Orthostatic hypertension: when pressor reflexes overcompensateOrthostatic hypertension—a rise in blood pressure upon assuming upright posture—is an underappreciated and understudied clinical phenomenon. There is currently no widely agreed-upon definition of clinical orthostatic hypertension, the current definitions being operational within the context of particular studies. The underlying pathophysiology is thought to involve activation of the sympathetic nervous system, but the actual etiology is poorly understood. Orthostatic hypertension is observed in association with a variety of other clinical conditions, including essential hypertension, and type 2 diabetes mellitus. Orthostatic hypertension has been associated with increased occurrence of silent cerebrovascular ischemia and possibly with neuropathy in type 2 diabetes.

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Health Promotion

Miss Shurouq Qadose27/2/2011

Could we catch a picture like this in Palestine ?

ألبومها تطلق عراقية فنانةبلوغها مع عاما 82األول

الوطن في نوعها من األولى تكون قد حالة فيمساء األورفلي، وداد العراقية الفنانة أطلقت العربي؛

/ 28السبت شباط الموسيقي 2011فبراير ألبومها م،بلغوها مع عاما 82األول .

Mrs. Martin is an 82-year-old woman who was admitted to the hospital after a recent fall. She claims that she tripped en route to the bathroom and woke up on the floor in the morning. She lives alone, has no prior

history of falls, and states that her daughter calls her daily and visits on weekends. You are the RN performing a follow-up home visit for a home safety check.

Upon visiting the home you discover that although it is very neat and clean, she has a number of throw rugs covering the hardwood floor in her living room. In addition, the carpet in her bedroom is coming up along the edges. Likewise, there currently is no clear path from her bed to the bathroom. After your assessment you make a plan to discuss your suggestions with Mrs. Martin.

These needs have resulted from both normal and pathological changes of aging. Pathological changes of aging may result from poor health practices acquired early in life and continued into older adulthood.

The Federal Interagency Forum on Aging-Related

Statistics (2004) reported that in the year 2001, the most leading causes of death in the United States were heart disease, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, influenza, pneumonia, and diabetes.

In fact, health promotion is as important in older adulthood as it is in childhood. Older adults are never “too old” to improve their nutritional level, start exercising, get a better night’s sleep, and improve their overall health and safety.

The U.S. Department of Health and Human Services developed National Health-Promotion and Disease-Prevention Objectives (http://www.health.gov/healthypeople) titled Healthy People 2010. These objectives are achieved through varying levels of prevention. Primary prevention

involves measures to prevent an illness or disease from occurring, for example, immunizations, proper nutrition, and regular fluoride dental treatments. Secondary prevention involves routine mammograms, hypertension screening, and prostate specific antigen (PSA) .

Tertiary prevention is needed after the disease or condition has been diagnosed and treated. This is an attempt to return the client to an optimum level of health and wellness despite the disease or condition, for example, physical, occupational, and speech pathology services following a cerebrovascular accident.

Many barriers stand in the way of improved health among this population. One of the greatest barriers surrounds misconceptions about the benefits of health promotion for older adults.

Another barrier lies in the challenge of separating the normal changes of aging from pathological illness.

A final barrier to improving the health promoting activities of older adults is their own motivation to change. In fact, this is the most important factor in improving health.

Primary Prevention1- Smoking

Currently, there is evidence to support that cigarette

smoking causes heart disease, several kinds of cancer (lung, larynx, esophagus, pharynx, mouth, and bladder), and chronic obstructive pulmonary

diseases, including bronchitis, asthma, emphysema, and bronchiectasis. Cigarette smoking also contributes to cancer of the pancreas, kidney, and cervix (U.S. Department of Health and Human Services, 2000).

Research has shown that because smoking begins and propagates disease development, it is one of the most critical negative predictors of longevity.

Because of the large number of medications older adults often take, including over-the-counter (OTC) and herbal medications, the potential for these drugs to interact with the nicotine in cigarettes is high. Nicotine– drug interactions can cause many problems for the older adult.

Interventions to stop smoking usually surround behavioral management classes, and support groups are available to community-dwelling older adults. Nicotine-replacement therapy and anti-depression medications are also helpful in assisting the older adult to quit smoking.

