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The Geriatric Patient • The number of people over 65 years of age in the United States is predicted to be more than 70 million people by the year 2030. At the present time, one in every eight persons falls into this category. With 85 million baby boomers, the largest population reaching 60 years of age, one out of every five Americans is projected to be over 65 by 2030. Persons over 85 years of age constitute one of the fastest-growing portions of the population.
The human body undergoes normal physiologic and anatomic changes as it ages. These changes do not occur uniformly in all people, so it is not correct to say that all persons begin to demonstrate the changes of age at the same time. Lifestyles, culture, and hereditary factors contribute to the aging process. When an elderly patient is admitted to the radiographic imaging department, the radiographer must be able to differentiate between the normal changes of aging and deficits resulting from a disease process
The elderly person is more frequently burdened with major illnesses that are chronic rather than acute in nature. Heart disease, cancer, and strokes are the cause of 80% of deaths in persons over age 65. Hypertension, arthritis, diabetes mellitus, pulmonary disease, and visual and hearing impairments are also common conditions requiring long-term care. These conditions result in a great deal of physical discomfort and a multitude of social and psychological problems
Changes Associated with Aging • Integumentary System • Head and Neck • Pulmonary System • The Cardiovascular System • The Gastrointestinal System • The Hepatic System • The Genitourinary System • Musculoskeletal System • The Neurologic System
Integumentary System • The skin wrinkles, becomes lax. • The vascularity of the dermis decreases, and the skin of white people begins to look paler and more opaque. • Skin on the back of the hands and forearms becomes thin and fragile. • Areas of skin lose pigment; purple macules and senile purpura may appear as a result of blood leaked through weakened capillaries. • Brown macules called senile lentigines appear on the backs of the hands, on the forearms, and on the face. • Nails lose their luster and may yellow and thicken, especially the toenails. • Hair loses its pigment and begins to gray. • Hair patterns change and the hair becomes thin and more brittle. • There is hair loss on the scalp and other body areas.
Implications for the Radiographer • The skin of the geriatric patient is more fragile than that of a younger person and is thus more easily traumatized. Ensure that the skin of the elderly patient is not damaged. The preventive measures listed in Chapter 3 must be followed at all times.
Changes in the Head and Neck • There is mild loss of visual acuity, particularly presbyopia. • The light-sensing threshold is affected, and adaptation from light to dark and color perception diminish. • Tear production is either reduced or increased. • The skin of the eyelid loosens and the muscle tone decreases. • Sensory, neural, and conductive changes occur in the ear. • Hearing loss is common. • There is loss of muscle mass in the neck. • There is an accentuated forward upper thoracic curve, which may result in kyphosis.
Implications for the Radiographer • Rapid changes in lighting, such as moving from a brightly lighted waiting room into a darkened examining room, may cause the elderly patient momentary blindness. Offer patients assistance so that they do not fall. • Loss of sense of smell and hearing loss must be considered. The radiographer must ascertain that the patient is able to hear directions and must speak loudly enough for the patient to understand what is being said. Do not assume, however, that all older persons have a hearing deficit and need to be spoken to in an abnormally loud voice. • During fluoroscopic examinations, background noise from the equipment may prevent the patient from hearing the instructions. Be especially careful to clearly state instructions and check for understanding.
Pulmonary System • Pulmonary function changes with age; lung capacity diminishes owing to stiffening of the chest wall, among other changes. • The cough reflex becomes less effective. • The normal respiratory defense mechanisms lose effectiveness.
Implications for the Radiographer • The patient becomes breathless and fatigues more easily. Because of the decreasing effectiveness of the cough reflex, the patient is more apt to aspirate fluids when drinking. There will be an increased risk of pulmonary infections resulting from the loss of respiratory defense mechanisms. A patient with chronic pulmonary disease cannot be expected to lie flat for more than brief periods of time, since this position increases dyspnea. • During chest radiographic examination, when possible, ask the geriatric patient to hold his or her breath on the second full inhalation to ensure full lung expansion. • The radiographer must instruct the patient to drink slowly to avoid choking when drinking the contrast media for an upper gastrointestinal examination. Position the patient in an upright sitting position to prevent aspiration.
