Older Adults

General Survey

The general survey begins during the initial nurse-patient encounter and includes a quick but careful head-to-toe scan of the older adult that the nurse writes in a brief description (see Chapter 30). An initial inspection reveals if eye contact and facial expression are appropriate to the situation and universal aging changes such as facial wrinkles, gray hair, loss of body mass in the extremities, and an increase of body mass in the trunk.

Integumentary System

With aging the skin loses resilience and moisture. The epithelial layer thins, and elastic collagen fibers shrink and become rigid. Wrinkles of the face and neck reflect lifelong patterns of muscle activity and facial expressions, the pull of gravity on tissue, and diminished elasticity. Spots and lesions are often present on the skin. Smooth, brown, irregularly shaped spots (age spots or senile lentigo) initially appear on the backs of the hands and on forearms. Small, round, red or brown cherry angiomas occur on the trunk. Seborrheic lesions or keratoses appear as irregular, round or oval, brown, watery lesions. Years of sun exposure contribute to the aging of the skin and lead to premalignant and malignant lesions. You need to rule out these three malignancies related to sun exposure when examining skin lesions: melanoma, basal cell carcinoma, and squamous cell carcinoma (see Chapter 30).

Head and Neck

The facial features of the older adult may become more pronounced from loss of subcutaneous fat and skin elasticity. Facial features appear asymmetrical because of missing teeth or improperly fitting dentures. In addition, common vocal changes include a rise in pitch and a loss of power and range.

Visual acuity declines with age. This is often the result of retinal damage, reduced pupil size, development of opacities in the lens, or loss of lens elasticity. Presbyopia, a progressive decline in the ability of the eyes to accommodate from near to far vision, is common. Ability to see in darkness and adapt to abrupt changes from dark to light areas (and the reverse) is reduced. More ambient light is necessary for tasks such as reading and other ADLs. Older adults have increased sensitivity to the effects of glare. Pupils are smaller and react slower. Objects do not appear bright, but the older adult has difficulty when coming from bright to dark environments. Changes in color vision and discoloration of the lens make it difficult to distinguish between blues and greens and among pastel shades. Dark colors such as blue and black appear the same. Diseases of the older eye include cataract, macular degeneration, diabetic retinopathy, and retinal detachment. Cataracts, a loss of the transparency of the lens, are a prevalent disorder among older adults. They normally result in blurred vision, sensitivity to glare, and gradual loss of vision. Chapter 49 outlines nursing interventions for adapting to a patient’s visual changes.

Noise is the most prevalent risk factor for impaired hearing. Exposure earlier in life exacerbates hearing loss in old age. However, auditory changes are often subtle. Most of the time older adults ignore the early signs of hearing loss until friends and family members comment on compensatory attempts such as turning up the volume on televisions or avoiding social conversations. A common age-related change in auditory acuity is presbycusis. Presbycusis affects the ability to hear high-pitched sounds and sibilant consonants such as s, sh, and ch. Before the nurse assumes presbycusis, it is necessary to inspect the external auditory canal for the presence of cerumen. Impacted cerumen, a common cause of diminished hearing acuity, is easy to treat.

Salivary secretion is reduced, and taste buds atrophy and lose sensitivity. The older adult is less able to differentiate among salty, sweet, sour, and bitter tastes. The sense of smell also decreases, further reducing taste. Health conditions, treatments, and/or medications can alter taste. It is often a challenge to promote optimal nutrition in an older patient because of the loss of smell and changes in taste.

Thorax and Lungs

Because of changes in the musculoskeletal system, the configuration of the thorax sometimes changes. Respiratory muscle strength begins to decrease, and the anteroposterior diameter of the thorax increases. Vertebral changes caused by osteoporosis lead to dorsal kyphosis, the curvature of the thoracic spine. Calcification of the costal cartilage causes decreased mobility of the ribs. The chest wall gradually becomes stiffer. Lung expansion decreases, and the person is less able to cough deeply. If kyphosis or chronic obstructive lung disease is present, breath sounds become distant. With these changes the older adult is more susceptible to pneumonia and other bacterial or viral infections.

