your doctor may have you try one or more antibiotics even if the cause of
your prostatitis can't be identified. If antibiotics don't help, your prostatitis is most
likely caused by something other than a bacterial infection.

Alpha blockers. These medications help relax the bladder neck and the
muscle fibers where your prostate joins your bladder. This treatment may lessen
symptoms, such as painful urination. Examples include tamsulosin (Flomax),
terazosin (Hytrin), alfuzosin (Uroxatral) and doxazosin (Cardura). Common side
effects include headaches and a decrease in blood pressure.

Pain relievers. Pain medications such as aspirin or ibuprofen (Advil, Motrin,

others) may make you more comfortable. You should discuss with your doctor what
doses you can safely take. Overusing these medications can cause problems.

Prostate massage. This is done by your physician using a lubricated,

gloved finger a procedure similar to a digital rectal exam. It may provide some
symptom relief, but doctors disagree about how effective it is.

Other treatments. Other potential treatments for prostatitis are being

studied. These treatments include heat therapy with a microwave device and drugs
based on certain plant extracts.

KIDNEY STONES (RENAL CALCULI):

Kidney stones, also called renal calculi, urolithiasis, or nephrolithiasis, usually
develop when the urine becomes too concentrated (urine acidification). As a result,
minerals and other substances in the urine form hard crystals in the kidneys. Over
time, these crystals may combine to form a small, hard mass or stone. There are
four types of kidney stones that can develop: calcium stones (calcium oxalate
stones), struvite stones, uric acid stones, and cystine stones.
Calcium stones are the most common type of kidney stones, accounting for 80% of
cases. Calcium stones develop when there are high levels of calcium
(hypercalcemia) and oxalate in the blood. Patients who consume excessive amounts
of vitamin D or have overactive thyroids may have high levels of calcium in the
blood. Patients who consume large amounts of oxalic acid or undergo intestinal
bypass surgery may have high levels of oxalate in the blood.
Struvite stones are usually caused by chronic urinary tract infections. The bacteria
that cause these infections release enzymes that increase the amount of ammonia
in the urine. This excess ammonia may form large, sharp stones that may damage
the kidneys.
Uric acid stones form when there is excess uric acid in the urine. Uric acid is a
byproduct of protein metabolism. These stones are usually caused by a cancer
treatment called chemotherapy. It may also develop in patients who eat highprotein diets. Some patients are genetically predisposed to develop uric acid stones.
Cystine stones develop in patients who have an inherited disorder called cystinuria.
This disorder causes the kidneys to release too many amino acids. The excess
amino acids then form stones.

MANAGEMENT:
Treatment for kidney stones varies, depending on the type of stone and the cause.
Small stones with minimal symptoms
Most kidney stones won't require invasive treatment. You may be able to pass a
small stone by:

Drinking water. Drinking as much as 2 to 3 quarts (1.9 to 2.8 liters) a day

may help flush out your urinary system. Unless your doctor tells you otherwise,
drink enough fluid mostly water to produce clear or nearly clear urine.

Pain relievers. Passing a small stone can cause some discomfort. To relieve
mild pain, your doctor may recommend pain relievers such as ibuprofen (Advil,
Motrin, others), acetaminophen (Tylenol, others) or naproxen sodium (Aleve).

Medical therapy. Your doctor may give you a medication to help pass your
kidney stone. This type of medication, known as an alpha blocker, relaxes the
muscles in your ureter, helping you pass the kidney stone more quickly and with
less pain.
Large stones and those that cause symptoms
Kidney stones that can't be treated with conservative measures either because
they're too large to pass on their own or because they cause bleeding, kidney
damage or ongoing urinary tract infections may require more invasive treatment.
Procedures may include:

Using sound waves to break up stones. For certain kidney stones

depending on size and location your doctor may recommend a procedure called
extracorporeal shock wave lithotripsy (SWL). SWL uses sound waves to create
strong vibrations (shock waves) that break the stones into tiny pieces that can be
passed in your urine. The procedure lasts about 45 to 60 minutes and can cause
moderate pain, so you may be under sedation or light anesthesia to make you
comfortable. SWL can cause blood in the urine, bruising on the back or abdomen,
bleeding around the kidney and other adjacent organs, and discomfort as the stone
fragments pass through the urinary tract.

Surgery to remove very large stones in the kidney. A procedure called

percutaneous nephrolithotomy (nef-row-lih-THOT-uh-me) involves surgically
removing a kidney stone using small telescopes and instruments inserted through a
small incision in your back. You'll receive general anesthesia during the surgery and
be in the hospital for one to two days while you recover. Your doctor may
recommend this surgery if SWL was unsuccessful or if your stone is very large.