2- Nutrition and Hydration

A large study was conducted among older adults aged 65 and older (n = 1113) to determine whether older adult diets met the Recommended Daily Allowance (RDA) and what factors contributed to dietary adequacy. The results showed that diets were inadequate in 16.7% of the older participants. Nutritional knowledge and the possession of positive

attitudes and beliefs contributed to good diets in the older population (Howard, Gates, Ellersieck, & Dowdy, 1998).

Risk Factors for Malnutrition

1- The normal and pathological changes of aging.- For example, loss of teeth

- Replacement with poorly fitting dentures may cause older adults to make poor food choices simply because they’re easier to eat, such as ice cream, milk shakes, and other foods high in carbohydrates.

- The presence of chronic disease among older adults,

such as cardiovascular diseases and diabetes, further impact nutrition.

2- A decrease in the smell, vision, and taste senses and the high frequency of dental problems makes it

difficult for the older adult to maintain adequate daily nutrition.

3- Lifelong eating habits, such as a diet high in fat andCholesterol.4- Limited income5- Lack of transportation to purchase food and poor

eating environments

Title III Meal Program. This program offers Meals-on-Wheels, which serves healthy, home-delivered, hot meals to older adults. The cost of this program varies depending on the older adult’s ability to pay.

6- isolation from family members and friends often negatively impacts nutrition by making the eating experience lonely.

Malnutrition among older adults may be closely linked to loneliness, boredom, anxiety, fear, bereavement, general unhappiness, isolation, and depression.

Failure to Thrive (FTT)

Is a syndrome used to describe a client who experiences malnutrition in absence of an explanatory medical diagnosis. It was first recognized as a syndrome in the late 1980s and is derived from work with infants bonding with their mothers. In these studies, a lack of maternal bonding seemed to be the cause of FTT in infants (Hogstel, 2001).

FTT in adults is thought to be similar in that it seems to result from a lack of physical touching or affection and meaningful care. Earlier work on touch indicates that when human beings lack touch, the experience is

equivalent to malnutrition and may possibly cause psychotic breakdown (Colton, 1983). FTT has often been found in conjunction with dehydration, impaired cognition, dementia, impaired ambulation, and difficulty with at least two activities of daily living. Neglect is a frequent cause of FTT and is usually accompanied by family dysfunction and stress.

Interventions to Promote Nutrition

In 2003, the U.S. Preventive Services Task Force (USPSTF) conducted a comprehensive review of dietary education programs. They found sufficient support to recommend dietary counseling to produce

small to moderate changes in diet in primary care populations. They also found that the need to increase dietary counseling increased greatly in the presence of high cholesterol, obesity, diabetes, and hypertension.

One guideline that has been effective in this teaching is the Food Guide Pyramid. These Dietary Guidelines for Americans recommend 3 to 5 servings of vegetables or vegetable juices, 2 to 4 servings of fruits and fruit juices, and 6 to 11 servings of grain products daily.

Foods in one group cannot replace those in another, therefore, no one food group is more important than another; they are all necessary for good health. It is a convenient plan designed to help a person plan an adequate diet, because it allows you to evaluate the daily intake of milk and milk products, meat, fruits, vegetables, and bread, grains, and cereals. Many older adults can name the food groups but are unable to recall the amount of each food group that should be consumed per day.

3- Exercise There is overwhelming evidence that regular exercise

results in improved sleep, reduced constipation, lower cholesterol levels, lower blood pressure, improved digestion, weight loss, and enhanced opportunities for socialization. A recent study by Melov,Tarnopolsky,

Beckman, Felkey, and Hubbard (2007) found that six months of resistance exercise training resulted in reverses signs of aging in human skeletal tissue.

a great deal of research shows that the amount of exercise performed by older adults in industrialized countries is reduced with age. This reduction occurs despite the absence of both physiological and psychological restrictions against exercise. However, normal changes of aging, diseases, and environmental

changes often result in barriers to effective exercise among older adults.

Helping older adults choose exercise programs that

they will enjoy, as well as encouraging them to exercise with others, are key factors in motivating them to exercise. The ideal exercise program will combine strength training, flexibility, and balance. One of the most popular forms of exercise among older adults is walking.

Aquatic exercises are a pain-free method of promoting health and increasing functional ability, especially for older adults with arthritis and osteoporosis. It is important that older adults who have not been regularly exercising have a complete health assessment prior to beginning a new exercise regime.

