1

ROSE ANN R. PAET, MAN.,RN MODULE

AURAPHEL B. BAUTISTA, MAN.,RN AY 2021-2022

2021 NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

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 2

TABLE OF CONTENTS
Table of Contents i
List of Tables vi
List of Figures vi

UNIT I. Concepts, Principles and Theories in the Care

of the Older Adults 1
Introduction 1
Objectives 1
Pre-test 1
Perspective on Aging 2
Classifications of Aging 2
Concepts of Aging 2
Demographics of Aging 3
Global Aging 3
Aging in the Philippines 4
Impact of Aging Members in the Family 4
Emotional Effects 4
Financial Effects 5
Structural Effects 5
Physical Effects 5
Theories of Aging 5
Biological Theories of Aging 5
Psychosocial Theories of Aging 5
Implications of Nursing 7
Reflection 7
Post-test 7
References 8

UNIT II. Physiological Changes in Aging 9

Introduction 9
Objectives 9
Pre-test 9
Physiologic Changes in Aging affecting various Systems 8
Body Composition Changes in Old Age 10
Reflection 12
Post-test 12
References 14

UNIT III. Nursing Care of the Older Adult in Wellness 14

Introduction 14
Objectives 14
Pre-test 14
Gerontology 14
Functional Assessment 15
Activities of Daily Living (ADLs) 16
Instrumental Activities of Daily Living (IADLs) 16
Advanced Activities of Daily Living (AADLs) 16
Psychological Assessment 17
Depression 17
Substance Abuse 17
Delirium 17
Dementia 18
Alzheimer’s disease 18
Alzheimer’s Medical Management 19
Nursing Management 19
Reflection 20

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UNIT I. CONCEPTS, PRINCIPLES, AND THEORIES IN THE CARE OF OLDER

ADULTS
I. Introduction

As a nursing student, you may have preconceived ideas about caring for older adults.
Such ideas are influenced by your observations of family members, friends, neighbours, the
media, and your own experience with the elderly. Perhaps you have a close relationship with
your grandparents or you have noticed the aging of your parents. For some of you, the aging
process may have become noticeable when you look at yourself in the mirror. But for all of
us, this universal phenomenon we call aging has some type of meaning, whether or not we
have taken the time to consciously think about it.
The way that you view aging and the elderly is often a product of your environment
and the experiences to which you have been exposed. Negative attitudes towards aging or the
elderly (ageism) often arise in the same way—from negative past experiences. Many of our
attitudes and ideas about older adults may not be grounded in fact. Some of you may have
already been exposed to ageism, which is often displayed much in the way that sexism or
racism is in people’s attitudes and actions towards older people. This is yet another reason
for studying the aging process—to take a look at the myths and realities, to separate fact from
fiction, and to gain value for the wisdom of lifetimes that older adults have to offer.
As you will see, the majority of you in your careers as nurses will be caring for older
adults at some point. Population statistics make that an irrefutable fact. Because the elderly
have unique life situations and deal with physical changes as they age, nurses must be
prepared to provide quality of care to this group of individuals (Mauk, 2010).

II. Objectives/Competencies

At the end of the unit, I am able to:

1. describe the demographic trends and the physiologic aspects of aging in older adults
in the locally and globally;
2. describe the significance of preventive health care and health promotion for the older
adult;
3. examine the concerns of older people and their families in the home and community,
in the acute care setting, and the long-term care facility; and
4. identify and compare the similarities between biological and psychosocial theories.

III. Pre-Test

1. Older people are in the period of development known as late adulthood. In this stage, they
reflect on their lives and feel either a sense of satisfaction or a sense of failure.
a. Generativity vs. Stagnation
b. Integrity vs. Despair
c. Identity vs. Role Confusion
d. Intimacy vs. Isolation
2. Explain aging in terms of mental processes, emotions, attitudes. Motivation, and
personality development that is characterized by life stage transitions.
a. Biologic Theories
b. Physiological Theories
c. Erick Erickson’s Theory
d. Psychological Theories
3. A motivational theory in psychology comprising a five-tier model of human needs, often
depicted as hierarchical levels within a pyramid.
a. Abraham Maslow Hierarchy of Human Needs
b. Erick Erickson Theory of Psychosocial Development
c. Sigmund Freud Psychoanalytic Theory
d. Carl Rogers Humanistic Perspective on Personality
4. Realization of a person’s potential, self-fulfillment, seeking personal growth and peak
experiences
a. Esteem Needs
b. Love and Belongingness Needs

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c. Safety Needs
d. Self-actualization Needs
5. A coping mechanism that withdraws self from social life, concealment, and avoiding
other people.
a. Escape
b. Accommodation
c. Submission
d. Isolation

IV. Lesson Proper

Perspective on Aging
The process of aging is unavoidable and unrelenting in human beings. Growing older,
or chronological aging is a relentless and unstoppable process that happens to all humans.
For that reason alone, some bioethicists argue that aging is, in fact, a natural developmental
process for human beings (Meilaender, 2011). According to Meilaender (2011), aging is a
normal stage of life in which our bodies begin to function less effectively, making us more
vulnerable to disease. Evolutionary biologists refer to this process as “senescence.”
Senescence may be viewed most easily as the passage of biological time as opposed to
chronological time. More specifically, it refers to “the time-dependent accumulation of
damage at the molecular level that begins at fertilization and is eventually expressed as
nonspecific vulnerability, impaired function, disease, and ultimately death” (Carnes &
Olshansky, 1993). It is senescence that causes diseases of aging. Even if a person ages well,
because of senescence that person will still ultimately die of some cause (Gems, 2011).
Classification of Aging
● Objectively, ageing is a universal process that begins at birth and is specified by the
chronological age criterion
● Subjectively, aging is marked by changes in behavior and self- perception and reaction
to biologic changes.
● Functionally, aging refers to the capabilities of the individual to function in society.
Young Old (60 – 74 years), middle old (75-84 years), and old-old (above 85 years). The
life expectancy of Indians are 65- 67 years
Concepts of Aging
1. Chronological Aging: Chronological age refers to the actual amount of time a person has
been alive. In other words, the number of days, months or years a person has been alive
2. Biologic Aging
a. Senescence or biological aging is the gradual deterioration of function
characteristic.
b. Biological aging refers to the physical changes that “slow us down” as human get
into middle and older years. For example: arteries might clog up, or problems
with lungs might make it more difficult for us to breathe. This aging is also known
as physiologic aging.
3. Psychological aging refers to the psychological changes, including those involving
mental functioning and personality, that occur as human age.
• chronological age is not always the same thing as biological or psychological age.
• Some people who are 65, can look and act much younger than some who are 50.
• Psychological ageing may be seen as a continuous struggle for identity, i.e. for a sense of
coherence and meaning in thoughts, feelings and actions.
• Success depends on a lucky synchronization of changes through life in different parts of
the personal self.
4. Social aging refers to changes in a person’s roles and relationships, both within their
networks of relatives and friends and in formal organizations such as the workplace and
houses of worship.
• Social aging differ from one individual to another.
• It is also profoundly influenced by the perception of aging that is part of a society’s
culture.
• If a society views aging positively, the social aging experienced by individuals in that
society will be more positive and enjoyable than in a society that views aging negatively.
5. Cognitive aging is the decline in cognitive processing that occurs as people get older.
Age-related impairments in reasoning, memory and processing speed can arise during
adulthood and progress into the elder years.

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• Cognitive aging is concerned with the basic processes of learning and memory as well
as with the complex higher- order processes of language and intellectual competence or
executive functioning.
• The concept of cognitive aging, a term that describes a process of gradual, longitudinal
changes in cognitive functions that accompany the aging process.

Demographics of Aging
The demography of aging involves the investigation of trends in, and characteristics of,
fertility, mortality, and migration and how these components of population change influence, and
are influenced by, the physical and social environments in which people live. It is a new area of
scientific inquiry, principally because aging is a demographic phenomenon experienced for the
first time on a population scale largely by only one species—humans and then within only the
last two hundred years of our existence. Research on the demography of aging is conducted not
only by demographers but also by scientists representing a range of disciplines spanning the
social and biologic sciences—from social psychology to evolutionary biology. It is an area of
scientific inquiry that has important implications for public policy.
What Demographic Processes Produce Population Aging?
The shifting of high death and birth rates to low death and birth rates in a sequence of
change, a process called demographic transition, produces population ageing because the
proportion of older population within an age structure increases (de Souza, 1990; Quadagno,
1999).
What Causes an Aging Population?
The ageing of the world's populations is the result of the continued decline in fertility
rates and increased life expectancy. This demographic change has resulted in increasing numbers
and proportions of people who are over 60 access to age-friendly primary health care; creation
of age-friendly environments.
The Health of Aging Populations
As the length of life and number and proportion of older persons increase in most
industrialized and many developing nations, a central question is whether this population aging
will be accompanied by sustained or improved health, an improving quality of life, and sufficient
social and economic resources. The answer to this question lies partly in the ability of families
and communities, as well as modern social, political, economic, and health service delivery
systems, to provide optimal support to older persons. However, while all modern societies are
committed to providing health and social services to their citizens, these systems are always in
flux, guided by diverse and evolving national and regional policy formulations. Health, social, and
economic policies for older persons vary substantially among industrialized nations. Analysis of
these variations through appropriate cross-national research may assist greatly in the
formulation of effective policies aimed at enhancing the health status, as well as the social and
economic well-being, of elderly populations.

Global Aging
The proportion of Americans 65 years of age and older has tripled in the past 100
years (4.1% in 1900 to 13% of the population in 2010) (Howden & Meyer, 2011). Life
expectancy—the average number of years that a person can expect to live—varies by gender
and race, with women living longer than men and white women having the longest life
expectancy. Life expectancy has risen dramatically in the past 100 years. In 1900, the average
life expectancy was 47 years, and by 2009, that figure had increased to 78.2 years (Kochanek,
Xu, Murphy, et al., 2011). As the older adult population increases, the number of people who
live to very old age is also dramatically increasing. The older adult population is becoming
more diverse, rejecting changing demographics in the United States. Although this population
will increase in number for all racial and ethnic groups, the rate of growth is projected to be
fastest in the Hispanic population, which is expected to increase from 6 million in 2004 to an
estimated 17.5 million by 2050. Proportionally, there will be a significant decline in the
percentage of the White non-Hispanic population. By 2050, it is estimated that the White non-
Hispanic population will decrease to 59% of the older adult population; 20% will be Hispanic,
11% Black, and 8% Asian (Administration on Aging [AoA], 2010a).
Most deaths in the United States occur in people 65 years of age and older; 48% of
these are caused by heart disease and cancer (Kochanek et al., 2011). Owing to improvements
in the prevention, early detection, and treatment of diseases, there has been a noticeable
impact on the health of people in this age group. In the past 60 years, there has been a decline

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in overall deaths—specifically, deaths from heart disease. Besides, there has been a recent
decline in deaths from cancer and cerebrovascular disease.
Preliminary analysis of data suggests that chronic lower respiratory diseases have
risen to the third leading cause of death, and cerebrovascular disease is now the fourth
leading cause of death among this population of adults (Kochanek et al., 2011). Deaths from
Alzheimer’s disease (AD) have risen more than 50% between 1999 and 2007 (Kochanek et
al., 2011).
More than 70% of noninstitutionalized Americans aged 65 years and older rate their
health as good, very good, or excellent (AoA, 2010b). Men and women report comparable
levels of health; however, positive health reports decline with advancing age, and Blacks,
Hispanics, and Latinos appear less likely to report good health than their White or Asian
counterparts. Most Americans 75 years of age and older remain functionally independent
regardless of how they perceive their health, and the proportion of older Americans reporting
a limitation in activities declined from 49% in 2002 to 42% in 2007 (AoA, 2010b). These
declines in limitations may reject trends in health promotion and disease prevention
activities, such as improved nutrition, decreased smoking, increased exercise, and early
detection and treatment of risk factors such as hypertension and elevated serum cholesterol
levels.
Many chronic conditions commonly found among older people can be managed,
limited, and even prevented. Older people are more likely to maintain good health and
functional independence if encouraged to do so and if appropriate community-based support
services are available (Miller, 2012). Nurses are challenged to promote positive lifelong
health behaviors because the impact of unhealthy behaviors and choices can result in chronic
disease.

Aging in the Philippines

According to a 2018 study by the Philippine Institute for Development Studies (PIDS),
the Philippines is on its way to becoming an “aging society” in 2032. This means that in 13
years, Filipinos aged 65 years old and older will make up 7% of our country’s total population.
In 2069, this figure will go up to 14%, making the Philippines an “aged society.” PIDS research
fellow Michael Abrigo says that “Population aging is not a bad thing. It represents a story of
our collective success as Filipinos. It means that we can conquer challenges such as those
related to income, health, and education.”
Filipinos are found to have a generally positive view of aging. A 2013 study found that
receiving social support from relatives gives seniors more encouragement and allows them to
have a more positive outlook on life. Given our values system, the culture of caregiving
remains strong in our country. A study published by the Gerontological Society of America
claims that filial piety and family caregiving, in general, is “part of the of the very fabric of
Philippine society”, often utilizing the family’s resources to support the elderly relative as
opposed to formal services. Family members who have taken on the role of caregiving feel
fulfilled and find meaning in doing this task.
While an aging population is a sign of increased productivity, it also entails the
availability of more services and facilities that will support their needs. Seniors in the
Philippines benefit from the 2010 Expanded Senior Citizen’s Act which provides discounts on
medicine and health services, utilities, transportation, and even recreational activities.
However, there are still gaps in the provision of products and services for the elderly that both
the private and public sectors can fill in.

Impact of Aging Members in the Family

Caring for aging parents has multiple impacts on your family life, including emotional,
physical, financial, and structural effects. As you and your family make plans and you reflect
on your future as a caregiver, take time to appreciate the strength you derive from working
together and the unique bonds you share as a family.

Emotional Effects
Caring for your aging parents prompts a range of impulses and emotions. Katie
Thomas and Mishelle Segur, co-owners and directors of Hearts and Hands Counseling, say
that common responses include "Guilt for not being able to do more for parents; anger for
having to set aside your own needs or shift your priorities; and fear and anxiety, including
anticipatory grief and fear of financial strain." Caring for children and aging parents at the

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same time can make you feel as if you do not have the emotional strength and resources for
everyone.
Thomas and Segur also identify positive emotional effects of caring for aging parents,
such as "enrichment that comes with relationships between grandparents and
grandchildren; increased opportunity to pass on stories and knowledge to younger
generations; and [the] younger generations having a sense of being able to give back to
parents and grandparents," resulting in a "greater connection" between family members.

Financial Effects
Caring for aging parents often means extra costs related to home health care, medical
expenses not covered by insurance, and extra insurance premiums for services such as long-
term care. You also may need to take off extra time from work.

Structural Effects
When you live with your aging parents or assume a high amount of daily care for
them, you experience a change in your family roles. Thomas and Segur describe this as a
"shift in family structure and hierarchy related to [the] matriarch or patriarch no longer
being in their role." When this occurs, "someone new [has] to take their place."
This shift can cause guilt and stress, as family members work to find a place in the
new family dynamic, but it can also result in more open communication among family
members. In her article "Caregiving from a Distance," Carol Heffernan describes how some
families positively communicate their needs and responsibilities when managing caregiving.
The caregivers speak with aging parents about where they believe they need support.
Grandparents, parents, and children get creative, brainstorming about how to utilize
community resources such as church groups, social service organizations, and community
groups. In these cases, the family structure shifts to being less hierarchical and more
cooperative.

Physical Effects
Prioritizing parents' care can ease their pain and worry, but might impact your
health. The Family Caregiver site summarizes some of the physical effects of caregiving for
aging parents. The time and effort of keeping up with parents' care mean you may visit your
doctors less, resulting in undiagnosed problems or conditions getting worse. Caregiving for
a parent with dementia can cause chronic stress and illness. Time pressure might result in
caregivers and their children skipping exercise and eating more convenience foods, which
contribute to poor fitness and weight gain. Everything from mild depression to severe and
chronic depression can inflict caregivers, which can cause premature aging and shorten their
life span. Families who share responsibilities and secure outside help experience less stress
and have the time and resources to maintain their health and relationships with all members
of the family.

Theories of Aging
Biological Theories of Aging
The biological theories explain the physiologic process that changes with aging.
Several theories purport to explain aging at the molecular, cellular, organ, and system-level;
however, no one predominant theory has evolved. Both genetics and environment influence
the multifaceted phenomenon of aging (Lange and Grossman).
Some aging theorist divides the biological theories into two categories:
1. A stochastic or statistical perspective, which identifies episodic events that happen
throughout one’s life that cause random cell damage and accumulate over time, thus
causes aging.
2. The nonstochastic theories, which view aging as a series of predetermined events
happening to all organisms in a timed framework.
Psychosocial Theories of Aging
The earliest theories on aging came from the psychosocial disciplines (see Table 1).
These theories focus on changes in behavior, personality, and attitude as we age. Aging is a
lifelong process characterized by transitions. Psychological theories relate these transitions
to personality or ego development and the accompanying challenges associated with various
life stages. They speak to how mental processes, emotions, attitudes, motivation, and
personality influence adaptation to physical social demands (Grossman, 2014).

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TABLE 1. PSYCHOSOCIAL DISCIPLINES

Theory Description
Sociological Theories Changing roles, relationships, status, and generational cohort
impact the older adult’s ability to adapt.
Activity Remaining occupied and involved is necessary for a satisfying
late life.
Disengagement Gradual withdrawal from society and relationships serves to
maintain social equilibrium and promote internal reflection.
Subculture The elderly prefer to segregate from society in an aging
subculture sharing the loss of status and societal negativity
regarding the aged. Health and mobility are key determinants
of social status.
Continuity Personality influences roles and life satisfaction and remains
consistent throughout life. Past coping patterns recur as older
adults adjust to physical, financial, and social decline and
contemplate death. Identifying with one’s age group, finding a
residence compatible with one’s limitations, and learning new
roles post-retirement is a major task.
Age stratification Society is stratified by age groups that are the basis for
acquiring resources, roles, status, and deference from others.
Age cohorts are influenced by their historical context and
share similar experiences, beliefs and attitudes, and
expectations of life-course transitions.
Person-environment- The function is affected by ego strength, mobility, health,
fit cognition, sensory perception, and the environment.
Competency changes one’s ability to adapt to environmental
demands.
Gerotranscedence The elderly transform from a materialistic/rational
perspective toward oneness with the universe. The successful
transformation includes an outward focus, accepting
impending death, substantive relationships,
intergenerational connectedness, and unity with the universe.

Sociological theorist considers how changing roles, relationships, and status within
a culture or society impact an older adult’s ability to adapt. They assert that societal norms
can affect how individuals perceive and enact their roles within a community. How living
through key events such as the Vietnam war or civil rights eras affect aging is an important
component of sociological theories of aging (Grossman, 2014).

TABLE 2. PSYCHOSOCIAL THEORIES OF AGING

Theory Description
Psychological Theories Explain aging in terms of mental processes, emotions,
attitudes. Motivation, and personality development that is
characterized by life stage transitions.
Human Needs Five basics need to motivate human behavior in a lifelong
process toward need fulfilment
Individualism Personality consists of ego and personal and collective
unconsciousness that views life from a personal or external
perspective. Older adults search for life meaning and adapt to
functional and social losses.
Stages of personality Personality develops in eight sequential stages with
corresponding life development tasks. The eight phases,
integrity versus despair, is characterized by evaluating life
accomplishments; struggles include letting go, accepting
care, detachment, and physical and mental decline.
Life-course/life span Life stages are predictable and structured by roles,
relationships, values, development, and goals. Persons adapt
to changing roles and relationships. Age-group norms and
characteristics are an important part of the life course.

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Selective optimization Individuals cope with aging losses through activity/role

selection, optimization, and compensation. Critical life points
are morbidity, mortality, and quality of life. Selective
optimization with compensation facilitates successful aging.

Implications for Nursing

Nursing has incorporated psychosocial theories such as Erickson’s personality
development theory into its practice. Psychological theories enlighten us about the
developmental tasks and challenges faced by older adults and the importance of finding and
accepting meaning in one’s life. From sociologists, nursing has learned how to support
systems, functionality, activity and role engagement, cohorts, and societal expectations can
influence adjustment to age and life satisfaction. Nurses can learn from these theories to help
minimize the challenges of aging by connecting older adults to resources. These may include
an occupational therapist that can help families adopt a home environment to that it is safe
for an older adult to “age in place”, suggesting visiting nurse or physical therapy visits to help
manage chronic illnesses such as heart failure or diabetes, or to optimize physical
functioning, or to enlist a pharmacist to evaluate how medication regimens may be causing
side effects that adversely affect functioning. Dealing with the loss of friends, spouse and
other important relationships can lead to isolation and depression. Connecting older adults
to their communities through senior centers, online groups like “meet up” or “road scholar”,
adult education programs, or volunteer groups can help them explore new passions and
develop new relationships. Others may benefit from counselling with a mental health
provider or religious leader.

V. Reflection

Write a reflection paper citing your perception and beliefs about “Old Age and Death”
in a minimum of 100 words.

VI. Post Test

Encircle the letter of the correct answer.

1. Statement A: The process of aging is unavoidable and unrelenting in human beings.
Statement B: According to Meilaender (2011), aging is not a normal stage of life in which
our bodies begin to function less effectively, making us more vulnerable to disease.
Statement C: Senescence may be viewed most easily as the passage of biological time as
opposed to chronological time.
Statement D: Senescence does not always cause diseases of aging.
a. Statement A and B are correct.
b. Statement B and C are correct
c. Statement C and D are incorrect.
d. Statement B and D are incorrect
2. According to a 2018 study by the Philippine Institute for Development Studies (PIDS), the
Philippines is on its way to becoming an “aging society” in:
a. 2069
b. 2022
c. 2032
d. 2068
3. All are impacts or effects in caring for aging parents except:
a. Financial effects
b. Sympathy effects
c. Physical effects
d. Structural effects
4. It identifies episodic events that happen throughout one’s life that cause random cell
damage and accumulate over time, thus causing aging.
a. Stochastic perspective
b. Continuity perspective
c. Age stratification perspective
d. Geotranscendence perspective

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5. The earliest theories on aging came from the psychosocial disciplines and these are the
following except:
a. Stochastic perspective
b. Continuity perspective
c. Age stratification perspective
d. Geotranscendence perspective
6. A function is affected by ego strength, mobility, health, cognition, sensory perception, and
the environment.
a. Subculture
b. Person-environment-fit
c. Age stratification
d. Continuity
7. Characterized by evaluating life accomplishments; struggles include letting go, accepting
care, detachment, and physical and mental decline.
a. Individualism
b. Human Needs
c. Life span
d. Integrity vs. despair
8. Explain aging in terms of mental processes, emotions, attitudes. Motivation, and
personality development that is characterized by life stage transitions.
a. Stages of personality
b. Individualism
c. Psychological theories
d. Psychosocial theories
9. Nurses can learn from the theories to help minimize the challenges of aging by connecting
older adults to resources such as the following except:
a. Suggesting to visit physical therapy to help manage chronic illnesses
b. Enlist a pharmacist to evaluate how medication regimens may be causing side
effects that adversely affect the functioning
c. Introducing the older adult in a pub or casino for relaxation and entertainment
d. Connecting older adults to their communities through senior centers
10. Statement A: Dealing with the loss of friends, spouse and other important relationships
can lead to isolation and depression.
Statement B: Biological Perspective enlighten us about the developmental tasks and
challenges faced by older adults and the importance of finding and accepting meaning in
one’s life.
Statement C: Support systems, functionality, and activity can influence adjustment to age
and life satisfaction.
Statement D: Older adults can benefit from counselling with a mental health provider or
religious leader.
a. All statements are correct
b. Only statement B, C, and D are correct
c. Only statement A, C, and D are correct
d. None of the statement is correct

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

https://pubs.asha.org/doi/10.1044/gero19.1.44#:~:text=Growing%20older%2C%20o
r%20chronological%20aging,beings%20(Meilaender%2C%202011).&text=It%20is%2
0senescence%20that%20causes%20diseases%20of%20aging.

https://www.mc.edu.ph/alumni/news/ArticleID/1509/Ageing-in-the-
Philippines#:~:text=According%20to%20a%202018%20study,of%20our%20country'
s%20total%20population.

https://mom.com/kids/4870-how-does-caring-aging-parents-affect-family-
life#:~:text=When%20you%20live%20with%20your,change%20in%20your%20famil

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 11

y%20roles.&text=This%20shift%20can%20cause%20guilt,open%20communication%
20among%20family%20members.

http://samples.jbpub.com/9781284104479/Chapter_3.pdf

https://www.sciencedirect.com/topics/neuroscience/gerontology

https://academic.oup.com/gerontologist/article/58/2/212/4792953
https://www.ncbi.nlm.nih.gov/books/NBK218728/

UNIT II. PHYSIOLOGIC CHANGES IN AGING

I. Introduction
Without the physiological changes of aging, we might never say that a person's age.
The general population’s concept of aging is generally, and almost instinctively, characterized
by changes in physical appearance, functional decline, and chronic disease. All of these
characteristics are the result of physiological change. Even the psychological and social
changes associated with aging, such as depression and social withdrawal, are often rooted in
changes in the structure and function of the body’s physiological systems. Thus, it could be
argued that the physiology of aging is true aging (Mauk, 2010).
Although it is relatively easy to focus on changes in only one physiological system, a
broader scope is necessary to truly understand the influences and consequences of aging on
physiological structure and function. This is especially true given that people are now living
longer and for longer periods in that stage of life that is currently considered to be old age.
Although each cohort ages differently, general aging changes tend to remain stable. In this
topic, we will review the aging process of each of the body’s major physiological systems.
However, be mindful that physiological aging is an extremely individual process and how the
body ages are greatly affected by a person’s genetic makeup, health behaviors, and
availability of resources.
Aging is a significant life experience, and one that is an inevitable progression of life
for geriatric patients. Recognizing the risks related to the aging process, the differences
between disorders and aging, and acknowledging the challenges of geriatric syndromes is an
essential part of the nurse practitioner role. Additionally, recognizing the holistic experience
of aging with both challenges and resilience factors allows nurse practitioners to see their
patients fully. Through recognizing and responding to aging issues appropriately, nurse
practitioners can be key members of the geriatric healthcare team.

II. Objectives/Competencies
At the end of the unit, I am able to:
1. describe how the aging process of each physiological system correlates with the
functional ability of the older adult;
2. explain how the aging process of one system interacts with and/or affects other
physiological systems;
3. acknowledge that not every aspect of every physiological system change with age;
and
4. recognize that aging changes are partially dependent upon an individual’s health
behaviors and preventive health measures.

III. Pre-test
Sort out the group of words from the box below. Organize them as to where the health
promotion activity is needed in the complaint of an elderly adult.

Complaint Health Promotion Strategy

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Urinary retention Avoid night driving

Risk of dehydration Use lubricant
Poor night vision Limit phosphorus intake
Painful intercourse Limit fluid intake
Joint pain Eat a high-fiber, low-fat diet
Heartburn and indigestion Drink adequate fluids

IV. Lesson Proper

Physiologic Changes in Aging Affecting Various Systems
Intrinsic aging (from within the person) refers to those changes caused by the normal
aging process that is genetically programmed and essentially universal within a species.
Universality is the major criterion used to distinguish normal aging from pathologic changes
associated with illness. However, people age quite differently and at different rates; thus,
chronologic age is often less predictive of obvious age characteristics than other factors, such
as one’s genetics and lifestyle. For example, extrinsic aging results from influences outside
the person. Air pollution and excessive exposure to sunlight are examples of extrinsic factors
that may hasten the aging process and can be eliminated or reduced.
Cellular and extracellular changes of old age cause functional decline and measurable
changes in physical appearance, including changes in shape and body makeup. Cellular aging
and tissue deficits also diminish the body’s ability to maintain homeostasis and prevent organ
systems from functioning at full efficiency. As cells become less able to replace themselves,
they accumulate a pigment known as lipofuscin. Degradation of elastin and collagen causes
connective tissue to become stiffer and less elastic. These changes result in a diminished
capacity for organ function and increased vulnerability to disease and stress. Age-related
changes in the hematopoietic system influence red blood cell production leading to increased
rates of anemia (Bross, Soch, & Smith-Knuppel, 2010; Vanasse & Berliner, 2010).

