1. Chapter 32 Care of Elderly Patients

2. Definitions of Vascular Disorders
Cerebrovascular accident (CVA): Stroke
Ischemic stroke: CVA caused by a blood clot in a vessel in the brain
Hemorrhagic stroke: CVA caused by a bleeding blood vessel in the brain
Myocardial infarction: Heart attack
Transient ischemic attack (TIA): Temporary decrease in blood supply to the brain
Objective #1: Define various terms associated with the care of elderly patients.
Differentiate the following cardiovascular alterations seen when caring for the elderly population, including cerebrovascular accident, ischemic stroke, hemorrhagic stroke, myocardial infarction, and transient ischemic attack.
Ensure that students know the difference between a “brain attack” (stroke) and a “heart attack” (MI), as well as the difference between a TIA and a stroke, and the two types of strokes.

3. Definitions of Eye Disorders
Cataracts: Clouding of the lens of the eye, which causes blurred vision
Glaucoma: Increased pressure within the eye that can lead to blindness
Age-related macular degeneration: Destruction of an area in the retina where optic nerve attaches, which causes a loss of central vision
Objective #1: Define various terms associated with the care of elderly patients.
Discuss conditions associated with aging of the eyes, including cataracts, age-related macular degeneration, and glaucoma.
Assist students in differentiating different types of eye disorders seen in the elderly.
Help students understand that treatment for each eye disorder differs but all do have treatment.
In addition, discuss other terms in italics or bolded within the chapter to help students understand terminology. Ensure that they understand the meanings of each.

4. Classifications of Elderly
Young-old: 65 to 75
Middle-old: 75 to 85
Old-old: 85 and older
Elite-old: 100 years and older
Objective #2: Describe classifications of aging: young-old, middle-old, old-old, and elite-old.
Teach your students that for purposes of understanding how nurses care for the aging population, it is helpful to classify the different age groups of older adults. Note that each stage has its own nuances in terms of physiological and psychosocial changes that take place.
Discuss the major social situations each age group find themselves in:
Young-old: May still be working, volunteering, maintain social network with friends.
Middle-old: Often retired from working, physical changes limit activities that formerly brought pleasure; at risk for depression
Old-old: Significant health decline often, may need around-the-clock assistance
Elite-old: May continue to have significant health conditions, interactions may be limited to family and younger people
Discussion Point: Ask students to give the age of the oldest person they know personally. Graph the class’s response to demonstrate the different classifications of elderly.

5. Impact of Aging on Nursing
By 2030, 1 in 5 U.S. citizens will be elderly
Supply of nurses will fall by more than 1 million below the requirements needed by 2020
Objective #3: Discuss the impact of the aging population on nursing.
Discuss the projected statistic that one in every five US citizens will be elderly by the year Ask students what that will mean for the need for caregivers, including healthcare providers, nurses, and assistants.
Have students research the average age of nurses now and the number of nurses entering the job market each year.
Brainstorm ways to make nursing education more available and affordable to allow for more nurses to enter the job market more rapidly.
Discussion Point: Ask students what the statistics on the aging population of the future will mean for the need for caregivers, including providers, nurses, and assistants.

6. Misconceptions About Aging (Ageism)
Doting grandparents
Confused, incompetent, incapable of caring for themselves
Afterthoughts; incapable of having own interests, desires, friendships, or activities
Forgetful, cranky, boring
Objective #4: Discuss common misconceptions about aging.
Remind your students that it is not uncommon for others to categorize elderly people according to invalid assumptions. Review the misconceptions about aging.
Stress that when caring for elderly individuals, the nurse should first assess their state of health, their psychological well-being, and their own perceptions of their abilities.
Discuss with students how ageism can affect their nursing care if they are not careful to approach each elderly person as an individual with his or her own specific needs and problems.
Discussion Point: Discuss the following adage and what it means when caring for elderly patients: “You are only as old as you feel.”
Discussion Point: Ask students to give examples of ageism in their everyday lives, including TV shows, commercials, and movies.

