Sensory Changes in the Older Adult

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Sensory Changes in the Older Adult

• Kristen G. Barbee, RN, BSN
• MSN Student
• East Carolina University

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Visual Changes

• External eye
• Loss of skin elasticity may lead to entropian
• Lashes irritate cornea and conjuctiva
• Or extropian
• Lid margins turn out resulting in increased
  corneal exposure

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Visual Changes

• Refractive changes
• Presbyopia-loss of accommodation
• Arms are too short!
• Need to hold reading materials at a distance in
  order to focus

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Cataract

• Defined as a lens opacity or cloudiness
• Leading cause of blindness worldwide
• 3rd leading cause of disability in older adults

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Cataract

• 3 types
• Nuclear cataract is most common. Forms in
  nucleus, or center, of lens. Due to aging.
• Cortical cataract forms in the cortex. Extends
  spokes from outside of lens to center. Common in
  DM.
• Subcapsular cataract forms at back of lens. DM,
  farsightedness, retinitis pigmentosa, and
  long-term corticosteroids users develop these.

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Cataract

• Signs symptoms
• Painless, blurry vision
• Surroundings seem dimmer, as if glasses need
  cleaning
• Light scattering
• Glare sensitivity
• Reduced visual acuity

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Normal Vision
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Vision with a Cataract
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Cataract

• Risk factors for development of cataracts
  include
• Aging
• Eye infections (herpes, uveitis)
• Retinal detachment or surgery
• Long-term corticosteroid use
• Cigarette smoking
• Obesity
• Trauma
• UV radiation
• Lack of antioxidants in diet
• DM

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Diagnosis

• Snellen visual acuity test
• Ophthalmoscopy
• Slit-lamp biomicroscopic examination
• Degree of lens opacity does not always correlate
  with the level of function
• Some clients function well with clinically
  significant cataracts
• Some clients cannot function with relatively
  little opacification

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Treatment

• Medical management
• Not a cure
• Early stages may see improvement in vision with
  glasses, contacts, strong bifocals, or magnifying
  lenses
• Reducing glare is necessary
• Mydriatics (dilate the pupil) may be used
  short-term, although they increase glare

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Treatment

• Surgical management
• Extracapsular surgery-lens removed in 1 piece
• Posterior capsule (back membrane) left intact
• Smaller incision
• Usually no need for sutures
• Phacoemulsification
• Ultrasonic waves liquefies nucleus and cortex,
  which are suctioned out through tube
• Rapid recovery

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Phacoemulsification
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Cataract

• Lens replacement
• Usually an intraocular lens is placed during
  cataract removal surgery
• New lens are being used which block damaging UV
  light.
• Multifocal and accomodating IOLs correct
  nearsightedness and farsightedness
• Monovision lenses correct presbyopia

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Complications

• Infection
• Acute bacterial endophthalmitis
• Affects 1 in 1000 cases
• May require intravitreal antibiotics
• Malposition of IOL
• Chronic endophthalmitis
• Persistent low-grade inflammation
• After-cataract
• Posterior capsule becomes cloudy
• Treat with YAG laser

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Postoperative Care

• Eye shield for 24 hours, then at night for 1-4
  weeks
• Sunglasses when outside
• Mild oral analgesic may be needed
• Eye drops
• Antibiotic, anti-inflammatory, corticosteroid
• DO NOT RUB EYE!
• Call physician if vision changes new floaters
  flashing lights increased redness, swelling or
  painamt/type of eye drainage changes any
  injury significant pain not relieved by Tylenol

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Glaucoma

• Optic nerve damage related to increased
  intraocular pressure
• Leading cause of irreversible blindness in the
  world
• Leading cause of adult blindness in the US

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Glaucoma Risk Factors

• Age 40
• Men Women
• African-American and Asian races
• Family history of glaucoma
• Diabetes
• Cardiovascular disease
• Migraine syndromes
• Nearsightedness
• Eye trauma
• Prolonged use of topical/systemic steroids

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Types of Glaucoma

• Open-angle
• Outflow of aqueous humor impeded anterior
  chamber angle normal
• Normal-pressure
• IOP normal, yet individually too high
• Angle-closure
• Anterior chamber angle narrowed

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Clinical Manifestations

• Silent thief
• Many unaware of disease until have visual changes
  or loss of vision
• Halos around lights
• Blurred vision
• Tunnel vision
• Loss of peripheral vision
• Difficulty focusing
• Difficulty adjusting to low light
• Aching/discomfort around eyes headache

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Medical Management

• Goal is prevention of optic nerve damage
• No cure
• Lifelong therapy
• Lower IOP

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Pharmacological Treatment

• Miotics (pilocarpine)
• Constrict pupil, increase aqueous humor outflow
• B-blockers (timolol)
• Decrease aqueous humor production
• Alpha-adrenergic agonists (apraclonidine)
• Decrease aqueous humor production
• Carbonic anhydrase inhibitors (acetazolamide)
• Decrease aqueous humor production

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Surgical Treatment

• Laser trabeculectomy
• Make holes in the trabecular meshwork to increase
  outflow
• Laser iridotomy
• Opening into iris

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Nursing Management

• Safety, especially in unfamiliar surroundings
• Punctal occlusion
• Take eyedrops as directed, not when eyes feel
  irritated
• Regular ophthalmologist visits

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Age-related Macular Degeneration

• Most common cause of visual loss in people 60
• Drusen (tiny, yellowish spots) beneath the retina
• Central vision most affected
• Peripheral vision maintained

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Types of Macular Degeneration

• Dry, AKA nonexudative
• 85-90 of people
• Outer layers of retina breakdown and drusen
  appears
• Drusen in macula-blurring of vision
• No treatment

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Types of Macular Degeneration

• Wet, AKA exudative
• Abrupt onset
• Choroidal neovascularization
• Abnormal blood vessels grow under retina
• Treat with photodynamic therapy
• IV infusion of photosensitive dye
• Laser targets dye within abnormal vessels
• Dye also within blood vessels near skin and may
  be activated with sunlight

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Hearing Loss

• 30 of people 65 years and older
• 50 of people 75 years and older
• May be familial
• Presbycusis
• Progressive hearing loss with loss of high
  frequencies first, then middle and lower
  frequencies

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Hearing Loss

• External ear
• Cerumen impaction
• Wax harder and drier
• Otalgia-sense of fullness or pain in the ear
• Significant cause of hearing loss in elderly
• Removal by suction, irrigation, or instrumentation

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Hearing Loss

• Middle ear
• Tympanic membrane atrophy or sclerose
• Inner ear
• Cells at base of cochlea degenerate
• Long exposure to loud noises
• Medications
• Aminoglycosides, ASA, Quinine
• Diabetes

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Nursing Management

• Increasing volume only increases frequency
• Talk in a lower tone
• Talk directly to client
• Use gestures and facial expressions
• May be angry, suspicious, insecure
• Miscommunication with healthcare providers-write
  things down!