Body composition changes in old age

The human body is made up of fat, lean tissue (muscles and organs), bones and water.
After the age of 40, people start losing their lean tissue. Body organs like liver, kidneys and
other organs start losing some of their cells. This decline in muscle mass is associated with
weakness, disability and morbidity.
The tendency to become shorter occurs among the different gender groups and in all
races. Height loss is associated with ageing changes in the bones, muscles and joints. Studies
show that people typically lose almost one-half inch (about 1 cm) every 10 years after age 40.
Height loss is even more rapid after age 70. These changes can be prevented by following a
healthy diet, staying physically active and preventing and treating bone loss.
Changes in the total body weight vary for men and woman, as men often gain weight
until about age 55 and then begin to lose weight later in life. This may be related to a drop in
the male sex hormone testosterone. Women usually gain weight until age 67–69 and then
begin to lose weight. Weight loss later in life occurs partly because fat replaces lean muscle
tissue and fat weighs less than muscle. Studies have also shown that older people may have
almost one-third more fat compared to when they were younger. Fat tissue builds up towards
the centre of the body, including around the internal organs. Table 1 summarizes the signs
and symptoms of age-related changes in the functioning of body systems.
TABLE 1. SUMMARY OF THE SIGNS AND SYMPTOMS OF AGE-RELATED CHANGES IN THE
FUNCTIONING BODY SYSTEMS
CHANGES SUBJECTIVE AND HEALTH PROMOTION
OBJECTIVE FINDINGS STRATEGIES
Integumentary System
Decreased subcutaneous Thin, wrinkles and dry skin; Limit solar exposure 10-15
fat, interstitial fluid, complaints of injuries, minutes daily for Vitamin D
muscle tone, glandular bruises, and sunburn; (use protective clothing and
activity, and sensory complaints of intolerance to sunscreen); dress
receptors, resulting in heat; prominent bone appropriately for
decreased protection structure temperature; maintain in a
against trauma, sun safe indoor temperature; take
exposure, and shower rather than hot tub if
temperature extremes; possible; lubricate the skin
diminished secretion of

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natural oils and with lotions that contain

perspiration; capillary petroleum or mineral oil.
fragility

Musculoskeletal System
Loss of bone density; loss Height loss; prone to Exercise regularly; eat a high-
of muscle strength and fractures; kyphosis; back calcium diet; limit
size; degenerated joint pain; loss of strength, phosphorus intake; take
cartilage flexibility, and endurance; calcium and vitamin D
joint pain supplements as prescribed.
Respiratory System
Increase in residual lung Fatigue and breathlessness Exercise regularly; avoid
volume; decrease in with sustained activity; smoking; take adequate fluids
muscle strength, decreased respiratory to liquefy secretions; receive
endurance, and vital excursion and chest/lung yearly influenza
capacity; decreased gas expansion with less effective immunization and
exchange and diffusing exhalation; difficulty pneumonia vaccine at 65
capacity; decreased cough coughing up secretions years of age; avoid exposure
efficiency to upper respiratory tract
infections.
Cardiovascular System
Decreased cardiac output; Complaints of fatigue with Exercise regularly; pace
diminished ability to increased activity; increased activities; avoid smoking eat
respond to stress, heart heart rate recovery time a low-fat, low salt diet;
rate, and stroke volume participate in stress
does not increase with reduction activities; check
maximum demand; blood pressure regularly;
slower heart rate adherence to medications;
recovery rate; increased weight control
blood pressure

Gastrointestinal System
Decreased sense of thirst, Risk of dehydration, Use ice chips, mouthwash;
smell, and taste; electrolyte imbalances, and brush, floss, and massage
decreased salivation; poor nutritional intake; gums daily; receive regular
difficulty swallowing complaints of dry mouth; dental care; eat small
food; delayed esophageal complaints of fullness, frequent meals; sit up and
and gastric emptying; heartburn, and indigestion; avoid heavy activity after
reduced gastrointestinal constipation, flatulence, and eating; limit antacids; eat a
motility abdominal discomfort high-fiber, low-fat diet; limit
laxatives; toilet regularly;
drink adequate fluids
Genitourinary System
Male: Benign prostatic Urinary retention; initiative Limit drinking in evening (e.g.
hyperplasia voiding symptoms including caffeinated beverages,
frequency, feeling of alcohol); do not wait long
incomplete bladder periods between voiding;
emptying, multiple night- empty bladder all the way
time voiding when passing urine
Wear easily manipulated
Female: Relaxed perineal Urgency/frequency clothing; drink adequate
muscle; detrusor syndrome; decreased fluids; avoid bladder irritants
instability (urge “warning time”; drops of (e.g caffeinated beverages,
incontinence); urethral urine lost with cough, laugh, alcohol, artificial
position change sweeteners); perform pelvic

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 14

dysfunction (stress floor muscle exercises,

urinary incontinence) preferably learned via
biofeedback; consider
urologic workup.
Nervous System
Reduced speed in nerve Slower to respond and react; Pace teaching with
conduction; increased learning takes longer; hospitalization, encourage
confusion with physical becomes confused with visitors; enhance sensory
illness and loss of hospital admission; faintness; stimulation; with sudden
environmental cues; frequent falls confusion; encourage slow
reduced cerebral rising from a resting position
circulation (becomes
faint, losses balance)
Special Senses
Vision: Diminished ability Holds objects far away from Wear eyeglasses and use
to focus on close objects; the face; complaints of glare; sunglasses outdoors; avoid
inability to tolerate glare; poor night vision; confuses abrupt changes from dark to
difficulty adjusting to colors light; use adequate indoor
changes of light intensity; lighting with area lights and
decreased ability to nightlights; use large-print
distinguish colors books; use a magnifier for
reading; avoid night driving;
use contrasting colors for
color-coding; avoid glare
shiny surfaces and direct
sunlight
Hearing: Decreased Gives inappropriate Recommend a hearing
ability to hear high- responses asks people to examination; reduce
frequency sounds; repeat words; strains background noise; face
tympanic membrane forward to hear person; enunciate clearly;
thinning and loss of Uses excessive sugar and salt speak with a low-pitched
resiliency voice; use nonverbal cues

Taste and smell: Encourage use of lemon,

Decreased ability to taste spices, herbs; recommend
and smell smoking cessation

Reproductive System
Female: Vaginal Female: painful intercourse; May require vaginal estrogen
narrowing and decreased vaginal bleeding following replacement;
elasticity; decrease intercourse; vaginal itching gynecology/urology follow-
vaginal secretions and irritation; delayed up; use a lubricant with
Male: fewer firm testes orgasm sexual intercourse
and decreased sperm
production
Male and female: Slower
sexual response

V. Reflection
Identify preventive techniques that may enhance the aging experience or delay aging
processes throughout the life course. Discuss how these techniques work on the body for
every organ system and how they might help delay aging or maintain a healthy aging status.

VI. Post Test

Encircle the letter of the correct answer.

1. Statement A: Aging processes that occur in one physiological system can directly or
indirectly influence other physiological systems.
Statement B: Intrinsic aging refers to changes caused by the normal aging process.
a. Statement A and B are correct

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 15

b. Statement A and B are incorrect

c. Only Statement A is correct
d. Only Statement B is correct
2. Health teaching in the older adult with complaints of intolerance to heat are the
following except:
a. Stay indoors and limit sun exposure
b. Do not use sunscreen and lotions for it dries the skin
c. Take shower instead of a hot tub
d. Use protective clothing when outdoors
3. It is a spinal disorder in which an excessive outward curve of the spine results in an
abnormal rounding of the upper back
a. Lordosis
b. Scoliosis
c. Kyphosis
d. Osteoporosis
4. For older adults experiencing urinary retention the following must be done except:
a. Wear tight-fitting underwear to prevent leakage of urine
b. Avoid bladder irritants like coffee
c. Do not wait long periods between voiding
d. For female older adult practice doing pelvic muscle exercises
5. The following are health promotion strategies for the older adult with problems in the
Musculoskeletal system except:
a. Take calcium and vitamin D supplements
b. Increase intake of foods high in phosphorus
c. Exercise regularly
d. Eat a high calcium diet
6. Which of the following are the normal age-related physiological changes?
a. Increased susceptibility to urinary tract infection
b. The decline in visual acuity
c. Increased incidence of awakening after sleep onset
d. A decline in long term memory
7. Which of the following is a health promotion strategy for an older adult with problems
in the Cardiovascular system except?
a. Eat a low-fat, high salt diet
b. Participate in advance bodybuilding activities
c. Check blood pressure regularly
d. Check weight habitually
8. The following are health promotion strategies for the older adult with problems in the
Gastrointestinal system except:
a. Drink adequate fluids
b. Sit up and avoid heavy activity after eating
c. Eat a low-fiber, high-fat diet
d. Receive dental care regularly
9. These are the problems of an older adult associated in Nervous system except:
a. Increased confusion with physical illness
b. Reduced speed in nerve conduction
c. Loss of environmental cues
d. Increased cerebral circulation
10. Signs and symptoms of an older adult with problems in hearing:
a. Strains forward to hear
b. Answers immediately to questions
c. Confuses with colors
d. Frequent falls

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VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.intechopen.com/books/gerontology/ageing-process-and-
physiological-changes

UNIT III. NURSING CARE OF THE OLDER ADULT IN WELLNESS

I. Introduction

The intent of this gerontological nursing text is to provide comprehensive and

research-based information so that nurses can distinguish between the changes associated
with normal aging and those that result from risk factors. In addition, the text provides tools
for nursing assessment, interventions, and health education in relation to all aspects of
physical and psychosocial functioning. Nurses can use these tools to promote wellness—
which includes improved health, functioning, and quality of life—for the older adults for
whom they provide care.
An assessment has been described as the cornerstone of gerontological nursing, and
the goal is to conduct a systematic and integrated assessment (Olenek, Skowronski, &
Schmaltz, 2003). The health and health care needs of older adults are complex, deriving from
a combination of age-related changes, age-associated diseases, heredity, and lifestyle.
Assessment requires knowledge and an understanding of this complexity of factors. In
assessing and providing care to older adults, nurses are members of a health care team that
includes physicians, therapists, social workers, spiritual care workers, pharmacists,
nutritionists, and others. Each member of the team has a contribution to make, and nurses
are often in a position to draw upon the knowledge of other team members to enhance the
assessment process

II. Objectives/Competencies

At the end of the unit, I am able to:

1. identify the major components of a comprehensive assessment of older adults including
functional, physical, cognitive and psychological assessments;
2. recognize some of the challenges of conducting comprehensive assessments of older
adults; and
3. describe some of the issues concerning the comprehensive assessment of older adults.

III. Pre-test

Fill in the missing letter of the words below and write it on the space provided for the answer.

1. A _T_ _ITI_S OF DA_ _Y LI_I _NG _______________________________________

2. SU_S_ _ _CE A_ _S E _______________________________________
3. DEP_ _SS_ _N _______________________________________
4. A_ZH_I_E_ _ DISE_ _E _______________________________________
5. GER_ _T_IC N_RS_ _G _______________________________________

IV. Lesson Proper

Gerontology, the scientific study of the aging process, is a multidisciplinary field that
draws from the biological, psychological, and sociologic sciences (C.L.Estes, 2007). Geriatrics
is the practice (medical or nursing) that focuses on the physiology, pathology, diagnosis and
management of the disorders and diseases of older adults (MedicineNet). Because aging is a
normal process, care for older adults cannot be limited to one discipline but is best provided

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 17

through a cooperative effort. An interdisciplinary approach to providing care combines

expertise and resources to provide comprehensive geriatric assessment and intervention.
Nurses collaborate with the team to obtain appropriate services for patients and provide a
holistic approach to care.
Gerontologic/geriatric nursing is the field of nursing that specializes in the care of
older adults. The Scope and Standards of Gerontological Nursing Practice were originally
developed in 1969 by the American Nurses Association (ANA) and revised in 2010 (ANA,
2010). The nurse gerontologist can be either a specialist or a generalist providing
comprehensive nursing care to older people by combining the basic nursing process with
specialized knowledge of aging. Gerontologic nursing is provided in acute care, skilled and
assisted living, the community, and home settings. The goals of care include promoting and
maintaining functional status as well as helping older adults identify and use their strengths
to achieve optimal independence.

The Relationship between wellness and aging is the major focus of a “wellness
approach” to older adult health care is addressing the body–mind–spirit interconnectedness
of each older adult as a unique and respected individual. This requires that nurses assess each
older adult in the full context of his or her personal history and current situation. Based on
this holistic assessment, nurses identify realistic wellness outcomes and plan interventions
directed toward improved health, functioning, and quality of life. This approach may seem
challenging—or even impossible—for older adults who are seriously or terminally ill or for
those who have overwhelming chronic conditions. Even when there are serious physical
challenges, however, nurses need to recognize that they can implement interventions
directed toward improved physical comfort and psychological and spiritual growth. Some
nursing actions that promote wellness for older adults are as follows:
• Addressing the body–mind–spirit interrelatedness of each older adult
•Identifying and challenging ageist attitudes (including their own), especially those
that interfere with optimal health care assessing each older adult from a whole-
person perspective
•Incorporating wellness nursing diagnoses as a routine part of care
•Planning for wellness outcomes, which are directed toward improved health,
functioning, and quality of life
•Using nursing interventions to address the factors that interfere with optimal
functioning (including lack of accurate information about aging)
•Recognizing each older adult’s potential for improved health and functioning as well
as psychological and spiritual growth
•Teaching about self-care behaviors to improve health and functioning (or teaching
caregivers of dependent older adults)
•Promoting wellness for caregivers and other people who provide care for older
adults (including self-care for nurses).

In addition to specialists, nurses who work in all areas of adult medical-surgical

nursing encounter older adult patients. Nurses must be knowledgeable and skilled in meeting
the complex needs of these patients. Nurses and caregivers who work with older patients
must understand that aging is not synonymous with disease and that the effects of the aging
process alone are not the only or even the primary contributors to disability and disease.
Aging is a highly individualized and multifaceted process.
Functional assessment is a common framework for assessing older people. Age-
related changes, as well as additional risk factors such as disease and the effects of
medications, can reduce function. Assessing the functional consequences of aging and
proposing practical interventions helps maintain and improve the health of older adults. The
goal is to help older people sustain maximum functional level and dignity despite physical,
social, and psychological losses. Early intervention can prevent complications of many health
problems and help maximize the quality of life.

Functional Assessment
Nurses typically conduct a functional assessment to identify an older adult’s ability to
perform self-care, self-maintenance, and physical activities and plan appropriate nursing
interventions. There are two approaches. One approach is to ask questions about the ability
and the other approach is to observe ability through evaluating task completion. However,
although we tend to speak of “ability,” our verbal and observational tools tend to screen for

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 18

“disability.” Disability refers to the impact that health problems have on an individual’s ability
to perform tasks, roles, and activities, and it is often measured by asking questions about the
performance of activities of daily living (such as eating and dressing) and instrumental
activities of daily living (such as meal preparation and hobbies) (Verbrugge & Jette, 1994).
Functional assessment should first emphasize an older adult’s ability and the
appropriate nursing interventions to support, maintain, and maximize ability; second, it
should focus on an older adult’s disability and the appropriate nursing interventions to
compensate for and prevent further disability.
Tools to assess functional ability tend to address self-care (basic activities of daily
living or ADLs), higher-level activities necessary to live independently in the community
(instrumental activities of daily living or IADLs), or highest-level activities (advanced
activities of daily living or AADLs) (Adnan, Chang, Arseven, & Emanuel, 2005)

Activities of Daily Living (ADLs)

The original ADL tool was developed by Katz and colleagues during 8 years at the
Benjamin Rose Hospital, a geriatric hospital in Cleveland, Ohio, using observations of patients
with hip fractures and their performance of activities during recovery (Katz, Ford,
Moskowitz, Jackson, & Jaffee, 1963). The Katz Index of ADL (1970) distinguished between
independence and dependence in activities and created an ordered relationship among ADLs.
It addressed the need for assistance in bathing, eating, dressing, transfer, toileting, and
continence.
Tasks typically assessed with ADL Assessment Tools are the following:
1. Eating
2. Dressing
3. Bathing/washing
4. Grooming
5. Walking/ambulation
6. Ascending/ descending stairs C
7. Communication
8. Transferring (e.g., from bed to chair)
9. Toileting (bowel and bladder)

Instrumental Activities of Daily Living (IADLs)

Instrumental activities of daily living include a range of activities that are considered
to be more complex compared with ADLs and address the older adult’s ability to interact with
his or her environment and community.
IADLs include the ability to use the telephone, cook, shop, do laundry and housekeeping,
manage finances, take medications, and prepare meals. Missing from most IADL tools are
activities that may be more associated with men, such as fixing things around the house or
lawn care. One of the earliest IADL measures was developed by Lawton and colleagues
(1969).
Tasks typically assessed with ADL Assessment Tools are the following:
1. Using the telephone
2. Taking medications
3. Shopping
4. Handling finances
5. Preparing meals
6. Laundry
7. Light or heavy housekeeping
8. Light or heavy yard work
9. Home maintenance
10. Using transportation
11. Leisure/recreation

Advanced Activities of Daily Living (AADLs)

Advanced activities of daily living include societal, family, and community roles, as
well as participation in occupational and recreational activities. AADL assessment tools tend
to be used less often by nurses and more often by occupational therapists and recreation
workers to address specific areas of social tasks (Chan & Lee, 1997).
Tasks typically assessed with ADL Assessment Tools are the following:

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1. Self-care activities (personal care, functional mobility, and community

management)
2. Productivity (paid/ unpaid work, household management, and play/ school)
3. Leisure (quiet recreation, active recreation, and socialization)

Psychological Assessment
Changes in cognitive ability, excessive forgetfulness, and mood swings are not a part
of normal aging. These symptoms should not be dismissed as age-related changes; a
thorough assessment may reveal a treatable, reversible physical or mental condition.
Changes in mental status may be related to many factors, such as alterations in diet and fluid
and electrolyte balance, fever, or low oxygen levels associated with many cardiovascular and
pulmonary diseases. Cognitive changes may be reversible when the underlying condition is
identified and treated. However, the susceptibility to depression, delirium, and incidence of
dementia increase with age. Older adults are less likely than younger people to acknowledge
or seek treatment for mental health symptoms. Therefore, health professionals must
recognize, assess, refer, collaborate, treat, and support older adults who exhibit noticeable
changes in intellect or affect.

Depression
Clinical depression is the most common mental health problem among older adults,
and it often goes undetected because clinicians attribute depressive symptoms to age-
associated changes, chronic physical illness, medication side effects, or pain (Lebowitz et al.,
1997).
Depressed older adults may experience difficulty with sleeping, loss of appetite,
physical discomfort, anxiety, hopelessness, bouts of crying, and suicide ideation. They may
feel uncomfortable in social situations and curtail their usual social contacts and events,
creating a downward spiral of depression and isolation. Depression is associated with
cognitive limitations, and depressed older adults can experience disorientation, shortened
attention span, emotional outbursts, and difficulty in intellectual functioning.

Substance Abuse
Substance abuse caused by the misuse of alcohol and drugs may be related to
depression. Thirty-six percent of adults 65 years and older report that they are current
drinkers; 2% of men and less than 1% of women meet the criteria for alcohol abuse (Miller,
2012). Moderate levels of alcohol consumption may be associated with positive health risks,
such as lowering the risks for cardiovascular disease. Alcohol abuse, while rare, is especially
dangerous in older people because of age-related changes in renal and liver function as well
as the high risk of interactions with prescription medications and the resultant adverse
effects. Alcohol and drug-related problems in older people often remain hidden because
many older adults deny their habit when questioned. Assessing for drug and alcohol use with
direct questions in a no accusatory manner should be part of the routine physical assessment
(Meiner, 2011; Miller, 2012)
Delirium
Delirium, often called acute confusional state, begins with confusion and progresses
to disorientation (American Psychiatric Association). It is a common and life-threatening
complication for hospitalized older adults and the most frequent complication of
hospitalization.
Patients may experience an altered level of consciousness, ranging from stupor
(hypo alert–hypoactive) to excessive activity (hyperalert–hyperactive); alternatively, they
may have a combination of these two types (mixed). Thinking is disorganized, and the
attention span is short. Hallucinations, delusions, fear, anxiety, and paranoia may also be
evident. Patients who tend to be hyperalert and hyperactive demand more attention from
nurses and thus are easier to diagnose, whereas those who are hypo alert or hypoactive tend
to be less problematic and pose diagnostic difficulties. Recognition of delirium can also be
complicated in patients with mixed disorders. Patients with the hypo alert–the hypoactive
type of delirium have higher mortality rates and even poorer outcomes of care because the
delirium tends not to be recognized and treated (Meiner, 2011; Miller, 2012).
Nurses must recognize the implications of the acute symptoms of delirium and
report them immediately. Because of the acute and unexpected onset of symptoms and the
unknown underlying cause, delirium is a medical emergency. If the delirium goes

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 20

unrecognized and the underlying cause is not treated, permanent, irreversible brain damage
or death can follow.
The most effective approach is prevention. Strategies include providing therapeutic
activities for cognitive impairment, ensuring early mobilization, controlling pain, minimizing
the use of psychoactive drugs, preventing sleep deprivation, enhancing communication
methods (particularly eyeglasses and hearing aids) for vision and hearing impairment,
maintaining oxygen levels and fluid and electrolyte balance, and preventing surgical
complications (Meiner, 2011; Miller, 2012).

Dementia
Dementia is a decline in memory and other mental abilities that make daily living
difficult. As many as 7% of adults aged 60 and older suffer from dementia (U.S. Bureau of the
Census, 2000).
Dementia takes a toll on those who suffer from it, as well as their caregivers. Along
with problems with memory, language, and decision-making abilities, dementia can cause
other symptoms. Whatever the cause of dementia, symptoms may include:
1. memory loss
2. loss of understanding or judgment
3. decreased ability to make decisions
4. changes in how the person expresses their emotions
5. changes in personality
6. problems coping with daily living
7. problems with speech and understanding language
8. problems socializing

Receiving a diagnosis of dementia can be very difficult. Nevertheless, there are

several steps you can take to help yourself or a family member continue to enjoy life:
1. Focus on the things you can do, rather than on the things you can no longer do.
2. Stay involved in activities that give pleasure and that have meaning for you.
3. Stay physically active and eat a healthy diet.
4. Plan for the future so that your wishes can be respected.
5. Reach out for support, both from family, close friends, and from community
services that help people maintain their independence and dignity.
6. Learn about dementia to find out what to expect and about strategies that can
help you to live the fullest life possible.
7. Acknowledge that living with dementia can be difficult.

Alzheimer’s disease
Dementia and Alzheimer’s disease aren’t the same. Dementia is an overall term used
to describe symptoms that impact memory, the performance of daily activities,
and communication abilities (Legg, 2018). Alzheimer’s disease is the most common type of
dementia. Alzheimer’s disease gets worse with time and affects memory, language, and
thought.
While younger people can develop dementia or Alzheimer’s disease,
your risk increases as you age. Still, neither is considered a normal part of aging. Although
symptoms of the two conditions may overlap, distinguishing them is important for
management and treatment.
The National Institutes of Health estimate that more than 5 million people in the
United States have Alzheimer’s disease. Although younger people can and do get Alzheimer’s,
the symptoms generally begin after age 60. The time from diagnosis to death can be as little
as three years in people over 80 years old. However, it can be much longer for younger
people.
Damage to the brain begins years before symptoms appear. Abnormal protein
deposits form plaques and tangles in the brain of someone with Alzheimer’s disease.
Connections between cells are lost, and they begin to die. In advanced cases, the brain shows
significant shrinkage.
It’s impossible to diagnose Alzheimer’s with complete accuracy while a person is
alive. The diagnosis can only be confirmed when the brain is examined under a microscope
during an autopsy.
The symptoms of Alzheimer’s include:
1. difficulty remembering recent events or conversations

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2. apathy
3. depression
4. impaired judgment
5. disorientation
6. confusion
7. behavioral changes
8. difficulty speaking, swallowing or walking in advanced stages of the disease

Alzheimer’s Medical Management

No cure for Alzheimer’s is available, but options to help manage symptoms of the
disease include:
1. medications for behavioral changes, such as antipsychotics
2. medications for memory loss, which include cholinesterase inhibitors
donepezil (Aricept) and rivastigmine (Exelon) and memantine (Namenda)
3. alternative remedies that aim to boost brain function or overall health, such
as coconut oil or fish oil
4. medications for sleep changes
5. medications for depression

Nursing Management
Nurses play an important role in the recognition of dementia, particularly in
hospitalized older adults, by assessing for signs (e.g., repeating or asking the same thing
over and over, getting lost) during the nursing admission assessment. Nursing
interventions for dementia are aimed at promoting patient function and independence
for as long as possible (Murphy & Hickey, 2010).
1. Supporting Cognitive Function
a. Family members must provide more and more assistance and supervision
b. A calm, predictable environment helps people with dementia interpret their
surroundings and activities.
c. A quiet, pleasant manner of speaking, clear and simple explanations and the
use of memory aids and cues help minimize confusion and disorientation and
give patients a sense of security.
d. Prominently displayed clocks and calendars may enhance orientation to time.
e. Color-coding the doorway may help patients who have difficulty locating their
room.
f. Active participation may help patients maintain cognitive, functional, and
social interaction abilities for a longer period.
2. Promoting Physical Safety
a. To prevent falls and other injuries, all obvious hazards are removed and
handrails are installed in the home. A hazard-free environment allows the
patient maximum independence and a sense of autonomy.
b. Adequate lighting, especially in halls, stairs, and bathrooms, is necessary.
Nightlights are helpful, particularly if the patient has increased confusion at
night (sundowning).
c. Driving is prohibited, and smoking is allowed only with supervision.
d. Wandering behavior can often be reduced by gentle persuasion, distraction,
or by placing the patient close to the nursing station.
e. Restraints should be avoided because they increase agitation.
f. Doors leading from the house must be secured.
g. Outside the home, all activities must be supervised to protect the patient, and
the patient should wear an identification bracelet or neck chain in case of
separation from the caregiver.
3. Promoting Independence in Self-Care Activities
a. Simplify daily activities by organizing them into short, achievable steps so
that the patient experiences a sense of accomplishment.
b. Occupational therapists can suggest ways to simplify tasks or recommend
adaptive equipment.
c. Direct patient supervision is sometimes necessary; however, maintaining
personal dignity and autonomy is important for people with AD, who should
be encouraged to make choices when appropriate and to participate in self-
care activities as much as possible.

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4. Reducing Anxiety and Agitation

a. The environment should be kept familiar and noise-free.
b. When scream, cry or becoming abusive (physically or verbally) remain calm
and unhurried.
c. Measures such as moving to a familiar environment, listening to music,
stroking, rocking, or distraction may quiet the patient.
d. Structuring activity is also helpful. Becoming familiar with a particular
patient’s predicted responses to certain stressors helps caregivers avoid
similar situations.
5. Improving Communication
a. To promote the patient’s interpretation of messages, the nurse should remain
unhurried and reduce noises and distractions.
b. Use of clear, easy-to-understand sentences to convey messages
c. Lists simple written instructions that serve as reminders may be helpful.
d. Tactile stimuli, such as hugs or hand pats, are usually interpreted as signs of
affection, concern, and security.
6. Providing for Socialization and Intimacy Needs
a. Because socialization with friends can be comforting, visits, letters, and phone
calls are encouraged.
b. Recreation is important, and people with dementia are encouraged to
participate in simple activities.
c. Hobbies and activities such as walking, exercising, and socializing can
improve quality of life.
d. Patients and their spouses may continue to enjoy sexual activity. Spouses
should be encouraged to talk about any sexual concerns, and sexual
counseling may be necessary.
e. Simple expressions of love, such as touching and holding, are often
meaningful.
7. Promoting Adequate Nutrition
a. Mealtime should be kept simple and calm, without confrontations.
b. Patients prefer familiar foods that look appetizing and taste good.
c. Food is cut into small pieces to prevent choking.
d. Liquids may be easier to swallow if they are converted to gelatin.
e. Hot food and beverages are served warm, and the temperature of the foods
should be checked to prevent burns.
f. When lack of coordination interferes with self-feeding, adaptive equipment is
helpful
g. Some patients may do well eating with a spoon or with their fingers. If this is
the case, an apron or a smock, rather than a bib, is used to protect clothing.
8. Promoting Balanced Activity and Rest
a. If sleep is interrupted or the patient cannot fall asleep, music, warm milk, or a
back rub may help the patient relax.
b. During the day, patients should be encouraged to participate in exercise
because a regular pattern of activity and rest enhances night-time sleep.
c. Long periods of daytime sleeping are discouraged.

V. Reflection

How would you define “successful aging”? What are the implications of your
definition of decisions you might make during your lifetime? How might this definition affect
the way you view the aging process of others?

VI. Post Test

Encircle the letter of the correct answer.

1. The scientific study of the aging process and is a multidisciplinary field that draws from
the biological, psychological, and sociologic sciences.
a. Geriatrics
b. Geriatric nursing
c. Functional assessment
d. Gerontology

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 23

2. The purpose of functional assessment is the following except:

a. Ability to perform self-care
b. Promote disability
c. Self-maintenance
d. Perform physical activities
3. Statement A: Functional assessment should first emphasize an older adult’s ability and
the appropriate nursing interventions to support, maintain, and maximize ability.
Statement B: It should focus on an older adult’s disability and the appropriate nursing
interventions to compensate for and prevent further disability.
a. Statement A and B are correct
b. Statement A and B is incorrect
c. Only statement A is correct
d. Only statement B is correct
4. This includes a range of activities that are considered to be more complex and address
the older adult’s ability to interact with his or her environment and community.
a. Functional Assessment
b. Activities of Daily Living (ADLs)
c. Instrumental Activities of Daily Living (IADLs)
d. Advanced Activities of Daily Living (AADLs)
5. Often goes undetected because clinicians attribute symptoms to age-associated changes,
chronic physical illness, medication side effects, or pain.
a. Substance Abuse
b. Alzheimer’s disease
c. Delirium
d. Depression
6. Depression is associated with cognitive limitations, and depressed older adults can
experience the following except:
a. Euphoria
b. Shortened attention span
c. Emotional outbursts
d. Disorientation
7. Also called acute confusional state, begins with confusion and progresses to
disorientation
a. Substance Abuse
b. Alzheimer’s disease
c. Delirium
d. Depression
8. The most effective approach in delirium includes therapeutic activities like the following
except:
a. Limiting communication methods
b. Ensuring early mobilization
c. Maintaining oxygen levels and fluid and electrolyte balance
d. Preventing surgical complications
9. Statement A: Dementia and Alzheimer’s disease aren’t the same.
Statement B: Alzheimer’s disease gets better with time and affects memory, language, and
thought.
a. Statement A and B are correct
b. Statement A and B is incorrect
c. Only statement A is correct
d. Only statement B is correct
10. Steps that a person with dementia can do except:
a. Limit activities that give pleasure and that have meaning for you.
b. Acknowledge that living with dementia can be difficult.
c. Stay physically active and eat a healthy diet.
d. Plan for the future so that your wishes can be respected

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

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 24

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.camh.ca/en/health-info/guides-and-publications/dementia-in-older-
adults

https://www.healthline.com/health/alzheimers-disease/difference-dementia-
alzheimers#outlook

https://ecampusontario.pressbooks.pub/healthassessment/chapter/the-complete-
subjective-health-assessment/

UNIT IV. PLANS FOR HEALTH PROMOTION, HEALTH MAINTENANCE,

AND HOME HEALTH CONSIDERATIONS
I. Introduction

As people live longer and the percentage of older adults in the population increases,
society faces several major challenges. One of the most significant of these challenges involves
meeting the health care needs of the aging population. Today’s older adults are generally
healthier than were the older adults of previous generations. Improvements in sanitation,
public health, and occupational safety implemented during the twentieth century have
helped raise the age at which a person can expect to experience a life-threatening disease.
Although older adults make up only approximately 12% of today’s population, they account
for more than one-third of all health care expenditures. For the most part, today’s older adult
population has benefited from improvements in medical care. Advances in surgery,
technology, and pharmacology have enabled us to prolong life in situations that even a few
years ago would have been impossible.
This creates an exciting opportunity for nurses to improve the quality of life for the
elderly client through evidence-based health promotion activities. In this topic, we will
review the health promotion and disease prevention guidelines, health maintenance, and
home health considerations.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. describe the significance of preventive health care and health promotion for the older
adult; and
2. examine the concerns of older people and their families in the home and community, in
the acute care setting, and the long-term care facility.