Heart and Vascular System

Decreased contractile strength of the myocardium results in decreased cardiac output. The decrease is significant when the older adult experiences anxiety, excitement, illness, or strenuous activity. The body tries to compensate for decreased cardiac output by increasing the heart rate during exercise. However, after exercise it takes longer for the older adult’s rate to return to baseline. Systolic and/or diastolic blood pressures are sometimes abnormally high. Although a common chronic condition, hypertension is not a normal aging change and predisposes older adults to heart failure, stroke, renal failure, coronary heart disease, and peripheral vascular disease.

Peripheral pulses frequently are weaker, although still palpable, in the lower extremities. Older adults sometimes complain that their lower extremities are cold, particularly at night. Changes in the peripheral pulses in the upper extremities are less common.

Breasts

As estrogen production diminishes, the milk ducts of the breasts are replaced by fat, making breast tissue less firm. Decreased muscle mass, tone, and elasticity result in smaller breasts in older women. In addition, the breasts sag. Atrophy of glandular tissue, coupled with more fat deposits, results in a slightly smaller, less dense, and less nodular breast. Gynecomastia, enlarged breasts in men, is often the result of medication side effects, hormonal changes, or obesity. Both older men and women are at risk of breast cancer.

Gastrointestinal System and Abdomen

Aging leads to an increase in the amount of fatty tissue in the trunk. As a result, the abdomen increases in size. Because muscle tone and elasticity decrease, it also becomes more protuberant. Gastrointestinal function changes include a slowing of peristalsis and alterations in secretions. The older adult experiences these changes by becoming less tolerant of certain foods and having discomfort from delayed gastric emptying. Alterations in the lower gastrointestinal tract lead to constipation, flatulence, or diarrhea.

Reproductive System

Changes in the structure and function of the reproductive system occur in both sexes as the result of hormonal alterations. Female menopause is related to a reduced responsiveness of the ovaries to pituitary hormones and a resultant decrease in estrogen and progesterone levels. In men there is no definite cessation of fertility associated with aging. Spermatogenesis begins to decline during the fourth decade and continues into the ninth. However, the changes in reproductive structure and function do not affect libido; sexual desires, thoughts, and actions continue throughout all decades of life (Wallace, 2008). Less frequent sexual activity often results from illness, death of a sexual partner, or decreased socialization.

Urinary System

Hypertrophy of the prostate gland is frequently seen in older men. This hypertrophy enlarges the gland and places pressure on the neck of the bladder. As a result, urinary retention, frequency, incontinence, and urinary tract infections occur. In addition, prostatic hypertrophy results in difficulty initiating voiding and maintaining a urinary stream. Benign prostatic hypertrophy is different from cancer of the prostate. Cancer of the prostate is the second most common cause of cancer death in men over age 50. In 2010 the American Cancer Society estimated that one in six men will be diagnosed with prostate cancer and 1 in 36 will die (American Cancer Society, 2010).

Urinary incontinence is an abnormal condition that can occur in both older men and women. Men may be afraid to discuss incontinence with their physician because of embarrassment and because they think that urinary incontinence is a “woman’s disease.” Older women, particularly those who have had children, experience stress incontinence, an involuntary release of urine that occurs when they cough, laugh, sneeze, or lift an object. This is a result of a weakening of the perineal and bladder muscles. Other types of urinary incontinence are urge, overflow, functional, and mixed incontinence. The risk factors for urinary incontinence include age, menopause, diabetes, hysterectomy, stroke, and obesity.

Musculoskeletal System

With aging muscle fibers become smaller. Muscle strength diminishes in proportion to the decline in muscle mass. Beginning in the 30s, bone density and bone mass decline in men and women. Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Osteoporosis is a major public health threat. An estimated 10 million Americans already have the disease, and an additional 34 million are at risk with low bone mass (National Osteoporosis Foundation, 2010). Postmenopausal women experience a greater rate of bone demineralization than older men. Women who maintain calcium intake throughout life and into menopause have less bone demineralization than women with low calcium intake. Older men with poor nutrition and decreased mobility are also at risk for bone demineralization.

