GERONTOLOGICAL NURSING

Geriatrics – The study of old age, includes the physiology, pathology, diagnosis and management of the diseases of
the older adults

Gerontology- The broader field of geriatrics which is the study of the aging process including the biologic,
psychological and sociologic aspects.

Gerontologic nursing - the field of nursing that specializes in care of the elderly.
this can be provided in the acute, chronic or community settings.
Emphasis of care: a. promotes and maintain functional status- independence
b. maintain dignity and maximum autonomy

Ageism – Prejudice or discrimination against older people.

Theories of aging;

1. Genetic or Mutation Theory – Changes in the replication of DNA-RNA are the causes of aging.
2. Autoimmune or Immunologic Theory – Aging is caused by a change in the immune system.
3. Wear and Tear Theory – Believes that the body is like a machine where parts wear out and the machine
eventually breaking down.
4. Rate of Living Theory – States that the body has a fixed rate of potential for living.
5. Waste Theory – States that chemical wastes collect in the body and produce deterioration by interfering
with cellular functioning.
6. Collagen Theory – Collagen stiffens with age, producing loss of elasticity in organs, skin, tendons,
blood vessels and etc.
7. Endocrine Theory – Events occurring in the hypothalamus and pituitary are responsible for the changes
in the hormone production and response that result in the organism’s decline.

Cognitive aspects of aging:

Misconceptions with regards to the decline in the mental functioning of the elderly are caused by the
failure of early researchers to consider a multitude of factors that could alter the intelligence of the old adult
population. Hospitalization, institutionalization, sudden change in the environment, medical therapy and altered role
performance may cause temporary alterations in cognition.

Intelligence:
It has been demonstrated that when subjected to a test, older adults has a steady decline in their test
results. However, health and the environment has been attributed to cause a profound influence on this and
certain types of intelligence decline (spatial perceptions, nonintellectual information) while others do not
(problem solving ability, verbal comprehension, mathematical ability).

Learning and Memory

The ability to acquire new skills and information decreases in the older adult but with adequate
motivation they still continue to learn.
Memory has 3 components that includes short term (5-30seconds), recent memory (1hr.-several days),
long-term memory (lifetime). In the absence of pathology age related loss occurs more frequently with short-
term and recent memory acquisition, recording, storing and recall(benign senescent forgetfulness).
To facilitate learning:
1. Use of mnemonics
2. links new information with familiar information
3. use visual, auditory and other sensory cues
4. encourage wearing of prescribed sunglasses and hearing aids
5. provide a quiet, nondistracting environment
6. keep teaching periods short
7. pace learning task according to the endurance of the learner
8. encourage verbal participation
9. positive reinforcements

PHYSIOLOGIC CHANGES OF AGING

The well being of an individual depends on the physical, mental, social and environmental factors.
Therefore, we need to determine these factors and the effects it has on our clients in order to appropriately
effect our nursing interventions.

Cardiovascular System
Heart Disease- the leading cause of death among the aged
Changes:
Cardiac output decreases (1% annually after the age of 20)
Less reserve and responds less effectively to stress
Heart valves becomes thicker and stiffer
Heart muscles and arteries lose their elasticity
Calcium and fat deposits accumulate in the arterial walls
Veins become tortuous
Manifests as
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 Cardiac dysrrhythmias CHF CVA
Intermittent claudication CAD PVD
Hypertension MI Orthostatic hypotension
Health promotion
Regular exercise stress management
Proper diet smoking cessation
Weight control precautionary measures (sit-stand slowly)
Regular BP monitoring

Respiratory System
Changes
Increased AP chest diameter
Kyphosis
Calcification of the costal cartilages and reduced mobility of the ribs
Diminished efficiency of the respiratory muscles
Increased rigidity and loss of elastic recoil (increased RLV, decreased VC)
Diminished gas exchange and diffusing capacity
Decreased cough efficiency and reduced ciliary activity (prone to RTI)
Manifests as:
Altered lung capacity and function
Respiratory tract infections
Health promotion
Regular exercise Influenza immunizations
Appropriate fluid intake Smoking cassation
Regular pneumococcal vaccination