Using a scope to remove stones. To remove a smaller stone in your ureter

or kidney, your doctor may pass a thin lighted tube (ureteroscope) equipped with a
camera through your urethra and bladder to your ureter. Once the stone is located,
special tools can snare the stone or break it into pieces that will pass in your urine.
Your doctor may then place a small tube (stent) in the ureter to relieve swelling and
promote healing. You may need general or local anesthesia during this procedure.

Parathyroid gland surgery. Some calcium stones are caused by overactive

parathyroid glands, which are located on the four corners of your thyroid gland, just
below your Adam's apple. When these glands produce too much parathyroid
hormone (hyperparathyroidism), your calcium levels can become too high and
kidney stones may form as a result. Hyperparathyroidism sometimes occurs when a
small, benign tumor forms in one of your parathyroid glands or you develop another
condition that leads these glands to produce more parathyroid hormone. Removing
the growth from the gland stops the formation of kidney stones. Or your doctor may
recommend treatment of the condition that's causing your parathyroid gland to
overproduce the hormone.

PELVIC INFLAMATORY DISEASE:

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs.
It usually occurs when sexually transmitted bacteria spread from your vagina to
your uterus and upper genital tract.
Many women who develop pelvic inflammatory disease either experience no signs
or symptoms or don't seek treatment. Pelvic inflammatory disease may be detected
only later when you have trouble getting pregnant or if you develop chronic pelvic
pain.

MANAGEMENT:

Antibiotics are the standard treatment for pelvic inflammatory disease. Your doctor
may prescribe a combination of antibiotics before receiving the results of your
laboratory tests. The antibiotics may be adjusted once your results are known. Your
doctor may also prescribe a medication to relieve your pain and recommend bed
rest.
To prevent reinfection with an STI, advise your sexual partner to be examined and
treated. Avoid sexual intercourse until treatment is completed and tests indicate
that the infection has cleared in all partners.

More-serious cases
Outpatient treatment is adequate for treating most women with pelvic inflammatory
disease. However, if you're seriously ill, pregnant or HIV-positive, or have not
responded to oral medications, you may need hospitalization. At the hospital, you
may receive intravenous (IV) antibiotics, followed by oral antibiotics.
Surgery is rarely necessary. However, if an abscess ruptures or threatens to rupture,
your doctor may drain it. In addition, surgery may be performed on women who
don't respond to treatment or who have a questionable diagnosis, such as when one
or more of the signs or symptoms of PID are absent. In these cases, doctors often
try antibiotic treatment before surgery, because of the risks of surgery.

PROLAPSED UTERUS:
If the uterus collapses into the vaginal canal, the condition is called a prolapsed
uterus.
There are many causes of a prolapsed uterus. Weakened pelvic muscles caused by
aging may lead to a prolapsed uterus. Vaginal childbirth and medical conditions,
such as such as chronic cough, straining from constipation, pelvic tumors, or an
accumulation of fluid in the abdomen, may also cause the condition.

MANAGEMENT:
Simple self-care measures, such as performing exercises called Kegels to strengthen
your pelvic muscles, may provide symptom relief. Maintaining a healthy weight and
avoiding heavy lifting may help reduce pressure on supportive pelvic structures.
For more-severe cases of uterine prolapse, treatment options include:

Vaginal pessary. This device fits inside your vagina and holds your uterus in
place. Used as temporary or permanent treatment, vaginal pessaries come in many
shapes and sizes, so your doctor will measure and fit you for the proper device.
You'll also learn how to insert, remove and clean the pessary. You may be able to
take the pessary out overnight and reinsert it each day.
But a vaginal pessary may be of little use if you have severe uterine prolapse. Also,
a vaginal pessary can irritate vaginal tissues, possibly to the point of causing sores
(ulcers) on vaginal tissues, and it may interfere with sexual intercourse.

Surgery. To repair damaged or weakened pelvic floor tissues, doctors often

use a vaginal approach to surgery, although sometimes doctors recommend an
abdominal surgery. A hysterectomy, which removes your uterus, also may be
needed.
As an alternative to vaginal and abdominal surgery, your doctor may recommend
minimally invasive (laparoscopic) surgery. This procedure involves smaller
abdominal incisions, special surgical instruments and a lighted camera-type device
(laparoscope) to guide the surgeon.
In some cases, surgical repair may be possible through a graft of your own tissue,
donor tissue or some synthetic material onto weakened pelvic floor structures to
support your pelvic organs.