Neurological System

A decrease in the number and size of neurons in the nervous system begins in the middle of the second decade. Neurotransmitters, chemical substances that enhance or inhibit nerve impulse transmission, change with aging as a result of the decrease in neurons. All voluntary reflexes are slower, and individuals often have less of an ability to respond to multiple stimuli. In addition, older adults frequently report alterations in the quality and the quantity of sleep (see Chapter 42), including difficulty falling asleep, difficulty staying asleep, difficulty falling asleep again after waking during the night, waking too early in the morning, and excessive daytime napping. These problems are believed to be caused by age-related changes in the sleep-wake cycle.

Delirium

Delirium, or acute confusional state, is potentially a reversible cognitive impairment that often has a physiological cause. Physiological causes include electrolyte imbalances; cerebral anoxia; hypoglycemia; medication effects; tumors; subdural hematomas; and cerebrovascular infection, infarction, or hemorrhage. Delirium in older adults sometimes accompanies systemic infections and is often the presenting symptom for pneumonia or urinary tract infection. Sometimes it is also caused by environmental factors such as sensory deprivation or unfamiliar surroundings or psychosocial factors such as emotional distress or pain. Sleep deprivation is another possible reason for delirium. Although it occurs in any setting, an older adult in the acute care setting is especially at risk because of predisposing factors (physiological, psychosocial, and environmental) in combination with the underlying medical condition. Dementia is an additional risk factor that greatly increases the risk for delirium, and it is possible for delirium and dementia to occur in a patient at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention. Nurses are at the bedside 24/7 and in a position to recognize delirium development and report it. The cognitive impairment usually reverses once health care providers identify and treat the cause of delirium.

Dementia

Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer’s disease, Lewy body disease, frontal-temporal dementia, and vascular dementia. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs and IADLs. Unlike delirium, a gradual, progressive, irreversible cerebral dysfunction characterizes dementia. Because of the similarity between delirium and dementia, you need to assess carefully to rule out the presence of delirium whenever you suspect dementia.

Nursing management of older adults with any form of dementia always considers the safety and physical and psychosocial needs of the older adult and the family. These needs change as the progressive nature of dementia leads to increased cognitive deterioration. To meet the needs of the older adult, individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior. Box 14-6 lists general nursing principles for care of older adults with cognitive changes. Support and education about Alzheimer’s disease for patients, families, and professionals can be found at the Alzheimer’s Association website (www.alz.org).

Depression

Approximately one third of older adults experience depressive symptoms (Mental Health America, 2011). Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. Co-occurring diseases may include stroke, dementia, Parkinson’s disease, heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or a nursing center admission may precipitate depression. Clinical depression is treatable and includes medication, psychotherapy, or a combination of both. Of special note, suicide attempts in older adults are often successful. In fact, suicide in older adults comprises 20% of all suicides (Mental Health America, 2011).

Retirement

Many often mistakenly associate retirement with passivity and seclusion. In actuality it is a stage of life characterized by transitions and role changes. This transition requires letting go of certain habits and structure and developing new ones (Touhy and Jett, 2010). The psychosocial stresses of retirement are usually related to role changes with a spouse or within the family and to loss of the work role. Sometimes problems related to social isolation and finances are present. The age of retirement varies. But, whether it occurs at age 55, 65, or 75, it is one of the major turning points in life.

Preretirement planning is an important advisable task. People who plan in advance for retirement generally have a smoother transition. Preretirement planning is more than financial planning. Planning begins with consideration of the “style” of retirement desired and includes an inventory of interests, current skills, and general health. Meaningful retirement planning is critical as the population continues to age.