III. Pre-test

1. Includes bathing, dressing, grooming, showering, and toileting activities.

a. Skilled care
b. Independent living
c. Rehabilitation
d. Activities of daily living
2. Provides holistic, comprehensive care to the terminally ill patient and his or her family
through the dying and bereavement process
a. Assisted Living
b. Skilled Care
c. Subacute Care
d. Hospice
3. Medical care of the aged.
a. Geriatrics
b. Skilled care
c. Independent living

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d. Rehabilitation
4. A type of setting/housing in which the older adult performs all IADLs and ADLs
independently or with minimal supervision.
a. Skilled care
b. Independent living
c. Rehabilitation
d. Activities of daily living
5. Those persons ages 85 years and over; sometimes called the oldest old, the very old, or
the frail elderly
a. Young old
b. Middle Old
c. Old Old
d. None of the above

IV. Lesson Proper

Planning for Successful Aging

Coining the term successful aging in 1996, researchers Rowe and Kahn presented
their well-known definition that emphasized the interaction of three related elements:
1.) Avoidance of physical illness and disability
2.) Maintenance of high physical and cognitive function
3.) Continuing engagement in social and productive activities
It seems rather straightforward to say you will be successful if you are healthy, high
functioning, and socially engaged; however, this original definition was important because it
moved the conversation from what is normal to what is optimal in later life and opened the
door for researchers and others to think about what can we do, as individuals and as a
society, to foster optimal or successful aging.
Some gerontologists have noted that Rowe and Kahn’s definition of successful aging
might favor the fortunate who have been spared ill health and mental or physical disability
in later life. So, to broaden and refine the concept of successful aging, gerontologists in the
years since the publication of their work have incorporated issues such as privilege or
disadvantage across the lifespan to better address some of the diversity among older adults.
A few researchers have gone straight to the source: asking older adults for their
subjective perspectives on what successful aging means to them. Recent research on how
older people define successful aging illustrates that people do indeed value good health and
functioning (and the independence they allow) and social engagement, just as Rowe and
Kahn wrote. However, research has also found that older people value and consider
successful aging to include meaningful activity, not just keeping busy, and a sense of
belonging to a family, friendships, groups, or communities. Too many older people,
exercising their spiritual beliefs, and having a spiritual relationship with the world around
them is another element of successful aging (Mauk, 2010).
In more advanced old age, successful aging undoubtedly requires flexibility and
adaptation in response to changes in health and functioning and the social losses that are so
common. And when older people (or people of any age) are challenged by illness, pain, and
loss of functioning, they are going to value physical comfort, freedom from physical and
emotional suffering (including worry about finances), and access to the care they need.

Home Care
Older adults requiring a longer period of observation or care from nurses may be
candidates for home health care services. Visiting nurse associations (VNAs) have long been
known for their positive reputation in providing home care. Home care is designed for those
who are homebound due to the severity of illness or immobility. For reimbursement of
allowable expenses, home health care services must be ordered by a physician. There has
been recording growth in the number of home health agencies springing up in the past
decade. People’s desire to be cared for in familiar surroundings by their families, versus an
institution, has fueled the need for more agencies.
Although physical, occupational, and speech therapies may be obtained through
home care, as well as home health aide services, a nurse must open the case file and the
individual must warrant some type of nursing services to qualifying. The majority of home
care patients are elderly and experience a variety of problems needing nursing, such as

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chronic wounds, intravenous therapy, long-term indwelling urinary catheters, and tube
feedings.

Hospice
Hospice is a program of supportive and palliative services for terminally ill patients
and their families that includes physical, psychological, social, and spiritual care. In most
cases, patients are not expected to live longer than 6 months. The goal of hospice is to
improve the quality of life by focusing on symptom management, pain control, and emotional
support (Meiner, 2011). Under Medicare and Medicaid, medical and nursing services are
provided to keep patients as pain-free and comfortable as possible. Hospice services may be
incorporated into the care of residents in long-term care facilities and include care for end-
stage dementia and other chronic diseases such as end-stage heart failure.

Table 1. Comparisons Between Home Health & Hospice Care

Home Health Hospice

What is the To promote health, well-being, To provide compassionate care

Philosophy of and quality of life to promote well-being and
Care? To manage pain, symptoms and quality of life
side effects To manage pain, symptoms and
To support independent living in side effects
home of choice To support independent living
To prevent unnecessary in home of choice
hospitalizations To prevent unnecessary
hospitalizations
To counsel patient and family
through end-of-life process
To relieve caregiver burden and
stress
Who Benefits For recovery or rehabilitation For optimizing comfort and
from Services? following an: quality of life when:
injury A doctor certifies life
illness expectancy of six months or less
surgery Patient discontinues curative
hospitalization treatment for terminal illness
help managing a chronic
condition
What Services Nursing and/or therapy until Medical, social, emotional, and
are Provided? defined goals are met spiritual care for patients and
Personal care assistance families
Medical social work Bereavement support for
families

Where are Wherever the patient calls home, Wherever the patient calls
Services in a private home or facility home, in a private home or
Provided? residence facility residence
In a hospital or inpatient facility
for a short-term stay
How Long are Regular visits on an intermittent Care schedule varies by need
Services basis, depending on goals of care Unlimited recertification with
Provided? Recertification if medically ≤6-month life expectancy
necessary Bereavement support continues
after loss of loved one

Community-based Services
Continuing care retirement communities (CCRCs) offer three levels of living
arrangements and care that provide for aging in place (Meiner, 2011; Miller 2012). CCRCs
consist of independent single-dwelling houses or apartments for people who can manage
their day-to-day needs, assisted living apartments for those who need limited assistance with
their daily living needs, and skilled nursing services when continuous nursing assistance is
required. CCRCs usually contract for a large down payment before the resident moves into

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the community. This payment gives a person or couple the option of residing in the same
community from the time of total independence through the need for assisted or skilled
nursing care. Decisions about living arrangements and health care can be made before any
decline in health status occurs. CCRCs also provide continuity at a time in an older adult’s life
when many other factors, such as health status, income, and availability of friends and family
members, maybe changing.
Under Title III of the Older Americans Act, Senior Resources provides funding for
home and community based services. While not all services are funded in all areas, table 1.
List of the various services which may be funded with Older Americans Act funding.

Table 1. List of Various Services Funded with Older Americans Act funding.
Assisted Provision of assistance, including escort, to a person who has
Transportation difficulties (physical or cognitive) using regular vehicular
transportation.
Benefits This service helps the elderly in determining their eligibility for
Counseling income maintenance or public assistance, assists in processing or
filling out forms such as insurance, and teaches about local, state and
federal tax benefits or credits.
Benefits This category covers those educational programs designed to make
Education the participants aware of government or non-government programs
available to assist them in meeting their needs and solving their
problems. These programs address the details of the services
provided, eligibility requirements, and the places where services are
delivered.
Case Assistance either in the form of access or care coordination in
Management circumstances where the older person and/or their caregivers are
experiencing diminished functioning capacities, personal conditions
or other characteristics which require the provision of services by
formal providers. Activities of case management include assessing
needs, developing care plans, authorizing services, arranging
services, coordinating the provision of services among providers,
follow-up and reassessment, as required.
Chore Provision of assistance to persons experiencing difficulties with such
activities as heavy housework, yard work, sidewalk maintenance
and minor home repairs
Chronic Disease A program designed to help people with chronic diseases to gain
Management self-confidence in their ability to control their symptoms, take on
health challenges and maintain control of their lives.
Companion Service intended to provide company to a participant in a protective
and supervisory capacity. It may include such home management
activities as cooking and light housekeeping.
Continuing Service designed to provide the elderly with an opportunity to
Education acquire and/or improve their knowledge and skills through a formal
or informal mechanism of meetings, training sessions, seminars and
workshops.
Day Care Provision of personal care for dependent adults in a supervised,
protective, congregate setting during some portion of a twenty-four-
hour day. Services offered in conjunction with adult day care
frequently include social and recreational activities, training,
counseling and meals for adult day care participants while at the
facility. Service such as rehabilitation, medications assistance, and
personal care assistance are also provided by some adult day care
programs.
Dental Clinics Clinic programs that offer dental screening and/or treatment.
Employment This service designed to help participants locate and qualify for
Assistance gainful employment.
Employment This service assists the elderly in their adjustment to retirement
Counseling through pre-retirement programs or a more crisis-oriented service

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for retirees. This service may also include advice about employment
and enhancement of employability.
Energy Related Service designed to furnish fuel and/or utilities to participants who
Assistance are unable to purchase them at the market price. Special
arrangements are made with fuel and utility suppliers to reimburse
them for the delivery of fuel or the provision of utilities at prices
negotiated at or below the market price. The elderly participants or
their families are expected to share costs at levels determined by
their economic circumstances.
Fall Prevention A service designed to assess fall risk factors such as balance and gait
impairments, postural hypotension, medication use, vision
impairment and environmental hazards including unsafe footwear
or assistive devices. Consumers are counseled on appropriate steps
to take to reduce their risk for falls and are provided educational
materials. Fall prevention may also include programs that
incorporate strategies to reduce the fear of falling, increase physical
activity levels, increase strength and balance, and address
environmental changes to reduce falls.
Family Life This category is provided to cover those education or training
Education programs that deal with family and individual adjustment. It
provides participants with the skills required to cope with the
psychological and societal problems spawned by advancing years.
Food Buying Club A service that provides reduced costs in purchasing food through a
group buying process. Pre-orders are taken, bulk purchase is made,
packaging is performed by volunteers and distribution is made to
participants.
Food Pantry A service that distributes contributed food to seniors at no cost to
the participant. Participants may come to the pantry or the pantry
may bring food to the participant.
Foot Care Routine foot care provided by a licensed cosmetologist in a client’s
home which includes soaking and lotioning of feet and trimming,
filing and cleaning of toenails.
Foot Care - Nurse Routine foot care provided by a registered nurse in a client’s home
which includes soaking and lotioning of feet and trimming, filing and
cleaning of toenails when there is a diagnosis of diabetes, vascular
disease or when the client is on a blood thinner. A written
physician’s order is obtained and renewed every six months.
Friendly Visiting A service in which volunteers visit on a regularly scheduled basis the
homes of participants who live alone and are socially isolated and/or
geographically isolated. It provides protection and socialization for
the participant. The visitor helps the elderly participant maintain
contact with the outside world by providing such service activities
as letter writing and reading.
Health Service designed to develop an individualized profile of participants’
Assessments current health and the services required to maintain or improve
their functioning. Service may be provided by a medical doctor or a
diagnostically trained nurse practitioner or physician’s assistant.
Health Service designed to provide individuals with an awareness of
Counseling preventative, remedial and/or rehabilitative self-health care focused
on the particular health needs of participating individuals.
Health Education Service designed to provide individuals or groups of participants
with an awareness of preventative, remedial and/or rehabilitative
self-health care depending on the health needs of that particular
individual/group.
Health Service is designed to promote and maintain community health by
Screening/Clinic providing testing services for the assessment of a participant's
health status and the determination of need for further health care.
Home Health Service is designed to provide personal assistance, stand-by
Aide assistance, supervision or cues for persons having difficulties with

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one or more of the following activities of daily living: eating,

dressing, bathing, toileting, and transferring in and out of bed.
Home Repair & Service designed to help participants make essential repairs to their
Renovation homes either to restore them to their original condition or to make
them safe by removing health hazards. Includes renovations
designed to remove architectural barriers and provide structural
improvements that will enable participants suffering from chronic
disabling conditions to remain in their own homes.
Homemaker A service designed to maintain, strengthen and safeguard household
functioning and independent living for participants who need either
temporary assistance due to illness or long-term assistance due to
chronic disabling conditions. Homemakers perform home
management functions. These functions may include cooking,
cleaning, laundry, mending and other light household chores.
Although similar to companion, the primary emphasis in
homemaker service is on the performance of home management
functions while the primary emphasis in companion service is on the
provision of supervision and companionship.

Assisted Living Facilities

Assisted living facilities are an option when an older person’s physical or cognitive
changes necessitate at least minimal supervision or assistance. Assisted living allows for a
degree of independence while providing minimal nursing assistance with administration of
medication, assistance with ADLs, or other chronic health care needs. Other services, such as
laundry, cleaning, and meals, may also be included. Both assisted living and CCRCs are costly
and primarily paid out-of-pocket (Meiner, 2011).
In terms of the level of care provided, assisted living is a step below a nursing home
or skilled nursing facility. They are regulated by state laws, which vary by state.
● Assisted living provides skilled help and nursing for older people and people with
disabilities in a residential setting.
● They are designed for people who want some degree of independence and access to help
as needed.
● Residents may stay for as little as a month or long-term.
● Those who need assistance with ADLs can opt for in-home, assisted living, or nursing
home care.

Understanding Assisted Living

Assisted living generally allows more independence and costs less than nursing home
care, but is more expensive than an independent living facility. The assisted living setting is
similar to a personal residence, compared to a nursing home's hospital-like setting. Assisted
living is suitable for individuals who cannot manage on their own but want to maintain as
much independence as possible.
Paying for Assisted Living
Some people buy insurance that includes coverage for long-term care. Standard
Medicare coverage does not usually include the costs of assisted living.
In addition, some states offer financial assistance to help low-income individuals pay
for assisted living facilities.
Options for Assisted Living
There are thousands of assisted living facilities in the U.S., many of them offering
specialized services, so prospective residents have options depending on their circumstances
and preferences.
Assisted living facilities generally provide meals, housekeeping, transportation,
security, physical therapy, and activities for residents. Healthcare and supervision are
available 24/7 in most facilities. The facility will create a written care plan for each resident
and reassess and update the plan as needed.

Special Care Units

Subacute or Transitional Care

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Subacute care is generally for patients who require more intensive nursing care than
the traditional nursing home can provide, but less than the acute care hospital. Frequent
patient assessments are needed for a limited period for stabilization or completion of a
treatment regimen. “Typical individuals seen in subacute care are those needing assistance
as a result of nonhealing wounds, chronic ventilator dependence, renal problems,
intravenous therapy, and coma management and those with complex medical and/or
rehabilitative needs, including pediatrics, orthopedics, and neurological. These units are
designed to promote optimum outcomes in the least expensive cost setting”. Gerontological
nurses working in this setting would benefit from having a critical care background and
rehabilitation experience as well (Mauk, 2010).

Skilled Care
Skilled care units or skilled nursing facilities (SNFs) are for older adults requiring
more intensive nursing care. Some units are found within nursing homes, others within
hospitals. In this unit, one would expect to see persons with tube feedings, IV fluids, multiple
medications, chronic wounds, and even ventilators in some cases. The care required is at a
higher level, and the higher acuity of the residents or patients demands a greater nurse-to-
patient ratio. Persons in skilled care may include those with severe stroke, dementia, head
injury, coma, or advanced degenerative and/or neurological disorders.
The gerontological nurse working in skilled care must have expertise in preventing
the hazards of immobility such as pressure ulcers and contractures. The skilled care nurse
should know transfer techniques, prevention and assessment of swallowing problems, bowel
and bladder management, and nutrition. Good assessment and communication skills are
needed to care for these complex patients.

V. Reflection

What do you think about nurses who work in nursing homes? Have you ever
considered a career in gerontology? What are the positives you can see about developing
expertise in this field of nursing?
VI. Post Test

Encircle the letter of the correct answer.

1. This is designed for those who are homebound due to the severity of illness or
immobility.
a. Hospice
b. Home Care
c. Community-based services
d. Assisted Living
2. A program of supportive and palliative services for terminally ill patients and their
families that includes physical, psychological, social, and spiritual care.
a. Hospice
b. Home Care
c. Community-based services
d. Assisted Living
3. This is an option when an older person’s physical or cognitive changes necessitate at
least minimal supervision or assistance.
a. Hospice
b. Home Care
c. Community-based services
d. Assisted Living
4. Generally, for patients who require more intensive nursing care than the traditional
nursing home can provide, but less than the acute care hospital.
a. Assisted Living
b. Skilled Care
c. Subacute Care
d. Hospice
5. The goal is to improve the quality of life by focusing on symptom management, pain
control, and emotional support
a. Assisted Living

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b. Skilled Care
c. Subacute Care
d. Hospice
6. Allows for a degree of independence while providing minimal nursing assistance with
administration of medication, assistance with ADLs, or other chronic health care needs.
a. Assisted Living
b. Skilled Care
c. Subacute Care
d. Hospice
7. These units are designed to promote optimum outcomes in the least expensive cost
setting”.
a. Assisted Living
b. Skilled Care
c. Subacute Care
d. Hospice
8. The care in this unit required is at a higher level, and the higher acuity of the residents
or patients demands a greater nurse-to-patient ratio.
a. Assisted Living
b. Skilled Care
c. Subacute Care
d. Hospice
9. Older adults requiring a longer period of observation or care from nurses may be
candidates for this kind of service.
a. Hospice
b. Home Care
c. Community-based services
d. Assisted Living
10. In most cases, patients in this kind of care are not expected to live longer than 6 months.
a. Hospice
b. Home Care
c. Community-based services
d. Assisted Living

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.psychologytoday.com/us/blog/mid-life-what-crisis/201210/planning-
successful-aging-mid-life

https://www.vitas.com/hospice-and-palliative-care-basics/about-hospice-care/home-
healthcare-or-hospice-care

http://www.seniorresourcesec.org/programs-services/community-based-services

https://www.investopedia.com/terms/a/assisted-living.asp#options-for-assisted-
living

UNIT V. PHYSICAL CARE OF THE OLDER ADULT

I. Introduction

The body gradually changes over time as we age. These changes are expected and
usually depend on family patterns of aging or lifestyle choices made throughout the lifespan.

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Changes that are a result of a pre-existing medical condition are not considered to be a part
of healthy aging. Most of the time, normal age-related changes on the physical
Aging is a fact of life and it affects all families. As adult children, when imagining our
parents as seniors, we may not fully comprehend the extent to which their aging will affect
them or how it will affect us. Indeed, if they are already seniors and still in good health and
living independently, we may not feel any dramatic changes or concerns. However, the time
does come when the effects of aging become more evident and long-term care may be needed.
An overall decline in physical and mental vitality may result in visible and even
drastic changes to our parent’s appearance, the standard of living, and emotional well-
being. The more aware we are of how aging can affect them, and what options are available
to them as seniors and us as caring adult children, the better for all involved. In this topic, we
have to consider some essential things we should take into account regarding their welfare
during aging and how in-home care can make all the difference (Mauk, 2010).

II. Objectives/Competencies

At the end of the unit, I am able to:

1. Identify physical changes of aging and their effects on the older adult; and
2. Discuss interventions and strategies in the physical care of the older adult.

III. Pre-test

Arrange the words to form a meaningful sentence.

1. exercise routine. of to your Physical and part, they aim to make activity
are for you you good for and should

2. it makes Dryness important the sure dehydration caused throughout the often hydrated
day. skin stays is the by so to

3. outcomes. Florence Nightingale patient first improved environmental

restructuring
for the address was one of them to

IV. Lesson Proper

Aging Skin
The functions of the skin include protection, temperature regulation, sensation, and
excretion. Aging affects skin function and appearance. Epidermal proliferation decreases, and
the dermis becomes thinner. Elastic fibers are reduced in number, and collagen becomes
stiffer. Subcutaneous fat diminishes, particularly in the extremities, but gradually increases
in other areas, such as the abdomen (men) and thighs (women), leading to an overall increase
in body fat in older people (Tabloski, 2009). Decreased numbers of capillaries in the skin
result in diminished blood supply. These changes cause a loss of resiliency, wrinkling, and
sagging of the skin. The skin becomes drier and more susceptible to burns, injury, and
infection. Hair pigmentation may change, and balding may occur; genetic factors strongly
influence these changes. These changes in the integument reduce tolerance to temperature
extremes and sun exposure. Lifestyle practices are likely to have a large impact on skin
changes.
With all of these potential risks involved in the skin’s weakening with age, it becomes
clear why special attention needs to be given to elderly loved ones’ skin health. The following
must be avoided to support the well-being of a senior’s skin and these are:
1. Avoid Smoking
Along with numerous other health problems, smoking cigarettes can lead to skin
aging faster. The damaging effects of tobacco consumption deplete the skin of its nutrients
from the inside, causing saggier skin, more visible wrinkles (especially around the mouth),
and age spots.
2. Excessive Sunlight

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As mentioned earlier, the sun’s rays can greatly affect complexion and skin health,
causing more visible wrinkles, decreasing elasticity of the skin, and increasing the risk of
developing skin cancer. Elders should avoid exposure to direct sunlight as often as possible
(especially during the summer months) and wear sunscreen, clothing that covers the arms
and legs, and a hat that provides shade to the face and neck. Sunglasses are also important,
as squinting caused by sunlight can lead to wrinkles around the eyes.
3. Excessive Washing
While regular bathing is an important aspect of senior care to maintain proper
hygiene, showering too often or using harsh soaps can lead to degrading of the skin’s natural
protective oils. Seniors should bathe and shower only in warm water – steam and water that
is too hot can dry out the skin, causing redness and itchiness. However, it’s important to
remember that certain bath oils can make bath surfaces more slippery, increasing the risk of
injury in the tub.
4. Tanning Salons and Saunas
Tanning beds can have the same harmful effects of the sun’s rays, and the steam
of a sauna can cause dehydration of the skin in the elderly.

5. Staying In Bed
Remaining in the same position for too long can lead to bedsores caused by
pressure to the skin. If an elderly person is bedridden and cannot change positions on their
own, they should be moved by a family member or a professional caregiver every few hours.
An elderly should do the following:
1. Proper Nutrition
A diet rich in vitamins, minerals, and antioxidants can help the skin maintain its
integrity against the effects of aging, leading to a healthier-looking complexion and faster
healing of wounds and bruises. Seniors should incorporate berries and green veggies into
their everyday diet, as they contain essential vitamins to help maintain healthy skin. Healthy
fats from foods like avocados, salmon, and nuts are also important.
2. Humidity
During the winter months especially, when most seniors turn on the heat in their
homes, the air becomes dry and can lead to chapping and cracking of the skin. Getting a
humidifier can help prevent a loss of skin hydration by replacing the moisture in the air.
3. Moisture
A gentle skin moisturizer should be applied daily to the face, arms, neck, and legs.
This helps the skin keep its softness and stay moist, which is especially important for the
elderly, as the skin’s natural oils lose their ability to prevent dryness over the years.
4. Hydration
Possibly the most important item on this list, hydration is imperative to
maintaining healthy skin as well as a senior’s overall well-being. 64% of the skin is made up
of water, so even a slight loss of hydration can have devastating effects on skin health.
Dryness is often caused by dehydration, so it’s important to make sure the skin stays
hydrated throughout the day. Drinking water also helps flush out toxins from the body,
which can have a positive effect on an elderly person’s complexion and lead to more youthful,
healthy-looking skin.
Elimination
Digestive and urinary disorders are the usual health problems faced by older adults.
Even though elderly individuals have more time to relax and enjoy their lives, problems with
digestion tend to occur all of a sudden. One of the most common problems with aging
individuals is constipation. As people get into their 60s, bowel habits change. Painful and
infrequent bowel movements are associated with hard and dry stools that can lead to
hemorrhoids and other health-related concerns. These variations in the digestive system are
brought on by a decline in muscle contractions, which causes the food to move more slowly
through the colon. When the food movement slows down, waste absorbs more water, leading
to constipation and difficulty removing waste from the bowel (Mauk, 2010)
Constipation among older adults is also caused by daily medications. Anti-
hypertension drugs are just some of the drugs that can slow down bowel movement. Aside
from this, inactivity can exacerbate constipation, in particular in those elderly individuals
with existing medical conditions like diverticular disease, ulcers, arthritis, and many others.
A sedentary lifestyle can make a person feel constipated and allows other complaints like
bloating, cramps and abdominal pain to occur. The best thing to do in this situation is to keep

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digestion running smoothly through proper diet, exercise, hydration, and frequent visits to
the doctor.
Changes in the Kidneys and Bladder
The kidneys and the bladder are the two major organs in the urinary system. The
kidneys filter blood and remove waste or extra fluid from the body. They also help control
the chemical balance of the body to make other organs more functional and efficient.
However, as time passes, these organs change and their ability to function effectively
declines. There will be a gradual decline of kidney tissue, along with the number of filtering
units called nephrons. Nephrons are responsible for filtering waste materials from the
blood, and they have a huge role in keeping it clean and free of pathogens. If they decrease
in size and the blood vessels harden, the kidneys will not be able to perform their function
as well, causing some health issues.
Furthermore, changes in the bladder wall will become apparent as we age. The
bladder becomes less elastic and cannot hold as much of urine as before, causing urinary
incontinence. The urethra in women can become blocked due to weakened muscles that
cause the vagina or bladder to fall out of their normal position. Men with an enlarged
prostate gland may also have a blocked urethra. The only way to solve this problem is to
undergo a common surgery to promote proper urine output.

Activity and Exercise

Physical activity and exercise are good for you, and you should aim to make them part
of your routine. Countless studies prove the important health benefits associated with
exercise, and it becomes more important as we age. Regular physical activity helps improve
mental and physical health, both of which will help you maintain your independence as you
age. Below, we outline five benefits of exercise for seniors and aging adults.
1. Prevent Disease
Studies have shown that maintaining regular physical activity can help prevent many
common diseases, such as heart disease and diabetes. Exercise improves overall
immune function, which is important for seniors as their immune systems are often
compromised. Even light exercise, such as walking, can be a powerful tool for
preventable disease management.
2. Improve Mental Health
The mental health benefits of exercise are nearly endless. Exercise produces
endorphins (the “feel-good” hormone), which act as a stress reliever and leaves you
feeling happy and satisfied. Also, exercise has been linked to improving sleep, which is
especially important for older adults who often suffer from insomnia and disrupted sleep
patterns.
3. Decreased Risk of Falls
Older adults are at a higher risk of falls, which can prove to be potentially
disastrous for maintaining independence. Exercise improves strength and flexibility,
which also helps improve balance and coordination, reducing the risk of falls. Seniors take
much longer to recover from falls, so anything that helps avoid them in the first place is
extremely important.
4. Social Engagement
Whether you join a walking group, go to group fitness classes or visit a gardening
club, exercise can be made into a fun social event. Maintaining strong social ties is
important for aging adults to feel a sense of purpose and avoid feelings of loneliness or
depression. The key is to find a form of exercise you love, and it will never feel like a chore
again.
5. Improved Cognitive Function
Regular physical activity and fine-tuned motor skills benefit cognitive function.
Countless studies suggest a lower risk of dementia for physically active individuals,
regardless of when you begin a routine.
Risks of Exercise
The risk of a cardiac emergency is high when an older person is exercising
without previous experience and an active lifestyle. Some physicians believe that the
elderly who intend to start exercising at an older age should go through an exhaustive
preliminary screening such as an exercise electrocardiogram. This is desirable,
especially when the individual plans to embark on strenuous competitive training.
However, every older individual who wants to exercise should observe certain
precautions. The recommended dose of exercise should not leave an elderly

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overwhelmingly tired because the normal recovery process is slow. Some exercises like
running or jogging should be substituted with walking to minimize stress on the knees.
Older adults should do some type of physical activity every day. Any type of
activity is good for you. The more you do the better.
Adults aged 65 and over should:
● aim to be physically active every day. Any activity is better than none. The more you
do the better, even if it's just light activity
● do activities that improve strength, balance and flexibility on at least 2 days a week
● do at least 150 minutes of moderate intensity activity a week or 75 minutes of
vigorous intensity activity if you are already active, or a combination of both
● reduce time spent sitting or lying down and break up long periods of not moving
with some activity
If you've fallen or are worried about falling, doing exercises to improve your
strength, balance and flexibility will help make you stronger and feel more confident on
your feet. Speak to your GP if you have any concerns about exercising. Light activity is
moving rather than sitting or lying down.
Examples of light activity include:
● getting up to make a cup of tea
● moving around your home
● walking at a slow pace
● cleaning and dusting
● vacuuming
● making the bed
● standing up

Sleep and Rest

Sleep is considered a time of restoration for our bodies and minds. Sleep is
necessary to heal wounds, maintain normal hormonal function, and provide sound
emotional health. Disruptions in the sleep of older adults can worsen chronic illnesses
and exacerbate depression. The nurse must understand the normal changes in sleep
patterns in older adults and recognize sleep abnormalities that can negatively impact
health.
Table 1. Sleep Problems in Older Adult
Condition Description/Significance
Sleep disorders—combined Insomnia, snoring, breathing pauses, or restless
legs
Insomnia Difficulties falling asleep or staying asleep, waking
up early or unrefreshed

Snoring A symptom of sleep apnea

Breathing pauses A symptom of sleep apnea; observed or
experienced
Tingling and discomfort in legs A symptom of restless legs syndrome

Interventions/Strategies for Care

1. Sleep Hygiene

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Clients admitted to the hospital have illness and environment-related disruptions

to their sleep. Nursing interventions, including medication administration, taking vital
signs, and completing assessments, should be timed to allow long periods of
uninterrupted sleep whenever possible.
Caffeine avoidance is an important measure to enhance sleep. The stimulant
increases physiological arousal and prevents the onset of sleep. Caffeine has a half-life of
3–7 hours, and late afternoon to evening abstinence is recommended to avoid its
invigorating effect. Alcohol can expedite sleep onset, throughout the night. After alcohol
metabolizes, rebound arousal occurs that can precipitate early morning awakening. The
effect can last for several nights based on the individual’s metabolism. Smoking also
increases the awake time and causes a delayed sleep onset (Cheek, Shaver, & Lentz,
2004).
A consistent retiring and awakening time strengthen the circadian rhythm
through a homeostatic mechanism and a habitual light-dark cycle exposure. Getting up at
the same time each day is more important in establishing synchronization with the light-
dark cycle than going to bed at the same time (Cheek et al., 2003; Hoffman, 2003).

2. Environmental Restructuring
Florence Nightingale was one of the first to address environmental restructuring
for improved patient outcomes. She considered lighting, noise, and sensory stimulation
as care aspects that could enhance or hinder recovery. Lights should be on during the day
and off at night to trigger the normal sleep pattern.
The colors used in the environment also play a role in the sleep cycle. Nightingale
also incorporated color as a therapeutic tool by using flowers. Room colors that promote
sleep are soft mixed tones of blue, green, and violet without sharp contrasts. Artwork of
nature scenes can decrease the use of pain medication, lower blood pressure, and
increase the perception of relaxation (Fontaine et al., 2001).
Environmental noise can activate the sympathetic nervous system during sleep.
Sleep occurs best at noise levels below 35 decibels, and levels above 80 db are related to
sleep arousals. Television and talk were the two most frequent disruptive sounds.
Environmental “white noise” such as ocean or rain sounds or repetitive tones tend to
enhance sleep (Richards, 1996). Patients with sleep-onset difficulties respond better to
relaxation techniques and stimulus control than do those with sleep maintenance
problems (Mantle, 1996).

3. Relaxation
Music therapy promotes relaxation, decreases anxiety and pain perception,
improves sleep quality, and decreases heart rate and systolic pressure (Fontaine et al.,
2001; Richards, 1996).
4. Aromatherapy
Aromatherapy oils such as lavender, chamomile, lemon, peppermint, thyme,
geranium, and eucalyptus have been reported to enhance immunity and promote
relaxation. Poor industry control and lack of standardization are safety concerns. The
potential for allergic reactions also exists in patients who are taking multiple medications.
Therefore, caution should be used when recommending aromatherapy in this patient
population (Fontaine et al., 2001; Richards, et al., 2003).

V. Reflection

How do you feel about aging? Do you dread getting older, or look forward to it? Do you
see advanced age as a challenge or something to fear? Are you afraid that you can no longer
take care of yourself?