URINARY INCONTINENCE:
Urinary incontinence describes the inability to control the bladder. The
bladder spontaneously empties all or some of the urine. Aging is also associated
with urinary incontinence because the bladder muscles become weaker over time.
Also, elderly women produce less estrogen, a hormone that helps keep the lining of
the bladder and urethra healthy.

MANAGEMENT:

Medications
Often, medications are used in conjunction with behavioral techniques. Drugs
commonly used to treat incontinence include:

Anticholinergics. These prescription medications calm an overactive

bladder, so they may be helpful for urge incontinence. Several drugs fall under this
category, including oxybutynin (Ditropan), tolterodine (Detrol), darifenacin
(Enablex), fesoterodine (Toviaz), solifenacin (Vesicare) and trospium (Sanctura).
Possible side effects of these medications include dry mouth, constipation, blurred
vision and flushing.

Topical estrogen. Applying low-dose, topical estrogen in the form of a

vaginal cream, ring or patch may help tone and rejuvenate tissues in the urethra
and vaginal areas. This may reduce some of the symptoms of incontinence.

Imipramine. Imipramine (Tofranil) is a tricyclic antidepressant that may be

used to treat mixed urge and stress incontinence.

Duloxetine. The antidepressant medication duloxetine (Cymbalta) is

sometimes used to treat stress incontinence.
Medical devices
Several medical devices are available to help treat incontinence. They're designed
specifically for women and include:

Urethral insert. This small tampon-like disposable device inserted into the
urethra acts as a plug to prevent leakage. It's usually used to prevent incontinence
during a specific activity, but it may be worn throughout the day. Urethral inserts
aren't meant to be worn 24 hours a day. They are available by prescription and may
work best for women who have predictable incontinence during certain activities,
such as playing tennis. The device is inserted before the activity and removed
before urination.

Pessary (PES-uh-re). Your doctor may prescribe a pessary a stiff ring

that you insert into your vagina and wear all day. The device helps hold up your
bladder, which lies near the vagina, to prevent urine leakage. You need to regularly
remove the device to clean it. You may benefit from a pessary if you have
incontinence due to a dropped (prolapsed) bladder or uterus.
Interventional therapies

Bulking material injections. Bulking agents are materials, such as carboncoated zirconium beads (Durasphere), calcium hydroxylapatite (Coaptite) or
polydimethylsiloxane (Macroplastique), that are injected into tissue surrounding the
urethra. This helps keep the urethra closed and reduce urine leakage. The
procedure usually done in a doctor's office requires minimal anesthesia and
takes about five minutes. The downside is that repeat injections are usually needed.

Botulinum toxin type A. Injections of onabotulinumtoxinA (Botox) into the

bladder muscle may benefit people who have an overactive bladder. Researchers

have found this to be a promising therapy, but the Food and Drug Administration
(FDA) has not yet approved this drug for incontinence. These injections may cause
urinary retention that's severe enough to require self-catheterization. In addition,
repeat injections are needed every six to nine months.

Nerve stimulators. Sacral nerve stimulators can help control your bladder
function. The device,which resembles a pacemaker, is implanted under the skin in
your buttock. A wire from the device is connected to a sacral nerve an important
nerve in bladder control that runs from your lower spinal cord to your bladder.
Through the wire, the device emits painless electrical pulses that stimulate the
nerve and help control the bladder. Another device, the tibial nerve stimulator, is
approved for treating overactive bladder symptoms. Instead of directly stimulating
the sacral nerve, this device uses an electrode placed underneath the skin to deliver
electrical pulses to the tibial nerve in the ankle. These pulses then travel along the
tibial nerve to the sacral nerve, where they help control overactive bladder
symptoms.
Surgery
If other treatments aren't working, several surgical procedures have been
developed to fix problems that cause urinary incontinence.
Some of the commonly used procedures include:

Sling procedures. A sling procedure uses strips of your body's tissue,

synthetic material or mesh to create a pelvic sling or hammock around your bladder
neck and urethra. The sling helps keep the urethra closed, especially when you
cough or sneeze. There are many types of slings, including tension-free, adjustable
and conventional.

Bladder neck suspension. This procedure is designed to provide support to

your urethra and bladder neck an area of thickened muscle where the bladder
connects to the urethra. It involves an abdominal incision, so it's done using general
or spinal anesthesia.