Retirement affects more than just the retired. It affects the spouse, adult children, and even grandchildren. When the spouse is still working, the retired person faces time alone. There may be new expectations of the retired person. For example, a working spouse might have new ideas about the amount of housework expected of the retired person. Problems develop when the plans of the retired person conflict with the work responsibilities of the working spouse. The roles of the retiree and the working spouse need clarification. Adult children may expect the retired person to always babysit for the grandchildren, forgetting that this is a time for the retired person to pursue other personal interests.

Loss of the work role has a major impact on some retired persons. When so much of life has revolved around work and the personal relationships at work, the loss of the work role can be devastating. Personal identity is often rooted in the work role, and with retirement individuals need to construct a new identity. Individuals also lose the structure imposed on daily life when they no longer have a work schedule. The social exchanges and interpersonal support that occur in the workplace are lost. In the adjustment to retirement the older adult has to develop a personally meaningful schedule and a supportive social network.

Factors that influence the retired person’s satisfaction with life are health status and sufficient income. Positive preretirement expectations also contribute to satisfaction in retirement. The nurse can help the older adult and family prepare for retirement by discussing with them several key areas, including relations with spouse and children; meaningful activities and interests; building social networks; issues related to income; health promotion and maintenance; and long-range planning, including wills and advance directives.

Social Isolation

Many older adults experience social isolation. Isolation is sometimes a choice, the result of a desire not to interact with others. It is also a response to conditions that inhibit the ability or the opportunity to interact such as the lack of access to transportation. Although some older adults choose isolation or a lifelong pattern of reduced interaction with others, older adults who experience social isolation become vulnerable to its consequences. An older adult’s vulnerability increases in the absence of the support of other adults, as occurs with loss of the work role or relocation to unfamiliar surroundings. Impaired sensory function, reduced mobility, and cognitive changes all contribute to reduced interaction with others and can place the older adult at risk for isolation.

You assess patients’ potential for social isolation by identifying their social network, access to transportation, and willingness and desire to interact with others. Your findings assist you in helping a lonely older adult rebuild social networks and reverse patterns of isolation. Many communities have outreach programs designed to make contact with isolated older adults such as Meals on Wheels, which provides nutritional meals. Outreach programs such as daily telephone calls by volunteers or needs for activities such as social outings also meet socialization needs. Social service agencies in most communities welcome older adults as volunteers and provide the opportunity for them to serve while meeting their socialization or other needs. Churches, colleges, community centers, and libraries offer a variety of programs for older adults that increase the opportunity to meet people with similar activities, interests, and needs.

Sexuality

All older adults, whether healthy or frail, need to express their sexual feelings. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Sexuality plays an important role in helping the older adult maintain self-esteem. To help an older adult achieve or maintain sexual health, you need to understand the physical changes in a person’s sexual response (Chapter 34). You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Open-ended questions inviting the older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. Include information about the prevention of sexually transmitted infections when appropriate. Sexuality and the need to express sexual feelings remain throughout the human life span.

When considering the older adult’s need for sexual expression, do not ignore the important need to touch and be touched. Touch is an overt expression with many meanings and is an important part of intimacy (Atkinson, 2006). Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or possible. Knowing an older adult’s sexual needs allows you to incorporate this information into the nursing care plan.

The sexual preferences of older adults are as diverse as those of the younger population. Clearly not all older adults are heterosexual, yet little research has been done on older adult homosexuals and their health care needs. A number of emerging issues have the potential to substantially affect caregiving in the future, including the demographic changes and the overall aging of the U.S. population, shifts in the nature of families, growing economic pressures, and the societal context of caregiving (Fredriksen-Goldsen et al., 2009). Nurses often find that they are called on to help other health care professionals understand the sexual needs of older adults and advise them. Not all nurses feel comfortable counseling older adults about sexual health and intimacy-related needs. Be prepared to refer older adults to an appropriate professional counselor.

Housing and Environment

The extent of an older adult’s ability to live independently influences housing choices. Changes in social roles, family responsibilities, and health status influence their living arrangements. Some choose to live with family members. Others prefer their own homes or other housing options near their families. Leisure or retirement communities provide older people with living and social opportunities in a one-generation setting. Federally subsidized housing, where available, offers apartments with communal, social, and in some cases food-service arrangements.