The Cardiovascular System • Structural changes occur in the heart as aging progresses. • The coronary arteries calcify and lose elasticity • The aorta and its branches dilate and elongate; the heart valve thickens. • There is a decline in coronary blood flow.
Implications for the Radiographer • Owing to normal cardiovascular changes of aging, the elderly patient tires more easily; imaging examinations and procedures should be conducted in as efficient a manner as possible to avoid fatigue. If a procedure is unavoidably lengthy, the patient must be allowed to rest at intervals. • Hypothermia and complaints of feeling cold are common problems for the elderly patient because of decreased circulation; therefore, it is important to avoid chilling. Additional blankets may be helpful to prevent discomfort or, in extreme cases, hypothermia during and between radiographic examinations.
One fourth of people over age 65 have postural hypotension (a drop in systolic blood pressure of 20 to 30 mm Hg) for 1 to 2 minutes after changing from a prone to a standing position. Rapid position changes result in a feeling of dizziness and the patient may fall. The radiographer must always assist the elderly patient to a sitting position for a short time before he or she stands and steps off the radiographic table. This allows the patient to adjust to the new position before walking.
The Gastrointestinal System • Gastric secretion, absorption, and motility decrease. • There is a predisposition to dryness of the mouth, and the swallowing reflex becomes less effective. • The abdominal muscles weaken. • Absorption of iron, vitamin B12, and folate decreases, with resulting potential for anemia. • Many elderly patients are edentulous (without teeth), or the teeth present are decayed or gums diseased. Many have full dentures or partial plates. • Esophageal motility declines. • The tone of the internal anal sphincter decreases.
Implications for the Radiographer • If the patient is required to fast before a diagnostic examination, schedule the examination for the early morning so that the patient can have breakfast close to the usual time. • Medications may not be dissolved and absorbed from the stomach as effectively or as they are meant to be. Therefore, the ability to swallow is also affected. This may impair the elderly patient's ability to drink liquid contrast agents. Instruct the patient to drink slowly to avoid choking. The patient who must drink liquid in the imaging department must be positioned in an upright sitting position to prevent aspiration.
The Hepatic System • Liver size decreases. • Enzyme activity and the synthesis of cholesterol decrease. • Bile storage is reduced.
Implications for the Radiographer • The elderly person has an increased potential for drug toxicity, since most drugs are metabolized in the liver. Be alert for adverse drug reactions in the elderly patient.
The Genitourinary System • Normal Changes of Aging: Women • Muscle tone and bladder capacity decrease. • Vaginal atrophy occurs. • Involuntary bladder contractions increase.
Normal Changes of Aging: Men • The prostate gland enlarges • The capacity of the urinary bladder is reduced by 500 to 900 mL. The excretory urographic and the cystogram exams demonstrate the urinary bladder. • The size of the penis and testes is decreased, owing to sclerosis of blood vessels.
Implications for the Radiographer • Loss of muscle tone in the female genitourinary system may make the patient more susceptible to urinary incontinence in stressful situations. Both the elderly male and female patient may have a limited bladder capacity and may need to urinate more frequently. Have a bedpan and urinal available for elderly patients who cannot use the lavatory easily.
Musculoskeletal System • Bone mass is reduced and bones become weaker. • Muscle mass decreases. Muscle cells decrease in number and are replaced by fibrous connective tissue. • Muscle strength decreases. • Intervertebral discs shrink and vertebrae collapse, resulting in shortening of the spinal column. • Articular cartilage erodes. • The normal lordotic curve of the lower back flattens. • Flexion and extension of the lower back are diminished. • Placement of the neck and shaft of the femur changes. • Posture and gait change. In men, the gait narrows and becomes wider based. In women, the legs bow and the gait is somewhat waddling.