Integumentary System
Changes:
Thinning of the epidermis and dermis
Diminished subcutaneous fats, especially of the extremities
Collagen fibers become stiffer
Reduced elastic fibers
Diminished blood supply due to the decrease in the capillaries of the skin
Decreased hair pigmentation
Decreased sweat And sebaceous glands activities
Manifests as
Dry skin and increased susceptibility to infection
Intolerance to extremes in temperature and sun exposure
Graying of the hair
Health promotion
Avoid exposure to the sun
Use lubricating skin cream
Avoid excessive soaks in the tub
Adequate intake of water

Reproductive System
Changes: Women
Diminished ovarian and estrogen production
Thinning of the vaginal wall, narrowed size, loss of elasticity
Decreased vaginal secretions (dryness, itching, decreased acidity)
Uterine and ovarian involution
Decreased pubococcygeral muscle tone (relaxed vagina and perineum)
Changes: Men
Penis and testes decreased in size
Diminished levels of androgens
Manifests as:
Decreased sexual desire and activity secondary to:
Decreased vaginal lubrication, vaginal bleeding, painful sexual intercourse
Erectile dysfunction
Health promotion:
Local estrogen replacements
Vacuum penile pumps
Vasostimulating medications
Oral medication (viagra)

Genitourinary System:
Changes:
Decreased kidney mass secondary to loss of nephrons
Decreased filtration rate
Diminished tubular function and less efficiency in resorbing and concentrating urine
Slower restoration of acid-base balance in response to stress
Stress/ urge incontinence
BPH (men)
Manifests as:
Urinary incontinence
Retention of urine secondary to enlargement of the prostate
Bladder infections
Health promotion
Adequate hydration

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 Ready access to toilets
Voiding every 3-4 hours while awake
Practicing pelvic floor exercises (Kegel’s)
-Identify the pubococcygeus muscle
-Attempt to hold back flatus or stop the flow of urine without contracting the abdomen,
buttocks or inner thigh then let go (tighten then relax)
- 5 second contraction, 10 second rest interval, 30-80 repetitions per day
High fiber diet
Increase mobility

Gastrointestinal System:
Changes:
Tooth decay and loss
Decrease salivary flow
Dry mouth
Decreased gastric motility
Diminished absorption of nutrients and vitamins in the small intestines
Deficiencies in the absorption and tolerance to fat
Manifest as:
Periodontal diseases
Delayed emptying of the stomach contents
Constipation
Abdominal discomfort and flatulence
Fecal impaction
Fecal incontinence and obstruction
Predisposing factors
Lack of dietary bulk Inactivity
Prolonged laxative use Insufficient fluid intake
Ignoring the urge to defecate Excessive dietary fat
Medication side effects
Health promotion:
Regular dental care Adequate amount of fluids
Eating small, frequent meals Regular bowel habits
Avoiding heavy activity after eating Avoid using laxatives and antacids
Eating a high fiber, low fat diet

Nutritional Health
Changes:
Decreased physical activity reduces the number of calories needed to maintain
Slower metabolic rate ideal weight of the older adult
Manifest as:
Sub optimal nutrient intake
Predisposing factors:
Apathy Loneliness Lack of oral health
Immobility Poverty Lack of taste discrimination
Depression Inadequate knowledge
Health promotion
Low sodium and low fat diet
Increased fruit and vegetable diet
Fish , potato, whole grains, brown rice
Diet: 55-60% carbohydrates, 20-25% fat
Fluids: 8-10 eight ounce glasses/ day

Musculoskeletal System
Changes:
Loss of bone mass (>40, F>M)
Increased incidence of fracture (vertebra, humerus, radius, femur, tibia)
Diminished muscle size, strength, flexibility and endurance
Manifest as:
Osteoporosis (associated with inactivity, inadequate calcium intake, loss of estrogens)
Kyphosis (convexity of the spine)
Flexion of the hips and the knees (affects balance, mobility, internal organ function)
Decreased activity
Back pain
Health promotion:
Calcium, vitamin D, estrogen, and fluoride supplements
Regular Weight- bearing exercises (swimming and brisk walking): Done in moderation with
short and frequent rests
Effects
- Increases the efficiency of heart contraction
- Improves oxygen uptake by the cardiac and skeletal muscles
- Reduces fatigue
- Increased energy
- Increases muscle endurance, strength and flexibility
- Reduces cardiovascular risk factors
Hi- calcium intake: 1,500 mg/day :
Sources
-dairy products
-dark green vegetables
-broths from soup bone with vinegar
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 Low phosphorous diet:
Avoid
- red meats
- cola drinks
- processed foods