The goal of your assessment of a patient’s environment is to consider resources that promote independence and functional ability. When assisting older adults with housing needs, assess their activity level, financial status, access to public transportation and community activities, environmental hazards, and support systems (Touhy and Jett, 2010). When helping patients consider housing choice, anticipate their future needs as much as possible. For example, a housing unit with only one floor and without exterior steps is a prudent choice for the older adult with severe arthritis who has already had lower-extremity joint replacement surgery and anticipates the need for future operations. Assessment of safety, a major component of the older adult’s environment, includes risks within the environment and the older adult’s ability to recognize and respond to the risks (Chapter 27). Safety risks in the home include factors leading to injury such as water heaters set at excessively hot temperatures or environmental barriers such as throw rugs or slippery floor surfaces that could cause a fall. Assess if the person has a pet that could easily move around the person’s feet to cause a fall. Lighting in the home must be assessed. Is the light bright enough to see walkways and stairs, and is there a lit path to the bathroom at night? Conduct a home and environmental check with the person’s family caregiver present if possible.

Housing and environment affect the health of older adults. The environment can support or hinder physical and social functioning, enhance or drain energy, and complement or tax existing physical changes such as vision and hearing. For example, furnishings with red, orange, and yellow colors are easiest for older adults to see. Shiny waxed floors may appear to be wet or have a hole in them. Older adults have difficulty distinguishing between green and blue and among pastel shades. Door frames and baseboards should be a color that contrasts with the color of the wall to improve perception of the boundaries of halls and rooms. Stairs should have a color contrast at the edge of the step so the older person knows where the stair ends. Glare from highly polished floors, metallic fixtures, and windows is difficult for the older adult to tolerate.

Furniture must be comfortable and designed for the musculoskeletal changes of older adults. Older adults need to examine it carefully for size, comfort, and function before purchasing it. It must be easy to get into and out of and provide back support. Test dining room chairs for comfort during meals and for height in relation to the table. Armrests make it easier for patients to get in and out of a chair because they can use their arms to assist in lifting. Older adults often prefer transferring out of a wheelchair to another chair for meals because some styles of wheelchairs do not let older adults sit close enough to the table to eat comfortably. Raising the table to clear the wheelchair arms brings the table closer to the older adult but makes it too high for comfortable use. To make getting out of bed easier and safer, the height of the bed needs to allow the older adult’s feet to be flat on the floor when he or she is sitting on the side of the bed.

Death

Part of one’s life history is the experience of loss through the death of relatives and friends (see Chapter 36). This includes the loss of the older generations of families and sometimes, sadly, the loss of a child. However, death of a spouse is the loss that affects the lives of most older people. The death of a spouse affects older women more than men, a trend that will probably continue in the future. In spite of these experiences, it is wrong to assume that the older adult is comfortable with the idea of death. A key role of the nurse is to help older adults understand the meaning of the loss and cope with it.

Older people have a wide variety of attitudes and beliefs about death, but fear of their own death is uncommon (Friedman, 2006). Rather they are concerned with fear of being a burden, experiencing suffering, being alone, and the use of life-prolonging measures. The stereotype that the death of an older adult is a blessing does not apply to every older adult. Even as death approaches, many older adults still have unfinished business and are not prepared for it. Families and friends are not always ready to let go of him or her. The nurse is often the person to whom the older adult and family members or friends turn to for assistance. Knowledge of the grieving process (see Chapter 36), excellent communication skills; understanding of legal issues; familiarity with community resources; and awareness of one’s own feelings, limitations, and strengths as they relate to care of those confronting death are critical.