Implications for the Radiographer • Increased muscular weakness increases a patient's discomfort when he or she is expected to assume positions necessary for imaging procedures. Painful joints and deformities accompanied by decreased tolerance for movement also increase discomfort. The radiographer must assist the patient to the required position and then support him or her with positioning sponges to facilitate maintaining that position. The risk of falling is greater when caring for elderly patients owing to musculoskeletal changes. It is the radiographer's obligation to assist patients in positioning and in getting on and off the radiographic table to prevent falls.
The Patient Who Has Had Arthroplastic Surgery • Total joint replacement has become a common procedure in hospitals throughout the United States. The joints of many elderly persons become very painful because of degenerative joint disease, and an operative procedure is done to replace the diseased joint with a prosthesis. Arthroplasty is also indicated for persons with joint diseases such as rheumatoid arthritis or for persons with joint deformities due to injury. Although knee and hip arthroplasty are the most common, almost any joint that is malfunctioning can be replaced. • Radiographs are frequently requested several days after arthroplastic surgery to determine the rate of the healing process and the ability of the patient to return to daily activities.
The most common complication after hip replacement is dislocation of the prosthesis. Correct positioning following surgery is necessary to prevent this. The affected leg must be prevented from adducting and the operative hip must be kept in extension. A special pillow is sometimes used for this purpose; at other times, a regular, large pillow is used. When the patient is sitting in a chair, the legs must remain uncrossed and the hips must not be flexed more than 90 degrees. Weight bearing on the affected side is restricted for varying lengths of time depending on the type of prosthesis chosen. The radiographer must understand the needs of the patient who has had an arthroplasty so that he or she will not be injured while being cared for in radiographic imaging. • After knee arthroplasty, the patient is sometimes placed on a continuous passive motion device. Weight bearing is restricted and restored gradually. The knee should not be hyperflexed and the patient should not kneel.
Radiographer's Response • When the patient with a recent arthroplasty comes to the radiographic imaging department, the radiographer must understand and adhere to the limits that have been placed on the patient's weight bearing and mobility of the restricted joint. • Move patients who have had hip, knee, or ankle arthroplasty to and from the department by gurney. They cannot get onto and off the radiographic table without placing weight on the affected limb. Move patients toward their affected side in this situation. • After hip arthroplasty, do not allow the patient's affected leg to adduct (move toward the center of the body). Keep a pillow or block between the legs to prevent this.
The Neurologic System • The ability to store information changes very little in the absence of disease; however, some short-term memory loss occurs. • Sensorimotor function decreases. • Reaction time to both simple and complex stimuli decreases. • The time needed to perform activities increases. • The lens of the eye thickens, making the pupils of the eye appear smaller. • There is a decrease in postural stability that is greater in women than in men. • Problems with spatial relations. • There is loss of sensitivity to deep pain.
Radiographer's Response • When the patient with a recent arthroplasty comes to the radiographic imaging department, the radiographer must understand and adhere to the limits that have been placed on the patient's weight bearing and mobility of the restricted joint. • Move patients who have had hip, knee, or ankle arthroplasty to and from the department by gurney. They cannot get onto and off the radiographic table without placing weight on the affected limb. Move patients toward their affected side in this situation. • After hip arthroplasty, do not allow the patient's affected leg to adduct (move toward the center of the body). Keep a pillow or block between the legs to prevent this.
Implications for the Radiographer • Remember that the elderly patient is less responsive to painful stimuli and is not aware of a painful stimulus until an injury has occurred. The radiographer must increase awareness of potential for patient injury. • The elderly patient may have visual problems in the dimly lit radiographic imaging rooms. He or she may also need guidance to avoid colliding with objects that are not seen easily. For example, the patient may not see the stool to determine where to place the feet to step down from the radiographic table. • The elderly person processes information and direction in a slower fashion. The radiographer must be certain that the patient understands directions and allow him more time to execute moves.