Artificial urinary sphincter. This small device is particularly helpful for men
who have weakened urinary sphincters from treatment of prostate cancer or an
enlarged prostate gland. Shaped like a doughnut, the device is implanted around
the neck of your bladder. The fluid-filled ring keeps your urinary sphincter shut tight

until you're ready to urinate. To urinate, you press a valve implanted under your
skin that causes the ring to deflate and allows urine from your bladder to flow.
Absorbent pads and catheters
If medical treatments can't completely eliminate your incontinence or you need
help until a treatment starts to take effect you can try products that help ease
the discomfort and inconvenience of leaking urine.

Pads and protective garments. Various absorbent pads are available to

help you manage urine loss. Most products are no more bulky than normal
underwear, and you can wear them easily under everyday clothing. Men who have
problems with dribbles of urine can use a drip collector a small pocket of
absorbent padding that's worn over the penis and held in place by closefitting
underwear. Men and women can wear adult diapers, pads or panty liners, which can
be purchased at drugstores, supermarkets and medical supply stores.

Catheter. If you're incontinent because your bladder doesn't empty properly,

your doctor may recommend that you learn to insert a soft tube (catheter) into your
urethra several times a day to drain your bladder (self-intermittent catheterization).
This should give you more control of your leakage, especially if you have overflow
incontinence. You'll be instructed on how to clean these catheters for safe reuse.

URINARY TRACT INFECTIONS (UTI):

A urinary tract infection (UTI) is an infection of the urinary system. UTIs may
affect any part of the urinary tract including the kidneys, ureters, bladder, and
urethra. However, most infections involve the lower tract, which includes the
urethra and the bladder.

MANAGEMENT:

Simple infection
Drugs commonly recommended for simple UTIs include:

Sulfamethoxazole-trimethoprim (Bactrim, Septra, others)

Amoxicillin (Amoxil, Augmentin, others)

Nitrofurantoin (Furadantin, Macrodantin, others)

Ampicillin

Ciprofloxacin (Cipro)

Levofloxacin (Levaquin)
Usually, symptoms clear up within a few days of treatment. But you may need to
continue antibiotics for a week or more. Take the entire course of antibiotics
prescribed by your doctor to ensure that the infection is completely gone.
For an uncomplicated UTI that occurs when you're otherwise healthy, your doctor
may recommend a shorter course of treatment, such as taking an antibiotic for one
to three days. But whether this short course of treatment is adequate to treat your
infection depends on your particular symptoms and medical history.
PHYSICIAN may also prescribe a pain medication (analgesic) that numbs your
bladder and urethra to relieve burning while urinating. One common side effect of
urinary tract analgesics is discolored urine orange or red.
Frequent infections
If you experience frequent UTIs, your doctor may make certain treatment
recommendations, such as:

Longer course of antibiotic treatment or a program with short courses of

antibiotics at the start of your urinary symptoms

Home urine tests, in which you dip a test stick into a urine sample, to check
for infection

A single dose of antibiotic after sexual intercourse if your infections are

related to sexual activity

Vaginal estrogen therapy if you're postmenopausal, to minimize your chance

of recurrent UTIs
Severe infection
For a severe UTI, you may need treatment with intravenous antibiotics in a hospital.

NURSING CONSIDERATIONS:

1. Phisycal examination and clients history and assess voiding habits.

2. Monitor Vital signs and monitor Input and ouput.
3. Assess the level of pain and Give pain relievers or analgesics when
needed.
4. Advised client to take antibiotics in full course of treatment.
5. Explain the side effects of the medication prescribed by the physician.
6. Assist the Client in urinating or advised to use diaper for urinary
incontinence.
7. Advised to increased fluid intake especially other than incontinence.
8. Teach the client proper genital hygiene.
9. Advice to eat nutritious foods.
10.If possible advised the client to avoid foods that may contribute to
renal dysfunction, such as soda drinks and coffee.
11.Give antipyretics for fever.
12.Encourage the client to do simple exercises.
13.Perform gentle prostatic massage if indicated(for non bacterial prostitis
only)
14.Encouraged follow up especially for diseases with infection s the cause.
15.Explain the surgical procedures when needed.
16.Assess the level of anxiety.
17.Observe for the signs of irritability.

ENDOCRINE SYSTEM
DEFINITION:
The endocrine system consists of glands and organs that produce and release
hormones. Three of the most important hormone axis in the endocrine system
affected by aging are: growth hormone (GH)/insulin-like growth factor I (IGFI), cortisol/dehydroepiandrosterone (DHEA), and testosterone/estradiol.