• Participation in screening activities (e.g., blood pressure, mammography, Pap smears, depression, vision and hearing testing, colonoscopy)

• Regular exercise

• Weight reduction if overweight

• Eating a low-fat, well-balanced diet

• Moderate alcohol use

• Regular dental visits

• Smoking cessation

• Immunization for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease

Heart Disease

Heart disease is the leading cause of death in older adults (CDC, 2010a). Common cardiovascular disorders are hypertension and coronary artery disease. Hypertension is a silent killer because often the person is unaware that his or her blood pressure is elevated (see Chapter 29). Although over half of Americans have elevated diastolic and/or systolic pressures, the fact that hypertension is common does not make it normal or harmless. Treatment of systolic pressures 160 mm Hg or higher is linked to reduced incidence of myocardial infarction, stroke, and heart failure. In coronary artery disease partial or complete blockage of one or more coronary arteries leads to myocardial ischemia and myocardial infarction. The risk factors for both hypertension and coronary artery disease include smoking, obesity, lack of exercise, and stress. Additional risk factors for coronary artery disease include hypertension, hyperlipidemia, and diabetes mellitus. Nursing interventions for hypertension and coronary artery disease address weight reduction, exercise, dietary changes, limiting salt and fat intake, stress management, and smoking cessation. Patient teaching also includes information about medication management, blood-pressure monitoring, and the symptoms indicating the need for emergency care.

Cancer

Malignant neoplasms are the second most common cause of death among older adults (CDC, 2010a). Nurses educate older adults about early detection, treatment, and cancer risk factors. Examples include smoking cessation, teaching breast self-examination (see Chapter 30), and encouraging all older adults to have annual screening for fecal occult blood with a rectal examination. It is also important to educate older adults about the signs of cancer and encourage prompt reporting of nonhealing skin lesions, unexpected bleeding, change in bowel habits, nagging cough, lump in breast or another part of body, change in a mole, difficulty swallowing, and unexplained weight loss. Cancer is difficult to detect because providers often mistake symptoms as part of the normal aging process or signs of a person’s chronic disease. You need to carefully distinguish between signs of normal aging and signs of pathological conditions.

Stroke (Cerebrovascular Accident)

Cerebrovascular accidents (CVAs) continue to be the third leading cause of death in the United States and occur as brain ischemia (inadequate blood supply to areas of brain caused by arterial blockage) or brain hemorrhage (subarachnoid or intercerebral bleeds) (CDC, 2010a). Risk factors for CVAs include hypertension, hyperlipidemia, diabetes mellitus, history of transient ischemic attacks, and family history of cardiovascular disease. CVAs often impair the functional abilities of older adults and lead to the inability to live independently. The scope of nursing interventions ranges from teaching older adults about risk-reduction strategies to teaching family caregivers the early warning signs of a stroke and ways to support a patient during recovery and rehabilitation.

Smoking

Cigarette smoking is a risk factor among the four most common causes of death: heart disease, cancer, stroke, and lung disease. Smoking is the most preventable cause of disease and death in the United States. As of 2009 an estimated 9.5% of people ages 65 and older smoked cigarettes (CDC, 2010b). Approximately 440,000 people die annually from smoking-related diseases, and 300,000 of those deaths occur in people ages 65 and older (CMS, 2010).

Smoking cessation is a health promotion strategy for older adults just as it is for younger adults. Older smokers still benefit from smoking cessation. In addition to reducing risk, it sometimes stabilizes existing conditions such as chronic obstructive pulmonary disease (COPD) and coronary artery disease. Smoking cessation after age 65 can add 2 to 3 years to life expectancy. Within a year of quitting, former smokers reduce their risk of coronary heart disease by 50% (National Cancer Institute, 2010). Smoking-cessation programs recommended by the CDC (2008) include individual, group, and telephone counseling and the use of nicotine (gum and patch) or nonnicotine medications. If the patient rejects smoking cessation, suggest at least a reduction in smoking. Finally, arrange with the older adult a quit or reduction date and a follow-up visit or contact to discuss the quit attempt. At follow-up visits, offer encouragement and assistance in modifying the plan as necessary.