VI. Post Test

1. The functions of the skin include the following except:

a. Reduced protection
b. Temperature regulation
c. Sensation
d. Excretion

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 37

2. Statement A: Aging causes the skin to becomes drier and more susceptible to burns,
injury, and infection.
Statement B: Hair pigmentation may change, and balding may occur; genetic factors
strongly influence these changes.
Statement C: Lifestyle practices don’t have a large impact on skin changes.
Statement D: Decreased numbers of capillaries in the skin result in diminished blood
supply.
a. Statement A, B, and C are correct
b. Statement B, C, and D are correct
c. Statement A, B, and D are correct
d. None of the statement is correct
3. Excessive exposure to sun’s rays can greatly affect complexion and skin health, causing
the following except:
a. Increasing the risk of developing skin cancer
b. Visible wrinkles
c. Decreasing elasticity of the skin
d. The suppleness of the skin
4. The following supports the well-being of an older adult except:
a. Excessive exposure to sunlight
b. Changing of position every few hours
c. Wearing sunscreen
d. Bathe and shower only in warm water
5. Constipation among older adults is caused by:
a. Inactivity
b. Proper diet
c. Exercise
d. Hydration
6. Difficulties falling asleep or staying asleep, waking up early or unrefreshed
a. Snoring
b. Restless legs syndrome
c. Breathing pauses
d. Insomnia
7. Physical activity and exercise benefits for older adults are the following except:
a. Improves mental health
b. Improves cognitive function
c. Limits social engagement
d. Decreased risk of falls
8. Statement A: Caffeine has a half-life of 2–6 hours, and late afternoon to evening
abstinence is recommended to avoid its invigorating effect.
Statement B: Caffeine avoidance is an important measure to enhance sleep.
a. Statement A and B are correct
b. Statement A and B are incorrect
c. Only Statement A is correct
d. Only Statement B is correct
9. Florence Nightingale was one of the first to address environmental restructuring for
improved patient outcomes considering the following except:
a. Lighting, noise, and sensory stimulation as care aspects that could enhance or
hinder recovery
b. Room colors that promote sleep are soft mixed tones of red, green, and violet
without sharp contrasts
c. Lights should be on during the day and off at night to trigger the normal sleep
pattern
d. Artwork of nature scenes can decrease the use of pain medication, lower blood
pressure, and increase the perception of relaxation
10. Aromatherapy oils have been reported to enhance immunity and promote relaxation
like lavender, chamomile, lemon, peppermint, thyme, geranium, and eucalyptus.
a. True
b. False
c. Sometimes
d. Neither True nor False

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 38

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

http://www.healthyeating-life.com/physical-care-for-the-elderly

https://aginginplace.org/a-guide-to-caring-for-elderly-parents/

https://www.completecare.ca/blog/elderly-care/senior-skin-care/

https://thegreenfields.org/5-benefits-exercise-seniors-aging-adults/

https://geriatricnursing.org/physical-care-of-the-elderly/
UNIT VI. PSYCHO-SOCIAL CARE OF THE OLDER ADULT
I. Introduction

Psycho-social care, as defined by the National Council for Hospice and Specialist
Palliative Care Services, is care concerned with the psychological and emotional well-being
of the patient and their family/carers, including issues of self-esteem, insight into an
adaptation to the illness and its consequences.
Psychological assessment of older adults presents a wide continuum from positive
mental health to mental health problems, and the tendency seems to be weighted toward
assessment of mental health disorders. Successful psychological aging is reflected in the
ability of older people to adapt to physical, social, and emotional losses and to achieve life
satisfaction. Because changes in life patterns are inevitable over a lifetime, older people need
resiliency and coping skills when confronting stresses and change. A positive self-image
enhances risk-taking and participation in new, untested roles (Mauk, 2010).
Fear of aging and the inability of many to confront their aging process may trigger
ageist beliefs. Retirement and perceived nonproductivity are also responsible for negative
feelings, because a younger working person may falsely see older people as not contributing
to society, as draining economic resources, and may feel that they compete with children for
resources. Negative images are so common in society that older adults themselves often
believe and perpetuate them. An understanding of the aging process and respect for each
person as an individual can dispel the myths of aging.
In this unit, we will be looking at psychological assessment which includes cognition
and perception engagement with life, self-perception, and self-concept, coping and stress,
values and beliefs, and sexuality and aging.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. define quality of life for the elderly;
2. describe the common mental health problems of aging and their effects on the
functioning of older people and their families; and
3. identify the role of the nurse in utilizing strategies to meet the health care needs of
older people and promote optimal active aging.

III. Pre-test

Fill in the crossword puzzle with the words missing from the sentences below. Match the
number of the sentence to the boxes placed across or down the grid. If filled out correctly, the
words will fit neatly into the puzzle.

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 39

1 X L Y

3 4
2 E E I O

T G
I

Across:
1 sexual feelings, thoughts, attractions, and behaviors towards other
people
2 a common and serious medical illness that negatively affects how
you feel,
Down:
1 subject to pressure or tension
3 Alzheimer's is the most common
cause
4 to deal successfully with a difficult
situation

IV. Lesson Proper

Cognitive Assessment
Cognitive function is usually understood concerning the qualities of attention,
memory, language, visuospatial skills, and executive capacity. For nurses, assessing cognitive
function is a challenging task because of the combination of factors that may be interacting:
age-related changes, diseases associated with aging, heredity, and lifestyle. Added to this is
the concern that for older adults and their families, even the suspicion of Alzheimer’s disease
can be a frightening and discouraging experience. A relatively new area of assessment of
older adults with progressive dementia is that of “social ability.” Social abilities include giving
and receiving attention, participating in the conversation, recognizing social stimuli,
appreciating humor, and being helpful to others.

Quality of Life
Quality of life and successful aging are two central concepts in the assessment and
care of older adults. Broadly speaking, quality of life encompasses all areas of everyday life:
environmental and material components, and physical, mental, and social well-being
(Fletcher, Dickinson, & Philp, 1992). Quality of life among older adults is highly
individualistic, subjective, and multidimensional in scope. Concerning what constitutes
quality of life, what is important to one person may be quite unimportant to another. Related
to quality of life is the concept of successful aging.
Grant, Ferrell, Schmidt, Fonbuena, Niland, and Forman (1992) have proposed a model
for understanding the components of quality of life (Figure 1). Related elements were divided
into four domains of quality of life: health and functioning, psychological/spiritual, social and
economic, and family. The Ferrell and Grant model identify the four concepts of quality of life:
physical well-being, psychological well-being, social well-being, and spiritual well-being.
Table 1 displays the major concepts of this model.

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The WHO has integrated health and quality of life into a program called active aging.
This program is designed to help people remain independent and active as they age. Active
aging encourages older individuals to continue to work according to their capacity and to
delay disabilities and chronic diseases. Active aging is being promoted by the WHO as a
process of optimizing opportunities for health, participation in the community, and safe
living to enhance the quality of life as people age (WHO, 2002, p. 12). Maintaining the quality
of life is at the center of active aging.
Table 1. Physical, Psychological, Social and Spiritual Well-Being
Physical Well-Being Functional ability, strength/fatigue, sleep/rest, nausea,
appetite, constipation
Psychological Well-Being Anxiety, depression, enjoyment/leisure, pain distress,
happiness, fear, cognition/attention
Social Well-Being Caregiver burden, roles, and relationships,
affection/sexual function, appearance

Spiritual Well-Being Suffering, the meaning of pain, religiosity, transcendence

Social Assessment
Social functioning affects health, and health status affects the ability to socialize and
interact with others. As people age, they may find that their social networks become smaller
and this may place them at risk in several ways. Decades of research have told us that
individuals with low quantity and quality of social relationships have a higher morbidity and
mortality risk compared with those who have a good quantity and quality of social contacts.
A supportive social network and in particular the presence of a spouse can act to maintain
an older adult in the community; the lack of a partner is a predictor of institutionalization.
Social assessment of older adults includes collecting information on the presence of a social
network and the interaction between the older adult and family, friends, neighbors, and
community (Mauk, 2010).
Having a social network does not necessarily mean that there are social supports.
The more important aspects of social support may be the number of supportive persons and
the various types of support (emotional, instrumental, and informational) that are available.
Seeman and Berkman (1988) have identified four questions that assess the adequacy of
social support. Using these kinds of questions will help assess the adequacy and range of
support available to an older adult. These questions are:
a. When you need help, can you count on anyone for house cleaning, groceries, or a
ride?
b. Could you use more help with daily tasks?
c. Can you count on anyone for emotional support (talking over problems or helping
you make a decision)?
d. Could you use more emotional help (receiving sufficient support)?

Stress and Coping in the Older Adult

Coping patterns and the ability to adapt to stress develop throughout a lifetime and
remain consistent later in life. Experiencing success in younger adulthood helps a person
develop a positive self-image that remains solid through old age. A person’s abilities to adapt
to change, make decisions, and respond predictably are also determined by past experiences.
A flexible, well-functioning person will probably continue as such. However, losses may
accumulate within a short period and become overwhelming. The older person often has
fewer choices and diminished resources to deal with stressful events. Common stressors of
old age include normal aging changes that impair physical function, activities, and
appearance; disabilities from injury or chronic illness; social and environmental losses
related to loss of income and decreased ability to perform previous roles and activities; and
the deaths of significant others. Many older adults rely strongly on their spiritual beliefs for
comfort during stressful times (Mauk, 2010).

Sexuality and Aging

Many people want and need to be close to others as they grow older. For some, this
includes the desire to continue an active, satisfying sex life. With aging, that may mean
adapting the sexual activity to accommodate physical, health, and other changes. There are

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many different ways to have sex and be intimate—alone or with a partner. The expression of
your sexuality could include many types of touch or stimulation. Some adults may choose not
to engage in sexual activity, and that's also normal (Mauk, 2010).
Normal aging brings physical changes in both men and women. These changes
sometimes affect the ability to have and enjoy sex. A woman may notice changes in her vagina.
As a woman ages, her vagina can shorten and narrow. Her vaginal walls can become thinner
and a little stiffer. Most women will have less vaginal lubrication, and it may take more time
for the vagina to naturally lubricate itself. These changes could make certain types of sexual
activity, such as vaginal penetration, painful or less desirable. If vaginal dryness is an issue,
using water-based lubricating jelly or lubricated condoms may be more comfortable. If a
woman is using hormone therapy to treat hot flashes or other menopausal symptoms, she
may want to have sex more often than she did before hormone therapy.
As men get older, impotence (also called erectile dysfunction, or ED) becomes more
common. ED is the loss of ability to have and keep an erection. ED may cause a man to take
longer to have an erection. His erection may not be as firm or as large as it used to be. The
loss of erection after orgasm may happen more quickly, or it may take longer before another
erection is possible. Some illnesses, disabilities, medicines, and surgeries can affect your
ability to have and enjoy sex (Mauk, 2010).

1. Arthritis.
Joint pain due to arthritis can make sexual contact uncomfortable. Exercise,
drugs, and possibly joint replacement surgery may help relieve this pain. Rest, warm
baths, and changing the position or timing of sexual activity can be helpful.
2. Chronic pain.
Pain can interfere with intimacy between older people. Chronic pain does not
have to be part of growing older and can often be treated. But, some pain medicines can
interfere with sexual function.
3. Dementia
Some people with dementia show increased interest in sex and physical
closeness, but they may not be able to judge what is appropriate sexual behavior. Those
with severe dementia may not recognize their spouse or partner, but they still desire
sexual contact and may seek it with someone else. It can be confusing and difficult to
know how to handle this situation.
4. Diabetes
This is one of the illnesses that can cause ED in some men. In most cases, medical
treatment can help. Less is known about how diabetes affects sexuality in older women.
Women with diabetes are more likely to have vaginal yeast infections, which can cause
itching and irritation and make sex uncomfortable or undesirable. Yeast infections can be
treated
5. Heart disease
Narrowing and hardening of the arteries can change blood vessels so that blood
does not flow freely. As a result, men and women may have problems with orgasms. For
both men and women, it may take longer to become aroused, and for some men, it may
be difficult to have or maintain an erection. People who have had a heart attack, or their
partners, maybe afraid that having sex will cause another attack.
6. Incontinence
Loss of bladder control or leaking of urine is more common as people, especially
women, grow older. Extra pressure on the belly during sex can cause loss of urine. This
can be helped by changing positions or by emptying the bladder before and after sex. The
good news is that incontinence can usually be treated.
7. Stroke
The ability to have sex is sometimes affected by a stroke. A change in positions or
medical devices may help people with ongoing weakness or paralysis to have sex. Some
people with paralysis from the waist down are still able to experience orgasm and
pleasure.
8. Depression
Lack of interest in activities you used to enjoy, such as intimacy and sexual
activity, can be a symptom of depression. It's sometimes hard to know if you're
depressed. Depression can be treated.
9. Surgery

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Many of us worry about having any kind of surgery—it may be even more
troubling when the breasts or genital area are involved. Most people do return to the kind
of sex life they enjoyed before surgery.
A hysterectomy is a surgery to remove a woman's uterus because of pain,
bleeding, fibroids, or other reasons. Often, when an older woman has a hysterectomy, the
ovaries are also removed. Deciding whether to have this surgery can leave both women
and their partners worried about their future sex life.
A mastectomy is a surgery to remove all or part of a woman's breast because
of breast cancer. This surgery may cause some women to lose their sexual interest, or it
may leave them feeling less desirable or attractive to their partners. In addition to talking
with your doctor, sometimes it is useful to talk with other women who have had this
surgery.
Prostatectomy is a surgery that removes all or part of a man's prostate because
of cancer or an enlarged prostate. It may cause urinary incontinence or ED.
10. Medications
Some drugs can cause sexual problems. These include some blood
pressure medicines, antihistamines, antidepressants, tranquilizers, Parkinson's
disease or cancer medications, appetite suppressants, drugs for mental problems, and
ulcer drugs. Some can lead to ED or make it hard for men to ejaculate. Some drugs can
reduce a woman's sexual desire or cause vaginal dryness or difficulty with arousal and
orgasm.
11. Alcohol
Too much alcohol can cause erection problems in men and delay orgasm in
women.

Six Ways the Elderly Can Improve Self-Esteem by Taking Control

1. Take control of your attitude. Attitude is an important part of aging. Health is not the
best measure of successful aging—attitude is. A positive attitude is the starting point to
taking control of other areas of life. Have a “can do” frame of mind. Seek out small changes
at first—ones that you can make easily. A success will increase positive attitude and
enhance your motivation to keep trying.
2. Take control of your health. See your physician and dentist regularly. Follow a
regular exercise plan. Eat balanced meals. Get enough sleep.
3. Take control of your appearance. Stand up straight and hold your head high. Take
time to dress up, have your hair styled, wear make-up, get a manicure, shave, buy some
new clothes (or use some of the items that have been given as gifts and are hiding in your
closet or drawers).
4. Take control of your time. Be as active as you can. Establish a schedule that gets you
up and moving. Plan to get out for visits, shopping, or activities—or just a walk several
times a week. Better still, at least once a day.
5. Take control of your social life and relationships. Call friends and family; do not
wait for them to call you. Go to church or a social gathering, join a book club, or do
anything you enjoy where you may meet new people and form new friendships.
6. Take interest in both old and new activities. Recognize any physical limitations but
do not use them as an excuse for inactivity. Take up old hobbies or find new ones. Find
out what classes are offered at the senior center, library, or community college. Find a
part-time job, or volunteer.

V. Reflection

If an older patient was having problems dealing with sexuality after a life-changing
event, how could you assist him or her? What is your comfort level with discussing sexual
information with patients? How could you become more comfortable with this important
aspect of nursing?

VI. Post Test

Encircle the letter of the correct answer.

1. This includes suffering, the meaning of pain, religiosity, and transcendence
a. Social well-being
b. Psychological well-being

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 43

c. Physical well-being
d. Spiritual well-being
2. The following are the major concepts of psychological well-being except:
a. Depression
b. Happiness
c. Attention
d. Appetite
3. This concept includes caregiver burden, roles, and relationships, affection or sexual
function and appearance
a. Social well-being
b. Psychological well-being
c. Physical well-being
d. Spiritual well-being
4. It is the male loss of ability to have and keep an erection
a. Erectile Dysfunction
b. Dyspareunia
c. Sexually Transmitted Infections
d. Hyposexuality
5. Women with diabetes are more likely to have the following except:
a. Yeast infections
b. Vaginal itching
c. Comfortable sexual activity
d. None of the above
6. Removal of a woman’s uterus because of pain, bleeding, fibroids, etc.
a. Prostatectomy
b. Hysterectomy
c. Mastectomy
d. Lumpectomy
7. Surgery that removes all or part of a man's prostate because of cancer or an enlarged
prostate
a. Prostatectomy
b. Hysterectomy
c. Mastectomy
d. Lumpectomy
8. Surgery to remove all or part of a woman's breast because of breast cancer
a. Prostatectomy
b. Hysterectomy
c. Mastectomy
d. Lumpectomy
9. The following are the changes that affect older women’s ability to have and enjoy sex
except:
a. Less vaginal lubrication
b. Vaginal walls can become thinner and a stiffer
c. Painless and desirable sexual activity
d. Vagina shorten and narrow
10. The following are the changes that affect older men’s ability to have and enjoy sex
except:
a. Take a longer time to have an erection
b. Erection is as firm as before
c. Delayed or loss of orgasm
d. Inability to have an erection
VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

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https://www.nia.nih.gov/health/sexuality-later-
life#:~:text=With%20aging%2C%20that%20may%20mean,types%20of%20touch%20
or%20stimulation.

UNIT VII. NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS

I. Introduction

Chronic illness combined with functional impairment often results in an increased

need for medical care and supportive long-term care (LTC) services. Over time, chronic
disabilities are linked to a decline in physical and functional ability, increased risk, and the
likelihood of future illness, social isolation, and loss of independence. For many clinically and
functionally impaired older adults without supportive LTC services, the option to remain in
their home and community becomes less likely, and their quality of life is significantly
diminished (Mauk, 2010).
Focusing on health promotion, disease prevention and early detection is the best
strategy for successful chronic disease management. Identification and early treatment of
intercurrent illness is particularly important in frail seniors. Equally important is open
communication. Geriatric nurses are educated to understand and treat the often complex
physical and mental health needs of older people. They try to help their patients protect their
health and cope with changes in their mental and physical abilities, so older people can stay
independent and active as long as possible.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. identify the role of the nurse in meeting the health care needs of older adults with chronic
illness; and
2. examine the concerns of older people and their families in the management of long-term
care due to chronic illness.

III. Pre-test

Unscrambled each jumbled arrangement of letters to form words related to the topic and
write the answers on the space provided.

YESSRYON TNEDIIROVPA ________ ___________

RMALCAU NIOEDNEARGET _______ ____________
CRINHOC FOCUSNOIN _______ _________
ALGOAMCOU _________
IADTBIECHTETYIRONPA ________ ___________

IV. Lesson Proper

Sensory System
People interact with the world through their senses. Losses associated with old age
affect all sensory organs, and it can be devastating not to be able to see to read or watch
television, hear conversations well enough to communicate or discriminate taste well enough
to enjoy food. Nearly half of older men and one-third of older women report difficulty hearing
without a hearing aid. Most adults have a decrease in visual acuity beginning at the age of 50
years (Miller, 2012). An uncompensated sensory loss negatively affects the functional ability
and quality of life of older adults. However, assistive devices such as glasses and hearing aids
can compensate for a sensory loss.

Sensory Loss Versus Sensory Deprivation

In contrast to sensory loss, sensory deprivation is the absence of stimuli in the
environment or the inability to interpret existing stimuli (perhaps as a result of a sensory
loss). Sensory deprivation can lead to boredom, confusion, irritability, disorientation, and

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anxiety. A decline in sensory input can mimic a decline in cognition that is not present.
Meaningful sensory stimulation provided to the older person is often helpful in correcting
this problem. In some situations, one sense can substitute for another in observing and
interpreting stimuli. Nurses can enhance sensory stimulation in the environment with colors,
pictures, textures, tastes, smells, and sounds. The stimuli are most meaningful if they are
appropriate for older people and the stimuli are changed often. Cognitively impaired people
tend to respond well to touch and to familiarize music (Hinkle & Kerry, 2014).

Vision
As new cells form on the outside surface of the lens of the eye, the older central cells
accumulate and become yellow, rigid, dense, and cloudy, leaving only the outer portion of the
lens elastic enough to change shape (accommodate) and focus at near and far distances. As
the lens becomes less flexible, the near point of focus gets farther away. This common
condition—presbyopia—usually begins in the fifth decade of life and requires the person to
wear reading glasses to magnify objects (Miller, 2012). Also, the yellowing, cloudy lens causes
light to scatter and sensitivity to glare. The ability to distinguish colors decreases, particularly
blue from green. The pupil dilates slowly and less completely because of increased stiffness
of the muscles of the iris, thus the older person takes more time to adjust when going to and
from light and dark settings and needs brighter light for close vision. Pathologic visual
conditions are not a part of normal aging; however, the incidence of eye disease (most
commonly cataracts, glaucoma, diabetic retinopathy, and age-related macular degeneration)
increases in older people.
Although many normal aging changes occur in the sensory system, most of the
common abnormalities seen in the elderly related to vision. The most common age-related
vision problems are cataracts, glaucoma, macular degeneration, and diabetic neuropathy.

1. Cataracts.
Cataracts are so common in older adults that some almost consider them an
inevitable consequence of old age. The etiology is thought to be from oxidative damage to lens
protein that occurs with aging.
Causes:
a. advanced age – the most common cause
b. heredity – most common cause
c. diabetes
d. poor nutrition
e. hypertension
f. excessive exposure to sunlight (ultraviolet radiation)
g. cigarette smoking
h. high alcohol intake, and
i. eye trauma (Lighthouse International, 2005).
Symptoms:
a. no pain or discomfort
b. the gradual loss of vision
c. complaints of vision being fuzzy
d. sensitivity to glares
e. noticing a halo effect around light
f. decreased night vision
g. yellowing of the lens
h. trouble distinguishing colors may also be noted.
i. pupil changes color to a cloudy white
j. decreased visual acuity
Treatment:
a. changes in sunglasses – first option
b. surgery – most effective when the quality of life becomes affected; relatively safe;
done as an outpatient procedure
Procedure:
a. the lens is removed through an incision in the eye and an intraocular lens is
inserted
b. a surgical incision is either closed with sutures or can heal itself
Benefits of surgery:
a. improved visual acuity

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b. depth perception
c. peripheral vision, leading to better outcomes related to ADLs and quality of life.
Management after surgery:
a. patients will need to avoid bright sunlight
b. wear wraparound sunglasses for a short time
c. avoid straining, lifting, or bending
Cataract surgery today offers a safe and effective treatment to maintain independence
and improve the quality of life for older adults.

2. Glaucoma
A glaucoma is a group of degenerative eye diseases in which the optic nerve is
damaged by high intraocular pressure (IOP) resulting in blindness due to nerve atrophy
(Podolsky, 1998). Unlike cataracts, there are some ethnic distinctions with the development
of glaucoma. Blacks tend to develop it earlier than whites, and females more often than males.
Glaucoma is more common in African Americans, Asian Americans, and Eskimos. Glaucoma
results from a pupillary blockage that limits the flow of aqueous humor, causing a rise in
intraocular pressure (IOP). Glaucoma often involves one eye but may occur in both.
Causes:
a. eye trauma
b. small cornea
c. small anterior chamber
d. family history
e. cataracts
f. some medications (Eliopoulos, 2005; Malone, Fletcher, & Plank, 2000).
Two major types:
a. Acute glaucoma – also known as closed-angle or narrow-angle
Signs and symptoms:
a. severe eye pain in one eye
b. blurred vision
c. seeing colored halos around lights
d. red eye
e. headache
f. nausea and vomiting
g. maybe associated with emotional stress
b. Chronic glaucoma - also called open-angle or primary open-angle, is more
common than acute (90% of cases are this type). This type of glaucoma occurs
gradually. Peripheral vision is slowly impaired.
Signs and symptoms:
a. tired eyes
b. headaches
c. misty vision
d. seeing halos around lights
e. worse symptoms in the morning.
Treatment:
a. Aimed at reducing IOP
b. Medications to decrease pressure may be given
c. Surgical iridectomy to lower the IOP may prevent future episodes of acute
glaucoma
d. In chronic glaucoma, there is no cure, so treatment is aimed at managing IOP
through medication and eyedrops
Nurses should monitor patients for response to medications and to verify that
eyedrops are being taken regularly and properly. Also, older adults should be assessed for
safety related to visual changes and also reminded to keep regular visits with their eye doctor.

3. Macular Degeneration
Age-related macular degeneration (ARMD) is the most common cause of blindness
(Hinkle & Kerry, 2014). Risk factors for this sensory problem include high cholesterol,
hypertension, diabetes, smoking, overexposure to ultraviolet light, and heredity. Macular
degeneration results from damage or breakdown of the macula and subsequent loss of central
vision. Generally associated with the aging process, it can also result from injury or infection.
Two types

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a. Dry (nonexudative) - affects 90% of those with the disease (Lighthouse

International, 2005); has a better prognosis; progresses slowly with more subtle
changes in vision
b. Wet (exudative) - comes on suddenly and may cause more severe loss in vision
Signs and symptoms:
a. decreased central vision
b. seeing images as distorted
c. decreased color vision
d. sometimes a central scotoma (a large, dark spot in the center of vision)
Treatment:
a. Photodynamic therapy - uses a special laser to seal leaking blood vessels in the eye
b. Antioxidant vitamins (C, D, E, and beta-carotene) and zinc - slow the progress of
the disease (Age-Related Eye Disease Study Authors [AREDS], 2001)
c. Retinal cell transplantation or regeneration - works by harvesting cells from the
body and injecting them into diseased macular sites in the hope that new and
healthy cells will grow, thus reversing the damage caused by ARMD (Macular
Degeneration Foundation, 2005).
Management:
a. better lighting in hallways
b. minimizing glare from lamps or shiny floors
c. decorating living spaces in contrasting colors (McGrory & Remington, 2004)
d. use of visual adaptive devices such as magnifying glasses and reading lamps
e. auditory devices such as books on tape and adaptation of the environment to the
visual impairment may help maintain independence
Nurses should be aware of the treatments being researched and can assure patients
that although there is no cure at present, there is hope for the future. Also, nurses should teach
the elderly that the modification of any controllable risk factors, such as smoking cessation,
can decrease the risk of developing ARMD.

4. Diabetic Retinopathy
Diabetic retinopathy is a leading cause of blindness among older adults, resulting from
the breakage of tiny vessels in the retina as a complication of diabetes. It generally affects both
eyes. The longer a person has diabetes, the more likely they are to suffer visual impairment
(Eyecare America, 2005). Early diagnosis and treatment can prevent much of the blindness
that occurs from this disorder.
As new fragile and abnormal blood vessels grow to compensate for the blocked vessels
in the retina, these vessels may leak blood into the eye, causing swelling of the macula and
blurred vision. This is what causes much of the blindness seen with diabetic retinopathy.
Diagnosis:
a. no early warning signs of diabetic retinopathy, so it is essential that older adults
with diabetes have a dilated eye exam each year

Procedure:
a. visual acuity test
b. a dilated eye exam
c. tonometry – measures pressure inside the eye
Treatment
a. Scatter laser treatment - helps shrink the abnormal vessels; this procedure may
require at least two visits because multiple areas away from the retina are burned
with a laser to shrink abnormal vessels
b. Vitrectomy - for more severe cases of bleeding in the eye
When blood collects in the center of the eye, a vitrectomy allows removal
of the vitreous gel that has blood in it through a small incision in the eye. The
blood-contaminated vitreous gel is replaced with a saline-type solution. This is
often done as an outpatient procedure. The patient will need to wear an eye patch
for days to weeks and use medicated eye drops to prevent infection. After a
vitrectomy, the person’s eye may be red and sensitive for some time.
Management
a. regular eye exams
b. good control of blood sugars
c. monitoring hypertension

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d. controlling cholesterol levels

The nurse should encourage the older adult with diabetes to develop a good working
relationship with a trusted eye care professional.

Hearing
Auditory changes begin to be noticed at about 40 years of age. Environmental factors,
such as exposure to noise, medications, and infections, as well as genetics, may contribute to
hearing loss as much as age-related changes. Presbycusis is a gradual sensorineural loss that
progresses from the loss of the ability to hear high-frequency tones to a generalized loss of
hearing. It is attributed to irreversible inner ear changes. Older people often cannot follow
the conversation because of tones of high-frequency consonants (the sounds f, s, th, ch, sh, b,
t, p) all sound alike. Hearing loss may cause older people to respond inappropriately,
misunderstand conversation, and avoid social interaction. This behavior may be erroneously
interpreted as confusion. Wax build-up or other correctable problems may also be
responsible for hearing difficulties. A properly prescribed and fitted hearing aid may be
useful in reducing some types of hearing deficits.
Taste and Smell
The senses of taste and smell are reduced in older adults (Murphy & Hickey, 2010).
Of the four basic tastes (sweet, sour, salty, and bitter), sweet tastes are particularly dulled in
older people. The blunted taste may contribute to the preference for salty, highly seasoned
foods, but herbs, onions, garlic, and lemon can be used as substitutes for salt to flavor food.
Changes in the sense of smell are related to cell loss in the nasal passages and the olfactory
bulb in the brain. Environmental factors such as long-term exposure to toxins (e.g., dust,
pollen, and smoke) contribute to cellular damage.

Chronic Confusion
It is not unusual to occasionally forget where you put your keys or glasses, where you
parked your car or the name of an acquaintance. As you age, it may take you longer to
remember things. Not all older adults have memory changes, but they can be a normal part
of aging. This type of memory problem is more often annoying than serious. Memory loss that
begins suddenly or that significantly interferes with your ability to function in daily life may
mean a more serious problem is present.
1. Dementia is a slow decline in memory, problem-solving ability, learning ability, and
judgment that may occur over several weeks to several months. Many health conditions
can cause dementia or symptoms similar to dementia. Alzheimer's disease is the most
common cause of dementia in people older than age 65.
2. Delirium is a sudden change in how well a person's brain is working (mental status).
Delirium can cause confusion, change the sleep-wake cycles, and cause unusual behavior.
Delirium can have many causes, such as withdrawal from alcohol or drugs or medicines,
or the development or worsening of an infection or other health problem.
3. Amnesia is memory loss that may be caused by a head injury, a stroke, substance abuse,
or a severe emotional event, such as from combat or a motor vehicle accident. Depending
upon the cause, amnesia may be either temporary or permanent.

Tips for effectively working with and communicating with cognitively impaired patients.

1. Try to address the patient directly, even if his or her cognitive capacity is diminished.
2. Gain the person's attention. Sit in front of and at the same level as him or her and maintain
eye contact.
3. Speak distinctly and at a natural rate of speed. Resist the temptation to speak loudly.
4. Help orient the patient. Explain (or re-explain) who you are and what you will be doing.
5. If possible, meet in surroundings familiar to the patient. Consider having a family member
or other familiar person present at first.
6. Support and reassure the patient. Acknowledge when responses are correct.
7. If the patient gropes for a word, gently assist.
8. Make it clear that the encounter is not a "test" but rather a search for information to help
the patient.
9. Use simple, direct wording. Present one question, instruction, or statement at a time.
10. If the patient hears you but does not understand you, rephrase your statement.