7. Effects of Aging on the Neurological System
Slowed reflexes
Inability to process information from the neurological and sensory system
Neurological disorders causing a decrease in alertness, awareness, and orientation
Delirium, hallucinations, illusions, dementia
Difficulty with communication
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Discuss the changes in neurological functioning that occur with aging. (Refer to Tables 32-1 and 32-2.)
Refer to Table 32-2 as you discuss neurological changes in the elderly. Emphasize that not all changes will affect all people, but that some changes are apparent in most all elderly people.
Ask students what action nurses can take to help prevent injuries and accidents that can occur to patients as a result of neurologic changes.

8. Changes in Orientation
Confusion
Delerium
Dementia
Depression
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Ensure that students understand the difference between the changes in orientation. It can be difficult for students who want to use one label for all conditions.
Ensure that students also understand the differences between a hallucination and an illusion.
Ask students to give examples of each disorder from their own experiences with patients, friends, or family members. Ask the student to determine how the example falls into the description and whether or not a listed associated disorder or condition was present. (Refer to Table 32-1.)

9. Alzheimer’s Disease Most common type of dementia but not the only type
Strongly associated with aging but can occur in younger people, too
Increasing dementia to the point that the person no longer recognizes own family
Requires complete care and is totally dependent
Family caregivers at high risk for caregiver burnout
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Ensure that students understand the broad changes that occur gradually in people with Alzheimer’s disease.
Ask students to share experiences in having a family member, friend, or neighbor with this condition.

10. Multiple Choice Question
A nurse is caring for an elderly patient who insists that a robe hanging on her door is an angel. What is the name for this sensory alteration? A. Dementia B. Hallucination C. Illusion D. Dysphasia
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Tell your students that the most common type of dementia is seen in Alzheimer’s disease, which is strongly associated with aging.

11. Changes in Respiratory Function With Aging
Decreased lung elasticity
Increased risk for pneumonia and bronchitis
Complications of chronic pulmonary disease
Increased risk for infections
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Discuss respiratory changes related to aging.

12. Changes in Gastrointestinal Functioning With Aging
Slowed peristalsis and food digestion
Poor appetite and decreased food intake
Malnutrition, weight loss
Decreased immune function
Constipation
Xerostoma (excessive dry mouth)
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Point out that as peristalsis slows in the older adult, the cycle of food digestion slows, which can lead to poor appetite and decreased food intake and constipation.

13. Changes in Endocrine and Genitourinary Functioning
Function of pancreas decreases, leading to poorly controlled diabetes
Metabolism slows, leading to weight gain
Renal function changes may lead to kidney failure
Capacity of bladder decreases, leading to nocturia
Incidence of UTIs increases due to more concentrated urine
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Tell your students that as people age, the function of the pancreas decreases, which can lead to poorly controlled diabetes, and metabolism can slow, which means weight can increase.

14. Changes in Reproductive Functioning
Decrease in hormone levels may change sexual drive
Erectile dysfunction may occur
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Note that older adults experience a normal decrease in hormone levels as they age, which may affect sexual drive.

15. True/False Question
The elderly patient is less interested in sex because of a decrease in hormonal activity. A. True B. False
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Note that older adults experience a normal decrease in hormone levels as they age, which may affect sexual drive.

16. Changes in Musculoskeletal and Integumentary Function with Aging
Increased bone and muscle mass loss
Increases the risk for falls
Osteoporosis may develop
Skin becomes less elastic, dryer; bruises easily
Nails thicken
Decrease in sweat gland activity
Changes the ability to thermoregulate
Objective #5: Describe changes that occur in the functions of each body system due to aging.
Point out that as patients age, there is increased bone loss and muscle mass loss that increases the risk for injury.
Student Assignment: Ask your students to use the Internet or journals to research the results of aging on specific body systems. Have them choose one body system and write a report on the effects of aging and appropriate nursing interventions that should be performed by the nurse to minimize the negative effects of aging on the elderly patient.
Objective #6: Enumerate recommended nursing actions to take for body system deficits.
Discuss interventions appropriate for elderly patients experiencing body system deficits. (Refer to Table 32-2.)
Discussion Point: What can be done to minimize falls for patients in hospitals or long-term healthcare facilities? What safety issues must be addressed for elderly adults living in home situations?

