Introduction

Getting old is not for sissies. No matter who we are, man, woman, rich or poor, we all grow old.

But the pace and precise way it happens varies from person to person, depending on genetic, lifestyle and

environmental factors. However, as we grow old the deterioration rally starts to kick in, hence ailments

in later life may seem unavoidable. Last Febuary 23, 2018, we, the Adventist Medical Center College

(AMCC) nursing students had an exposure in Iligan City Elderly Clinic and probed for an elderly individual

to be interviewed and assessed. As we accommodate the clients, we came across an individual whom we

called as Nanay Belle. She was suffering from hypertension and gouty arthritis with complaints of hearing

impairments.

Brunnner & Suddarth’s (2014) defines hypertension as a systolic blood pressure greater than 140

mmHg and a diastolic pressure greater than 90 mmHg based on two or more accurate blood pressure

measurements taken during two or more contacts with a health care provider. The prevalence of

hypertension increases significantly as people get older or have other cardiovascular risk factors.

Structural and functional changes in the heart, blood vessels and kidneys contribute to increases in blood

pressure that occur with aging. These changes include accumulation of atherosclerotic plaque,

fragmentation of arterial elastins, increased collagen deposits, impaired vasodilation and renal

dysfunction.

The result of these changes is decreased elasticity of the major blood vessel and volume

expansion. Consequently, the aorta and large arteries are less able to accommodate the volume of blood

pumped out by the heart, and the energy that would have stretched the vessels instead elevates the

systolic blood pressure. Hypertension accompanies risk factors such as advancing age, race,

atherosclerotic heart disease, obesity, diabetes, metabolic syndrome, sedentary lifestyle, heart failure,

coronary artery disease and a history of stroke.

Hypertension can either be viewed as a sign, a risk factor or as a disease. Physical examination

may reveal no abnormalities other than elevated blood pressure. It is often called as silent killer because
individuals with hypertension may be asymptomatic and remain for so many years. However, when

specific signs and symptoms appear, they usually indicate vascular damage with specific manifestations

related to the organs served by the involved vessels.

Prolonged blood pressure elevation gradually damages blood vessels throughout the body,

particularly in target organs such as the heart, kidneys, brain and eyes. Left ventricular hypertrophy occurs

in response to the increased workload placed on the ventricles as it contracts against higher systemic

pressure. When heart damage is extensive, heart failure follows. Pathologic changes in the kidneys may

manifest as nocturia. Cerebrovascular involvement may led to transient ischemic attack (TIA), manifested

by alterations in speech or vision, dizziness, weakness a sudden fall or transient hemiplegia.

Nanay Belle reported that she had suffered from mild stroke in her early 50’s due to inability to

control anger upon arguing with her son. She was hospitalized for a night and was prescribed with some

medications. She was unable to recall the prescribed drugs she has taken. She was then given a

maintenance medication of Losartan 50mg and was compliant to it.

When hypertension is detected, nursing assessment involves carefully monitoring the blood

pressure at frequent intervals and then at routinely scheduled intervals. When the patient begins an

antihypertensive treatment regimen, blood pressure assessments are needed to determine the

effectiveness of the medication and to detect changes in blood pressure that indicate the need for lifestyle

modification in the treatment plan. Older patients should begin treatment with lifestyle modifications.

Medication starting dose should be the lowest available and then gradually increased with the second

medication from a different class added if control is difficult to achieve. As older adults often have other

comorbid conditions, awareness of possible drug interactions is critical. In addition, older adults are at

increased risk for the side effects of hyperkalemia and orthostatic hypertension, putting them at increased

risk for falls and fractures.

Another diagnosis of our chosen client is gouty arthritis (GA). Musculoskeletal problems are the

most frequently reported conditions in older adults. According to Brunner & Suddarth’s (2014), GA is the
most common form of inflammatory arthritis. Gout is a disease characterized by an abnormal metabolism

of uric acid, resulting in an excess of uric acid in the tissues and blood. People with gout either produce

too much uric acid, or more commonly, their kidneys are inadequate in removing it. Men are three to four

times more likely to be diagnosed with gout than women. The incidence of gout increases with age, BMI,

alcohol consumption, hypertension and diuretic use. Evidence links the consumption of fructose-rich

beverages with the risk of GA for both men and women (Choi, Willett & Curhan, 2010; Greener, 2011).