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11. Although open-ended questions are advisable in most interview situations, patients with
cognitive impairments often have difficulty coping with them. Consider using a yes-or-no
or multiple-choice format.
12. Remember that many older people have hearing or vision problems, which can add to
their confusion.
13. Consider having someone call the patient to follow up on instructions after outpatient
visits.
14. If the patient can read, provide written instructions and other background information
about the problem and options for solutions.
15. Address potential issues of driving, getting lost, and home safety each time you see the
patient. And, encourage regular physical activity, social activity, hobbies, and intellectual
stimulation, as well as a healthy diet.

Table 1. Nursing Care Plans for Chronic Confusion

Diseases, medical conditions, and related nursing care plans for Chronic Confusion nursing
diagnosis: Alzheimer’s Disease and Dementia
Assessment Rationale
Collect information about Knowing the patient’s background can help the nurse identify
patient functioning, agenda behavior and use validation therapy, which will
including social situation, provide guidance for reminiscence. Background information
physical condition, and may help the nurse to understand the patient’s behavior if the
psychological functioning. patient becomes delusional and hallucinates.
Evaluate the level of The level of confusion will determine the amount of
impairment: reorientation and intervention the patient will need to
evaluate reality accurately. The patient may be awake and
aware of his or her surroundings.
● Review responses to Using a standard evaluation tool such as the Mini-Mental State
diagnostic Examination (MMSE) can help determine the patient’s abilities
examinations (e.g., and assist with planning appropriate nursing interventions.
memory The Confusion Assessment Method (CAM) is a valid and
impairments, reality reliable instrument that can help monitor changes in the
orientation, attention patient’s cognitive function.
span, calculations).
● Examine the ability Ability/readiness to reply to verbal direction/limits may vary
to receive and send with the degree of orientation.
effective
communications.
● Observe decline and This information assists in promoting a particular program for
variations in grooming and hygiene activities.
personal hygiene or
behavior.
● Communicate with These determine areas of physical care in which the patient
family members or needs support. These areas include nutrition,
significant others elimination, sleep, rest, exercise, bathing, grooming, and
regarding the dressing. The patient may have the ability and minimal
progression of the motivation, or motivation and minimal ability.
problem, prognosis,
and other concerns.
Assess the patient for signs Patients with chronic confusion may
of depression: insomnia, have depressive symptoms.
poor appetite, flat affect, and
withdrawn behavior.
Assess for sundown This phenomenon associated with confusion happens in the
syndrome. late afternoon. The patient displays increasing restlessness,
agitation, and confusion. Sundowning may be a manifestation
of sleep disorders, hunger, thirst, or unmet toileting needs.
Determine the Confusion, disorientation, suspiciousness, impaired judgment,
patient’s anxiety level in and loss of social inhibitions may result in socially
connection with the inappropriate/harmful behaviors to self or others. The patient
situation. Observe behavior may have poor impulse behavior control.

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 50

that may be suggestive of a

potential for violence.

Table 2. Nursing Interventions for Chronic Confusion

The following are the therapeutic nursing interventions for Chronic Confusion nursing diagnosis
and care plan:
Nursing Interventions Rationale
Place an identification bracelet on the Patients with chronic confusion may wander and
patient. can become lost; identification bracelets increase
patient safety.

Prevent further deterioration and

maximize level of function:
● Avoid exposing the patient to Situational anxiety associated with
unusual situations and people as environmental, interpersonal, or structural
much as possible. Maintain change can intensify into disturbed behavior.
continuity of caregivers. Maintain
routines of care through
established mealtimes, bathing,
and sleeping schedules. Send a
familiar person with a patient
when the patient goes for
diagnostic testing or into
unfamiliar environments.
● Provide a calm environment. Any extraneous noise and stimuli can be
misinterpreted by the confused patient. Images
on walls may be threatening for the patient.
● Promote reality-oriented Orientation to one’s environment increases one’s
relationships and environment ability to trust others.
(e.g., display clocks, calendars,
personal items, seasonal
decorations).
● Encourage the patient to check the Familiar personal possessions increase the
calendar and clock often to orient patient’s comfort level.
himself or herself.
● Talk to the patient using simple, This method can reduce anxiety. Saying “stay
concrete nouns in positive terms. sitting on the chair” is more positive than saying
“Don’t get up.”
● Allow family members to orient A confused patient may not completely
the patient about current news understand what is happening. Increased
and family events. orientation promotes a greater degree of safety
for the patient.
● Keep the environment quiet and Sensory overload can result in agitated behavior
nonstimulating; avoid using in a patient with chronic confusion.
buzzers and alarms if possible. Misinterpretation of the environment can also
Reduce sights and sounds that contribute to agitation.
have a high potential for
misinterpretation such as buzzers,
alarms, and overhead paging
systems.
● Avoid challenging illogical This can be threatening for the patient and can
thinking. result in a defensive reaction.
● Approach patient with a caring, Patients can sense feelings of compassion. A
friendly, and accepting attitude calm, slow manner projects a feeling of comfort
and talk calmly and slowly. to the patient.
● Promote participation in This promotes a sense of responsibility and
resocialization groups. independence.
● Ensure that the patient is in a safe Patients with chronic confusion lose the ability to
environment by eliminating make good judgments and can easily harm self or
others.

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possible hazards such as pointed

objects and harmful liquids.
● Allow the patient to reminisce, Depending on the cause, long-term memory is
existing in his or her own reality if usually retained longer than short-term memory.
not detrimental to the patient’s This approach can be enjoyable for the patient.
well-being.
Provide repetitive hand activities. Involving the patient in safe, repetitive activities
occupies the patient’s mind and hands. The
activities may reduce agitation and provide
release of energy (e.g., fold and refold towels and
washcloths).
Present one simple direction at a time and People with chronic confusion need time to
repeat as necessary. understand and interpret directions.
Break down self-care tasks into simple Confused patients are incapable to follow
steps. complicated instructions; breaking down an
activity into simple steps makes completing the
activity more achievable.
Let the patient eat in a peaceful The noise and confusion in a large dining room
environment with a smaller number of can be overwhelming for a confused patient and
people. can result in agitated behavior.
Give finger food if the patient has difficulty Feeding oneself is a complicated task and may
using eating utensils or if unable to sit to prove challenging for someone with chronic
eat. confusion.
Help the family and significant others in
developing coping strategies.
● Determine family members’ The family members need to let the patient do all
resources and their availability that he or she is able to do. This approach will
and eagerness to participate in maximize the patient’s level of functioning.
meeting the patient’s needs.
● Refer family to social services or To assist with meeting the demands of caregiving
other supportive services. for older patients.
● Encourage family to make use of Community resources provide support, assist
support groups or other service with problem-solving, and reduce the demands
programs. associated with caregiving.
● Validate the family members’ Validation lets the patient understand that the
feelings with regard to the impact nurse has heard and realizes what was said, and
of patient behavior on family it improves the nurse-patient relationship.
lifestyle.
● Encourage family to include These steps help the patient maintain dignity and
patient in family activities when lead to familiar socialization of the patient.
desirable.

V. Reflection

Of the disorders presented in this topic, which are the most familiar to you? Which do you
feel you need to do more reading about? Have you ever cared for an older patient with any of
these problems? Did the information in the text present what you saw as signs and symptoms
in this patient?

VI. Post Test

1. Absence of stimuli in the environment or the inability to interpret existing stimuli

a. Sensory loss
b. Sensory deprivation
c. Vision Loss
d. Macular degeneration
2. Farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in
middle and old age.
a. Presbyopia
b. Myopia

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 52

c. Hyperopia
d. Macular degeneration
3. Near-sightedness is a common vision condition in which you can see objects near to you
clearly, but objects farther away are blurry.
a. Presbyopia
b. Myopia
c. Hyperopia
d. Macular degeneration
4. It is a degenerative condition affecting the central part of the retina (the macula) and
resulting in distortion or loss of central vision
a. Presbyopia
b. Myopia
c. Hyperopia
d. Macular degeneration
5. These are the signs and symptoms of cataracts except:
a. decreased night vision
b. decreased visual acuity
c. reddening of the lens
d. sensitivity to glares
6. Management for patients who underwent cataract surgery is the following except:
a. patients will need to avoid bright sunlight
b. wear wraparound sunglasses for a short time
c. avoid straining
d. can bend immediately
7. This type of glaucoma occurs gradually, peripheral vision is slowly impaired and also
called angle or primary open-angle
a. Acute
b. Chronic
c. Exudative
d. Nonexudative
8. Statement A: Diabetic retinopathy is a leading cause of blindness among older adults,
resulting from the breakage of tiny vessels in the retina as a complication of diabetes.
Statement B: Early diagnosis and treatment can prevent much of the blindness that occurs
from this disorder.
a. Statement A and B are correct
b. Statement A and B is incorrect
c. Only statement A is correct
d. Only statement B is correct
9. A gradual sensorineural loss that progresses from the loss of the ability to hear high-
frequency tones to a generalized loss of hearing
a. Otosclerosis
b. Conductive hearing loss
c. Sensorineural hearing loss
d. Presbycusis
10. The following are ways for effectively working with and communicating with cognitively
impaired patients
a. Support and reassure the patient. Acknowledge when responses are correct.
b. Help orient the patient. Explain (or re-explain) who you are and what you will be
doing
c. If the patient hears you but does not understand you, end the discussion.
d. Try to address the patient directly, even if his or her cognitive capacity is
diminished.

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

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including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the
institution. Unauthorized reproduction is punishable by law.
 53

https://www.nia.nih.gov/health/tips-communicating-confused-patient

https://www.uofmhealth.org/health-library/confusion

https://www.cms.gov/Research-Statistics-Data-and-
Systems/Research/HealthCareFinancingReview/Downloads/05Fallpg33.pdf

https://www.healthline.com/health/tonometry#:~:text=Tonometry%20is%20a%20di
agnostic%20test,fluid%20pressure%20within%20your%20eye.

https://www.parentgiving.com/elder-care/common-chronic-conditions-and-aging-at-
home/
https://medlineplus.gov/ency/article/004013.htm
https://nurseslabs.com/chronic-confusion/
https://nurseslabs.com/impaired-verbal-communication/

UNIT VIII. CORE ELEMENTS OF EVIDENCE-BASED GERONTOLOGICAL

NURSING PRACTICE
I. Introduction

Clinical decision making that is grounded in the best available evidence is essential to
promote patient safety and quality health care outcomes (Mauk, 2010). With the knowledge
base for geriatric nursing rapidly expanding, assessing geriatric clinical practice guidelines
for their validity and incorporation of the best available evidence is critical to the safety and
outcomes of care. The purpose of this unit is to describe the scope of practice in gerontological
nursing and competencies.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. discuss the scope of practice in gerontological nursing;
2. relate the ANA standards for gerontological nursing to quality of care for older adults;
and
3. describe core competencies in geriatric nursing.

III. Pre-Test

Unscrambled each jumbled arrangement of letters to form words related to the topic and
write the answers on the space provided.

ZINITSOTDNAAARD _______________
EEECDNVI ________
HAELHR EARC ______ ____
IESMTOPCCNEE ____________
EOCR EKEDOWLGN ____ _________

IV. Lesson Proper

Evidence-based practice (EBP) is a framework for clinical practice that integrates

the best available scientific evidence with the expertise of the clinician and with patients’
preferences and values to make decisions about health care (Levin & Feldman, 2006; Sackett,
Straus, Richardson, Rosenberg, & Haynes, 2000). Health care professionals often use the
terms recommendations, guidelines, and protocols interchangeably but they are not
synonymous. A recommendation is a suggestion for practice, not necessarily sanctioned by a
formal, expert group. A clinical practice guideline is an “official recommendation” or
suggested approach to diagnose and manage a broad health condition (e.g., heart failure,

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 54

smoking cessation, or pain management). A protocol is a more detailed guide for approaching
a clinical problem or health condition and is tailored to a specific practice situation.
Standardization gives both nurses, who use the guideline/protocol, and patients, who
receive care based on the guideline/protocol, assurance that the geriatric content and
practice recommendations are based on the best evidence. In contrast to these practice
guides, “standards of practice” are not specific or necessarily evidence-based; rather, they are
a generally accepted, formal, published framework for practice.

Standards of Practice
These standards are developed by gerontological nurses and used by them to
evaluate and guide practice. The standards for clinical gerontological nursing include
assessment, diagnosis, outcome identification, planning, implementation, and evaluation
(ANA, 2001). The standards of professional gerontological nursing performance include
quality of care, performance appraisals, education, collegiality, ethics, collaboration,
research, and research utilization.

Core Competencies
The American Association of Colleges of Nursing (AACN) and the John A. Hartford
Foundation sponsored the input of many qualified gerontological nursing experts to publish
Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for
Geriatric Nursing Care (2000). The core competencies set forth for gerontological nursing was
shown in Table 1. The purpose of this document specific to gerontological nursing was to use
the AACN’s The Essentials of Baccalaureate Education for Professional Nursing Practice (1998)
as a framework to help nurse educators integrate specific nursing content into their
programs. The original AACN document suggested core competencies, knowledge, and role
development for professional nurses. These are shown in Table 2.

Table 1. Competencies Necessary for Nurses to Provide High-Quality Care to Older Adults
and their Families

1. Recognize one’s own and others’ attitudes, values, and expectations about aging
and their impact on the care of older adults and their families
2. Adopt the concept of individualized care as the standard of practice with older
adults
3. Communicate effectively, respectfully, and compassionately with older adults
and their families.
4. Recognize that sensation and perception in older adults are mediated by
functional, physical, cognitive, psychological, and social changes common in old
age
5. Incorporate into daily practice valid and reliable tools to assess the functional,
physical, cognitive, psychological, social, and spiritual status of older adults
6. Assess older adults’ living environment with special awareness of the functional,
physical, cognitive, psychological, and social changes common in old age
7. Analyze the effectiveness of community resources in assisting older adults and
their families to retain personal goals, maximize function, maintain
independence, and live in the least restrictive environment
8. Assess family knowledge of skills necessary to deliver care to older adults.
9. Adapt technical skills to meet the functional, physical, cognitive, psychological,
social, and endurance capacities of older adults.
10. Individualize care and prevent morbidity and mortality associated with the use
of physical and chemical restraints in older adults
11. Prevent or reduce common risk factors that contribute to functional decline,
impaired quality of life, and excess disability in older adults.

12. Establish and follow standards of care to recognize and report elder
mistreatment
13. Apply evidence-based standards to screen, immunize, and promote healthy
activities in older adults.

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 55

14. Recognize and manage geriatric syndromes common to older adults.

15. Recognize the complex interaction of acute and chronic co-morbid conditions
common to older adults
16. Use technology to enhance older adults’ function, independence, and safety
17. Facilitate communication as older adults’ transition across and between the
home, hospital, and nursing home, with a particular focus on the use of
technology
18. Assist older adults, families, and caregivers to understand and balance
“everyday” autonomy and safety decisions

19. Apply ethical and legal principles to the complex issues that arise in the care of
older adults
20. Appreciate the influence of attitudes, roles, language, culture, race, religion,
gender, and lifestyle on how families and assistive personnel provide long-term
care to older adults.
21. Evaluate differing international models of geriatric care
22. Analyze the impact of an aging society on the health care system.
23. Evaluate the influence of payer systems on access, availability, and affordability
of health care for older adults.
24. Contrast the opportunities and constraints of a supportive living arrangement on
the function and independence of older adults and their families

25. Recognize the benefits of interdisciplinary team participation in the care of older
adults.
26. Evaluate the utility of complementary and integrative health care practices on
health promotion and symptom management for older adults.

27. Facilitate older adults’ active participation in all aspects of their health care
28. Involve, educate, and when appropriate, supervise family, friends, and assistive
personnel in implementing best practices for older adults
29. Ensure quality of care commensurate with older adults’ vulnerability and
frequency and intensity of care needs.

30. Promote the desirability of quality end-of-life care for older adults, including pain
and symptom management, as essential, desirable, and integral components of
nursing practice.

The geriatric competencies in Table 1 correlate with and were derived from the
suggestions in the more general AACN document in Table 2. By using these published
documents as guides, nursing professors and others who educate in the area of gerontological
nursing should be able to prepare students to be competent to provide excellent care to older
adults.

Table 2. American Association of Colleges of Nursing Essentials

Core Competencies
1. Critical Thinking
2. Communication
3. Assessment
4. Technical Skills

Core Knowledge
1. Health promotion, risk reduction, and disease prevention
2. Illness and disease management
3. Information and health care technologies
4. Ethics

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 56

5. Human diversity
6. Global health care
7. Health care systems and policy

Role Development
1. Provider of care
2. Designer/manager/coordinator of care
3. Member of a profession

V. Reflection

Look at the list of competencies for gerontological nurses in Table 1. How many of these
competencies do you feel you meet at this point? Make a conscious effort to develop these
skills as you go through your career.

VI. Post Test

Encircle the letter of the best answer.

1. A framework for clinical practice that integrates the best available scientific evidence
with the expertise of the clinician and with patients’ preferences and values to make
decisions about health care.
a. Core Competencies
b. Standards
c. Core Knowledge
d. Evidence-based practice
2. A suggestion for practice, not necessarily sanctioned by a formal, expert group
a. Recommendation
b. Clinical Practice Guideline
c. Protocol
d. Evidence-based practice
3. A more detailed guide for approaching a clinical problem or health condition and is
tailored to a specific practice situation
a. Recommendation
b. Clinical Practice Guideline
c. Protocol
d. Evidence-based practice
4. An “official recommendation” or suggested approach to diagnose and manage a broad
health condition
a. Recommendation
b. Clinical Practice Guideline
c. Protocol
d. Evidence-based practice
5. The standards for clinical gerontological nursing include the following except:
a. Evaluation
b. Diagnosis
c. Planning
d. Outcome Implementation
6. The standards of professional gerontological nursing performance include all of the
following except:
a. Quality of care
b. Education
c. Performance utilization
d. Research
7. Statement A: Communicate effectively, respectfully, and compassionately with older
adults and their families.
Statement B: Establish and follow standards of care to recognize and report elder
mistreatment.

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 57

Statement C: Involve, educate, and when appropriate, supervise family, friends, and
assistive personnel in implementing best practices for older adults
Statement D: Analyze the impact of an aging society on the health care system.
a. All of the statements are correct
b. None of the statement is correct
c. Only A and B are correct
d. Only C and D are correct
8. American Association of Colleges of Nursing Essentials core knowledge includes:
a. Technical skills
b. Information and health care technologies
c. Member of a profession
d. Assessment
9. American Association of Colleges of Nursing Essentials role development includes:
a. Technical skills
b. Information and health care technologies
c. Member of a profession
d. Assessment
10. American Association of Colleges of Nursing Essentials core competencies includes:
a. Ethics
b. Designer/manager/coordinator of care
c. Global Health care
d. Communication

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://pubs.asha.org/doi/10.1044/gero19.1.44#:~:text=Growing%20older%2C%20o
r%20chronological%20aging,beings%20(Meilaender%2C%202011).&text=It%20is%2
0senescence%20that%20causes%20diseases%20of%20aging.

https://www.mc.edu.ph/alumni/news/ArticleID/1509/Ageing-in-the-
Philippines#:~:text=According%20to%20a%202018%20study,of%20our%20country'
s%20total%20population.

https://mom.com/kids/4870-how-does-caring-aging-parents-affect-family-
life#:~:text=When%20you%20live%20with%20your,change%20in%20your%20famil
y%20roles.&text=This%20shift%20can%20cause%20guilt,open%20communication%
20among%20family%20members.

http://samples.jbpub.com/9781284104479/Chapter_3.pdf

http://eprints.qums.ac.ir/1713/1/Evidence_based_Geriatric.pdf

UNIT IX. ETHICO-LEGAL CONSIDERATIONS IN THE CARE OF THE OLDER

ADULT
I. Introduction

The ethics of care in the geriatric population, as in others, include compassion, equity,
fairness, dignity, confidentiality, and mindfulness of a person’s autonomy within the realm
of the person’s abilities and mental capacity. It is not possible to care for this population
without being faced with difficult choices surrounding issues relating to the ability to live
independently. Independence in the community requires some level of self-sufficiency in the
management of medications, health care, driving, and maintaining and running a home (self-

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 58

care, pet care, meals, housekeeping, shopping, banking, etc.). Self-sufficiency, issues of
finance, and personal choices directly impact adherence to a plan of care (Mauk, 2010).
Ethical concepts are principles that facilitate decision making and guide our
professional behavior (Mauk, 2010.)They evolve from our beliefs and values and therefore
have their foundations in religion, culture, and family expectations. Ethical decision making
is driven by moral reasoning— our determination of what is right and wrong. Ethical
concepts and personal values define our character and are expressed in our conduct and
actions. Professional codes or standards within the profession of nursing help to define
ethical actions. Changes in our social networks, including global awareness, cultural
diversity, and advances in science, medicine, and technology, have created increasingly
complex conflicts and dilemmas. Therefore, nurses must have a clear understanding of their
values and a strategy for decision making because personal beliefs may be quite different
from the patient’s, from the organization’s values and expectations, or the community’s
public rules.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. define key ethical constructs as they relate to the care of geriatric patients;
2. discuss concepts of ethics and the implications in the care of geriatric patients; and
3. recognize the influence of personal values, attitudes, and expectations about aging on
the care of older adults and their families.

III. Pre-Test

Fill in the crossword puzzle with the words missing from the sentences below. Match the
number of the sentence to the boxes placed across or down the grid. If filled out correctly, the
words will fit neatly into the puzzle.

4
1 E F C N

2 H A R Y
R C

3 U S
C Y

Across:
1 Do good
2 Administration of more medications
3 Fairness of an act or situation
Down:
4 Truthfulness and refers to telling the truth
2 An accepted or professed rule of action or conduct

IV. Lesson Proper

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 59

Laws Affecting Senior Citizens

As defined under Republic Act No. 7432, as amended by RA No. 9257(“Expanded
Senior Citizens Act of 2003”), and further amended by RA 9994, known as the “Expanded
Senior Citizens Act of 2010,” defines senior citizen or elderly as any resident citizen of the
Philippines at least 60 years old.
Senior citizens are entitled to a 20% discount and exemption from the value-added
tax (VAT) on certain goods and services for their exclusive use. Among these are the purchase
of medicines and essential medical supplies, accessories, and equipment; professional fees of
attending physicians and licensed health workers as well as on medical and dental services,
diagnostic and laboratory fees in private hospitals, medical facilities, outpatient clinics, and
home health care services.
They are also entitled to a 20% discount on fare for land (jeepneys, buses, taxis,
shuttle services, MRT, LRT, PNR,) sea shipping vessel and domestic transport services. Many
elderlies do not know that the 20% discount also applies to taxis.
This also applies to restaurants, hotels and similar lodging establishments, and
recreation centers. Seniors should be reminded though that the discount only applies to them.
Also subject to the 20% discount are admission fees charged by theatres, cinema
houses and concert halls, circuses, leisure, and amusement. In some local government units
like Baguio City, SM Cinema Baguio is offering free movies to senior citizens who are residents
of the city once a day from Monday to Friday.
When they die, there is a discount for their funeral and burial services.
The law also provides a grant of a minimum of 5% discount on water and electric bills
registered in the name of the senior citizen residing therein, and provided that the monthly
consumption does not exceed 100 kilowatt-hours of electricity and 30 cubic meters of water:
Seniors can also get a 5% discount without VAT exemption on certain on groceries
granted by the Department of Trade and Industry and the Department of Agriculture.
For groceries worth up to PHP 1,300 per week, they can enjoy 5% off the retail prices
of at least four kinds of the following necessities and prime commodities: Rice, bread, and
corn; Chicken, beef, and pork; Fresh eggs; Coffee, creamer, and sugar; Fresh fruits and
vegetables; Garlic and onions; cooking oil and salt; Noodles, canned sardines, and canned
tuna; Fresh milk and other dairy products; detergents; Electrical supplies, light bulbs, and
batteries and geriatric diapers.
Senior citizens though cannot avail of this special discount in sari-sari stores,
cooperative stores, and wet markets.
As the government cares for the health of senior citizens, they have mandatory
PhilHealth coverage as stipulated in RA 9994. When they are confined in private hospitals,
they can avail of PhilHealth benefits in addition to the 20% discount and VAT exemption. In
government hospitals, the No Balance Billing Policy applies.
To augment their daily subsistence and other medical needs, the government also
provides monthly social pension amounting to P500 to indigent senior citizens.
Another privilege of senior citizens is the provision of express lanes for them in all
commercial and government establishments.
For the 60 and above citizens to enjoy these benefits and privileges, they must present
their senior citizen
ID issued by the Office of the Senior Citizen Affairs (OSCA). They may present their
government-issued ID that shows their age in the absence of senior citizen ID but not all
establishments honor this. That is why it is very important to apply for their senior citizen's
ID at the OSCA or the Department of Social Welfare and Development (DSWD) in their
respective city or municipality.
An elderly should get a senior citizen identification card and present it whenever
needed to avail of the benefits and discounts.
Weak or bedridden senior citizens can still avail of the discount especially in the
purchase of their medicines and groceries. They only have to make and sign an authorization
letter for their duly authorized representatives, who will present it along with the senior
citizens’ ID, OSCA purchase booklet, and their government-issued ID when paying for the
purchases.

Medications of Older Adults (Polypharmacy)

Polypharmacy, or the prescription, use, or administration of more medications than
is clinically indicated, is common in older adults (Meiner, 2011; Miller, 2012). The potential

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for drug-drug interactions increases with increased medication use and with multiple
coexisting diseases (comorbidity) that affect the absorption, distribution, metabolism, and
elimination of the medications. Such interactions are responsible for numerous emergency
department and physician visits, which cost billions of dollars annually. Any medication is
capable of altering nutritional status, and the nutritional health of an older adult may already
be compromised by a marginal diet or by chronic disease and its treatment. Medications can
affect the appetite, cause nausea and vomiting, irritate the stomach, cause constipation or
diarrhea, and decrease the absorption of nutrients. Also, these medications may alter
electrolyte balance as well as carbohydrate and fat metabolism. Combining multiple
medications with alcohol, as well as with over-the-counter and herbal medications, further
complicates gastrointestinal problems.

Nursing Implications
Prescription principles that have been identified as appropriate for older patients
include starting with a low dose, going slowly, and keeping the medication regimen as simple
as possible (Meiner, 2011; Miller, 2012). A comprehensive assessment that begins with a
thorough medication history, including the use of alcohol, recreational drugs, and over-the-
counter and herbal medications, is essential. It is best to ask the patient or reliable informants
to provide all medications for review. Assessing the patient’s understanding of when and how
to take each medication, as well as the purpose of each medication, allows the nurse to assess
the patient’s knowledge about and compliance with the medication regimen. The patient’s
beliefs and concerns about the medications should be identified, including beliefs on whether
a given medication is helpful. Nonadherence with medication regimens can lead to significant
morbidity and mortality among older adults. The many contributing factors include the
number of medications prescribed, the complexity of the regimen, difficulty opening
containers, inadequate patient education, financial cost, and the disease or medication
interfering with the patient’s life (Meiner, 2011). Furthermore, visual and hearing problems
may make it difficult to read or to hear directions.

Table 1. Nursing Strategies for Improving Medication Management and

Adherence
The following strategies can help patients manage their medications and improve
adherence:
1. Explain the purpose, adverse effects, and dosage of each medication.
2. Provide the medication schedule in writing.
3. Encourage the use of standard containers without safety lids (if there are no
children in the household).
4. Suggest the use of a multiple-day, multiple-dose medication dispenser to help
the patient adhere to the medication schedule.
5. Destroy or remove old, unused medications.
6. Encourage the patient to inform the primary health care provider about the use
of over-the-counter medications and herbal agents, alcohol, and recreational
drugs.
7. Encourage the patient to keep a list of all medications, including over-the-
counter and herbal medications, in his or her purse or wallet to share with the
primary care provider at each visit and in case of an emergency.
8. Review the medication schedule periodically, and update it as necessary.
9. Recommend using one supplier for prescriptions; pharmacies frequently track
patients and are likely to notice a prescription problem such as duplication or
contraindications in the medication regimen.
10. If the patient’s competence is doubtful, identify a reliable family member or
friend who might monitor the patient for adherence.

Moral Principles
Moral principles are incorporated into professional codes of ethics, organizational
value statements, and position statements published by professional groups such as the
American Nurses Association (ANA). This code forms the cornerstone of nursing practice. The
purpose of this code is to provide nurses with tools for identifying ethical responsibilities and
to guide decision making within the primary goals, values, and obligations of the profession.

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Advocacy
Advocacy refers to loyalty and a championing of the needs and interests of others
requiring the nurse to educate patients and their families so that they know their rights, are
fully informed and can access all the benefits they are entitled to (Hoeman & Duchene, 2002).
Nurses also advocate for patients by supporting them in their efforts to retain as much
autonomy as their abilities allow. At times, nurses advocate for the expressed desires of the
patient within the context of team and family discussions in which the patient is not present,
assuring a true representation of the patient’s desires when known. Other situations require
advocacy efforts to prevent abuse, neglect, and exploitation.
Advocacy also refers to maintaining the status of safe care. The nurse is committed to
the well-being of the patient and thus must take appropriate action if incompetent, illegal,
unethical, or impaired practice puts a patient at risk.

Autonomy
Autonomy is the concept that each person has a right to make independent choices
and decisions. It is reflected in guidelines and laws regarding patient rights and self-
determination. Inherent in the concept of autonomy is respect for another and their decisions
and that each person should be treated with dignity as a unique individual with inherent
worth. Evidence of respect for autonomy is found in care that considers the patient’s lifestyle,
value system, and religious beliefs. Such respect does not mean that the nurse condones those
beliefs or choices, but rather that the nurse respects the patient as a person with autonomy
and rights.
Autonomous choices are based on values and experiences. For patients and their
families to make sound choices, they must have appropriate resources and information
available. Thus, autonomy is supported by informed consent and patient and family
education. Informed consent means making sure that consent has been granted, not assumed,
following an educational process that facilitates the weighing of benefits, risks, and available
options (Aveyard, 2005). Informed consent is not compliance, but assuring that voluntariness
is honored.

Beneficence / Nonmaleficience
These concepts of do good (beneficence) and do no harm (nonmaleficence) are
integral to health care. Nurses intend to do good for their patients.

Confidentiality
The ANA Code of Ethics (2001) emphasizes respect for human dignity that is
demonstrated in daily work. This includes respect for privacy and maintaining
confidentiality. There is so much value placed on the concept of confidentiality that it is
considered a right—the right to privacy
Nurses are entrusted with personal information in the course of providing care that
should be shared only as necessary to facilitate that patient’s care. In addition to the personal
responsibility for protecting privacy, legal ramifications for failure to comply with this law
are steep; the nurse should be well informed of organizational guidelines for compliance with
this regulation. Health care providers can be held liable for harm that results from sharing
information without permission. Nurses should be able to easily access appropriate
administrative personnel if a request for patient information is questionable.