17. Psychosocial Concerns of the Elderly
Fears about the dying process, as some people may struggle with spiritual beliefs
Loss and grief as friends and family die or leave
Safety concerns, including scams and crimes
Elder abuse by caregivers
Financial concerns regarding retirement and living arrangements
Objective #7: Discuss psychosocial problems of aging, including elder abuse.
Ask students for ideas about other psychosocial concerns the elderly may have, in addition those in the slide.
Point out that older adults are at risk for elder abuse, crimes, and scams, and nurses should work with the patient and the caregivers to decrease the risks associated with these events.

18. Signs of Elder Abuse Excessive bruises in unexpected places
Bruises in multiple stages of healing
Bite marks, burns, lacerations
Fractures or dislocations
Sedation
Dehydration or malnutrition
Excessive poor hygiene or unsuitable clothing
Objective #7: Discuss psychosocial problems of aging, including elder abuse.
Point out that older adults are at risk for elder abuse, scams, and crimes, and the nurse should work with the patient and the caregivers to decrease the risks associated with these events.
Review the signs that suggest elder abuse, including excessive bruises in unexpected places, bruises in multiple stages of healing, bite marks, burns, lacerations, fractures or dislocations, sedation, dehydration or malnutrition, excessive poor hygiene, and unsuitable clothing.
Student Assignment: Divide the class into 4 groups. Ask each group to consider one of the following psychosocial issues that affect the elderly:
Loss, grief and dying
Safety concerns (including scams and crime)
Elder abuse by caregivers
Financial concerns about retirement and living arrangements
Have each group research available help in your area regarding their topic and report back to the class about what can be done to assist elderly people who encounter each issue.

19. Interventions for Patients Dealing With Loss or Grief
Refer them to support groups
Educate them about nutrition and exercise
Help them find comfort and meaning
Encourage spirituality if desired
Allow them to grieve
Objective #8: Discuss nursing interventions to promote health and prevent illness and injury in the older adult.
Discuss interventions for caring for older patients dealing with loss and grief, including referring them to support groups, educating them about nutrition and exercise, helping them find comfort and meaning, encouraging spirituality if desired, and allowing the patient to grieve.

20. Interventions of Safety Concerns Including Scams and Crime
Caution them not to give out personal info over telephone, mail, or internet.
Caution them not to allow anyone in the home that they are not expecting, and to always ask for identification before allowing a worker inside.
Encourage them to consult with a trusted family member or friend about hiring workers.
Objective #8: Discuss nursing interventions to promote health and prevent illness and injury in the older adult.
Discuss interventions for safety concerns including scams and crimes.
Discuss with students how a nurse in home health or a physician’s office might need to assist elderly patients with safety concerns in the home.

21. Interventions for Elder Abuse
Can be neglect, psychological abuse, physical abuse or exploitation
If any of these are suspected, follow the facility policy for reporting to the supervisor or the appropriate state agency for investigation.
Objective #8: Discuss nursing interventions to promote health and prevent illness and injury in the older adult.
Discuss the nurse’s responsibility when confronted with the indications of elder abuse of a patient or resident.
Ensure that students know when and how to report suspected elder abuse if it is encountered.
Review the differences between neglect, psychological abuse, physical abuse, and exploitation of elders.
Determine ways nurses can help caregivers who are overwhelmed with the care of an elderly relative.