Alcohol Abuse

Alcoholism can be found in older adults. Alcohol is inexpensive, legal, and accessible. Studies of alcohol abuse in older adults report two patterns: a lifelong pattern of heavy drinking that continues and a pattern when heavy drinking begins late in life. Frequently cited causes of excessive alcohol use are depression, loneliness, and lack of social support.

Alcohol abuse may be underidentified in older adults. The clues to creating suspicion of alcohol abuse are subtle, and coexisting dementia or depression sometimes complicates the assessment. Suspicion of alcohol abuse increases when there is a history of repeated falls and accidents, social isolation, recurring episodes of memory loss and confusion, failure to meet home and work obligations, a history of skipping meals or medications, and difficulty managing household tasks and finances. When you suspect that an older adult is abusing alcohol, realize that a variety of treatment needs are present. Treatment includes age-specific approaches that acknowledge the stresses experienced by the older adult and encourage involvement in activities that match the older adult’s interests and increase feelings of self-worth. The identification and treatment of co-existing depression are also important. The continuum of interventions can range from simple education to formalized treatment programs that include pharmacotherapy, psychotherapy, and rehabilitation.

Nutrition

Lifelong eating habits and situational factors influence how older adults meet their needs for good nutrition. Lifelong eating habits based in tradition, ethnicity, and religion influence the choice of what foods are eaten and how they are prepared. Situational factors affecting nutrition include access to grocery stores, finances, physical and cognitive capability for food preparation, and a place to store food and prepare meals. Older adults’ levels of activity and clinical conditions affect their nutritional needs. Level of activity has implications for the total amount of required calories. Older adults who are sedentary usually need fewer calories than those who are more active. However, activity alone does not determine caloric requirements. Additional calories are often necessary in clinical situations such as recovery from surgery, whereas fewer calories are necessary when the older adult has diabetes or is overweight.

Good nutrition for older adults includes appropriate caloric intake and limited intake of fat, salt, refined sugars, and alcohol. The nutritional guidelines displayed in the USDA’s MyPlate (see Chapter 44) are the basic recommendations for older-adult nutrition. Protein intake is sometimes lower than recommended if older adults have reduced financial resources or limited access to grocery stores. Difficulty chewing meat because of poor dentition or poor-fitting dentures also limits protein intake. Fat intake is higher than usual because of the substitution of fast-food restaurant meals for meals prepared at home or because of methods of cooking featuring fried foods and sauces using butter and cream. Some use extra salt and sugar while cooking or at the table to compensate for a diminished sense of taste.

Older adults with dementia have special nutritional needs. As their memory and functional skills decline with the progression of dementia, they lose the ability to remember when to eat, how to prepare food, and how to feed themselves. Caloric needs may increase because of the energy expended in pacing and wandering activities. When caring for older adults with dementia, routinely monitor weight and food intake, serve food that is easy to eat such as finger foods (e.g., chicken strips, sandwiches, cut-up vegetables, and fruit), provide assistance with eating, and offer food supplements that are tasty and easy to swallow.

Dental Problems

Dental problems with natural teeth and dentures are common in older adults. Dental caries, gingivitis, broken or missing teeth, and ill-fitting or missing dentures affect nutritional adequacy, cause pain, and lead to infection. Dentures are a frequent problem because the cost is not covered by Medicare and dentures tend to be quite expensive. Help prevent dental and gum disease through education about routine dental care (see Chapter 39).

Exercise

Encourage older adults to maintain physical exercise and activity. The primary benefits of exercise include maintaining and strengthening functional ability and promoting a sense of enhanced well-being. Regular daily exercise such as walking builds endurance, increases muscle tone, improves joint flexibility, strengthens bones, reduces stress, and contributes to weight loss. Other benefits include improvement of cardiovascular function, improved plasma lipoprotein profiles, increased metabolic rate, increased gastrointestinal transit time, prevention of depressive illness, and improved sleep quality. Older adults who participate in group exercise programs or physical therapy may experience improved mobility, gait, and balance, resulting in fewer falls (Michael et al., 2010).