Fidelity
Fidelity refers to keeping promises or being true to another; being faithful to
commitments and responsibilities (Ellis & Hartley, 2004). Fidelity is particularly important
in the care of geriatric patients because of the amount of trust they put into the health care
system. Fidelity is also important in relationships with team members and the organization
at which the nurse works. The team and the organization need to be able to trust the nurse
to keep promises and honor relationships with them. Trust is earned, and fidelity is
demonstrated in daily work and the relationships therein

Fiduciary Responsibility
In this age of diminishing health care resources, all nurses must have an
understanding of the costs and benefits of care that is given. Health care professionals have
an ethical obligation to good stewardship of both the patient’s and the organization’s funds—

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fiduciary responsibility. This refers to using both fiscal reserves and caregiving resources
wisely, potentially requiring a cost-benefit analysis to facilitate decision making. It becomes
more difficult to deal with persons who are non-compliant or who have conditions that could
have been prevented through healthier lifestyles as resources and manpower decline
(Hoeman & Duchene, 2002). For many, rehabilitation and other special health care programs
are not a right, they are a privilege that is rationed and controlled by those who control
funding.

Justice
Fiduciary responsibility and fidelity are some of the moral principles that help to
determine what is just. Justice refers to the fairness of an act or situation. Health care is
replete with issues of justice. Is it just for one patient to receive rehabilitation following a
stroke and another to be sent to a nursing home without acute rehabilitation? Is it just for a
person who has attempted suicide and severely damaged his liver to receive a transplant
before another who has been patiently waiting for the same liver? Who decides what is just
and right? Does age make a difference? Why should one person receive more resources than
another? Is the government responsible for providing resources to those unable to provide
for themselves?

Reciprocity
Reciprocity is a feature of integrity concerned with the ability to be true to one’s self
while respecting and supporting the values and views of another. Living according to this
principle is particularly important when values and views are different. Nurses need to be
impartial once a plan of care is agreed on, actively facilitating the achievement of intended
goals and outcomes. Passive resistance does not support reciprocity or trust. If a nurse or
other health care provider cannot demonstrate reciprocity, another should take his or her
place in the care of the patient.

Veracity
Veracity means truthfulness and refers to telling the truth, or, at the very least, not
misleading or deceiving patients or their families. Veracity forms the basis of informed
consent—without truthfulness and an explanation of options, the patient cannot possibly
make the best choice. Failure to be truthful impairs trust and reliability (Ellis & Hartley,
2004). But issues of truthfulness create conflict as well. Do you tell the truth when you know
it will cause harm or distress? How do you maintain hope while sharing a poor prognosis? It
is possible to support hopefulness and decrease stress with truthfulness through careful
choices of words. It is as simple as the difference between simply stating, “You will not likely
walk again considering the severity of this stroke” and compassionately saying “It will take
considerable work and fortunate healing of your brain for you to walk again, but we will work
with you and see what happens.”

V. Reflection

As you prepare to care for older adults, what values, conflicts, or ethical dilemmas do you
anticipate you will face?

VI. Post Test

Encircle the letter of the correct answer.

1. Expanded Senior Citizens Act of 2003
a. Republic Act No. 7432
b. Republic Act of 9257
c. Republic Act 9994
d. Republic Act of 9600
2. Statement A: Senior citizens are entitled to a 10% discount and exemption from the
value-added tax (VAT) on certain goods and services for their exclusive use.
Statement B: The law also provides a grant of a minimum of 5% discount on water and
electric bills registered in the name of the senior citizen residing therein.
a. Statement A and B are correct
b. None of the statement is correct

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c. Only statement A is correct

d. Only statement B is correct
3. The discount for senior citizen applies on the following except:
a. purchase of medicines and essential medical supplies
b. medical and dental services
c. diagnostic and laboratory fees in private hospitals
d. purchase of non-essential goods
4. Statement A: As the government cares for the health of senior citizens, they have
mandatory PhilHealth coverage as stipulated in RA 9995.
Statement B: When they are confined in private hospitals, they can only avail of
PhilHealth benefits and cannot avail of the 20% discount and VAT exemption.
Statement C: In government hospitals, the No Balance Billing Policy applies.
a. Statement A and B are correct
b. Statement B and C are correct
c. Only statement A is correct
d. Only statement B is correct
5. Nursing Strategies for Improving Medication Management and Adherence are the
following except:
a. Explain the purpose, adverse effects, and dosage of each medication.
b. Destroy or remove old, unused medications.
c. Encourage the patient to keep a list of all medications.
d. If the patient’s competence is doubtful, advise the patient not to take the
medication.
6. Refers to loyalty and a championing of the needs and interests of others
a. Advocacy
b. Autonomy
c. Fiduciary Responsibility
d. Justice
7. A feature of integrity concerned with the ability to be true to one’s self while respecting
and supporting the values and views of another
a. Veracity
b. Reciprocity
c. Fidelity
d. Confidentiality
8. Being faithful to commitments and responsibilities
a. Veracity
b. Reciprocity
c. Fidelity
d. Confidentiality
9. These concepts of doing good and do no harm integral to health care.
a. Fiduciary Responsibility
b. Reciprocity
c. Beneficence / Nonmaleficence
d. Advocacy
10. The purpose of this code is to provide nurses with tools for identifying ethical
responsibilities and to guide decision making within the primary goals, values, and
obligations of the profession.
a. Polypharmacy
b. Advocacy
c. Autonomy
d. Moral Principle

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

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https://pia.gov.ph/features/articles/1026127
______________________________________________________________________________________________________________
UNIT X. LONG TERM CARE
I. Introduction
Reality tells us that every person will die. Less than 10% will die suddenly; more than
90% will die after a prolonged illness (Emanuel, von Gunten, Ferris, 1999). The accumulation
of experiences throughout a person’s lifetime helps to clearly define the way he or she wishes
to experience his or her end of life. Familial and cultural factors, along with life events, often
provide defining moments that influence a person’s choices when facing the end of his or her
life and death that will come sooner rather than later. Anthropologist Margaret Mead was
quoted as saying, “When a person is born, we rejoice, and when they’re married, we jubilate,
but when they die, we try to pretend nothing happened.”
This unit deals with the nurse’s role in assisting a patient and family to identify the
options for meeting end-of-life needs. It promotes the role of the nurse as a member of a
team of professionals who focus on care and treatment of issues specific to the elderly as
their health declines. It also offers practical assistance for nurses as they deal with various
aspects of end-of-life care.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. recognize the choices of the elderly and their families in directing their end-of-life
care as well as the nurse’s role in support/implementation of the patient’s choice;
2. examine the goals/objectives of palliative care at end of life;
3. discuss the nurse’s role at end of life using the above concepts of care; and
4. describe the nurse’s role as a member of an interdisciplinary team focused on the end
of life care.

III. Pre-Test

Combine and guess the word.

1.

3.

2.

IV. Lesson Proper

Long Term Care

Long-term care “refers to the health, mental health, social, and residential services
provided to a temporarily or chronically disabled person over an extended period to enable
the person to function as independently as possible” (Evashwick, 2002). Most long-term care
is a community and institutionally based.
There are many different levels of care that fall under the long-term care umbrella.
These may include assisted living, intermediate care, skilled care, and Alzheimer’s units.
Facilities that offer these services are generally called by one of several names: nursing
homes, long-term care facilities (LTCFs), skilled nursing facilities (SNFs), retirement homes,

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assisted living facilities, or rehabilitation and health care villages. The places that offer these
services may advertise just one or a multitude of levels of care.
The most common type of long-term care is personal care—help with everyday
activities, also called "activities of daily living." These activities include bathing, dressing,
grooming, using the toilet, eating, and moving around—for example, getting out of bed and
into a chair.
Long-term care also includes community services such as meals, adult daycare, and
transportation services. These services may be provided free or for a fee.
People often need long-term care when they have a serious, ongoing health condition
or disability. The need for long-term care can arise suddenly, such as after a heart attack or
stroke. Most often, however, it develops gradually, as people get older and frailer or as an
illness or disability gets worse.
It is difficult to predict how much or what type of long-term care a person might need.
Several things increase the risk of needing long-term care and these are:
1. Age
The risk generally increases as people get older.
2. Gender
Women are at higher risk than men, primarily because they often live longer.
3. Marital status
Single people are more likely than married people to need care from a paid
provider.
4. Lifestyle
Poor diet and exercise habits can increase a person's risk.
5. Health and family history
These factors also affect risk.

Palliative Care
Palliative care is specialized medical care for people living with a serious illness. This
type of care is focused on providing relief from the symptoms and stress of the illness. The
goal of palliative care is to achieve the best possible quality of life for patients and their
families.
Palliative care is provided by a specially-trained team of doctors, nurses, and other
specialists who work together with a patient’s other doctors to provide an extra layer of
support. Palliative care is based on the needs of the patient, not on the patient’s prognosis. It
is appropriate at any age and any stage in a serious illness, and it can be provided along with
curative treatment.
Control of pain, of other symptoms, and psychological, social, and spiritual problems
is paramount (Storey, 1996). It can be very difficult for a patient and family to choose one of
these options for care. A practical suggestion that may help the patient and/or family in
weighing the choices is to encourage a frank discussion with the physician, which would
include several important questions: “What is the expected outcome if I do treatment option
#1? What is the choose comfort care?” Weighing the answers to each of these questions may
help the individual make an informed choice, based on the differences between the expected
outcomes and the individual’s philosophy about how to experience his or her end of life.
expected outcome if I do treatment option #2? What is the expected outcome if I do neither
of these and choose comfort care?” Weighing the answers to each of these questions may help
the individual make an informed choice, based on the differences between the expected
outcomes and the individual’s philosophy about how to experience his or her end of life.

Primary Roles of Palliative Care Nurses

Palliative care providers perform a wide range of tasks that support the long-term
well-being of patients. These include monitoring symptoms over time and evaluating the
health of patients to ensure that the proper care is given each day. Palliative care nurses
help patients adhere to their medication schedules and protocols while maintaining a direct
line of communication between the patient, doctors, and other allied health professionals.
Many patients need help with mobility, and a palliative care nurse can assist them in
maintaining physical activity and accomplishing everyday tasks. They can maintain and
monitor equipment and assist with personal care needs such as bathing and feeding. Most
importantly, palliative care nurses help patients and their families feel safe and comfortable.

Benefits of Palliative Care

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Palliative care alleviates symptoms related to disease that include pain, chronic
fatigue, and muscle weakness. It can also help reduce emotional symptoms such as
depression and anxiety. Palliative care nurses provide an integrative and multidisciplinary
treatment approach that helps patients maintain physical, mental, and emotional health.
They take the time to understand the needs of each patient in order to provide a customized
treatment plan that provides lasting relief. By emphasizing the improvement of a patient’s
quality of life, palliative care plays an essential role in the long-term care of you or your
loved one. As more health care providers focus on providing the highest quality of life for
their patients, palliative care services have become even more essential in disease
treatment and the healing process.

Advance Directive
The most fundamental patient right is the right to decide. The Patient Self-
Determination Act of 1990 was enacted to reduce the risk that life would be shortened or
prolonged against the wishes of the individual. Following the belief that each has a
fundamental right to decide (autonomy), this law requires that patients are provided the
opportunity to express their preferences regarding life-saving or life-sustaining care on
entering any health care service, including hospitals, long-term care centers, and home care
agencies. The law also requires that adequate information be supplied to the patient so that
informed decisions regarding self-determination are made. Decisions regarding life-saving or
life-sustaining care are recorded in legal documents known as advance directives. Advance
directives describe actions to be taken in a situation where the patient is no longer able to
provide informed consent.
An advance directive is a legal document that explains how you want medical
decisions about you to be made if you cannot make the decisions yourself. These directives
pertain to treatment preferences and the designation of a surrogate decision-maker in the
event that a person should become unable to make medical decisions on their own behalf.
Advance directives generally fall into three categories: living will, power of attorney and
health care proxy.

Living Will: This is a written document that specifies what types of medical
treatment are desired. A living will can be very specific or very general.
The most common statement in a living will is to the effect that: If I suffer an incurable,
irreversible illness, disease, or condition and my attending physician determines that my
condition is terminal, I direct that life-sustaining measures that would serve only to prolong
my dying be withheld or discontinued. More specific living wills may include information
regarding an individual's desire for such services such as analgesia (pain relief), antibiotics,
hydration, feeding, and the use of ventilators or cardiopulmonary resuscitation.
Durable Power of Attorney: This is the third type of advance directive. Individuals
may draft legal documents providing power of attorney to others in the case of incapacitating
medical condition. The durable power of attorney allows an individual to make bank
transactions, sign Social Security checks, apply for disability, or simply write checks to pay
the utility bill while an individual is medically incapacitated.
Healthcare Proxy: This is a legal document in which an individual designates
another person to make health care decisions if he or she is rendered incapable of making
their wishes known. The health care proxy has, in essence, the same rights to request or
refuse treatment that the individual would have if capable of making and communicating
decisions.

Do Not Resuscitate
A Do Not Resuscitate is a document that informs medical professionals that they
should not provide cardiopulmonary resuscitation (CPR) or advanced cardiac life support
(ACLS) to an individual if that individual stops breathing or if their heart stops. In common
language, this is a document that essentially says "don't put me on life support". There are
variations on this concept, such as Do Not Intubate (PayingforSeniorCare.com)
In the context of the elderly who are receiving care, a DNR is more relevant to those
living at home. A DNR is largely intended for emergency response personnel who are
unfamiliar with the individual. Those who live in residential care will likely have
communicated (or been asked) their wishes in advance by the caregivers around them.
A DNR is similar to an advance health care directive or a living will. Some may argue
that a DNR is, in fact, a type of advance health care directive. However, there is a clear

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distinction in that a DNR is under the order of a physician while a health care directive or
living will simply be an expression of the individual's desire. A DNR is a more formal, legal
document and it is intended for emergency medical personnel.
A DNR also tends to have a single, very distinct purpose: "Don't revive me". While a
living will might state the opposite: "Do everything in your power to keep me alive". This
lack of ambiguity in a DNR makes it more likely that the individual's preferences will be
followed.
The decision to forego CPR and “full care” must be made by the patient themselves if
they are competent to do so. If they are not competent, then their named surrogate decision-
maker or health care proxy must make this decision on their behalf. In either case, a care plan
meeting with the patient’s physician(s) is highly recommended to thoroughly discuss all
aspects of implementing or deciding against a DNR order.
A DNR order may be a part of a hospice care plan. The focus of this care is not to
prolong life, but to treat symptoms of pain or shortness of breath, and to maintain comfort. f
you have a DNR order, you always have the right to change your mind and request CPR.

End-of-Life Care
Nurses have the opportunity and ability to influence the process of death by their
proximity to patients and families. Nurses spend more time with patients and their families
at end of life than any other member of the health care team (Ferrell, Grant, & Virani, 1999).
Families and patients look to the nurse for support, education, and guidance at this difficult
time, yet little education is provided to prepare nurses for this unique type of care. Nurses
face end-of-life situations in almost all practice settings, including hospitals, hospices, long-
term care facilities, home care, prisons, and clinics, but many remain uncomfortable
providing care.
The focus of care at end of life should center on living with a terminal illness—with
medical care, support, and interventions geared toward the quality of life and comfort, rather
than on prolonging suffering or the dying process—if that is what the patient wants. In
determining the wishes of patients for end-of-life care, their physical, emotional,
psychosocial, and spiritual needs must all be addressed. The cumulative nature of these
aspects of a person’s life will impact the choices they make at this important time.

Peaceful Dying
It may be possible to plan for a peaceful death, given the knowledge of having a
terminal illness.
“The key to peaceful dying is achieving the components of peaceful living during the time
you have left” (Preston, 2000, p. 161). Some components are accomplished only by the
individual, whereas others may require the assistance of family and medical providers,
such as the following (Preston, 2000):
1. Instilling good memories
2. Uniting with family and medical staff
3. Avoiding suffering, with the relief of pain and other symptoms
4. Maintaining alertness, control, privacy, dignity, and support
5. Becoming spiritually ready
6. Saying good-bye
7. Dying quietly
When death approaches for the elderly patient, the role of the nurse changes
along with the patient’s changing condition. The role moves from a fix-it focus to that of
presence—the ability to be with the patient and with his or her family. This presence
involves the provision of comfort measures, lending a listening ear, providing a peaceful
environment, and compassionately educating patients and family about the dying
process. The nurse’s gratification does not come from curing, but rather from supporting
the patient in a peaceful and dignified death.
“You matter because you are. You matter to the last moment of your life, and we
will do all we can not only to help you die peacefully but to live until you die.” — Cicely
Saunders (1984, p. 33)

Spirituality among Older Persons

Spiritual assessment is an integral part of the comprehensive assessment and
provides a basis for an individualized plan of care (Forbes, 1994). Although there is a link
between religiosity and spirituality, the two concepts are not synonymous. Religiosity refers

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to believing in God, organized rituals, and specific dogma; spirituality refers to broader ideas
of the belief that encompass personal philosophy and an understanding of meaning and
purpose in life. Having religious beliefs may foster spirituality, but those without formal
religious beliefs still can experience spirituality. Most health service intake forms have a
place for collecting information on formal religious affiliation, but this does not necessarily
mean that the older adult is practicing his or her faith, or is active in a place of worship.
One of the earliest guidelines for spiritual assessment was developed by Stoll (1979),
and it contains questions that address both religiosity and spirituality. The guidelines are
divided into four areas:
1. The concept of God or deity (for example, “Is religion or God significant to you?”)
2. Personal source of strength and hope (for example, “What is your source of strength
and hope?”)
3. Significance of religious practices and rituals (for example, “Are there any religious
practices that are important to you?”)
4. Perceived relationship between spiritual belief and health (for example, “Has being
sick made any difference in your feelings about God or the practice of your faith?”)
Nurses may not be comfortable conducting a spiritual assessment because it may
seem inappropriately invasive or because it is an area that some nurses do not feel
adequately prepared to address as an unmet need. If the intake record indicates a formal
religious affiliation, then it is fairly straightforward to ask, “Do you have any religious
needs?” or “Would you like to speak with a pastoral care worker?” Questions that address
spirituality can begin by asking, “Are you having a spiritual need? Is there some way that
I might help with your spiritual needs?” Another spiritual assessment question asks,
“Have your health problems affected your feelings of meaning or purpose?”. Spiritual
assessment is an area that would benefit greatly from more research.

Harmful Effects of Religion and Spirituality

Religion is not always beneficial to older adults. Religious devotion may promote
excessive guilt, inflexibility, and anxiety. Religious preoccupations and delusions may
develop in patients with obsessive-compulsive disorder, bipolar disorder, schizophrenia,
or psychoses.
Certain religious groups discourage mental and physical health care, including
potentially lifesaving therapies (eg, blood transfusions, treatment of life-threatening
infections, insulin therapy), and may substitute religious rituals (eg, praying, chanting,
lighting candles). Some more rigid religious groups may isolate and alienate older people
from nonparticipating family members and the broader social community.

Role of the Health Care Practitioner

Talking to older patients about their religious beliefs and practices helps health
care practitioners provide care because these beliefs can affect the patients’ mental and
physical health. Inquiring about religious issues during a medical visit is appropriate
under certain circumstances, including the following:
When patients are severely ill, under substantial stress, or near death and ask or
suggest that a practitioner talk about religious issues
When patients tell a practitioner that they are religious and that religion helps
them cope with illness When religious needs are evident and may be affecting patients’
health or health behaviors Older adults often have distinct spiritual needs that may
overlap with but are not the same as psychologic needs. Ascertaining a patient’s spiritual
needs can help mobilize the necessary resources (eg, spiritual counseling or support
groups, participation in religious activities, social contacts from members of a religious
community).

Ethical Decision Making

Nurses make decisions constantly in regards to patient care and welfare. Nurses are
obligated by the nature of the profession to act as an advocate, liaison, intercessor, and
spokesperson for patients and their families. The profession is bound in the role of the nurse
to act ethically and morally and to be loyal to the patient, to the physician, and to the system,
which is sometimes at odds with each other. Many of the daily decisions in regards to patient

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interaction, while simple at first consideration, have an ethical component to them that can
be quite complex (Mauk, 2010).

Common Ethical Dilemmas

1. Ensuring Informed Consent
Informed consent means making sure that consent has been granted, not assumed,
following an educational process that facilitates the weighing of benefits, risks, and
available options (Aveyard, 2005). Informed consent is not compliance, but assuring
that voluntariness is honored.

2. Ensuring Patient Confidentiality

The ethical principle of autonomy requires clinicians to maintain patient
confidentiality. To be autonomous, patients must be able to control personal
information. Furthermore, maintaining confidentiality is necessary for the proper
evaluation and treatment of patients. Issues concerning confidentiality that are more
common among older adults include elder abuse issues, harm to self, and release of
information to family members and other professionals.

3. Determining Decision-making capacity

Decision-making capacity includes the ability to communicate a choice, understand
the nature and consequences of the choice, manipulate rationally the information
necessary to make the choice, and reason consistently with previous expressed
values and goals.

V. Reflection

Assess your feelings about the right to die and assisted suicide. How would you respond
if an elderly patient asks “please help me die” when death is not near?

VI. Post Test

Encircle the letter of the correct answer.

1. Refers to health, mental health, social, and residential services provided to a temporarily
or chronically disabled person over an extended period to enable the person to function
as independently as possible.
a. Retirement homes
b. Assisted living facilities
c. Nursing homes
d. All of the above
2. All of the following are risk identified that resulted in long term care except:
a. Health and family history
b. Lifestyle
c. Nutritional preference
d. Gender
3. Statement A: Long term care is a type of care that is focused on providing relief from the
symptoms and stress of the illness.
Statement B: Palliative care is based on the prognosis of the patient, not on the patient's
needs.
a. Only statement A is correct
b. Only statement B is correct
c. Statement A and B are correct
d. None of the statements are correct
4. This law requires that patients are provided the opportunity to express their preferences
regarding life-saving or life-sustaining care on entering any health care service, including
hospitals, long-term care centers, and home care agencies.
a. Palliative care
b. Patient Self-Determination Act
c. Long Term care
d. End-of-life care

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5. Describe actions to be taken in a situation where the patient is no longer able to provide
informed consent.
a. Palliative care
b. Advance Directive
c. Long Term care
d. End-of-life care
6. Do not resuscitate in common language except:
a. "Do everything in your power to keep me alive"
b. "Don't put me on life support"
c. “Do Not Intubate”
d. "Don't revive me"
7. The focus of care at end-of-life care are the following except:
a. Quality of life
b. Comfort
c. Prolonging the dying process
d. Medical care support
8. Ways on how a family can assist and support a terminally-ill patient
a. Avoiding family and medical staff
b. Forgetting the past
c. Question God why this is all happening
d. Maintaining privacy
9. This means making sure that consent has been granted, not assumed, following an
educational process that facilitates the weighing of benefits, risks, and available options
a. Informed consent
b. Confidentiality
c. Decision-making capacity
d. Veracity
10. A patient decision-making capacity includes the ability to:
a. Make a choice
b. Understand the consequence of the choice
c. Reason for his/her choice
d. All of the above

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.nia.nih.gov/health/what-long-term-care
https://www.makatimed.net.ph/patient-and-visitor-guide/patient-
references/advanced-
directives#:~:text=A%20Do%20Not%20Resuscitate%20(DNR,or%20if%20you%20sto
p%20breathing.

https://dailycaring.com/what-is-a-dnr-do-not-resuscitate/

https://www.agingcare.com/articles/what-is-a-do-not-resuscitate-dnr-order-and-how-
does-it-work-134190.htm

https://med.virginia.edu/dom/wp-content/uploads/sites/210/2015/11/ethical-
issues-in-Geriatrics-from-Mayo.pdf

https://cdn.ymaws.com/www.cpapsych.org/resource/resmgr/imported/files/ethics/2
009-n5-Jordan.pdf

https://www.payingforseniorcare.com/legal/do-not-resuscitate

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https://www.msdmanuals.com/professional/geriatrics/social-issues-in-older-adults/religion-
and-spirituality-in-older-adults

UNIT XI. THERAPEUTIC COMMUNICATION WITH OLDER ADULTS

I. Introduction

Communication is a core skill in health care professions. We rely on our ability to

communicate effectively to gather and share information as well as to build relationships
with patients and their families. Learning and practicing the art of communication is key to
our success as clinicians (Mauk, 2010).
For many clinicians, communicating with older adults can be anxiety-producing and
fraught with challenges. These challenges may be associated with our memories of past
difficulties communicating with older adults, be they family members, clergy, teachers, or
neighbors, or they may be related to the physiological or psychosocial characteristics
associated with aging. The purpose of this topic is to review the basic principles of
communication and present strategies for communicating with older adults. This information
should promote the development of the skills needed to communicate effectively and
promote optimal health for older adults.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. communicate effectively, respectfully, and compassionately with older adults and
their families;
2. identify physiological and psychosocial barriers to communication among older
adults;
3. recognize the nurse’s role and responsibility in the process of communication;
4. utilize basic principles when communicating with older adults; and
5. identify and use strategies to overcome communication barriers.

III. Pre-test

What are the steps involved in the process of communication? Fill in the flow chart
and choose from the words given below.

Noise Decoding Receiver Message

Encoding Feedback Sender

IV. Lesson Proper

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When communicating verbally, whether in a formal or an informal situation, nurses

should know as much as possible about the other person involved. A person’s age, marital
status, cultural or ethnic orientation, educational background, interests, and the ability to
hear and see influence the communication techniques used and the words chosen. As nurses,
we need to be careful to choose words that the patient can understand—not so simple that
we are “talking down” to the patient, but also not so technical or “medical” that the meaning
is unclear. Careful listening to the patient’s speech can give clues about the appropriate level
of language. This is particularly important to remember when working with older adults.
Oldest adults of today formed their opinions, values, and beliefs in a very different society
from ours today.

Communication
The term communication is used frequently in our language and our work. The term
originates from the Latin word “commune,” which means “to hold in common.” By its origins,
the word implies that communication is a process that involves more than one person.
Communication is the process or means by which an individual relates experiences, ideas,
knowledge, and feelings to another. Communication is a reciprocal process involving
minimally two people, a sender, and a receiver. Effective communication depends on the
ability of both to engage in the process of sharing not merely words, but also concepts,
emotions, and thoughts (Mauk, 2010).

Problems between individuals, families, or groups, as well as difficulties on the job or

in society, are often the result of poor communication. Each of us who participates in
communication is a unique individual with our own personal values, beliefs, perceptions,
culture, and understanding of how the world operates. Whatever their background, older
adults have had time to encounter many situations, both good and bad. It is often difficult for
a younger person to understand the experiences that have made older adults whom they are
today. Most of today’s oldest adults grew up during the Great Depression, when men sold
apples on street corners and searched for pieces of coal in railroad yards to survive. They
lived through a major world war and witnessed the beginning of the Nuclear Age when the
first atomic bomb was dropped. They grew up in a world without many of today’s
conveniences, including televisions and private telephone lines. The upcoming generation of
elderly is very different. The Baby Boomers who came of age during the Vietnam war, grew
up in a world challenged by drugs, protests, and “free love.” They grew up with stereos,
television, and astronauts walking on the moon. Most Baby Boomers have adapted to the use
of cell phones and computers. Technology was, and will continue to be, a part of their lives.
The most effective way to bridge the gulf between the generations is good communication
(Table 1).

Table 1. Communication Dos and Don’ts When Working with Older Adults
DO’S DONT’S
Identify yourself. Assume that the person knows who
you are.
Address the person using the name he or Use “baby talk” or patronizing names
she desires (e.g., Mrs. Smith and Bill). such as “sweetie” or “honey.”
Speak clearly and slowly in a low tone of Shout.
voice.
Get to know the person. Make generalizations about older
people.
Listen empathetically. Pay too much attention to tasks and
forget the person.
Pay attention to body language—yours and Ignore non-verbal messages as
theirs. insignificant.
Use touch appropriately and frequently. Be afraid to use touch as a method of
communication.

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Effective communication is not easy, even among people of the same age group and
background. Communication among people from different age groups and backgrounds is even
more challenging. This is particularly true when one of the parties is elderly; however, effective
communication can occur even when people hold significantly different values, beliefs, and
perspectives. Effective communication does not mean that we will like or agree with everything
that another person says, but rather that we respect the person’s right to think and say it. This
atmosphere of mutual respect and understanding helps build trust and rapport. Conscious,
ongoing effort is required to become an effective communicator.

Nonverbal Communication
Communication can be verbal or nonverbal. Nonverbal communication refers to
behaviors or gestures that convey a message without the use of verbal language. Nonverbal
communication can either enhance the delivery of a message or create a barrier to
understanding. When we use eye contact in addition to a verbal greeting, we are using a
nonverbal gesture along with words to welcome the individual. When similar verbal
communication and nonverbal gestures are together, they can help us to deliver our message
and improve communications (Mauk, 2010).
Nonvocal nonverbal communication refers to the use of facial gestures, body posture,
eye contact, and touch as a means of communication. Nonverbal communication on the part
of the patient is also an important factor in therapeutic communication in a health care
setting. A patient’s nonverbal communication can provide nurses insight into the person’s
feelings and emotions. Learning to read the patient’s nonverbal gestures is important for
nurses (Mauk, 2010).

Communication in Health Care

Communication is the essence of nursing. Good communication in health care is the
foundation for optimal outcomes. Nurses use therapeutic communication skills to gather
assessment data from patients and their families that are essential to diagnosis and care
planning. We rely on our communication skills to provide information and education, and to
encourage patients to change behavior and promote health. Nurses provide the caring word
or touch that helps to relieve pain or distress (Caris-Verhallen, Kerkstra, and colleagues,
1997).
Communication is a two-way process, so it is important to look at communication in
health care from the consumer or patient perspective and these are:
a. Instrumental or task-focused communications
b. Affective communication
Instrumental or task-focused communications
Instrumental or task-focused communications refer to the behavior necessary for
assessing and solving problems. Think about the conversations you have with patients that
are focused on “caring for” the person. In these conversations, the primary interest of the
health care provider is to gather the information that will help them provide care for the
person. These conversations may be formal and structured, such as the admission interview,
a health assessment, discussion of advance directives, or patient-family education. In these
conversations, the health care provider is initiating the conversation with the specific intent
of gathering information from the patient that will be of assistance in diagnosing or treating
patient problems.
The conversation is generally initiated by the health care provider and the focus is a
question about how best to care for the patient. Patients want to be cared for, but they often
also want more—to be “cared about” as a person.

Affective communication
Focuses on how the health care provider is caring about the patient and his or her
feelings and emotions. Affective communications tend to be more informal and more difficult
for health care providers. There is a greater degree of vulnerability for the health care
provider in affective or psychosocial communications to develop an emotional or personal
relationship with the patient.
Affective communication is important in long-term health care relationships, be it a
nurse practitioner treating a patient with chronic illness in the clinic or a nurse working with
a patient in long-term care or the home. Think about ways a nurse can demonstrate caring
about the person rather than merely caring for the person.