CHANGES IN ELDERLY:

"Somatopause" is a term used to describe the change in GH/IGF-I axis which

involves a decrease in production and sensitivity to GH and IGF-I. Typically, GH
secretion declines 14% with each decade of life.

Declines in pituitary GH secretion is associated with loss of skeletal

muscle mass, increased adiposity, and other detrimental effects of aging in

elderly humans. With aging, there is a decrease in the amount of circulating GH

and consequently IGF-I which results in weaker bones with a low BMD.

Another hormone axis that changes with aging is the cortisol/DHEA axis.
DHEA peaks in the mid-20s and then gradually declines with aging (termed
adrenopause). Cortisol on the other hand remains relatively unchanged with
aging, causing an imbalance in hormone levels and thus altered immune function.

Menopause/andropause refers to the decrease in production and circulation

of estradiol in females and testosterone in males. In addition to their role in
reproduction and growth, both hormones demonstrate neuroprotective effects
and have been theorized to reduce the effects of Alzheimers disease.

COMMON DISORDERS:
HYPOADRENOCORTICISM
The clinical syndrome of adrenocortical hypofunction is unaltered by aging. Because asthenia and
easy fatigability may be associated with the stereotype of normal aging, these symptoms as
heralds of hypoadrenocorticism may attract insufficient medical attention in the elderly. Hyponatremic
and hyperkalemic syndromes of various causes are relatively common in the older patient. In the
majority of elderly patients with hyponatremia, however, euvolemia is present, and hyponatremia
reflects impaired free water clearance (syndrome of inappropriate secretion of antidiuretic hormone,
SIADH).

MANAGEMENT:
The situations in which renal free water clearance is decreased include tumoral secretion of arginine
vasopressin (AVP, ADH) and administration of a variety of drugs, including diuretics, carbamazepine,
chlorpropamide, and antipsychotic medications.
In addition to hypoadrenocorticism, hyperkalemic syndromes in older patients may be related to
decreased renal function, excessive use of potassium-sparing diuretics (particularly when oral
potassium intake is high, as it is with use of a salt substitute), administration of angiotensinconverting enzyme (ACE) inhibitors, and hypoaldosteronism.

HYPOTHYROIDISM:
The subtlety of early hypothyroidism in elderly subjects is easily confused with the
progression of normal aging, and a low diagnostic threshold for the possibility of
hypothyroidism should be maintained by the physician in evaluating this age group.
The classic features of hypothyroidism are well known. Several of these should be
emphasized as herald findings of the disease. As many as one third of hypothyroid
patients are hypertensive, and one third of these patients can normalize their blood
pressure with thyroid hormone replacement therapy alone. Gait disorders,
apparently due to cerebellar dysfunction, occur in hypothyroidism, as does a
striated muscle myopathy, usually in a proximal muscle distribution. Asymmetrical
hypertrophy of the myocardial ventricular septum is an occasional feature of
hypothyroidism, and remission of this sign may occur with hormone replacement.

MANAGEMENT:
1. Monitor VS, and alert for signs and symptoms of Cardiovascualr
Disorders.
2. Monitor daily weights.
3. Diet: Decrease Caloric intake and increase fiber
4. Provide Warm environment.
5. Pharmacotherapy includes:
a. Proloid(Thyroglobulin)
b. Synthroid(Levothyroxine)
c. Dessicated Thyroid Extract
d. Cytomel(Liothyronine)
Check BP, PR before administration.
Start with Low Dose, gradually increase

HYPERTHYROIDISM:
Hyperthyroidism in the elderly is a great masquerader, and even severe, lifethreatening hyperthyroidism can easily be missed in patients older than 60 years.
Again, like hypothyroidism, the symptoms of hyperthyroidism are often atypical
instead of classic and may mimic other common diseases in this age group.
MANAGEMENT:
Pharmacotherapy:
Beta-Blockers: Inderal to control tachycardia
Iodides: Lugols solution SSKI( Saturated Solution of potassium Iodide)
Thioamides: PTU(Propylthiouracil and Tapazole(Methimazole)
Calcium Channel Blockers
Dexamethasone
NURSING CONSIDERATIONS:
1.
2.
3.
4.
5.
6.

Monitor Vital Signs, Input and output.

Monitor Neurologic and cardiovascular status every hour.
Administer meds as ordered.
Explain the side effects of the drugs or meds.
Check if there is fever and provide nursing actions for it.
Maintain quiet, calm, cool, private environment until crisis is over.
(hyperthyroidism)
7. Daily weights.
8. Diet for hypothyroidism should decrease caloric intake and hig in fiber.
9. Provide warm environment for hypothyroidism.