Comorbid conditions such as hypertension, dyslipidemia, diabetes, OA and kidney disease may be present

in patients with gout.

The first symptom of gouty arthritis is typically the sudden onset of a hot, red, swollen, stiff,

painful joint. Almost any joint can be involved (e.g. big toe, knee, ankle, and small joints of the hands). In

some people, the acute pain is so intense that even a bed sheet on the toe causes severe pain. Even

without treatment, the first attacks stop spontaneously, typically within one to two weeks. While the pain

and swelling completely go away, gouty arthritis commonly returns in the same joint or in another joint.

With time, attacks of gouty arthritis can occur more frequently and may last longer.

In gout uric acid crystals can form outside joints, it is a by-product of purine metabolism; purines

are basic chemical compounds found in high concentrations in meat products. Collections of these

crystals, complications known as tophi, can occur in the earlobe, elbow, and Achilles tendon (back of the

ankle), or in other tissues. The initial cause for the gout attack occurs when the macrophages in the joint

space phagocytize urate crystals. Through a series of immunologic steps, IL-1 beta is secreted, increasing

the inflammation. This process is exacerbated by the presence of free fatty acids. Both alcohol and large

meal consumption especially red meat can lead to increases in free fatty acid concentrations. Altered

renal tubular function, either as a major action or as unintended side effect of pharmacologic agents (e.g.

diuretics, low-dose salicylates or ethanol) can also contribute to uric acid overexcretion.

Hence, management between gout attacks needs to include lifestyle modification such as

avoiding purine-rich foods, weight loss, decreasing alcohol consumptions and avoiding certain
medications. Acute attacks are managed with colchiline, NSAID such as indomethacin or corticosteroid.

Uricosuric agents such as probenecid or sulfinpyrazone may be indicated in patients with frequent acute

attacks. In an acute episode of gouty arthritis, pain management with prescribed medication is essential,

along with avoidance of factors that increases pain and inflammation such as trauma, stress and alcohol.

Once the acute attacks have subsided, uric acid lowering therapy should be considered. Xanthine oxidase

inhibitors such as allopurinol and febuxostat are the agents of choice.

Your ears are also not immune to aging, age-related hearing loss is one of the most common

health conditions that affect older individuals. Factors include auditory nerve degeneration leading to

hearing loss or few changes occuring in the ear. Cerumen tends to become harder and drier posing a

greater chance of impaction in the external ear. In the middle ear, the tympanic membrane may atrophy

or become sclerotic. In the inner ear, cells at the base of the cochlea degenerate. A familial predisposition

is also seen, manifested by inability to hear high frequency sounds, followed in time by the loss of middle

and lower frequencies. The term presbycusis is used to describe this progressive hearing loss (Eliopoulos,

2010). Exposure to loud-noises, certain medications (e.g. aminoglycosides, aspirin, loop-diuretics, quinine

and platinum-based antineoplastic medications) imposes ototoxicity effects hence can affect hearing in

older people. Loss of hearing can contribute to confusion, anxiety, disorientation, misinterpretation of the

environment, feelings of inadequacy and social isolation, which puts a negative impact on quality of life

in the older adult.

Aging imposes various anatomical and physiological problems, hence, it is a great challenge for

health care providers to deal with older individuals. They serve as a catalysts throughout the health care

system to ensure that accommodation are made to meet the communication needs of these clients.

This exposure did not only provide an avenue to apply what we have acquired in the classroom

but also provides an opportunity to serve our fellowmen. Because being in the community is more than

meeting the requirements in the related learning experience, it is the experience in the real world, making

real memories and rendering service, conscience, commitment and care.