22. Intervention for Financial Concerns
Listen to concerns with empathy, using therapeutic techniques
Refer to the appropriate resources: social worker, social service agencies, area agency on aging, and other senior assistive facilities
Objective #8: Discuss nursing interventions to promote health and prevent illness and injury in the older adult.
Note that nurses should address the concerns of older adults and their caregivers.
Ensure that students know how to refer people for help with financial concerns and do not just walk away from a patient because the student does not know how to help.
Discussion Point: Ask students for ideas about how a nurse in various settings can help an elderly person with one of the psychosocial problems in Objective 8. Be sure to include nurses in a variety of settings: hospital, long-term care facility, home health, and physician’s office.

23. Positive Aspects of Aging
Wisdom and insight
Feeling of accomplishment
Mastery of concepts
Much to share
Objective #9: Identify positive aspects of aging.
Ensure that students understand that with aging also comes wisdom and insight, and often contentment from a life well-lived. Help them see ways that older people can be a positive influence in society and share that wisdom.
Teach students to be respectful of the elderly and promote self-esteem in each individual patient they encounter. Being old does not mean they are not human beings with feelings and wisdom to share.
Student Assignment: Assign students to interview an elderly friend or relative. Make this a thoughtful assignment, emphasizing what the elderly person considers the positives in his or her life and what he or she would advise a young person to know or understand about life.
Discussion Point: Discuss ways that nurses can promote self-esteem as physical, psychosocial, and spiritual changes take place in an elderly person’s life.

24. Meeting Needs in LTC Settings
Resident versus patient
Resident rooms
Personal attire
Personal care and safety
Nutrition and hydration
Elimination and toileting
Immobility
Activity and entertainment
Objective #10: Describe ways to meet the needs of residents in long-term care.
Review with students Maslow’s hierarchy of needs, especially as they apply to the elderly person.
Discuss the term “resident” and why it is more appropriate than patient for people who are in long-term care settings.
Discuss how resident rooms and personal attire help create a home-like atmosphere rather than an institutional atmosphere.
Discuss how working in long-term care requires acute awareness of safety, individual needs for toileting, grooming, bathing, and mobility, activity, and medications.
Discussion Point: Ask students ways to make long-term care facilities more “homey” than they currently appear.

25. Differences in Long-Term Care Settings
Resident status and contents of rooms
Personal attire and personal care
Nutrition and hydration
Elimination and toileting
Immobility and activity
Medications
Assessment and documentation
Objective #11: Compare the differences between acute-care nursing routines and those in long-term care.
Point out that while the aging process creates the advantages of wisdom, more life experiences, and new and different opportunities, it also sometimes involves the loss of ability to live independently due to health problems, forcing elderly adults to live in assisted-living facilities or long-term care facilities.
Discuss the differences between providing care in an acute setting versus long-term care setting. (Refer to Figure 32-6.)

26. Assessment of Older Adults
Consider the patient holistically
Pay extra attention to safety
Modify session times
Consider having a family member present to help with the health history
Objective #12: Discuss special considerations when assessing elderly patients.
Discuss the fact that although the physical assessment they learned in Chapter 21 is identical to what they will perform for older adult patients, there are still elements that they need to focus on more intently to make this process as comfortable as possible. (Refer to Box 32-2.)
Discuss the differences that occur in assessment in the long-term care setting versus the acute setting.

27. True/False Question
The term polypharmacy refers to the availability of many pharmacies to fill prescriptions for the elderly. A. True B. False
Objective #13: Discuss the problem of polypharmacy in the older adult.
Tell your students that when a patient is taking many multiple medications, a potential concern exists for polypharmacy complications, which means the ingestion of many medications.

28. Patient Teaching for Multiple Medications
Reasons for taking each medication
Dosage for each medication
How often each medication is taken
How each medication should be taken
Safety precautions associated with each medication
How to tell if a medication is effective
Potential side effects of each medication
Interactions between or among substances
Objective #13: Discuss the problem of polypharmacy in the older adult.
Discuss the information that should be given when teaching patients about medication for multiple conditions.