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Communicating with the Older Adult

Communication with older adults can be quite rewarding, though at times it is fraught
with challenges for both the sender and the receiver. Physiological changes associated with
aging or secondary to chronic illness and disease can pose a barrier to communication.
Communicating with others can be facilitated by paying attention to the basic
principles of conversation. In her book, Making Contact, renowned family therapist and
author Virginia Satir describes the basic principles for making contact and communicating
with others. The basic principles are invited, arrange environment, maximize
communication, maximize understanding, and follow through.
Invite
1. arranging a time for a conversation rather than assessing the run
2. greet the person by name and ask a non-threatening open-ended question, thereby
engaging the person in conversation

Arrange an environment conducive to communication

1. the environment should be comfortable
2. provide privacy
3. minimize distractions that could be barriers to communication, such as noise or poor
lighting

Maximize communication
1. using language and terminology that are familiar to the patient
2. use age-appropriate language in communication
3. ask the receiver to clarify what he or she is hearing as a means of ensuring accurate
interpretation of your message

Maximize understanding
1. learn to listen
2. minimize environmental distractions

Follow up and follow-through

1. words backed up by actions help develop trust

Challenges in Communicating with Older Adults

Memory or Cognitive Deficits

Individuals with cognitive deficits secondary to diffuse cortical damage present with
signs of dementia, including decreased attention span, memory loss, word-finding problems,
and perseveration. These individuals often have difficulty with conversation and are
dependent upon others to initiate conversation (Mauk, 2010).
An individual’s posture and nonverbal communication convey a sense of disinterest;
thus, staff members are reluctant to initiate conversations.

Table 1. Communicating with Individuals with memory or cognitive deficits

Invite, Respect 1. Approach persons in a nonthreatening manner within their visual
field.
2. Sit quietly with the person and gently touch her hand.
3. Be respectful of the patient’s belongings. Ask permission before
moving objects.
4. Show concern; stop and have a conversation—don’t limit
communication to times when you need information.
Environment 1. Post a few pictures, a calendar, or a daily schedule in the patient’s
room and use it to enhance conversation or promote recall.
2. Sit so you are facing the person when speaking.
3. Avoid a setting with a lot of sensory stimulation
4. Maintain eye contact
5. Be respectful of space.

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Understanding 1. Speak in normal tones.

2. Use age-appropriate language.
3. Start with a familiar topic
4. Talk about people or events known to the person.
5. For many individuals, pleasant memories from the past are a
source of comfort.
6. Orientation questions can be confusing and frustrating for the
person, so rather than asking, “What’s today’s date?” consider asking,
“Where’s the calendar? Let’s find today’s date and mark it so we can
find it later.”
7. Ask one question at a time.
8. If the individual becomes upset or agitated, ease up, and use
distraction to change the topic or provide a period of quiet to allow a
cool-down period.

Communication 1. Show interest in the person. If it is difficult to hear the person,

gently ask his or her to speak louder.
2. Provide time for conversation.
3. Don’t laugh at responses, no matter how bizarre. Acknowledge
your inability to understand and your frustration. It’s probably a
mutual feeling that both parties share.

Speech Deficits or Impairments (Aphasia)

Aphasia is an acquired loss or impairment of language that occurs as a result of
damage to the speech centers in the dominant hemisphere of the brain (Mauk, 2010). There
are many types of aphasia. Individuals with aphasia should be evaluated by a speech-
language pathologist who can provide instruction on the best strategies to use with each
person.

The most common type of aphasia

Global Aphasia. Patients with global aphasia typically have problems understanding
language as well as producing speech. Language is typically non-functional in all modalities,
speaking, reading, and writing. At times the individual may repeat a sound or word over and
over. Although the individual may have difficulty speaking, he or she may understand
nonverbal gestures. It is important to include all patients with aphasia into social groups.
Nonverbal gestures such as nodding toward the individual as you address them to make the
individual feel included (Mauk, 2010).

Broca’s Aphasia. Broca’s aphasia is a nonfluent, agrammatic expressive aphasia.

Individuals with Broca’s aphasia typically have good auditory comprehension. They can
understand what is said to them; however, they have difficulty producing intelligible speech.
This is often quite frustrating for these individuals because they know what they want to say
but just can’t get it out in words that have meaning to the receiver. Communication requires
great patience. It is important to allow the patient to speak, because with time and therapy
these individuals may make important gains in learning to communicate with others (Mauk,
2010).

Wernicke’s aphasia. Wernicke’s aphasia is fluent aphasia. The individual can speak
and produce language, although the speech may contain many odd words and sounds.
Wernicke’s aphasia is characterized by impaired auditory comprehension, so in this case, the
individual has great difficulty understanding what is said. Often, he or she must rely on our
nonverbal gestures to understand directions or questions (Mauk, 2010).

Table 2. Communicating with Individuals with Aphasia

Invite, Respect 1. Include the individual in conversations.
2. Treat the person as an adult.
3. Provide time for the individual to speak.

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4. If you don’t understand the person, politely say so: “I’m sorry, I
can’t understand what you are saying to me.”
5. Remember, frustration works both ways—it’s always better to
end the conversation with a smile rather than a frown.
Environment 1. Position yourself across from the person so they can see your face
and you can see theirs.
Understanding 1. Speak naturally. Don’t raise your voice—it won’t help.
2. Speak slowly using simple words and sentences.
3. Use simple gestures to supplement your message.
4. Tell the patient one thing at a time.
Communication 1. Provide time for the individual to speak.
2. Look at the person and listen as they speak.
3. If you don’t understand, ask them to describe the word, use
another word, say or write the first letter, point to the item,
or describe the context for use.
4. If the individual can write, ask them to write the word or
use a word board to spell the word.
5. Follow instructions from the speech-language pathologist
to improve the consistency of communication.

Speech Impairments (Dysarthria)

Dysarthria can occur secondary to several diseases. Even the loss of dentition that
occurs with aging may predispose the individual to dysarthria. Individuals with dysarthria
may be difficult to understand when they are speaking. Patience and practice are key to
understanding individuals with dysarthria. As one gets accustomed to the language sounds
it becomes easier to understand what the individual is trying to say. As the receiver, it is
important not to fake or pretend you understand. If the message is not clear, ask the
individual to repeat, write, or communicate keywords by using gestures.

Table 3. Communicating with Individuals with Dysarthria

Invite, Respect 1. Remember, speech impairment is not related to intelligence.
Use age-appropriate language.
2. Make a note in the medical record if the individual uses a
device.
Environment 1. A quiet environment with minimal distractions can help
facilitate understanding. Face the person as they are speaking
for facial cues and gestures that can enhance understanding.
Understanding 1. Remember, the individual has no problem hearing from you.
Speak in a normal tone.
Communication 1. Encourage the person to speak slowly and use simple sentences
or single words.
2. Allow time for the patient to respond. Don’t try to complete
their words or sentences.
3. If there is no speech (aphasia, presence of an artificial airway,
post-operatively after oral surgery):
4. Assess the individual’s yes/no reliability.
5. Establish a system for yes/no communication (picture board or
eye blink—1 yes, 2 no). Post rules for use at the bedside and in
the medical record. Ask yes/no questions and allow the person
time to respond. Confirm response before acting.

Visual Impairments
Individuals with visual impairments have no difficulty hearing or speaking; however,
they will miss nonverbal communications. These individuals will have difficulty reading
signs of relying on visual cues for orientation or education purposes.

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Table 4. Communicating with Individuals with Visual Impairments

Invite, Respect 1. Gently call out to the individual when entering the room and
identify yourself and anyone with you in the room.
2. If the individual can see shapes or outlines, stand where he or she
can see you.
3. The best location will vary—make a note on the medical record
alerting other staff to the patient’s needs
Environment 1. Minimize distractions. Describe the environment and where you
are located concerning the person.
2. Explain what you are doing, especially when you are moving and
creating sounds in the room
3. Make certain not to move frequently used objects
Understanding 1. Alert the person when you will be touching them
Communication 1. Oral communication with touch is more important than nonverbal
gestures that they cannot see; use an appropriate tone of voice.

Hearing Impairments
Individuals with a hearing impairment have a reduced ability to hear across the
spectrum of sound. Typically, with age, it becomes more difficult to hear soft, high-pitched
sounds. Based on the severity of the damage, the individual may or may not elect to use a
hearing aid. Unless the hearing loss poses a significant disability, the individual may elect to
just get by without the hearing aid, at times much to the dismay of other family members.
Many hearing-impaired elders have learned the language and lived in an aural world so they
tend to rely on lip-reading, which matches oral gestures with sounds that are familiar to
them (Mauk, 2010).

Table 5. Communicating with Individuals with Hearing Impairments

Invite, Respect 1. To get the attention of the person, touch the person gently, wave,
or use another physical sign.
2. Store assistive devices—hearing aid, notepad, and pen—within
reach of the individual.
3. Make certain any emergency alarms essential for safety have a light
or visual alert to get the individual’s attention in case of emergency.
4. Allow time for the conversation

Environment 1. If the individual uses a hearing aid, check to see whether he or she
is wearing it and that it is turned on.
2. Minimize background noise (turn off the radio or TV and close the
door to minimize distractions from the hall).
3. When speaking, face the person directly so he or she can see your
lips and facial expressions. The preferred distance is 3–6 feet from the
person.
Understanding 1. Speak clearly in a low-pitched voice; avoid yelling or exaggerating
speaking movements—it won’t help.
2. Use short sentences.
3. Don’t hesitate to use written notes to maximize understanding and
involve the person in the conversation.
4. Avoid chewing, eating, or smoking as you speak; they will make
reading your speech more difficult.
5. Keep objects away from your face when speaking

Communication 1. Allow the individual to be involved in making decisions—don’t

assume it takes too much time to ask.
2. Provide time for the individual to speak.
3. Ask questions to clarify the message; if needed, have the individual
write a response.

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To summarize, communication with older adults may present some unique

challenges, including physical changes from normal aging as well as those associated with
common disease processes. By using the basic techniques discussed in this topic, nurses can
facilitate effective communication with older adults within a variety of situations and
settings.

V. Reflection

Reflect on your last day at clinical. What type of conversations did you have with your
assigned patient? Were there opportunities for you to engage in an effective conversation
with your assigned patient? Did you observe other staff members engaging also in other
patients? List barriers in health care that limit staff engaging in an effective conversation with
patients.

VI. Post Test

Encircle the letter of the correct answer.

1. The term communication originates from the Latin word “____________,” which means
“_________________.”
a. Commune; to hold a commonality
b. Commonality; to be one
c. Commune; to hold in common
d. Common; to hold common
2. Statement A: Effective communication depends on the ability of both to engage in the
process of sharing not merely words, but also concepts, emotions, and thoughts.
Statement B: communication is a process that involves one person.
a. Statement A is correct
b. Statement B is correct
c. All of the statements are correct
d. None of the statements are correct
3. Refers to the use of facial gestures, body posture, eye contact, and touch as a means of
communication.
a. Communication
b. Verbal Communication
c. Non-verbal Communication
d. None of the above
4. The following are the uses of communication in health care except:
a. Promoting health
b. Providing information and education
c. Encourage patients to change behavior
d. Promoting distress and pain
5. Refers to behavior necessary for assessing and solving problems
a. Task-focused communications
b. Non-verbal communication
c. Behavioral communication
d. Affective communication
6. Focuses on how the health care provider is caring about the patient and his or her feelings
and emotions.
a. Task-focused communications
b. Non-verbal communication
c. Behavioral communication
d. Affective communication
7. Which of the following is the management for an elderly with memory or cognitive
deficits?
a. Use medical terms in conversing with the patient
b. Be respectful of space
c. Ask too many questions at once
d. Show concern only when necessary.

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8. The following are the effective communication to an elderly with visual impairments
except:
a. Use short sentences.
b. Alert the person when you will be touching them
c. If the individual can see shapes or outlines, stand where he or she can see you.
d. Explain what you are doing, especially when you are moving and creating sounds
in the room
9. The following are the effective communication to an elderly with hearing impairments
except:
a. Use short sentences.
b. Keep objects away from your face when speaking
c. Minimize background noise
d. Allow limited time for the conversation
10. A type of aphasia wherein the individual can speak and produce language, although the
speech may contain many odd words and sounds.
a. Broca’s Aphasia
b. Global Aphasia
c. Wernicke’s Aphasia
d. Auditory Aphasia

VIII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.google.com/search?q=communication+process

https://nurseslabs.com/geriatric-nursing-care-
plans/#:~:text=Gerontology%20nursing%20or%20geriatric%20nursing,needs%20of
%20an%20aging%20individual.

UNIT XII. GERIATRIC HEALTH CARE TEAMS

I. Introduction

Geriatric care usually consists of a team-based approach. The care team can include
but is not limited to, a geriatrician, nurse gerontologist, case manager, physical therapist,
occupational therapist, and speech therapist. This team focuses on evaluating medical, social,
and emotional needs, with special emphasis on common problems in older adults, such as
memory problems, falls, incontinence, and multiple medications. The ultimate goal of this
care team is to help older adults age gracefully (Mauk, 2010).

II. Objectives/Competencies

At the end of the unit, I am able to:

1. identify the components of the geriatric health care team and their function; and
2. describe how the geriatric health care team will enhance the capability of the older
adult in decision making.

III. Pre-test

Find and circle the following words in the puzzle below. Words may be vertical, horizontal,
and diagonal, forward or backward.

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speech occupational dysarthria

dementia manager aphasia
gerontologist dysphagia apraxia
therapist

A P H A S I A D M N X Q Z R F D S W
K F R E S T L P B N M A N A G E R E
D E M E N T I A G B S D Q A E E W R
Y G D H J K L P Z C F D S A R Q W T
S X C Y Q P O C C U P A T I O N A L
A P F D S Q Q Z X C A Q H E N S Q Y
R O G S P P L Q T V P W E R T S W U
T I H A E G H S G B R E R F O D E I
H U J Z E H G A F N A R A L L G R O
R Y K X C N H Q G M X T P O O H T P
I T L V H B J K Z I I Y I Y G J Y L
A D F G H J Q E Y T A U S T I K U K
Q W D P O I U Y G H S G T R S W I J
Z X C V B N A S D F G H J K T E A H

IV. Lesson Proper

Geriatrician
A geriatrician is a primary care physician who specializes in treating conditions that
affect older adults (Mauk, 2010). The approach tends to be holistic and involves a
multidisciplinary team. The geriatrician concentrates on managing the medical conditions
affecting the patient.
Geriatricians diagnose and treat a wide range of conditions and diseases that affect
people as they age, including:
1. dementia
2. osteoporosis
3. incontinence
4. cancer
5. hearing and vision loss
6. osteoarthritis
7. insomnia
8. diabetes
9. depression
10. heart failure
11. frailty
12. balance issues

What is the difference between a Gerontologist and a Geriatrician? Gerontologists

aren’t medical doctors. They’re professionals who specialize in issues of aging or
professionals in various fields from dentistry and psychology to nursing and social work who
study and may receive certification in gerontology. These professionals are prepared to
provide their services and care to older adults.
Geriatricians also tend to coordinate the team of allied health specialists
like physiotherapists and occupational therapists that ensure the patient is in the best
environment and is safe and supported in their social situation whatever that may be.

Gerontologist Nurse
Gerontological nursing, then, is the aspect of gerontology that falls within the
discipline of nursing and the scope of nursing practice (Mauk, 2010). It involves nurses
advocating for the health of older persons at all levels of prevention. Gerontological nurses
work with healthy elderly persons in their communities, the acutely ill elderly requiring

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hospitalization and treatment, and the chronically ill or disabled elderly in long-term care
facilities, skilled care, home care, and hospice. The scope of practice for gerontological
nursing includes all older adults from the time of “old age” until death. The roles of
Gerontological nurses are:

1. Provider of care
In the role of caregiver or provider of care, the gerontological nurse gives direct,
hands-on care to older adults in a variety of settings. Older adults often present
with atypical symptoms that complicate diagnosis and treatment. Thus, the nurse
as a care provider should be educated about the common disease processes seen
in the older population.
2. Teacher
Gerontological nurses focus their teaching on modifiable risk factors. Many
diseases of aging can be prevented through lifestyle modifications such as a
healthy diet, smoking cessation, appropriate weight maintenance, increased
physical activity, and stress management.

3. Advocate
As an advocate, the gerontological nurse acts on behalf of older adults to promote
their best interests and strengthen their autonomy and decision making. Nurses
may also advocate for patients through other activities such as helping family
members choose the best nursing home for their loved one or listening to family
members vent their frustrations about health problems encountered
4. Research Consumer
This involves gerontological nurses being aware of current research literature,
continuing to read and put into practice the results of reliable and valid studies.
Using evidence-based keep gerontological nurses can improve the quality of
patient care in all settings.

Occupational Therapist
Occupational therapy is a process that involves helping people at all stages of life
(from toddlers to elderly) develop, maintain, or recover the skills they need to daily activities
(aka occupations) that are meaningful and necessary (Mauk, 2010). The type of occupational
therapy a person receives will vary greatly on their needs. Occupational therapists also
educate and work with the patient’s support team (parents, caregivers, teachers, etc) to
make sure everyone understands their role in the patient’s care program. The following are
the key benefits of occupational therapy for the elderly:

1. Keeps arthritis at bay

An occupational therapist will properly analyze their patient to determine
the type of arthritis and then take relevant action. Arthritis patients may feel pain and
discomfort when moving the affected joints. Therapists will help patients by helping them
use their hands differently or change their ‘resting’ positions to more comfortable
positions. This will allow them to perform heavier jobs with more ease. The use of
affected joints in a different manner will also help them perform tasks with fewer resting
breaks.
2. Increases movement range
One of the more common and helpful techniques used by therapists is “range of
motion” (ROM) exercises. ROM exercises do exactly what the name suggests: increase the
patient’s range of motion while decreasing pain and stiffness. This is particularly helpful
in the case of elderly patients who have worn out their ligaments, have stiff joints, or are
ailed by arthritis.
3. Improves Vision
OT can help elderly people with eye-conditions such as double vision, lazy eye,
balance, dizziness, strabismus, and reading. The therapist starts by identifying whether
the damage is repairable or not, after which they give the patient treatments tailored to
their needs.

4. Boosts Memory and Cognitive Skills

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 82

With age, it is common for the brain cells to deteriorate, leading to forgetfulness or
dementia in severe cases. OT can help patients retain and sharpen their memory and
cognitive skills at any stage of memory loss. However, the earlier the treatment begins,
the better. Solving crossword puzzles and reading books are prime examples of cognitive
exercises.
5. Helps Coping with Chronic Pain
Chronic pain continues beyond its usefulness as a warning. It might be due to several
factors, the most common of them being the normal aging of the affected bones and joints.
Other causes include nerve damage, traumatic injuries, injuries that fail to heal properly,
etc. Chronic pain can result in a loss of empowerment and control over daily activities.
Occupational therapists use managed approaches to provide patients with adaptive ways
of going about their daily tasks.

Physical Therapist
Physical therapy can help seniors retain their independence, whether they are
managing a long-term illness or just want to improve their general health and mobility. The
goal of physical therapy is to help restore and improve functionality, reduce pain, and
increase mobility for better strength and balance (Mauk, 2010). Physical therapy for seniors
is beneficial for a variety of reasons, including:
1. Reducing the risk of a fall.
One of the most common reasons a senior needs physical therapy is to recover
from a fall. Falls are the leading case of accidents among seniors and often result in bone
fractures and other injuries. A physical therapist can teach seniors techniques to prevent
a fall.
2. Lowering the risk of injury.
Physical therapy helps seniors learn how to maintain their stability as it relates
to gravity when they’re mobile. This awareness helps reduce the risk of injuries and re-
injury.
3. Decreasing pain from chronic conditions.
Physical therapy can help alleviate discomfort from conditions like arthritis or
osteoporosis and offset any future symptoms.
4. Lessening the need for prescription drugs
Seniors are often on a wide variety of prescription drugs to help manage their
chronic pain. However, a physical therapy regimen could help reduce the need for
medications and could be a more cost-effective form of treatment.
5. Maintaining an independent lifestyle
The quicker seniors can recover from an illness or injury and manage their pain
allows them to lead an active, independent lifestyle for a longer period.

Speech Therapist
Speech therapy for seniors is often necessary when recovering from the debilitating
consequences of a stroke or dementia. It may also be necessary after a head injury. The
ability to communicate effectively is important at any age, but for seniors, it can be vital. If a
senior cannot successfully describe what they need, where they hurt, or what is wrong in
general, an emergency can easily occur (Mauk, 2010). Speech therapy is considered for the
following reasons:
1. Aphasia
Aphasia is a communication disorder1 in which patients have trouble
finding the right word for their thoughts, or their speech is halting or unclear.
Speech therapy works to help patients concentrate to find the right word, as
well as respond to verbal and vocal cues. The goal of the therapy is to have the
patient reach the maximum possible functioning, although this may not be the
same level that they enjoyed before their stroke.
2. Apraxia
Symptoms include using words out of order or even having trouble
moving their lips correctly to form the words. Treatment can involve asking
the patient to repeat certain sounds, and then try to make these sounds into
words. Also, the patient may have to speak more slowly, at least at first, to
make the words, or say them in the correct order.

3. Dysphagia

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Dysphagia is the inability to swallow easily. A speech therapist may

recommend special positions for eating, certain foods, or modified utensils to
combat this problem.
4. Dysarthria
It is commonly seen in those with diseases that affect the nervous system,
such as Parkinson’s, because of weakness or paralysis that are typical of the
condition. Symptoms include a slow rate of speech or speech that sounds
mumbled, slurred, or hard to understand. In these cases, a speech therapist
will often monitor the patient’s muscle and breathing patterns, as well as have
them repeat certain sounds. Treatment techniques often involve having the
patient work on tongue and lip movement, breathing techniques, and
speaking more slowly to have time to form words.

Case Manager
Gerontological nurses act as managers during everyday care as they balance the
concerns of the patient, family, nursing, and the rest of the interdisciplinary team. Nurse
managers need to develop skills in staff coordination, time management, assertiveness,
communication, and organization. Nurse managers may supervise other nursing personnel
including licensed practical nurses (LPNs), certified nursing assistants (CNAs), nurse
technicians, nursing students, and other unlicensed assistive personnel (UAP) (Mauk, 2010)

V. Reflection

How important to you is the role of each member of the geriatric health care team?
Have you ever considered a career in one of the said members of the team? If so, how do you
visualize yourself 10 years from now in such a position?

VI. Post Test

Encircle the letter of the correct answer.

1. Statement A: Gerontologists are professionals who specialize in issues of aging.
Statement B: A geriatrician is a primary care physician who specializes in treating
conditions that affect older adults.
a. Statement A and B are correct
b. Statement A and B are incorrect
c. Only statement A is correct
d. Only statement B is correct
2. The roles of Gerontological nurses are the following except:
a. Advocate
b. Teacher
c. Provider of Care
d. All of the above
3. This role of a Gerontologist Nurse acts on behalf of the older adult to promote their best
interests and strengthen their autonomy and decision making.
a. Research Consumer
b. Teacher
c. Advocate
d. Provider of Care
4. This involves gerontological nurses being aware of current research literature,
continuing to read and put into practice the results of reliable and valid studies.
a. Research Consumer
b. Teacher
c. Advocate
d. Provider of Care
5. Statement A: The type of occupational therapy a person receives will vary greatly on
their family’s needs.
Statement B: The goal of physical therapy is to help restore and improve functionality,
reduce pain, and increase mobility for better strength and balance.
Statement C: The scope of practice for gerontological nursing includes all older adults
from the time of being terminally-ill until death.
a. Statement A and B are correct

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 84

b. Statement A and C are incorrect

c. All of the statements are correct
d. None of the statement is correct
6. Physical therapy for seniors is beneficial for a variety of reasons, including:
a. Maximizing the pain from chronic conditions
b. Maintaining a dependent lifestyle
c. Reducing the risk of fall
d. Increasing the need for prescription drugs
7. Symptoms include using words out of order or even having trouble moving their lips
correctly to form the words.
a. Aphasia
b. Apraxia
c. Dysphagia
d. Dysarthria
8. Symptoms include a slow rate of speech or speech that sounds mumbled, slurred, or hard
to understand.
a. Aphasia
b. Apraxia
c. Dysphagia
d. Dysarthria
9. A communication disorder1 in which patients have trouble finding the right word for
their thoughts, or their speech is halting or unclear
a. Aphasia
b. Apraxia
c. Dysphagia
d. Dysarthria
10. Treatment can involve asking the patient to repeat certain sounds, and then try to make
these sounds into words
a. Aphasia
b. Apraxia
c. Dysphagia
d. Dysarthria

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2006) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.sharecare.com/health/senior-health/what-professionals-geriatric-care-
team

https://healthengine.com.au/info/geriatrics#:~:text=A%20geriatrician%20is%20a%2
0doctor,medical%20conditions%20affecting%20the%20patient.

https://www.healthline.com/health/geriatrician-doctor#benefits

https://ptsolutions.com/key-benefits-ot-older-adults/

https://www.asccare.com/4-types-physical-therapy-seniors/

https://www.asccare.com/physical-therapy-for-
seniors/#:~:text=Physical%20therapy%20can%20give%20seniors,a%20higher%20qu
ality%20of%20life.

https://blog.ioaging.org/activities-wellness/speech-therapy-for-seniors-conditions-it-
can-address-tactics-may-be-explored/

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 85

UNIT XIII. EDUCATIONAL AND CAREER TRENDS IN GERONTOLOGICAL

NURSING
I. Introduction

Dozens of career options exist in the field of gerontological nursing. In addition to

various job descriptions, gerontological nurses work in a variety of settings, from the
community with well elderly to hospice with the dying, and every point in between along the
continuum of care. A few unique possibilities in gerontological nursing will be discussed in
this unit.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. Identify current career trends in gerontological nursing; and
2. Describe several settings and positions in which gerontological nurses may be
employed.

III. Pre-test

Unscrambled each jumbled arrangement of letters to form words related to the topic.

LEGOOOACIRNTLG GNINRUS ______________ _______

EOHISCP AIECFLITIS _______ __________
EEMTRRTIEN INGVIL __________ ______
RCDOOT OF GNINRUS EAPRCCTI ______ __ _______________
ADY ACRE EENCRST ___ ____ _______

IV. Lesson Proper

Career Trends in Gerontological Nursing

Most gerontological nurses with basic preparation find work in long-term care
facilities such as nursing homes, assisted living, independent living centers, adult day-care,
or in an acute care hospital. Nurses who obtain a BSN and continue to work in geriatrics often
become unit managers, then assistant directors or directors of nursing in nursing homes or
other long-term care settings (Mauk, 2010). Many geriatric nurses work in home health care
and hospice, those specialties that service many chronically ill and/or dying older adults.
1. Home Care
Older adults requiring a longer period of observation or care from nurses may be
candidates for home health care services. Visiting nurse associations (VNAs) have long
been known for their positive reputation in providing home care. Home care is designed
for those who are homebound due to the severity of illness or immobility.
The majority of home care patients are elderly and experience a variety of problems
needing nursing, such as chronic wounds, intravenous therapy, long-term indwelling
urinary catheters, and tube feedings.
2. Hospice Facilities
Gerontological nurses may also choose to work in hospice, caring for dying persons
and their families. Although many patients in hospice are not elderly, the majority of the
dying are older. The concept of hospice is centered around holistic, interdisciplinary care
that helps the dying person “live until they die”. Many team members who specialize in
thanatology and palliative care work together to provide quality care for patients in their
last months, weeks, days, and hours of life. Pain management and comfort care are the
standards upon which treatment is based. Nurses and physicians work closely with social
workers, chaplains, psychologists, and other hospice professionals to make death as
comfortable and as easy a transition as possible.
3. Drop-in or Day Care Centers

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Adult daycare or day services provide yet another avenue for older adults who are
unable to remain at home during the day without supervision. Usually, these services are
used by family members who are caring for older parents or loved ones in their own
homes, but who may work during the day and wish to have their relatives safely cared for
in their absence. This is an excellent alternative to institutionalization.
4. Retirement Living / Home / Village
As older persons continue to age, common disorders associated with the aging
process may likely interfere with their ability to care for themselves. Assisted living provides
an alternative for those older adults who do not feel safe living alone, who wish to live in a
community setting, or who need some additional help with activities of daily living (ADLs).
Assisted living is often connected with a facility or care network, generally, those that provide
long-term care, though the facility itself may be freestanding and cater exclusively to the
assisted living population. The drawback of this arrangement is not only that older adults
whose condition degenerates and who need greater assistance find a cost attached with each
extra bit of help they need in assisted living, but also that they may be turned out of the facility
when their care needs become greater, leaving them to find another institution that provides
a higher level of care.

Educational and Career Trends in Gerontological Nursing

For nurses with doctoral-level education, careers as faculty members abound. The
faculty shortage is acute and projected to continue. There is a tremendous need for certified
and well-prepared faculty members in gerontological nursing to teaching students who will
care for the aging population. Nurses may obtain several doctorates that may be considered
terminal degrees, though this varies with each university and school of nursing (Mauk, 2010).
The Ph.D. (doctor of philosophy in nursing) and DNS (doctor of nursing science) are
currently recognized as terminal nursing degrees by most universities. The Ph.D. is a
universal research degree recognized in most countries. This preparation allows the holder
to design and conduct research in addition to taking coursework in theory, statistics, and
philosophy (NursePractitionerSchools.com).
The Ph.D. in Nursing Program aims to produce a cadre of doctorally-prepared nurses
who will facilitate the development of theory-based nursing care practices in the Philippines.
The program is geared towards the advancement of research-based education and practice-
based nursing. Prospective students are provided a program directed towards structured
nursing knowledge and practice from formalized conceptions of nursing
(NursePractitionerSchools.com).
The DNP (doctor of nursing practice) is a clinical doctorate that is gaining more
popularity in combination with obtaining certification as a nurse practitioner. It is not
intended to prepare the nurse to be a researcher.
While both the Ph.D. in nursing and the DNP are terminal degrees, the curricula vary.
Ph.D. programs emphasize the development of research and writing skills, with specific
emphasis on utilizing quantitative and qualitative methods. The curriculum also devotes
more time to understand the history of the discipline alongside contemporary challenges and
opportunities (NursePractitionerSchools.com).
The DNP, in contrast, focuses on building advanced clinical skills that can be used in
advanced practice roles. Students spend much of their time examining how topics transfer
into their professional work as a nurse.