Nervous System:
Changes:
Loss Of nerve cells leading progressive loss of brain mass
Reduction in the synthesis and metabolism of major neurotransmitters
Reduced speed of nerve impulse conduction
Less efficient function of the ANS
Cerebral ischemia
More difficulty in maintaining homeostasis

Manifest as:
Slower reaction and response increases the risk for falls and injuries
Postural hypotension
Health Promotion
Allow a longer time to respond to a stimulus
Move more deliberately
Beware of sudden onset of confusion it may indicate UTI, pneumonia, medication interaction,
and dehydration

Sensory System:
Sensory deprivation- the absence of stimuli in the environment or the inability to interpret stimuli secondary to
sensory loss.
- this may lead to boredom, confusion, irritability, disorientation and anxiety
- this can be corrected by meaningful stimulation or substitution of one sense for another in
interpreting the stimuli and enhancing sensory stimulation in the environment with colors,
pictures, textures, sounds, smell and taste.
Increased incidence of eye disease : cataracts, senile macular degeneration, diabetic retinopathy.
Visual changes:
Presbyopia – difficulty in reading at the usual distance, usually begins at the fifth decade of life
Sensitivity to glare- yellowing cloudy lens of the eye causing the light to scatter
Color blindness -the ability to discriminate between blue And green declines.
Diminished accommodation – takes longer to adjust when going to and from light and dark
environment
as the pupil dilates slowly and less completely because of increased stiffness of the muscles of
the iris
Health Promotion:
Reading glasses
Dark glasses
Allow for longer periods to adjust

Auditory Changes:
Presbycusis- deafness, may cause older people to respond inappropriately to conversation. May be
mistaken for confusion
Difficulty in discriminating between high frequency tones of consonants (f, s, th, ch, b, t, p).
Wax builds up
Taste and Smell
Dulling of the sweet taste – may lead to preference of salty and highly seasoned foods
Health Promotion
Substitute salt in giving flavor to foods with herbs, onions, garlic and lemons

MENTAL HEALTH DISORDERS

DEPRESSION
- The most common affective/ mood disorder of old age and is often responsive to
treatment
- It can be an early sign of illness or a result of physical illness
- SSx : feelings of sadness feelings of guilt and worthlessness
fatigue sleep and appetite disturbances
restlessness diminished memory and concentration
suicidal ideation impaired attention span

- Treatment: SSRI (Paxil, Prozac) may take 4-6 wks for symptoms
TCA (Nortriptyline, Desipramine, Doxepine) to recede
Psychosocial approach
ECT

DELIRIUM
- A medical emergency, often called Acute Confusional State
-SSx: Altered LOC (stupor-hyperactivity) delusions
Disorganized thinking fear
Short attention span anxiety
Hallucinations paranoia

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 - May occur secondary to:
a. Physical illness f. Malnutrition
b. Medication or alcohol toxicity g. Head trauma
c. Fecal impaction h. Lack of environmental cues
d. Dehydration i. Sensory deprivation or overload
e. Infection
- Permanent irreversible brain damage or death may follow if unrecognized and underlying cause
is not treated.
- Therapeutic interventions: Varies depending on the reason for the symptoms
a. Withdrawal of non-essential medications
b. Supervised nutritional and fluid intake
c. Calm and quite environment
d. Provide familiar environmental cues-(S.A. family members and friends touching and talking
to the patient.)

