1. Chapter 14
Older Adults
America is aging. The number of older adults in the United States is growing, both absolutely and as a proportion of the total population.
However, chronological age may have little relation to the reality of aging.
When caring for this group of patients, nurses must consider cultural, ethnic, and racial diversity.
One major aim of care is to promote independence while helping patients maintain or restore activities of daily living.
Gerontology is the study of all aspects of the aging process and its consequences.

2. Variability Among Older Adults
Physiological, cognitive, and psychosocial health
Levels of functional ability
Dependence vs. independence
Strengths and abilities
Age 65 is an accepted boundary for old age.[Ask students why this age group continues to grow in number? Discuss longer life span, better medicine, better treatments, better diagnostic testing, and aging baby boomers.]
Diversity is increasing owing to immigration and naturalization.
Most older adults live in noninstitutional settings. However, a smaller number have lost the ability to care for themselves.
Aging does not inevitably lead to disability and dependence. Most older people remain functionally independent despite the increasing prevalence of chronic disease.
When you assess older adults, you will need to identify their strengths, weaknesses, and abilities when developing a plan of care.

3. Myths and Stereotypes Older adults are:
Ill, disabled, and unattractive
Forgetful, confused, rigid, boring, and unfriendly
Unable to learn and understand new information
Not interested in sex or sexual activities
These ideas demonstrate ageism, which is discrimination against people because of increasing age.
Nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health.
As nurses, you should not be susceptible to myths and stereotypes.
Even though older adults may be slower and may have troubles with vision, hearing, and dexterity, when you plan care, you will take into account their positive attributes.
Although reduced energy and endurance sometimes affect the process of learning, older adults are lifelong learners.
Box 14-1 (on text p. 172) presents Principles for Promoting Older-Adult Learning.
They have 60, 70, 80, 90, or 100 years of history to share and relate with younger generations.

4. Case Study
Sam is a nursing student assigned to a long-term care facility for his clinical rotation. Because Sam is a first semester nursing student, he is assigned to only one patient, Mr. Bob Calder. Mr. Calder, an 87 y/o Caucasian, has a reputation of being quite stubborn and noncompliant with his plan of care.
Before his shift begins, Sam pokes his head into Mr. Calder’s room to say a quick hello and to introduce himself. He informs Mr. Calder that he will return shortly to perform an assessment and give Mr. Calder his morning medication.
[Ask students: Why did Sam give Mr. Calder advance notice of the assessment he plans? Discuss.]

5. Nurses’ Attitudes Toward Older Adults
Nurses need to recognize and address ageism by questioning prevailing negative attitudes and stereotypes and reinforcing the realities of aging as they care for older adults in all care settings.
It is critical for you
to learn to respect older adults and
actively involve them in
care decisions and activities.
It is important for you to assess your own attitudes toward older adults, your own aging, and the aging of your family, friends, and patients.
When health care providers hold negative stereotypes about aging, these stereotypes can negatively affect the quality of patient care.
When caring for older adults, we need to be aware of their wishes, give them the opportunity to participate in their own care, and treat them with dignity.
Given the increasing number of older adults in health care settings, forming positive attitudes toward them and gaining specialized knowledge about aging and their health care needs are priorities for all nurses.

6. Theories of Aging Biological theories Psychosocial theories
Stochastic or nonstochastic
Psychosocial theories
Disengagement
Activity
Continuity or developmental
Gerotranscendence
Theories of aging will help you plan, implement, and evaluate older patients.
The stochastic theory views aging as a result of random cellular damage that occurs over time. Accumulated damage leads to the physical changes that we see as the aging process.
According to nonstochastic theories, genetically programmed physiological mechanisms within the body control the aging process.
Psychosocial theories attempt to explain changes in behavior roles and relationships that result from aging.
Disengagement theory states that the aging individual withdraws from roles and engages in more introspective, self-focused activities.
Activity theory considers the continuation of activities performed during middle age as necessary for successful aging.
Continuity theory or developmental theory states that personality remains the same and behavior becomes more predictable as people age.
The more recent theory of gerotranscendence proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one, causing an increase in overall life satisfaction, although this theory has been criticized as being too simplistic.