CENTRAL NERVOUS SYSTEM

DEFINITION:
The central nervous system (CNS) is the processing center for the nervous system.
It receives information from and sends information to the peripheral nervous
system. The two main organs of the CNS are the brain and spinal cord. The brain
processes and interprets sensory information sent from the spinal cord. Both the
brain and spinal cord are protected by three layers of connective tissue called the
meninges.
CHANGES IN ELDERLY:

The aging of the central nervous system is often portrayed as an irreversible loss of
functions and decline in abilities. The weight of your brain peaks around age 20 and
then a modest decline occurs with age that is limited to the gray matter (outer
surface of the brain) in healthy older people. Older nerve cells may have fewer
dendrites (branches) and some may become demyelinated (lose its coating) which
can slow the speed of message transmission. Most of these changes do not appear
to affect ordinary activities of living. People often fear cognitive decline in later life
more than any other disabling condition. Cognitive ability is crucial to the capacity
to live independently. Most of us do not want to be dependent on others as we age.
Impairment in cognitive capacity can threaten autonomy and the ability to manage
our daily activities.
Most neurological declines occur after age 60 and are not that severe. The incidence
of cognitive impairment increases with age so that by age 85, up to 1/3 of older
persons have some degree of cognitive impairment.
The cognitive abilities of older adults vary tremendously both within individuals and
across age groups. Within individuals some functions may change while others do
not.
COMMON DISORDERS:
DEMENTIA
Dementia is a loss of brain function that occurs with certain diseases. It
affects memory, thinking, language, judgment, and behavior.
It is a term that describes a collection of symptoms that include decreased
intellectual functioning that interferes with normal life functions and is usually used
to describe people who have two or more major life functions impaired or lost such
as memory, language, perception, judgment or reasoning; they may lose emotional
and behavioral control, develop personality changes and have problem solving
abilities reduced or lost.
MANAGEMENT:
Most types of dementia can't be cured. However, doctors will help you manage your
symptoms. Treatment of dementia symptoms may help slow or minimize the
development of symptoms.
Cholinesterase inhibitors. These medications including donepezil (Aricept),
rivastigmine (Exelon) and galantamine (Razadyne) work by boosting levels of a
chemical messenger involved in memory and judgment.
Side effects can include nausea, vomiting and diarrhea. Although primarily used to
treat Alzheimer's disease, these medications may also treat vascular dementia,
Parkinson's disease dementia and Lewy body dementia.
Memantine. Memantine (Namenda) works by regulating the activity of
glutamate. Glutamate is another chemical messenger involved in brain functions,
such as learning and memory. A common side effect of memantine is dizziness.

Some research has shown that combining memantine with a cholinesterase inhibitor
may have beneficial results.
Other medications. Doctor may prescribe other medications to treat other
symptoms or conditions, such as a sleep disorder.
Occupational therapy. Doctor may suggest occupational therapy to help you
adjust to living with dementia. Therapists may teach you coping behaviors and ways
to adapt movements and daily living activities as your condition changes.
NURSING CONSIDERATIONS:
1. Speak slowly and use short, simple words and phrases.
2. Consistently identify yourself, and address the person by name at each
meeting.
3. Focus on one piece of information at a time. Review what has been
discussed with patient.
4. If patient has vision or hearing disturbances, have him or her wear
prescription eyeglasses and/or hearing device.
5. Keep environment well lit.
6. Use clocks, calendars, and familiar personal effects in the patients
view.
7. If patient becomes verbally aggressive, identify and acknowledge how
he or she is feeling.
8. If Patient becomes delusional, acknowledge his or her feelings, and
reinforce reality. Do not attempt to challenge the content of the
delusions.
9. Advise significant others to lengthen the patience to the client, as it is
part of the degenerative process of the CNS of the elders.
10.Provide safety to the client always.
ALZHEIMER'S DISEASES
Alzheimer's disease is a progressive disease that destroys memory and other
important mental functions.
It's the most common cause of dementia a group of brain disorders that
results in the loss of intellectual and social skills. These changes are severe enough
to interfere with day-to-day life.
In Alzheimer's disease, the connections between brain cells and the brain
cells themselves degenerate and die, causing a steady decline in memory and
mental function.
MANAGEMENT:

Drugs
Current Alzheimer's medications can help for a time with memory symptoms
and other cognitive changes. Two types of drugs are currently used to treat
cognitive symptoms:

Cholinesterase inhibitors. These drugs work by boosting levels of a cellto-cell communication chemical depleted in the brain by Alzheimer's disease.
Most people can expect to keep their current symptoms at bay for a time.
Less than half of those taking these drugs can expect to have any
improvement. Commonly prescribed cholinesterase inhibitors include
donepezil (Aricept), galantamine (Razadyne) and rivastigmine (Exelon). The
main side effects of these drugs include diarrhea, nausea and sleep
disturbances.
Memantine (Namenda). This drug works in another brain cell communication
network and slows the progression of symptoms with moderate to severe
Alzheimer's disease. It's sometimes used in combination with a
cholinesterase inhibitor.
NURSING CONSIDERATIONS:
1.
2.
3.
4.

Creating a safe and supportive environment.

Remove excess furniture, clutter and throw rugs.
Install sturdy handrails on stairways and in bathrooms.
Ensure that shoes and slippers are comfortable and provide good
traction.
5. Reduce the number of mirrors. People with Alzheimer's may find
images in mirrors confusing or frightening.
6. Regular exercise is an important part of everybody's wellness
plan and those with Alzheimer's are no exception.
7. High-calorie, healthy shakes and smoothies.
8. Water, juice and other healthy beverages.
9. A diet low in fat and rich in fruits and vegetables.
10.
Omega-3 fatty acids are good for the heart.
11.
Social engagement and intellectual stimulation may make
life more satisfying and help preserve mental function.

SENSORY SYSTEM
DEFINITON:
A sensory system is a part of the nervous system responsible for processing sensory
information.

A sensory system consists of sensory receptors, neural pathways, and parts of the
brain involved in sensory perception.
Commonly recognized sensory systems are those for vision, hearing, somatic
sensation (touch), taste and olfaction (smell). Receptive fields have been identified
for the visual system, auditory system and somatosensory system, so far.
CHANGES IN ELDERLY:
Hearing loss is very common with aging and is one of the most correctable
yet often unrecognized problems. It contributes significantly to social isolation.
About 25% of people between 65 and 74 years of age and 50% of people age 75 or
older report difficulty hearing. Unfortunately, although 65% of those age 85 and
older report hearing difficulty only 8% use a hearing aid or other assistive listening
device. After age 60 there appears to be a 10dB reduction in hearing sensitivity
each decade. Older men are more likely to have hearing loss than older women and
people with Alzheimer's disease have a higher rate of hearing impairment than
others.
Age-related Changes in the Ear
A number of age-related changes occur in the ear. Membranes in the middle
ear, including the eardrum, become less flexible with age. In addition, the small
bones in the middle ear, the ossicles, become stiffer. Both these factors somewhat
decrease hearing sensitivity but are not thought to cause significant impairment.
Changes also occur in the inner ear but it is unclear whether is it aging or exposure
to environmental noise that causes these problems that result in hearing loss.
Changes in the middle ear with advancing age also contribute to a weakening
sense of balance. The vestibular system is responsible for our sense of balance. The
vestibular apparatus begins to degenerate with age in a similar way to the hearing
apparatus. Equilibrium becomes compromised and older individuals may complain
of dizziness and find it difficult to move quickly without losing their balance.
Smell
As we age, the number of functioning smell receptors decreases and this increases
the threshold for smell. It takes a more intense smell for it to be identified and
differentiated from other smells. After the age of 50 the sense of smell decreases
rapidly. By age 80, the sense of smell is reduced by about half. The lack of ability to
smell spoiled food can lead to indigestion and food poisoning. Even more seriously,
studies have show that older persons may not be able to detect relatively high
levels of mercaptoethanol. This odorant is added to natural gas so that individuals
can detect gas leakage. Thus older persons can miss detecting natural gas leakage
at levels that could cause explosions.