4- Sleep

• Inability to fall asleep and sleep through the night are among the most frequent complaints of older adults. Kryger, Monjan, Bliwise, and AncoliIsrael (2004) report that approximately 57% of older adults report one or more sleep problems. Sleep is affected by both normal and pathological changes of aging. Normal changes of aging include an increase in nighttime

• awakenings and overall sleep deficiency, shorter periods of deep sleep

Kryger et al. (2004) report that inability to get a good night’s sleep results in: excessive daytime sleepiness,

attention and memory problems, depressed mood, falls, use of sleeping medications, impaired health, and lower quality of life.

A good night’s sleep is essential to maintaining energy and function as well as motivation to continue a high quality of life. The first step toward achieving good sleep hygiene is to perform a comprehensive sleep assessment. Based on the results of the assessment, the nurse may provide teaching about the effects of normal changes of aging on sleep and reassure older adults that changes in sleep are not necessarily problematic.

The following recommendations may help the older adult to enhance their quality of sleep:

• Increase physical activity during the day.

• Increase pain medication or alternative pain methods to help older adults suffering from painful conditions to get better rest at night.

• Examine the sleep environment. Adjustments in noise and lighting may help older adults to sleep better.

• Assess the stress in the lives of older adults. Identification and resolution of stressful life factors may help older adults to sleep more peacefully.

• Some believe daytime napping can interfere with a good night’s sleep. Therefore, older adults who choose to nap during the day should acknowledge that it will likely reduce the total nighttime sleep needed.

5- Fall Prevention

In fact, the CDC (2006c) reports that 13,700 older adults died from falls in 2003. While older men tend to die from falls, older women experience more hospitalizations for fall-related hip fracture (http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/ss4808a3.htm).

Both normal and pathological aging changes, as well as unsafe environments, contribute to the high rate of falls among older adults and place them at higher risk for falls. Normal changes of aging surround

sensory alterations, such as visual and hearing decline, as well as changes in urinary function. Pathological changes include neuromuscular

and cognitive disorders, osteoporosis, strokes, and sensory impairments. Older adults who have fallen previously have a higher risk of experiencing

another fall.

Fall prevention interventions include:

• Area rugs and furniture that may be fall hazards should be removed.

• Appropriate lighting and supports should be added to areas in which older adults ambulate. Many homes and facilities have placed a patient’s mattress on the floor to prevent injuries from falling out of bed.

• The use of wall-to-wall carpeting also pads a patient’s fall, resulting in less injury on impact.

• The use of an alarm for the bed or wheelchair to alert caregivers of an older adult’s mobility may assist older adults who have had falls in the past.

Shelkey (2000) reports that specially trained dogs may also prevent falls by alerting caregivers of the sudden mobility of an older adult.

Restraint Usage

In the need to prevent older adults from falling or harming themselves or others, physical restraints were developed and once commonly used by many nurses and health care providers in several environments of care.

physical restraint is defined as a device or object attached to or adjacent to a person’s body that cannot be removed easily and restricts freedom of movement.

Several types of restraints are available and range from

physical restraints, such as traditional side-rails on hospital beds, jackets, belts, and wrist restraints, to chemical restraints, such as sedatives and hypnotics.

Physical restraints greatly impact the physical, psychological, and cognitive function of older adults.

Older adults should only be restrained if they are in immediate, physical danger or hurting themselves or others and then for only a brief period of time. Restraint alternatives should be implemented to keep residents safe from falls.

6- Adult Immunization People age 65 and older and persons of all ages with

chronic diseases are at increased risk for complications from viral infections.

During epidemic outbreaks, more than 90% of deaths attributed to pneumonia and influenza occurred among persons aged 65 and older.

Influenza

Influenza is a major cause of morbidity and mortality in older adults. The 80 and older population experiences an estimated 200,000 hospitalizations and 36,000 deaths per year due to flu (CDC, 2006).

The influenza vaccine, which is composed of inactivated whole virus or virus subunits grown in chick embryo cells, can markedly reduce the incidence of complications, hospitalizations, and death from the disease (and should be given annually to all older adults, especially those with chronic conditions such as pulmonary or cardiac problems

and those in long-term care facilities).

Vaccination is contraindicated in people who have experienced a reaction to the vaccine in the past and caution should be exercised in administering the vaccine to older adults who have allergies to eggs.