7. Developmental Tasks for Older Adults
Linked to the concept of developmental tasks appropriate for stages in life
Deaths of friends and significant others, retirement and reduced or fixed income, changes in quality of life or living arrangements
Redefining relationships
Structural and functional changes: Failing health and physical strength
Self-acceptance
The ways in which older adults adjust to these changes are highly individualized. Some have no problems with this adjustment. However, others do not have adequate coping skills to deal with these stressors.
Developmental tasks of aging include dealing with common losses, including loss of health, significant others, a sense of being useful, socialization, income, and independent living.
The other challenge that the older adult faces is loss of the physical ability to function. A lot of times, these changes are not related to a disease process but simply to the process of growing old.
Relationships are also changing. Children grow up, start their own families, and may not have enough time to devote to their aging parents.
As nurses who care for these patients, it will be necessary for us to find ways to help older adults maintain their quality of life.
Box 14-2 (on text p. 173) lists common developmental tasks faced.
[Ask students how developmental tasks of older adults affect individuals’ health. Discuss.]

8. Case Study (cont’d)
Upon Sam’s return to Mr. Calder’s room, he asks Mr. Calder what activities he enjoys participating in at the nursing home. Mr. Calder informs Sam that he is an avid baseball fan and never misses a televised game of his favorite team.
During Sam’s assessment of Mr. Calder, they talk about baseball, which makes Mr. Calder compliant with Sam’s assessment and health history questions.
[Why did Sam ask Mr. Calder what activities he enjoys? Discuss.]

9. Community-Based and Institutional Health Care Services
Nurses encounter older-adult patients in a wide variety of community and institutional health care settings:
Private homes, apartments, retirement communities, adult day care centers, assisted-living facilities, and nursing centers
Older adults need to help with decisions regarding which type of health care service is appropriate for them.
Box 14-3 (on text p. 174) Focus on Older Adults: Selection of a Nursing Center or Home presents some features to consider when selecting a nursing center, such as the home configuration, care provided, family involvement, overall environment, communication, and number of staff.
Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult, or when convalescence (recovery) from hospitalization requires more assistance than the family is able to provide. Although the decision to enter a nursing center is never final, and a nursing center resident is sometimes discharged to home or another less-acute facility, many older adults may view the nursing center as their final residence.
The best way to evaluate the quality of a nursing center in a community is for the patient and family to visit that facility and inspect it personally.
The Medicare website ( is an excellent resource for information about the quality rating of a nursing center based on health inspections, staffing, and quality measures of the facility. It offers a checklist.

10. Assessing the Needs of Older Adults: Age-Specific Approach
The interrelation between physical and psychosocial aspects of aging
Effects of disease and disability on functional status
Decreased efficiency of homeostatic mechanisms
Lack of standards for defining health/illness norms
Altered presentation and response to specific disease
This slide shows five key points to ensure an age-specific approach. [Discuss each.]
Obtaining a complete assessment takes time; older adults have lots of history! You cannot hurry the older patient. You also need to take into account vision and hearing constraints. Make sure to include cultural concepts with these patients. [See Box 14-4 on text p. 175, Cultural Aspects of Care: Communication During Assessment.]
Remember which changes are related to the aging process and which changes are related to a disease process.
[Ask students if they can differentiate age-related vs. illness-related signs and symptoms. ANSWERS: Illness indicators include change in mental status, falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence.] Dehydration is common for older adults; they do not drink because they do not want to get up to urinate.
Box 14-5 (on text p. 175) Examples of Altered Presentation of Illnesses in Older Adults Occurring in Various Health Care Settings gives more examples.

11. Older Adult Interview Techniques
Sit or stand at eye level, in front of the patient in full view.
Face the older adult while speaking; do not cover your mouth. Speak clearly.
Provide diffuse, bright, nonglare lighting.
Encourage the older adult to use his or her familiar assistive devices such as glasses or magnifiers.
Your choice of communication techniques depends on visual or hearing impairments of the older adult.
Memory deficits, if present, affect the accuracy and completeness of an assessment. Information contributed by a family member or another caregiver is sometimes necessary to supplement the older adult’s recollection of past medical events and information.

12. Assessment
Use caution when interpreting signs and symptoms of diseases and laboratory values.
It is important to recognize early indicators of an acute illness in older adults.
Some mental changes are often drug related, caused by drug toxicity or adverse drug events.
Many conditions are common causes of functional decline; thus nurses are essential in early identification, referral, and treatment of health problems in older adults.
Historically, researchers have used younger populations to establish these signs and norms. However, the classic signs and symptoms of diseases are sometimes absent, blunted, or atypical in older adults.
[Classic signs and symptoms of disease are sometimes absent, blunted, or atypical in older adults.]
Note changes in mental status, occurrence and reason for falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence because these may be indicators not presented in younger adults.