ALZHEIMER’S DISEASE AND OTHER DISORDERS

Dementia- A progressive deterioration in the intellectual abilities in such a severity that

it interferes with the persons social and occupational performance, the prevalence increases with age.
- characterized by:
1. losses in memory, abstract reasoning ability, judgment and language
2. Personality changes
3. deterioration of the ability to perform ADLs over time
- Symptoms are usually subtle in onset progressing slowly and eventually becoming
obvious and devastating
- 3 General categories:
a. cognitive
b. functional
c. behavioral
- Reversible causes:
a. alcohol abuse
b. polypharmacy
c. psychiatric disorders
d. normal pressure hydrocephalus
- 3 most common nonreversible dementias:
a. Multi –infarct dementia
b. Alzheimer’s disease (AD)
c. Mixed
- Other non- Alzheimer’s dementia
a. PD
b. AIDS related dementia
c. Pick’s disease

MULTI- INFARCT DEMENTIA

- Age of onset between 50- 70 years old, M>F
- Risk factors: Cardiovascular and cerebrovascular diseases
- MAKES UP around 15% of the cases, next to AD
- Characterized by unpredictable, uneven, downward decline in mental functioning
- Every small infarct is followed by some recovery followed by the next infarction

Pathology:

Disruption of the blood supply to the brain(multiple small strokes)

Rapid infarction (death of the brain tissue)

Cerebral damage

Dizziness, headaches, decreased mental and physical vigor

Sudden confusion
Gradual and spotty memory loss
May hallucinate and become delirious
AD- like manifestations in later stages

ALZHEIMER’S DISEASE (AD)

- Progressive, irreversible, degenerative, neurologic disease that begins insidiously and is
characterized by
gradual losses in cognitive function and disturbances in behavior and affect.
- 1-10% of the cases is found among middle aged individuals
- Risk factors: early onset AD late onset AD
a. Family history a. Genes c. Environmental factors
b. Down syndrome b. Life experiences

Pathology:
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 Neuropathologic changes (neuronal death)
Biochemical changes (loss of acetylcholine)

Neurofibrillary tangles cerebral cortex

Senile/ neuritic plaques

Decreased brain size

Clinical Manifestations:
Subtle memory loss (early stages, concealed with adequate cognitive function)
Depression
Marked/ obvious forgetfulness manifested in daily actions
a. lose the ability to recognize familiar faces, objects, places
b. gets lost in a familiar environment
c. repeating the same stories they forget that they have already told
Conversation becomes difficult and there are word finding difficulties
The ability to formulate concepts and think abstractly disappears (concrete interpretation)
Impulsive behavior
Difficulties with everyday activities
a. handling money
b. operating simple appliances

Personality changes
a. depressed
b. hostile
c. suspicious
d. paranoid
e. combative
With progression of the disease intensification of the symptoms occurs:
Speaking skills deteriorates to nonsense syllables
Agitation and physical activities increase: patient may wander at night
Total dependence on ADLs (eating, toileting)
Dysphagia
Incontinence
terminal stages: lasts for months
Immobile and requires total care
Death: resulting from
a. Pneumonia
b. Malnutrition
c. Dehydration

Assessment and diagnostic findings:

Health history
Diagnostic tests
a. CBC e. MRI
b. HIV testing f. CSF
c. Thyroid hormone levels g. CT scan
d. EEG
Depression scale and Cognitive function test

Medical management:
Tacrine HCL – enhances acetylcholine and manages symptoms of AD
- hepatotoxic thus clients must be closely monitored

Nursing management:
Supporting cognitive function - a calm and predictable environment helps the person interpret the
surroundings and his activities
a. Limit environmental stimuli and follow a regular routine
b. Quite and pleasant manner of speaking, clear and simple explanations
c. Use of memory aids and cues to minimize confusion and disorientation
d. Prominently displayed clocks and calendars may enhance orientation to time
e. Color coding the doorway to facilitate geographic orientation
f. Advocate active participation to keep client maintain abilities for a longer period

Promoting physical safety – a hazard free environment promotes maximum independence and a
sense of
autonomy
a. Remove potential hazards
b. Provide nightlights
c. Monitor food and drug intake
d. Allow smoking only with supervision
e. Distraction and persuasion may reducer wandering behavior
f. Avoid applying restraints since it increases agitation
g. Secure doors leading from the house
h. Supervise all outdoor activities

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 i. Wear ID bracelet

Reducing anxiety and agitation – patient may become aware of their diminishing abilities thus
emotional
support is needed to reinforce a positive self image
a. Goals are adjusted to fit the client’s declining abilities
b. Structuring activities
c. Environment should be kept simple and familiar and noise free
Catastrophic reaction- overreaction to excessive stimulation
- combative, agitated state characterized by: screaming, crying and
physical or verbal assault
- managed by: listening to music, distraction, rocking or stroking.