Taste
Taste also diminishes with age and older persons often complain that food doesn't
taste as good as it used to. Some atrophy of the tongue occurs with age and this
may diminish sensitivity to taste. Receptor cells for taste are found in the taste buds
on the tongue and are replaced continuously. Other factors that contribute to
changes in taste among seniors include poorly fitting dentures.
Touch
In later life, our sense of touch and response to painful stimuli decreases. The actual
number of touch receptors we have decreases which results in a higher threshold
for touch. The major concern a loss in touch sensitivity raises relate to personal
safety. For example, older adults do not sense heat as quickly so they tend to have
worse burns.
COMMON DISORDERS:
Presbycusis
Presbycusis-- literally "old man's hearing"-- is the most common form of hearing loss
with aging. It is characterized by a decrease in perception of higher frequency tones
and a decrease in speech discrimination. The magnitude of presbycusis varies
widely and it is hard to determine how much of the hearing loss is due to aging and
how much is due to exposure to environmental noise, ototoxic drugs, or chronic
age-related conditions such as hypertension and diabetes.
Beginning around age 55, most older adults experience a loss in threshold
sensitivity to pitch as the very high frequencies are lost. The higher frequency
consonants, such as t, p, k, f, s and ch, are no longer heard due to the sensitivity
loss in the high frequencies. In addition, elders have more difficulty in
understanding speech, especially when there are competing sounds such as
background noise.
Tinnitus
Tinnitus refers to a chronic ringing, buzzing, tinkling, humming or other noise in the
ears that only the individual can hear. Nearly 36 million Americans have tinnitus.
Tinnitus is more common among older adults because it may represent a lifetime of
exposure to loud noise. Treatable causes of tinnitus include high blood pressure,
wax in the ear canal, or some medications (e.g., aspirin, antibiotics,
antidepressants). Tinnitus may also be a symptom of ear infection, allergy or thyroid
problems. If a cause can be identified then tinnitus may be curable. More often
though the cause of tinnitus is unclear. Although there are no effective drug
therapies, you can do several things which may help:

use a masking devices that produces a noise to distract you from the tinnitus

avoid stimulants such as caffeine or nicotine which can increase tinnitus

limit stress and use biofeedback or relaxation techniques

join a support group.

MANAGEMENT:
Treatment
About one in three older adults have their hearing reduced by up to 35%
because of the accumulation of ear wax which blocks the sound. This is one of the
most treatable causes of hearing loss; health care professionals can remove excess
ear wax. Another common cause of hearing loss among older adults is medications,
especially antibiotics or diuretics which can cause permanent hearing impairment.
A hearing aid amplifies the intensity of sound and can be an effective way to
improve the hearing of most older adults. Nearly 2 million older people own hearing
aids. Unfortunately, less than 30 percent of those people actually use the hearing
aids, many for only a few hours per Module. Many older people dislike hearing aids
because room noises can be very distracting when they are amplified.
Fortunately, recent technological advances are improving the quality of the
experience which may make them more acceptable. In addition, hearing aids are
becoming smaller and which helps to remove the stigma of using them. Digitally
programmable hearing aids allow individuals to adapt their hearing needs to
different social contexts. However, hearing aids are quite expensive and most heath
insurance plans, including Medicare, do not cover the cost.
NURSING CONSIDERATIONS:
1.

Give food warm only not Hot, due to loss of painful stimuli is decrease.

2. Advise S.O. to assist the client needs.

3. Explain to S.O. them that due degenerative stage of the patients he or
she needs lot of patience and assistance.
4. Accepting the patient's perception of, stimulating the affected side or
body part, teaching the patient to position and care for the affected side
or body part, and positioning the affected side or part in the patient's
visual field.
5. Assist the client in his or her daily living.

6. Give nutritious foods, such as fruits, and vegetables, milk and so on.
7. Encouraging the patient to handle and use the affected side or body part
and teaching visual scanning and other compensatory measures.
8. Providing verbal cues and instructions to the affected side or body part.
9. Having the patient use other, intact senses to identify stimuli or objects,
teaching relearning via the drill method, protecting the patient from injury,
and interpreting the patient's behavior for the family.
10.Encouraging participation in ADLs, correcting mistakes or misuse of
equipment, and reteaching forgotten skills.
11.Accepting alternate forms of communication and showing the patient
pictures to permit communication.
12.Standing close so patient is aware of lip movements.
13.Speaking slowly and distinctly in a normal speaking voice, using
vocabulary or gestures the patient can understand.
14.Anticipating the patient's needs.
15.Memory: Encourage use of memory aids, provide clocks, calendars, radios
and TVs, structure daily exercises, post schedule/routine in a highly visible
place, and repeat and record new information as needed for later review.
16.Initiate/sequence: Post daily schedule in a highly visible place, break tasks
into smaller steps, provide cues for each step, allow patient to complete
each step, and provide supervision and support.
17.Attention: Reduce/minimize distractions, simply tasks and procedures,
allow ample time for task completion, refocus attention as needed, avoid
fatigue, provide frequent verbal, visual, or tactile cues, and encourage
simple leisure activities.