13. Physiological Changes
Perception of well-being defines quality of life.
Older patients’ concept of health revolves around how they perceive their ability to function.
Nurses need to be cognizant of normal age-related changes.
Not all physiological changes are pathological.
Normal physiological changes of aging are not pathological processes, but they make older adults more vulnerable to common clinical conditions and diseases.
Older adults engaged in activities of daily living (ADLs) usually consider themselves healthy, whereas those who have physical, emotional, or social impairments that limit their activities perceive themselves as ill.
[See Table 14-1 (on text p. 176) Common Physiological Changes With Aging at a Glance.]

14. Physiological Changes (cont’d)
General Survey
Integumentary System
Head and Neck
Thorax and Lungs
Heart and Vascular System
Breasts
Gastrointestinal System and Abdomen
Reproductive System
Urinary System
Musculoskeletal System
Neurological System
[Discuss physiological changes in each area. Some major points are listed below.]
An initial inspection reveals whether eye contact and facial expression are appropriate to the situation and universal aging changes such as facial wrinkles, gray hair, loss of body mass in the extremities, and an increase of body mass in the trunk.
With aging, the skin loses resilience and moisture.
Head and neck: The facial features of the older adult may become more pronounced from loss of subcutaneous fat and skin elasticity.
Visual acuity declines with age.
Noise is the most prevalent risk factor for impaired hearing. Exposure earlier in life exacerbates hearing loss in old age.
Respiratory muscle strength begins to decrease, and the anteroposterior diameter of the thorax increases. Vertebral changes caused by osteoporosis lead to dorsal kyphosis, the curvature of the thoracic spine.
Decreased contractile strength of the myocardium results in decreased cardiac output. Peripheral pulses frequently are weaker, although still palpable, in the lower extremities.
Decreased muscle mass, tone, and elasticity result in smaller breasts in older women.
Because muscle tone and elasticity decrease, the abdomen becomes more protuberant. Gastrointestinal function changes include slowing of peristalsis and alterations in secretions.
Changes in the structure and function of the reproductive system occur in both sexes as the result of hormonal alterations.
Hypertrophy of the prostate gland is frequently seen in older men.
Urinary incontinence is an abnormal condition that can occur in both older men and women.
With aging muscle, fibers become smaller. Muscle strength diminishes in proportion to the decline in muscle mass.
Postmenopausal women experience a greater rate of bone demineralization than older men.
Neurotransmitters, chemical substances that enhance or inhibit nerve impulse transmission, change with aging as a result of the decrease in neurons. All voluntary reflexes are slower, and individuals often have less ability to respond to multiple stimuli.

15. Functional Changes
Functional status in older adults includes the day-to-day activities of daily living (ADLs) involving activities within physical, psychological, cognitive, and social domains.
Changes are usually linked to illness or to disease and degree of chronicity.
Performance of ADLs is a sensitive indicator of health or illness.
Occupational and physical therapists are your best resources for a comprehensive assessment.
A sudden change in function with ADLs is often a sign of onset of an acute illness or worsening of a chronic illness.
When planning and implementing care for older adults, you will want to develop interventions aimed at maintaining, restoring, or maximizing their functional status, while maintaining independence and preserving dignity.
It may be difficult for older adults to accept the changes that are occurring in all areas of their lives, which in turn have a profound effect on functional status.

16. Case Study (cont’d) Sam performs his assessment of Mr. Calder.
What findings are considered normal for a patient of Mr. Calder’s age?
(Select all that apply.)
A. Thin skin
B. Decreased saliva production
C. Decreased muscle strength
D. Whitening of the eye lens
Answers: A, B, C
Rationale: Many physiological changes occur in the elderly, including thinning of the skin, decreased saliva production, and decreased muscle strength. Yellowing of the lens of the eye also occurs with age.

17. Cognitive Disorders Delirium Acute confusional state Dementia
Generalized impairment of intellectual functioning
Depression
A mood disturbance characterized by feelings of sadness and despair
A common misconception about aging is that cognitive impairments are widespread among older adults.
Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes.
Remember that forgetfulness is an expected symptom of aging, but confusion is not.
Table 14-2 (on text p. 179) compares the clinical features of these three disorders.
Delirium is potentially a reversible cognitive impairment that often has a physiological cause.
Dementia is characterized by a gradual, progressive, irreversible cerebral dysfunction. It interferes with social and occupational activities and is an umbrella term for many conditions, including Alzheimer’s.
Depression is the most common, yet most undetected and untreated, impairment in older adulthood. Suicide in older adults accounts for 20% of all suicides.

