It is very important we recognize a change of condition and not just assume aging is the cause.

Sunlight is a major cause of skin changes.

Often thought of as "aging changes", examples include:

• Wrinkles
• Dryness
• Age Spots

• Over time the sun’s ultraviolet light damages the fibers in the skin called elastin. The breakdown of these fibers causes the skin to lose its ability to snap back after stretching. As a result, wrinkles form.

• Wrinkles are especially pronounced in sun exposed areas.
• Gravity also is at work, pulling the skin and causing it to sag, most noticeably on the face, neck and upper arms.

• As skin ages it becomes thinner and loses fat
• Looks less plump and smooth

• Underlying structures (veins, bones) become more prominent

• Sebaceous glands produce less oil with aging
  • Effects are less significant in men than women.
  • Changes for women begin following menopause.
• Skin appears dry, rough, scaly.

• Appearance can become translucent, thin, pale...often itchy.
  • With itching, it is easy to damage the skin down to the dermis – since the dermis is only 20-30 cells thick.
• Most dry on lower legs, elbows and forearms.

Lentigos – also called age spots, liver spots

• Flat, brown spots caused by years of sun exposure

• The number of pigment-containing cells (melanocytes) decreases, but the remaining melanocytes increase in size.

• Located on the face, hands, arms, back and feet

• May be accompanied by wrinkling, dryness and roughness

• Located primarily where the sun shines on our body

• Bruises – loss of fat and connective tissue weakens the support around blood vessels making them more susceptible to injury. Blood vessels of the dermis become more fragile, leading to bruising, bleeding under the skin (senile purpura) and cherry angiomas.

• Skin Tears – more fragile skin, loss of support causes skin to tear easily and take longer to heal.

• The most common type of cancer in the US and affects 40 – 50% of Americans who live to age 65…then the % goes up!

• UV radiation from the sun is the main cause of skin cancer.
• We're never too old to use sun screen!!

• Sweat glands produce less sweat.

  • Increases the risk for becoming overheated or developing heat exhaustion or heat stroke
  • Harder to keep cool

• Growths such as skin tags, warts and blemishes are more common.

• Must stay hydrated and watch for heat exhaustion and heat stroke.

• Aging skin repairs itself more slowly.

• Wound healing may be up to four times slower than younger skin.

• Conditions such as diabetes, vascular disease, lung disease, lowered immunity, chronic illnesses affect the skin and increase the potential for injury, decline and delayed healing.

• Pharmacokinetics - what the body does to a drug

• Pharmacodynamics - what the drug does to the body

• Three components
  • Absorption - primarily in the GI tract
  • Distribution - primarily in the bloodstream
    • Bioavailability – the amount of drug reaching the circulatory system
  • Clearance
    • Kidneys - renal excretion
      • Excretion is primarily the kidneys, but also excrete minute amounts through breath, tears, sweat, feces, saliva, bile, hair.
    • Liver - metabolism
    • Creatinine clearance decreases up to 50% by age 75

• Absorption

  • Generally slower

  • Skin absorption

  • Lean body mass ratio

  • Nutritional status

  • Constipation/laxative

  • Fat & water solubles

  • Decreased cardiac output

• With age – absorption and excretion are slower

• The balance of fat, lean tissue & hydration in the body alters absorption, metabolism, distribution and excretion.

• Skin absorption is generally increased in the elderly

• Fruits, vegetables & grains help keep the GI track stable and improve absorption.

• PPI’s (proton pump Inhibitors (prevacid, prilosec, nexium, protnix) decrease gastric PH and affect the absorption of some medications.

• Constipation – obstructs the mucous membranes in the intestines so the body cannot absorb as well.

• Laxative use – causes rapid elimination of meds from the body – so poorer absorption too.

• Excretion

  • Function of the liver decreases

    • Cytochrome P450 enzyme overwhelmed

    • Decreased blood flow to the liver

  • Decline in creatinine clearance

    • Prolonged half-life for many drugs

    • 2/3 of population with declined creatinine clearance

  • Medications

    • Heart disease and decreased liver blood flow causes a reduction in clearance of the drug through the liver– so longer ½ life.

    • The liver size and blood flow decreases with age, so doing medication must be adjusted accordingly.

• An “acute change of condition” as defined in the long term care setting by the American Medical Directors Association (AMDA) is:

  • “A sudden clinically important change from a patient’s well established and documented baseline in physical, cognitive, behavioral, or functional domains.” AMDA further states “an acute change of condition may occur abruptly or over several hours to several days, presenting as physical changes or as changes in function, mood, cognition, or behavior. An acute change of condition without intervention may result in complications or death.”

  • Up to 50% of long term care residents experience an “acute change of condition” every two months and of these events, 14-38% lead to resident transfer to a hospital or will have more hospitalizations and will have decreased survival rates. (Hamilton 2007)

• Stop and watch was created for the Interact II™ program developed by Joseph G. Ouslander, MD and Mary Perloe, MS, GNP

• It provides a very simple but very useful mnemonic to help direct care givers detect subtle deviations in the resident.

• Signs and symptoms our residents display may often be ambiguous and non-specific but are especially important to recognize and evaluate as they may be early indications of an acute change of condition.
• As we become more familiar with patients we must take action when subtle and non-subtle changes are identified.