Potential Opportunities in Gerontological Nursing

The opportunities for nurses in geriatrics cover a wide variety of educational levels
and settings for employment. Although many nurses will find their first jobs in acute care
hospitals, nurses historically change positions throughout their careers. With the projected
changes in the population distribution to a large older cohort of baby boomers, nurses are
likely to see a dramatic shift in the types and numbers of nonhospital opportunities for career
advancement (Mauk, 2010).
The need for clinical nurse specialists in gerontology is likely to increase, as is the
need for geriatric nurse practitioners. Because the baby boomer generation is known to be
an autonomous, well educated, informed consumer group, this population cohort is more
likely to demand a higher level of education and expertise among care providers. As health-
conscious and savvy researchers, baby boomers will want the highest quality care from those
with the most expertise (and for the best value for their money). These trends point to

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advanced practice nurses as the most valuable professionals of the upcoming older
generation.
Over the next decades, the health care system may experience unexpected shifts, such
as more care being provided in the home by spouses and family members. Nurses may be
called upon to train family members to care for loved ones in their homes to a much greater
extent than occurs today. On the other hand, though baby boomers may not wish to be cared
for in institutions or long-term care facilities, their children are a generation that tends to be
quite mobile and more focused on meeting their own life goals than perhaps taking care of
elderly parents. If life expectancy continues at its current rate or even increases, baby
boomers may be assisted in later life more often by their spouses, friends, church
communities, and assistive technology than ever before. The demand for better, higher
quality, more personal, and professional care in nursing homes may also increase if aging
baby boomers can no longer be cared for in the home environment.
All these potential changes lead to the possibility that gerontological nurses of the
future will need to be more highly educated and have a good business sense, excellent
management skills, and greater flexibility in the workplace. Nurses may be seen more often
in collaborative practice to meet the growing needs of greater numbers of older adults.
Advanced practice nurses will become more entrepreneurial, creating companies that
specialize in educating businesses, churches, organizations, and private health care
consumers about the aging process and how to stay healthy longer.

V. Reflection

If you would choose between Doctor of Philosophy in Nursing and Doctor of Nursing
Practice which would you take and why? Is this something that you might like to do in the
future?

VI. Post Test

Encircle the letter of the correct answer.

1. The majority of patients are elderly and experience a variety of problems needing
nursing, such as chronic wounds, intravenous therapy, long-term indwelling urinary
catheters, and tube feedings.
a. Hospice care facilities
b. Day Care Centers
c. Retirement Living
d. Home Care
2. The concept of this is centered around holistic, interdisciplinary care that helps the dying
person “live until they die”.
a. Hospice care facilities
b. Day Care Centers
c. Retirement Living
d. Home Care
3. This provides an alternative for those older adults who do not feel safe living alone, who
wish to live in a community setting, or who need some additional help with activities of
daily living (ADLs).
a. Hospice care facilities
b. Day Care Centers
c. Retirement Living
d. Home Care
4. Statement A: Nurses and physicians work closely with social workers, chaplains,
psychologists, and other hospice professionals to make death as comfortable and as easy
a transition as possible.
Statement B: Several team members who specialize in palliative care work together to
provide quality care for patients in their last months, weeks, days, and hours of life.
a. Statement A and B are correct
b. Statement A and B are incorrect
c. Only statement A is correct
d. Only statement B is correct
5. This program aims to produce a cadre of doctorally-prepared nurses who will facilitate
the development of theory-based nursing care practices in the Philippines.

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a. Doctor of Philosophy in Nursing

b. Doctor of Education in Nursing
c. Doctor of Nursing Practice
d. None of the above
6. The program is geared towards the advancement of research-based education and
practice-based nursing.
a. Doctor of Philosophy in Nursing
b. Doctor of Education in Nursing
c. Doctor of Nursing Practice
d. None of the above
7. Focuses on building advanced clinical skills that can be used in advanced practice roles.
a. Doctor of Philosophy in Nursing
b. Doctor of Education in Nursing
c. Doctor of Nursing Practice
d. None of the above
8. Students in this program are directed towards structured nursing knowledge and
practice from the formalized conceptions of nursing.
a. Doctor of Philosophy in Nursing
b. Doctor of Education in Nursing
c. Doctor of Nursing Practice
d. None of the above
9. Students spend much of their time examining how topics transfer into their professional
work as a nurse.
a. Doctor of Philosophy in Nursing
b. Doctor of Education in Nursing
c. Doctor of Nursing Practice
d. None of the above
10. Statement A: Doctor of Nursing Practice emphasizes the development of research and
writing skills, with specific emphasis on utilizing quantitative and qualitative methods
Statement B: Doctor of Nursing Practice intended to prepare the nurse to be a researcher.
a. Statement A and B are correct
b. Statement A and B are incorrect
c. Only statement A is correct
d. Only statement B is correct

VIII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

http://archive.su.edu.ph/resources/college-of-nursing/doctor-of-philosophy-in-
nursing-1372814085.pdf

https://www.nursepractitionerschools.com/faq/difference-between-dnp-phd-nursing/

UNIT XIV. ADVOCACY PROGRAMS FOR OLDER ADULT

I. Introduction

The care for older Filipinos is guaranteed by the fundamental law of the land. The
1987 Philippine Constitution ensures the promotion and protection of the rights and welfare
of Filipino senior citizens as a minority population sector. Laws and programs focusing on
services for older Filipinos have developed incrementally over the past 40 years, although
much remains to be done to ensure their full implementation (Chalkasra, 2014; Commission

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on Human Rights, 2019; Salenga et al. 2016). In this unit programs supporting care for an older
adult will be discussed.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. identify the support and program initiatives of the Philippine government to older
adults; and
2. realize the need and importance of the different programs in ensuring the health of
the older adult.

III. Pre-test

Find and circle the following words in the puzzle below. Words may be vertical, horizontal,
and diagonal, forward or backward.

DSWD kinship senior citizen community

DOH residential family
caregiver senior citizen act advocacy

M D Y F Q W E R L A N I K L S S C A X
N Z U A C K T D A A U D R E Y D W D K
B Q I M O R I B W U I M T R I X I V J
V W D I M K P N S R F T R I X I E O H
C L W L M W L R S A Q G N J S A X C G
X K S Y U K D E T H O O O E A C V A F
Z T D F N Q O T Y K I L E F D X M C F
G G Y R I E H K O Q R P F F Y I W Y D
N E Z W T O C R O I N E S M A Y S O S
W E X Y Y P Z X C V B N M A S D F E A
H E X Q D W R E V I G E R A C E E E R
K D C T C A N E Z I T I C R O I N E S

IV. Lesson Proper

Philippine Government Programs for Older Adult

Department of Social Welfare and Development (DSWD)

The overall lead of the National Inter-Agency Coordinating and Monitoring Board of
RA 9994 implementation has designed long-term care (LTC) program strategies to
respond to the need of the older persons for care and support as provided in RA 9994:
1. Home Care Support Services for Senior Citizens (HCSSC)
This pertains to services provided to senior citizens while in their homes such
as assisting senior citizens in their daily living activities (e.g. bathing, eating, dressing,
etc); training volunteers and family members on caregiving for senior citizens;
provision of assistive devices for senior citizens: and community-based rehabilitative
activities. Examples of Home Care Support Service are the following:
a. Hospice Care Service
This service offers shelter and care to weary sick senior citizens.
Volunteers will be mobilized/utilize to provide direct services and/or
assistance to the dying senior citizens and psychosocial support to their
families.
b. Foster Home

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This is the provision of a planned temporary alternative family

care for older persons who are abandoned, neglected, unattached from
the community, or those in residential care facilities but found eligible to
benefit from the program. It will provide subsidies and caregiver training
for foster families licensed by the DSWD.
c. Family/Kinship Care
This is a form of foster care which involves the placement of a
senior citizen under the care of his/her relatives and/or family members.
This includes the provision of caregiving training to the main family carer;
establishing a community-based support system to prevent burn-out of
the carer; and prevent institutionalization of the senior citizens.
d. Support Services for Caregivers
This refers to capability building and continuing education for
caregivers on the care and management of older persons and burn-out
prevention. It also seeks to relieve caregivers/ family carers of stress
arising from the responsibility of providing daily care. It will also provide
subsidies and allowances to volunteers in the amount approved by the
LGUs.

2. Residential Care Service (RCS)

A 24-hour facility that provides long term or temporary multidisciplinary care
to senior citizens who are abandoned by their families or with no significant others
to provide the needed supervision and supportive care. The services that will be
provided Includes social services, health & medical services, psychological services,
skills training, group work activities, dietary services, home life /group living
services, spiritual services (I.e. religious services, masses, confession, bible studies,
etc.) and provision of assistive devices.

3. Community-based Services for Senior Citizens and their families

This refers to the programs and services rendered when the helping process
takes place in the community as the primary client system, or when social welfare
and development activities are provided to individuals, groups, and families while
they remain in their own homes.
4. Volunteer Resource Services (VRS)
This will encourage and mobilize individuals, interested groups, and
intermediaries, as well as able-bodied senior citizens, to voluntarily contribute their
time, skills, and capabilities for the delivery of programs/services for the benefit of
the impoverished senior citizens.

Department of Health (DOH)

1. Health and Wellness Program for Senior Citizens
In support of the RA 9257 (The Expanded Senior Citizens Act of 2003) and
the RA 9994 (Expanded Senior Citizen Act of 2010), the Department of Health issued
Administrative Orders for health implementors to undertake and promote the health
and wellness of senior citizens as well as to alleviate the conditions of older persons
who are encountering degenerative diseases. With the goal of the Health and
Wellness Program for Senior Citizen of promoting quality of life among older persons
and contribute to the nation-building, the HWPSC intends to provide the following:
a. focused service delivery packages and integrated continuum of
quality care,

b. patient-centered and environment standard to ensure safety and

accessibility for senior citizens,
c. equitable health financing,
d. capacitated health providers in the implementation of health
programs for senior citizens,
e. database management, and
f. strengthened coordination and collaboration with other
stakeholders involved in the implementation of programs for senior
citizens.

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In the current Philippine Health Agenda (2017 - 2022), guarantees that

centralize health services for care in all life stages, service delivery networks, and
financial risk protection, geriatric health is mentioned as an area of concern. All
senior citizens are mandatorily covered by the Philippine Health Insurance
Corporation under Republic Act No. 10642 “An act granting mandatory national
health insurance program of PhilHealth for all senior citizens”.

Vision
A country where all Filipino senior citizens can live an improved quality of life
through healthy and productive aging.

Mission
Implementation of a well-designed program that shall promote the health and
wellness of senior citizens and improve their quality of life in partnership with other
stakeholders and sectors.

Objectives

1. To ensure better health for senior citizens through the provision of focused
service delivery packages and integrated continuum of quality care in various
settings.
2. To develop patient-centered and environmental standards to ensure the safety
and accessibility of all health facilities for the senior citizens.
3. To achieve equitable health financing to develop, implement, sustain, monitor,
and continuously improve quality health programs accessible to senior citizens.
4. To enhance the capacity of health providers and other stakeholders including
senior citizens group in the implementation of health programs for senior
citizens.
5. To establish and maintain a database management system and conduct
researches in the development of evidence-based policies for senior citizens.
6. To strengthen coordination and collaboration among government agencies, non-
government organizations, partner agencies, and other stakeholders involved in
the implementation of programs for senior citizens.

V. Reflection

Do you think that the programs cited in this unit truly meet the needs of older people?
If you could build a program for the elderly what would it be and why?

VI. Post Test

Encircle the letter of the correct answer.

1. A 24-hour facility that provides long term or temporary multidisciplinary care to senior
citizens who are abandoned by their families or with no significant others to provide the
needed supervision and supportive care.
a. Home Care Support Services for Senior Citizens (HCSSC)
b. Residential Care Service (RCS)
c. Community-based Services for Senior Citizens and their families
d. Volunteer Resource Services (VRS)
2. This pertains to services provided to senior citizens while in their homes such as
assisting senior citizens in their daily living activities.
a. Home Care Support Services for Senior Citizens (HCSSC)
b. Residential Care Service (RCS)
c. Community-based Services for Senior Citizens and their families
d. Volunteer Resource Services (VRS)
3. Encourage and mobilize individuals, interested groups, and intermediaries to voluntarily
contribute their time, skills, and capabilities for the delivery of programs/services for the
benefit of the impoverished senior citizens.
a. Home Care Support Services for Senior Citizens (HCSSC)
b. Residential Care Service (RCS)

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c. Community-based Services for Senior Citizens and their families

d. Volunteer Resource Services (VRS)
4. This refers to the programs and services rendered when the helping process takes place
in the community as the primary client system, or when social welfare and development
activities are provided to individuals, groups, and families while they remain in their own
homes.
a. Home Care Support Services for Senior Citizens (HCSSC)
b. Residential Care Service (RCS)
c. Community-based Services for Senior Citizens and their families
d. Volunteer Resource Services (VRS)
5. Services include health & medical services, psychological services, skills training, group
work activities, dietary services, home life /group living services, spiritual services
a. Home Care Support Services for Senior Citizens (HCSSC)
b. Residential Care Service (RCS)
c. Community-based Services for Senior Citizens and their families
d. Volunteer Resource Services (VRS)
6. An act granting mandatory national health insurance program of PhilHealth for all
senior citizens
a. Republic Act No. 10642
b. Republic Act No. 9257
c. Republic Act No. 9994
d. Republic Act No. 10644
7. The following are the objectives of the health and wellness program for senior citizens
by DOH except:
a. enhance the capacity of health providers and other stakeholders
b. achieve equitable health financing
c. provision of focused service delivery packages and integrated continuum of
quality care
d. limit the development of patient-centered and environment standards
8. This is the provision of a planned temporary alternative family care for older persons
who are abandoned, neglected, unattached from the community
a. Hospice care service
b. Foster home
c. Family or Kinship Care
d. Support Services for Caregivers
9. This includes the provision of caregiving training to the main family carer; establishing
a community-based support system to prevent burn-out of the carer; and prevent
institutionalization of the senior citizens.
a. Hospice care service
b. Foster home
c. Family or Kinship Care
d. Support Services for Caregivers
10. Seeks to relieve caregivers/ family carers of stress arising from the responsibility of
providing daily care
a. Hospice care service
b. Foster home
c. Family or Kinship Care
d. Support Services for Caregivers

VII. REFERENCES

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins
Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

https://www.un.org/en/development/desa/population/events/pdf/expert/29/sessio
n8/EGM_26Feb2019_S8_PleneeGraceJCastillo.pdf

https://www.dswd.gov.ph/issuances/AOs/AO_2010-005.pdf

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UNIT XV. TELEHEALTH AND THE OLDER PERSON

I. Introduction

This century reflects a time of change for nursing and the way that nurses deliver
health care to the population over the age of 65 years. Americans are living longer, and by the
year 2030, this age cohort will increase from about 30 million in the 1990s to more than 70
million (U.S. Census Bureau, 2004). In the Philippines according to a 2018 study by the
Philippine Institute for Development Studies (PIDS), the Philippines is on its way to becoming
an “aging society” in 2032. This means that in 13 years, Filipinos aged 65 years old and older
will make up 7% of our country’s total population. In 2069, this figure will go up to 14%,
making the Philippines an “aged society.”
Most of these individuals expect to have an active life in the community well into their
seventh decade. Each decade of life past age 65 brings with it acute illnesses and chronic
conditions accompanied by increased disability (CDC, 2004). Nurses caring for older adults
must advocate for and use new ways to provide care to these adults that promote their quality
of life. The purpose of this topic is to provide information about the integration of nursing
care with the latest assistive technology that supports the care of older adults, as well as
describe the technologies on the horizon.

II. Objectives/Competencies

At the end of the unit, I am able to:

1. identify assistive technology and methods for teaching older adults about their use;
2. recognize common applications of assistive technology to enhance older adults’
functioning independence, and safety;
3. describe Internet and Web approaches for assistive technology, including learning
activities, health information, and health care services that can be used in caring for
older adults and their families, along with teaching strategies for its access; and
4. discuss new assistive technologies on the horizon.

III. Pre-test

Fill in the missing letters in the following words related to the topic and write the answers on
the space provided.

1. A_ _ ist_ _e Te_h_ol_gy ________________________________

2. _nd_pe_d_ nce ________________________________

3. Po_iti_n and _ob_l_ty ________________________________

4. Eme_ _enc_ Resp_ _ _e S_s_em ________________________________

5. Alte_ _ ative Co _ _ u n _ca _ ion ________________________________

IV. Lesson Proper

Assistive Technology
This growing population of older adults will change many aspects of health care. One
change will be an increase in the number of people who experience disabling conditions. As
individuals age or become disabled, mental and physical changes may influence their ability
to live as independently and productively as they would wish. A lessening or loss of strength,
balance, visual and auditory acuity, cognitive processing, and/or memory may affect the way
they can function at home. Assistive technology devices are mechanical aids that substitute
for or enhance the function of some physical or mental ability that is impaired (Kelker, 1997).
The term assistive technology encompasses a broad range of devices from “low tech”
(e.g., pencil grips, splints, paper stabilizers) to “high tech” (e.g., computers, voice

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synthesizers). These devices include the entire range of supportive tools and equipment,
from adapted spoons to wheelchairs and computer systems for environmental control.
As a tool for living, the primary purpose of assistive technology is to bridge the gap
between an older person’s declining capabilities and the unchanging environmental demands
of home and community (Gitlin, 1998). The use of assistive devices may enable independent
performance, increase safety, reduce risk of injury, improve balance and mobility, improve
communication, and limit complications of an illness or disability. These devices are not just
for those who are disabled or have functional limitations. Assistive devices can also help
individuals who are aging and who may benefit from using them to promote safety and
reduce the risk of injury, as well as individuals experiencing age-related changes or functional
decline and who may benefit from equipment and devices that enable independent
performance and prevent disability.

Telemedicine The practice of medicine using technology to deliver care at a distance. A

physician in one location uses a telecommunications infrastructure to deliver care to a patient
at a distant site.
Telehealth Refers broadly to electronic and telecommunications technologies and services
used to provide care and services at-a-distance.
Benefits of Telemedicine
Telemedicine requires no significant outlay other than a web camera and a secure
patient portal that connects the doctor to a secured electronic medical record database
online. This type of system ensures the safety of the private information discussed during a
telemedicine call, while also providing the treating clinician with the ability to store
necessary medical records. In addition to these required devices, the physician will also
require a medical license that has been provided by the same state where the patient
receives will receive their prescription. Those who support the use of telemedicine point to
its convenience, reduced waiting times, expanded access to high-quality medical diagnosis
and treatment, as well as its lower cost as compared to most other medical consultations. In
addition, the ready availability of patient records online has the potential to make patient
prescriptions more reliable and accurate. By providing second opinions more easily and
faster, telemedicine can also make the patient and physician experience better. Finally, it
produces improved health outcomes, which should be the primary goal of all health
services. Many studies that have drawn direct comparisons between telemedicine and other
approaches to patient management have shown that a clear benefit associated with the use
of telemedicine. The benefit was greatest in the areas of teleradiology, telemental health,
telecardiology (echocardiography in particular), home telecare, and teledermatology. Many
researchers agree, however, on the limited evidence at present on the benefits or cost-
effectiveness of telemedicine, which requires further studies.

Benefits for patients

Telemedicine can help treat a range of medical conditions. It is most successful when a
person seeks care from a qualified physician and provides clear details about their
symptoms. Some other benefits of telemedicine include:
● Lower costs: Some research suggests that people who use telemedicine spend less time
in the hospital, providing cost savings. Also, less commuting time may mean fewer
secondary expenses, such as childcare and gas.
● Improved access to care: Telemedicine makes it easier for people with disabilities to
access care. It can also improve access for other populations, including older adults,
people who are geographically isolated, and those who are incarcerated.
● Preventive care: Telemedicine may make it easier for people to access preventive care
that improves their long-term health. This is especially true for people with financial or
geographic barriers to quality care. For instance, a 2012 study of people with coronary
artery disease found that preventive telemedicine improved health outcomes.
● Convenience: Telemedicine allows people to access care in the comfort and privacy of
their own home. This may mean that a person does not have to take time off of work or
arrange childcare.
● Slowing the spread of infection: Going to the doctor’s office means being around
people who may be sick, often in close quarters. This can be particularly dangerous for
people with underlying conditions or weak immune systems. Telemedicine eliminates
the risk of picking up an infection at the doctor’s office.

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Benefits for healthcare providers

Healthcare providers who offer telemedicine services may gain several benefits,
including:
● Reduced overhead expenses: Providers who offer telemedicine services may incur
fewer overhead costs. For example, they may pay less for front desk support or be able
to invest in an office space with fewer exam rooms.
● Additional revenue stream: Clinicians may find that telemedicine supplements their
income because it allows them to provide care to more patients.
● Less exposure to illness and infections: When providers see patients remotely, they
do not have to worry about exposure to any pathogens the patient may carry.
● Patient satisfaction: When a patient does not have to travel to the office or wait for
care, they may be happier with their provider.

Disadvantages of Telemedicine
● However, telemedicine may not suit every person or situation. There are some potential
disadvantages when using telemedicine over traditional care methods.
● The following sections look at some disadvantages for patients and healthcare
providers.

Disadvantages for patients

Telemedicine is not a good fit for all patients. Some drawbacks of this type of care include:
● Protecting medical data: Hackers and other criminals may be able to access a
patient’s medical data, especially if the patient accesses telemedicine on a public
network or via an unencrypted channel.
● Care delays: When a person needs emergency care, accessing telemedicine first
may delay treatment, particularly since a doctor cannot provide life saving care or
laboratory tests digitally.

Disadvantages for healthcare providers

Healthcare providers may also face some drawbacks associated with telemedicine,
including:
● Technological concerns: Finding the right digital platform to use can be
challenging. Also, a weak connection can make it difficult to offer quality care.
Clinicians must also ensure that the telemedicine program they use is secure and
fully compliant with privacy laws.
● An inability to examine patients: Providers must rely on patient self-reports
during telemedicine sessions. This may require clinicians to ask more questions to
ensure that they get a comprehensive health history. If a patient leaves out an
important symptom that might have been noticeable during in-person care, this can
compromise treatment.

Teaching About the Use of Assistive Technology

The use of assistive technology is a type of health behavior among older adults to
maintain their independence and enable them to live at home. From the viewpoints of the
national health economy and quality of life of older adults and caregivers, it is important to
understand who does not use devices and why they do not. This type of technology offers the
potential of increasing independence and quality of life for older individuals, as well as
reducing health-related costs.
A careful evaluation of older adults is an important step in determining their need for
assistive devices and equipment to enhance and maintain independence and quality of life
(Kraskowsky & Finlayson, 2001). The evaluation may occur during acute care, inpatient
rehabilitation, home care, or outpatient visits (Roelands, Van Oost, Depoorter, & Buysse,
2002) by an interdisciplinary team member (i.e., nurse, physician, therapist, dietitian, or
social worker). Typically, an occupational therapist determines whether the equipment is
appropriate for older adults and their environment and educates them and their caregivers
on the use and care of assistive devices. However, all team members have a responsibility for
evaluation and follow-up, as needed. The appropriate fit between the person’s ability, the
demands of the environment, and each piece of equipment or device is essential to successful
task performance. Assistive devices and equipment are typically first introduced in the
hospital, outpatient, or home care setting, primarily to enhance independence in self-care.
During inpatient rehabilitation, an older adult will receive an average of eight pieces of

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equipment and/or devices to use in the home for mobility, dressing, eating, bathing,
grooming, and feeding. Those living in the community with a functional impairment report
having an average of 14 pieces of equipment and/or devices in the home, including those for
hearing and vision (Gitlin & Schemm, 1996). With shortened hospital stays and briefer
exposure to occupational and physical therapy, the need for efficient and effective instruction
in assistive device use becomes that much more important for nurses. Teaching an elderly
person to use technology should not be limited to the person alone, but should include
caregivers and other family members. Education must be sensitive to any physical, cognitive,
psychological, and environmental factors that affect the elderly person. When introducing
technology to the elderly and teaching them to use it, several guidelines can be employed and
these are the following:
a. The use of technology must be perceived as needed and meaningful and must be
linked to the lifestyle of the person.
b. Cautions and disbelief in one’s capability may be an obstacle in accepting new
technology and must be considered when creating the learning environment.
c. A generous amount of time as well as repeated short training sessions should be
allowed.
d. More stress should be placed on the practical application of the device than on its
technical features.
e. Only selective, central facts should be presented.
f. Mnemonics and cues will favorably affect self-efficacy in handling new products.
g. Training sessions should be held in the home or natural meeting places of the elderly.
h. The instructor should be well-known by the elderly or introduced well in advance of
the training.
i. The attitudes of the instructors toward the aged must be positive and realistic.

Common Applications of Assistive Technology

The following are common assistive technology applications (Kelker, 1997):
1) position and mobility
2) environmental access and control
3) self-care
4) sensory impairment
5) social interaction and recreation, and
6) computer-based technology.

Position and Mobility

Older adults may need assistance with their positions for seating so that they can
effectively participate in activities and interact with others. Generally, nurses or therapists
try to achieve an upright, forward-facing position for the individual by using padding,
structured chairs, straps, supports, or restraints to hold the body stably and comfortably
(Kelker, 1997). Examples of equipment used for positioning are walkers, floor sitters, chair
inserts, wheelchairs, straps, traps, and standing aids.
Conversely, older adults whose physical impairments limit their mobility may need
a device to help them get around or participate in activities. Mobility devices include self-
propelled walkers, manual or powered wheelchairs, and powered recreational vehicles like
bikes and scooters.

Environmental Access and Control

Access to shopping centers, places of business, schools, recreation, and
transportation is possible because of assistive technology modifications. This kind of
assistive technology includes modifications to buildings, rooms, or other facilities that allow
people with physical impairments to use ramps and door openers to enter, allow people with
visual disabilities and move more freely within a facility, and allow people of short stature
or people who use wheelchairs to reach payphones or operate elevators (Kelker, 1997).

Self-care
Assistive devices for self-care include such items as robotics, electric feeders,
adapted utensils, specially designed toilet seats, and aids for tooth brushing, washing,
dressing, and grooming. An emergency response system (ERS) can increase the safety of an
individual who requires assistance with self-care activities. The most common ERS is the
telephone-based personal emergency response system (PERS), which consists of the

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subscriber wearing a small help button as a necklace or wristband, with a home

communicator that is connected to a residential phone line (Mihailidis & Lee, 2003). In the
event of an emergency, the subscriber presses the help button and is connected to a live
emergency response center, which arranges for appropriate help, such as calling paramedics
or the person’s family.

Sensory Impairment
Older adults may experience impairment in their speech, hearing, or sight. The term
augmentative and alternative communication (AAC) refers to all forms of communication
that enhance or supplement speech and writing, either temporarily or permanently. The goal
of AAC is to encourage and support the development of communicative competence so that
people can participate as fully as possible in-home and community environments and to
improve the efficiency and use of communication aids are in place, the user must learn to
operate each part of the system effectively and efficiently. Professionals (e.g., nurses,
therapists) need to help the user and his or her communication partners learn a variety of
skills and strategies, which might include the meaning of certain hand shapes and how to
make them; starting and stopping a piece of electronic equipment at a desired word or
picture; ways to get a person’s attention; ways to help a communication partner understand
a message; and increasing the rate of communication (ASLHA, 1997).

Social Interaction and Recreation

Older adults still want to have fun and interact socially with others. Assistive
technology can help them to participate in all sorts of recreational activities that can interact
with friends (Kelker, 1997). Some adapted recreational activities include drawing software,
computer games, computer simulations, painting with a head or mouth wand, and adapted
puzzles.

Computer-Based Assistive Technology

Some older adults may require special devices that provide access to computers.
Controllable anatomical movements like eye blinks, head or neck movements, or mouth
movements may be used to operate equipment that provides access to the computer.
Computers are an important type of assistive technology because they open up so
many exciting possibilities for writing, speaking, finding information, or controlling an
individual’s environment. The software can provide tools for written expression, calculation,
reading, basic reasoning, and higher-level thinking skills. The computer can also be used to
access a wide variety of databases.
Today’s technologies provide many opportunities for older adults to maintain their
independence and stay connected to the world even when functional limitations are present.
Nurses should be aware of the latest trends in technology, the use of computers among the
older adult population, and how assistive devices help promote autonomy for this cohort.
Also, nurses can use different strategies to enhance learning and teaching with older adults
by incorporating technology into the care of both well and ill elderly (Mauk, 2010).

V. Reflection

How do you feel about older adults becoming part of the technology revolution? Do
you feel that they are using the computer and the World Wide Web more often? Do you know
any older adults who use iPods, MP3 players, PDAs, Flash drives, or other gadgets used by the
younger population today? How are they use the same as or different from your generation?

VI. Post Test

Encircle the letter of the correct answer.
1. Mechanical aids that substitute for or enhance the function of some physical or mental
ability that is impaired
a. Assistive Technology
b. Technology Tools
c. Computer-Based Assistive Devices
d. Software Devices
2. The following are the uses of the assistive device except:
a. Improve balance and mobility

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including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the
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 98

b. Increase complications of an illness or disability

c. Reduce the risk of injury
d. Increase safety
3. Statement A: The primary purpose of assistive technology is to bridge the gap between
an older person’s declining capabilities and the unchanging environmental demands of
home and community.
Statement B: Assistive Technology are not just for those who are disabled or have
functional limitations.
Statement C: The term assistive devices encompass a broad range of strategies from
“low tech” (e.g., pencil grips, splints, paper stabilizers) to “high tech” (e.g., computers,
voice synthesizers).
Statement D: Assistive devices can also help individuals who are aging and who may
benefit from using them to promote injury and increase the risk of injury.
a. Statement A and C are correct
b. Statement B and C are correct
c. Statement C and D are incorrect
d. Statement B and D are incorrect
4. – 7. Guidelines when introducing assistive technology devices to the elderly are the
following:
Check all the appropriate answers.
_____ a. Only selective, central facts should be presented.
_____ b. The attitudes of the instructors toward the aged do not need to be positive and
realistic.
_____ c. A generous amount of time as well as repeated short training sessions should be
allowed.
_____ d. More stress should be placed on the practical application of the device than on its
technical features.
_____ e. Cautions and disbelief in one’s capability is not an obstacle in accepting new
technology and must not be considered when creating the learning environment.
_____ f. Training sessions should be held in the clinic or hospital.
_____ g. The instructor should be well-known by the elderly or introduced well in advance
of the training.
8. Common applications of assistive technology are the following except:
a. Computer-based Technology
b. Sensory Impairment
c. Access and Control
d. Social Interaction and Recreation
9. Refers to all forms of communication that enhance or supplement speech and writing,
either temporarily or permanently
a. Emergency Response System
b. Augmentative and Alternative Communication
c. Personal Emergency Response System
d. Social Interaction and Recreation
10. This kind of assistive technology includes modifications to buildings, rooms, or other
facilities that allow people with physical impairments to use ramps and door openers to
enter, allow people with visual disabilities and move more freely within a facility, and
allow people of short stature or people who use wheelchairs to reach payphones or
operate elevators.
a. position and mobility
b. environmental access and control
c. self-care
d. sensory impairment

VII. References

Hinkle, Janice L. and Cheever, Kerry H. (2014) Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing 13th Ed., Lippincott Williams &Wilkins

Mauk, Kristen L. (2010) Gerontological Nursing. Competencies for Care. Jones and
Bartlett Publishers, Inc.

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including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the
institution. Unauthorized reproduction is punishable by law.
 99

https://nurseslabs.com/geriatric-nursing-care-
plans/#:~:text=Gerontology%20nursing%20or%20geriatric%20nursing,needs%20of
%20an%20aging%20individual.

https://www.news-medical.net/health/What-is-Telemedicine.aspx
https://www.medicalnewstoday.com/articles/telemedicine-benefits#summary

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All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means,
including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the
institution. Unauthorized reproduction is punishable by law.