18. Nursing Management of Dementia
Nursing management of older adults with any form of dementia always considers the safety and physical and psychosocial needs of the older adult and the family.
These needs change as the progressive nature of dementia leads to increased cognitive deterioration.
To meet the needs of the older adult, individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior.
See also Box 14-6 (on text p. 180) Nursing Care Principles for Care of Cognitively Impaired Older Adults.
Information about support and education about Alzheimer’s disease for patients, families, and professionals can be found at the Alzheimer’s Association website (

19. Psychosocial Changes Retirement Social isolation Sexuality
Housing and environment
Death
Psychosocial changes revolve around life transitions and loss. The longer we live, the longer we have to cope with losses. Remember that this group makes up a large part of the U.S. population, as was previously stated.
[Discuss each change.]
Assess a patient’s potential for social isolation by identifying his or her social network, access to transportation, and willingness and desire to interact with others.
All older adults, whether healthy or frail, need to express their sexual feelings. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Not all nurses feel comfortable counseling older adults about sexual health and intimacy-related needs. Be prepared to refer older adults to an appropriate professional counselor.
The extent of an older adult’s ability to live independently influences housing choices. The goal of your assessment of a patient’s environment is to consider resources that promote independence and functional ability.
When assessing these five changes, make sure to also assess older adults’ family situation, intimate relationships, past and present occupations, finances, housing, social networks, normal activities, health and wellness, and spirituality.
[Fig is shown from text p. 183.]

20. Quick Quiz!
1. A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes for the older adult include A. A transition from young adulthood. B. The ability of the older adult to achieve sexual arousal. C. A time when cognitive performance begins to peak. D. Adjusting to decreasing health and physical strength.
Answer: D

21. Healthy People 2010 Goals: Older Adults
Increasing the number with one or more chronic conditions who report confidence in maintaining their conditions
Reducing the number with moderate to severe functional limitations
Reducing the number of emergency department visits resulting from falls
As the population ages and life expectancy increases, emphasis on health promotion and disease prevention increases.
The challenges of health promotion and disease prevention for older adults are complex and affect health care providers as well.

22. Healthy People 2010 Goals: Older Adults (cont’d)
Increasing the number who live at home but have unmet long-term services and support
Increasing the number with reduced physical or cognitive function who engage in leisure-term physical activities
The nurse’s role is to focus interventions on maintaining and promoting patients’ function and quality of life.
[Fig is shown from text p. 184.]

23. Health Promotion and Maintenance: Physiological
Heart disease
Cancer
Stroke
Smoking
Alcohol abuse
Nutrition
Dental problems
Exercise
Falls
Sensory impairments
Pain
Medication use
Approximately 80% of adults over 65 have at least one chronic illness.
The AOA reports that in % of older persons had some type of disability (i.e., difficulty in hearing, vision, cognition, ambulation, self-care, or independent living). Limitations in ADLs limit the ability to live independently. A strong relationship has been noted between disability status and reported health status.
[Discuss each area of health promotion shown on the slide. Ask students for suggestions about health promotion for specific areas. Some main points are given below.]
Treatment of systolic pressures of 160 mm Hg or higher is linked to reduced incidence of myocardial infarction, stroke, and heart failure.
Nurses educate older adults about early detection, treatment, and cancer risk factors.
Risk factors for cerebrovascular accidents (CVAs) (stroke) include hypertension, hyperlipidemia, diabetes mellitus, history of transient ischemic attacks, and family history of cardiovascular disease. [Ask students: What do nurses do to effect changes in these risk factors?]
Within a year of quitting, former smokers reduce their risk of coronary heart disease by 50%.
Suspicion of alcohol abuse increases when there is a history of repeated falls and accidents, social isolation, recurring episodes of memory loss and confusion, failure to meet home and work obligations, a history of skipping meals or medications, and difficulty managing household tasks and finances. Identification and treatment of coexisting depression are important.
Good nutrition for older adults includes appropriate caloric intake and limited intake of fat, salt, refined sugars, and alcohol. [Ask students: What special challenges do older adults face in meeting nutritional needs? Answers: income limits, trouble cooking, dental problems. Discuss.]
Help prevent dental and gum disease through education about routine dental care.
Regular daily exercise such as walking builds endurance, increases muscle tone, improves joint flexibility, strengthens bones, reduces stress, and contributes to weight loss.
[Fall-prevention interventions are covered in Chapter 38. Discuss a preview here.]
Whenever you provide care activities, make sure that the patient is wearing assist devices such as a hearing aid or glasses, so he or she can fully participate in care. (See also Chapter 49.)
The goal of nursing management of pain in older adults is to maximize function and improve quality of life.
Medication use presents one of the largest challenges for nurses. Older adults can take numerous prescription and over-the-counter medications. Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects, inappropriate use of medications, and falls in older adults.
See Box 14-8 (on text p. 185) Evidence-Based Practice Polypharmacy in Older Adults.
See Box 14-7 (on text p. 185) Risk Factors for Falls in Older Adults.