A Healthy People 2010 goal (#14–29 a-b) is to increase the number of older adults who are vaccinated annually against influenza and ever vaccinated against pneumococcal disease (U.S. Department of Health and Human Services, 2000).

Pneumonia

Estimates indicate that pneumococcal infections resulted in death in approximately 7% of older adults hospitalized for the disease in 2004 (CDC, 2006b). Despite this high death rate, many older adults still remain unvaccinated. The CDC recommends that all older adults should get the pneumonia vaccination every 10 years.

Tetanus and Diphtheria

In contrast to pneumonia vaccination, the effectiveness of tetanus and diphtheria (TD) toxoids is established on the basis of clinical studies and decades of experience. Currently, adults aged 50 and older account for the majority of cases of tetanus, with persons age 70 and older having a 26% case fatality rate.

The TD vaccine series should be completed for all clients who have not received the primary series, and all adults should receive periodic TD boosters. The optimal interval for booster doses is not established, but the standard regimen suggests a booster about every 10 years.

Secondary Prevention

The secondary level of prevention is essential in

detecting diseases at an early stage. Strategies for

detecting disease at an early stage involve annual physical examinations; laboratory blood tests for tumor markers, cholesterol, and other highly

treatable illnesses; and diagnostic imaging for the presence of internal disease.

Cardiovascular Disease

It affects approximately 50% of older women and 70% to 80% of elderly men (Williams, Fleg, Ades, Chaitman, et

al. 2002). The CVDs most common among older adults include hypertension, coronary heart disease, and stroke. Early detection of CVDs will likely greatly impact treatment among older adults and has the potential to decrease morbidity and mortality.

Risk factors for cardiovascular disease, which include obesity, sedentary lifestyle, stress, alcohol, and smoking.

The U.S. Preventive Services Task Force (USPSTF) recommends that older adults with normal blood pressure readings participate in blood pressure screening at least every 2 years.

Assessing cholesterol levels in clients within the normal range is important in order to reduce morbidity and mortality among this population. The USPSTF recommends that cholesterol levels be evaluated every 5 years after age 45

Total Cholesterol Level

Less than 200 mg/dL Desirable level

200 to 239 mg/dL Borderline

high 240 mg/dL and above

High blood cholesterol.

Lipid-lowering medications, known popularly as statins, are often effective in reducing further occlusion of the cardiac vessels. Statin medications, such a atorvastatin (Lipitor), fluvastatin (Lescol), lovastain (Mevacor), pravastain (Pravachol), and simvastatin (Zocor), are usually prescribed and must be taken daily.

It is important to know that cultural backgrounds play an important role in cholesterol levels among older adults. For example, Mexican American men generally have higher cholesterol levels than any other ethnic group.

Diabetes

Type 2 Diabetes Mellitus (DM) is a chronic medical disease that occurs commonly among older adults. It is estimated that 20% of the U.S. population will develop Type 2 DM by the age of 75. The CDC reports that 17 million Americans have DM, and over 200,000 deaths occur each year from diabetes-related complications.

DM is often a silent killer as the CDC estimates that 5.9 million Americans are currently unaware that they have the disease. As people age, there is a normal increase in insulin resistance and DM.

Identification of risk factors for Type 2 DM, such as cultural influence, obesity, low levels of activity, and poor nutrition, is the first step toward successful diagnosis and treatment of this disease.

Management of DM often involves the administration of hypoglycemic medications, as well as insulin.

Dietary management and weight loss are also recommended.

Cancer

Over half of cancer diagnoses in the United States occurs in those age 65 and older. The cancer incidence rate among people aged 65 to 69 is

approximately double that for those age 55 to 59. Age is also an important predictor of cancer stage; those of advanced age often have their cancers diagnosed at later stages than do younger persons.

For all age groups, lung cancer is still the number one cause of cancer mortality.

For older men, the other major cancer killers, in order, are prostate, colon/ rectum, and pancreas.

For older women, colon/rectum cancer is the highest

killer, followed by cancers of the lung, breast, pancreas, and ovary.

Screening for cancer among older adults is the most effective manner in which to detect the disease at the earliest possible stage. Consequently, early detection leads to the most effective treatment. Table 5.3 provides the American Cancer Society Recommendations on Screening for cancer.