Elder Abuse • It is estimated that one out of every 20 seniors experiences elder abuse; the abusers are family members, caregivers, strangers, men, and women. Elder abuse is the neglect, mistreatment, or exploitation of anyone age 65 or older (or any disabled dependent adult). Unfortunately, the prevalence and reporting of elder abuse have increased in recent years.
Reporting Requirements • A majority of states now mandate reporting of elder abuse. Currently, only 16 states require all citizens to report elder abuse. Many states mandate reporting of elder abuse by health and human services professionals, long-term care facilities employees, and law enforcement personnel. A few states require financial professionals such as bankers to report elder abuse, while even fewer require the clergy to report elder abuse. • States also have different punishment schemes for failure to report. The majority of states now makes the failure to report elder abuse a misdemeanor and may punish that failure with a fine and/or jail time. Those charged with the responsibility of reporting elder abuse are generally required to have a "reasonable belief" that an elderly person has been the victim of elder abuse. A few states provide that the failure to report is a ground for civil liability. Institutional caregivers and their employers are also subject to penalties and sanctions for failing to report elder abuse. However, various levels of immunity from civil liability and retaliation for failure to report are afforded. If immunity is recognized, it generally does not extend to a reporter who is also the abuser. Typically, a reporter is afforded protection if he or she notifies the appropriate authorities of suspected elder abuse in "good faith."
New York State Senate, May 02, 2005 • Senator Jim Alesi (R,C - Perinton) today announced that the Senate passed legislation he sponsored which would require the mandatory reporting of elder abuse. • The passage of Senator Alesi’s legislation follows recent events in the Monroe County area which have highlighted the horrors of elder abuse. The bill is not a reaction to these events, however, as it has now passed the Senate five years in a row. Although the Assembly continues to ignore the elder abuse problem, Senator Alesi has vowed to continue the fight to see mandatory reporting of elder abuse passed into law. • "Elder abuse is an escalating problem, and it is extremely alarming how often such cases go unreported," said Senator Alesi. "Victims are either unable or too afraid to report the abuse themselves. By instituting a system that holds nursing homes and caretakers responsible for reporting symptoms of abuse, we help protect these vulnerable citizens." • Senator Alesi’s bill, Senate Bill S.44, is patterned after New York State child abuse laws. The bill outlines how to report a case of maltreatment should someone have reasonable cause to suspect abuse, with abuse being defined in the bill as meaning the willful infliction of injury, unreasonable confinement, verbal or mental anguish or financial exploitation. Those who knowingly or willingly fail to report abuse shall be civilly liable for the damages caused by such failure and will be guilty of a class "A" misdemeanor.
Physical abuse or violence: the use of physical force that may result in bodily injury, physical pain, or impairment • Sexual abuse: nonconsensual sexual contact of any kind with an elderly person • Emotional or psychological abuse: the inflicting of anguish, pain, or distress through verbal or nonverbal acts • Isolation or caregiver's neglect or self-neglect: the refusal or failure to fulfill any part of a person's obligations or duties to an elder or self • Financial abuse: occurs when anyone takes or keeps an elder's property with the intent to defraud
Avoid pinching patient's skin, rough handling, or shoving while transferring the geriatric patient from a gurney or wheelchair onto the radiographic table. • When immobilizing elderly patients, utilize the standards of care for immobilizing the geriatric patient as prescribed by the institution during radiographic procedures. • Assist geriatric patients when they ask for help.
Implications for the Radiographer • The radiographer may be assigned to image a geriatric patient and suspect abuse. It will be the radiographer's ethical and legal obligation to report elder abuse to the person at the institution who makes the inquiries and the required report in such cases. In some states, all health care personnel are obligated to report suspected cases of elder abuse. In other states, designated health care providers are obligated to do so. The radiographer must learn the legal parameters of this obligation for the state in which he or she practices. Mandatory reporting laws, including penalties for not reporting abuse, exist in most states. Each institution has a protocol that dictates the method of reporting and processing suspected cases of elder abuse, which the radiographer is obliged to know and use if the situation arises.