24. Health Promotion Preventive Measures
Participation in screening activities
Regular exercise
Weight reduction, if overweight
Eating a low-fat, well-balanced diet
Moderate alcohol use
Regular dental visits
Smoking cessation
Immunizations
Older adults vary in their desire to participate in health promotion activities; therefore, use an individualized approach, taking into account the person’s beliefs about the importance of staying healthy and fit and remaining independent.
Screening activities include blood pressure, mammography, Pap smears, depression, vision and hearing testing, and colonoscopy.
Immunizations are recommended for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease.

25. Case Study (cont’d)
Sam notices that Mr. Calder’s face is gaunt and drawn in appearance.
Sam knows that thinning of the face in the elderly is due to ____________________.
Answer: Loss of subcutaneous fat and skin elasticity
Rationale: With aging, the facial features of the older adult become more pronounced from loss of subcutaneous fat and skin elasticity.

26. Health Promotion and Maintenance: Psychosocial Concerns
Therapeutic communication
Touch
Reality orientation
Validation therapy
Reminiscence
Body image interventions
Some interventions are more crucial for older adults experiencing social isolation; cognitive impairment; or stresses related to retirement, relocation, or approaching death.
Therapeutic communication skills enable you to perceive and respect the older adult’s uniqueness and health care expectations.
Touch provides sensory stimulation, induces relaxation, provides physical and emotional comfort, orients the person to reality, shows warmth, and communicates interest.
Reality orientation is a communication technique that makes an older adult more aware of time, place, and person.
Validation therapy is an alternative approach to communication with a confused older adult. Reality orientation insists that the confused older adult agree with your statements of time, place, and person; validation therapy accepts the description of time and place as stated by the confused older adult.
Reminiscence (recalling the past) uses the recollection of the past to bring meaning and understanding to the present and to resolve current conflicts.
You influence the older adult’s appearance by helping with grooming and hygiene.

27. Older Adults and the Acute Care Setting
Acute care settings pose risks for adverse events:
Delirium
Dehydration
Malnutrition
Health care–associated infections
Urinary incontinence
Falls
Pay special attention to the basic needs of comfort, safety, nutrition/hydration, and skin integrity.
To promote independence and a sense of dignity, you need to include the patient in his or her care. However, you also need to be firm with these patients to ensure that their basic needs are met, and that no decline in their health status occurs owing to hospitalization.
The risk for delirium increases when hospitalized older adults experience immobilization, sleep deprivation, infection, dehydration, pain, sensory impairment, drug interactions, anesthesia, and hypoxia.
Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests and medications that decrease appetite.
Increased risk for health care–associated infections in older adults is associated with age-related reductions in immune system responses.
Causes of incontinence include delirium, untreated urinary tract infection, medications, restricted mobility or need for assistance to get to the bathroom, and constipation or stool impaction.
The cause of a fall is typically multifactorial and composed of intrinsic or extrinsic factors. (See Box 14-7 on text p. 185 if you have not yet reviewed it.)

28. Case Study (cont’d)
Mr. Calder’s blood pressure is 162 systolic/92 diastolic.
True or False: Mr. Calder’s hypertension is a normal sign of aging.
Answer: False
Rationale: Hypertension is not a normal sign of aging, although it is a common chronic condition that predisposes older adults to heart failure, stroke, renal failure, coronary heart disease, and peripheral vascular disease.

29. Quick Quiz!
2. Which of the following might be a cause of stress for the older adult? A. Financial security B. Planned retirement C. Maintaining satisfactory living environment D. Adjusting to decreasing health and physical strength
Answer: D

30. Older Adults and Restorative Care
Types of ongoing care:
Continues recovery from acute illness
Addresses chronic conditions that affect daily functioning
Goal
To regain or improve prior level of independence, ADLs, instrumental ADLs (IADLs)
Both types of restorative care take place in private homes and long-term care settings.
You will pay attention to exercise regimen, wound care regimen, medication schedules, vital signs monitoring, and blood glucose monitoring. You will include the patient and family members. The aim is to stabilize their condition while promoting health and independence.
Restorative nursing interventions stabilize chronic conditions, promote health, and promote independence in basic and instrumental activities of daily living.
Beyond the basic ADLs, you need to support an older adult’s ability to perform IADLs (instrumental ADLs) such as using a telephone, doing laundry, cleaning the home or apartment, and driving an automobile.
Thoughtful assessment and planning lead to goals of care that consider the influence of normal aging changes, facilitate an optimal level of comfort and coping, and promote independence in self-care activities.