Improving communication
a. Unhurried and reduction of noises and distractions
b. Clear, easy to understand sentences
c. Lists and simple written instructions
d. Using an object / nonverbal language to communicate
e. Tactile stimuli to reinforce affectation

Promoting independence in self care activities – AD makes it difficult for the person to maintain
functional
independence, efforts are directed towards helping them remain functionally independent for
as long as possible.
a. Simplify daily activities into short achievable steps to give as sense of accomplishment.
b. Direct supervision may sometimes be necessary.
c. Encourage to make choices when appropriate and to participate in self care activities as
much as possible

Providing for socialization and intimacy needs –

a. Visits, letters, and phone calls are encouraged, visits should be brief and non-stressful,
limit visitors to 1-2 at a time to avoid over stimulation
b. Encourage recreation and simple activities
c. Set realistic goals that provide satisfaction
d. Promote hobbies and activities to improve the quality of life (walking, exercise, socializing).
e. Pet – may provide comfort, stimulation and contentment with its non-judgmental
friendliness
f. Encourage to verbalize about sexual concerns and provide sexual counseling
g. Encourage meaningful expression of love such as touching and holding.

Promoting adequate nutrition

a. Mealtime should be kept simple and calm, without confrontations
b. Offer familiar foods that look appetizing and taste good
c. Offer one dish at a time, to avoid client playing with the food
d. Cut food into small pieces to prevent choking
e. Convert liquids to gelatin to facilitate swallowing
f. Serve hot foods and beverages warm, check the temperature of foods to prevent burns
g. Provide adaptive means for incoordination that interferes with feeding
h. To protect clothing use apron or smock rather than a bib
i. With progression it would be necessary to feed the patient.

Promoting balanced activity and rest – Some clients may exhibit sleep disturbances, wandering
and other inappropriate behaviors that may arise when some physical or psychological needs are
unmet. As caregivers we need to discern the need of the patient exhibiting this type of behaviors to
prevent further decline in their health with the problem remaining uncorrected.
a. To promote sleep: milk, music or a back rub
b. Promote a regular pattern of activity and rest
c. Discourage long periods of daytime sleeping.

GERIATRIC SYNDROMES: MULTIPLE PROBLEMS WITH MULTIPLE ETIOLOGIC FACTORS

Geriatric syndromes
- Frequently seen in the elderly, when combined with decreased host resistance will lead to illness or injury
- Not associated with normal aging and thus can be prevented with early interventions to help maximize the
quality of life.
Frailty
- Used to describe those elders at higher risk for adverse health outcomes or geriatric syndromes
- Applies to elderly people who are most vulnerable to significant problems as a result of any of the following:
a. extreme old age (85 and above)
b. inability to perform ADL and IADLs independently
c. presence of multiple chronic diseases

Impaired Mobility
Multifactoral causes includes:
PD OA
Diabetic neuropathy Osteoporosis
Cardiovascular compromise Sensory deficits
Elderly clients should be encouraged to stay active as possible

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 Bed rest should be kept to a minimum when ill to avoid deconditioning and other complications
When in bed rest, perform AROM in unaffected aside and PROM in the affected part
Change the position frequently

Dizziness
-Older people frequently seek help for dizziness, this is further aggravated by their inability to
determine
between:
dizziness – a sensation of disorientation in relation to position
vertigo – spinning sensation
- Causes maybe
cerumen build up
dysfunction in the: cerebellum proprioceptive receptors
cerebral cortex vestibular system
brainstem
- May lead to falls and injuries

Falls and falling

- Common and preventable source of mortality and morbidity related to greater decline in ability to
perform ADL and social activities and increased incidence of institutionalization
- Women > men
- hip fx – most common

Restraints- physical: lap belts, geriatric chairs, vest, waist and jacket restraints
Chemicals: medications
-May lead to injury or death: strangulation skin tears
vascular and neurologic damage fractures
pressure ulcers increased confusion
significant emotional trauma
-The time spent to supervise client on restraint is better used in addressing the unmet need
that
provoked the behavior that resulted in the use of the restraint.