Consult with physical therapists and the patient’s physician to plan an exercise program that meets physical needs and is one the patient enjoys. Consider the patient’s physical limitations and encourage the older adult to stick with the exercise program. Many factors influence an individual’s willingness to participate in an exercise program. These include general beliefs about benefits of exercise, past experiences with exercise, personal goals, personality, and any unpleasant sensations associated with exercise.

Walking is the preferred exercise of many older adults (Fig. 14-2). Walking and other low-impact exercises such as riding a stationary exercise bicycle or water exercises in a swimming pool protect the musculoskeletal system and joints. Other exercises can be included in the older adult’s ADLs. For example, adults can perform arm and leg circles while watching television. Before beginning an exercise program, the older adult needs to have a physical examination. Exercise programs for sedentary older adults who have not been exercising regularly need to begin conservatively and progress slowly. Safety considerations include wearing good support shoes and clothing appropriate to the exercise, drinking water before and after exercising, avoiding outdoor exercise when the weather is very warm or very cold, and exercising with a partner. Instruct older adults to stop exercising and seek help if they experience chest pain or tightness, shortness of breath, dizziness or light-headedness, joint pain, or palpitations during exercise.

Falls

Falls are a safety concern of many older adults. One in three adults age 65 and older falls each year (CDC, 2010c). Fall-related injuries are often associated with a patient’s preexisting medical conditions such as osteoporosis and bleeding tendencies. Hospitalization and placement in a nursing center for rehabilitation or long-term placement is sometimes necessary after a fall. In 2009 emergency departments treated 2.2 million nonfatal fall injuries among older adults; more than 582,000 of these patients had to be hospitalized (CDC, 2010c). The most common injuries in older adults include fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand. Older adults who fall may develop a fear of falling, which may in turn cause them to limit their activities, leading to reduced mobility and loss of physical fitness (CDC, 2010c). See Chapter 38 for a complete description of fall-prevention interventions. Box 14-7 summarizes both intrinsic and extrinsic risk factors leading to falls.

Sensory Impairments

Because of common sensory impairments experienced by an older adult, it is important to promote existing sensory function and to be sure that the patient lives in a safe environment. Whenever you provide care activities, make sure that the patient is wearing any assist devices such as a hearing aid or glasses so he or she can fully participate in care. Chapter 49 describes in detail the nursing interventions used to maintain and improve sensory function.

Pain

Pain is not a normal part of healthy aging. It is a symptom and a sensation of distress, alerting the person that something is wrong. It is prevalent in the older-adult population; it may be acute or chronic. The consequences of persistent pain include depression, loss of appetite, sleep difficulties, changes in gait and mobility, and decreased socialization. Many factors influence the management of pain, including cultural influences on the meaning and expression of pain for older adults, fears related to the use of analgesic medications, and the problem of pain assessment with cognitively impaired older adults. Nurses caring for older adults have to advocate for appropriate and effective pain management (see Chapter 43). Again, the goal of nursing management of pain in older adults is to maximize function and improve quality of life.

Medication Use

One of the greatest challenges for older adults is safe medication use. Although the elderly make up approximately 12% of the U.S. population, they consume 31% of the nation’s prescribed drugs (Lehne, 2010). Some medication categories such as analgesics, antidepressants, antihistamines, antihypertensives, sedative-hypnotics, and muscle relaxants create a high likelihood of adverse effects in older adults. They are at risk for adverse medication effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs, collectively referred to as the process of pharmacokinetics (see Chapter 31). Medications sometimes interact with one another, adding or negating the effect of another drug. Examples of adverse effects include confusion, impaired balance, dizziness, nausea, and vomiting. Because of these effects, some older adults are unwilling to take medications; others do not adhere to the prescribed dosing schedule, or they may try to medicate themselves with herbal and over-the-counter medications.

Polypharmacy, the concurrent use of many medications, increases the risk for adverse drug effects (Box 14-8). Although polypharmacy may reflect inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. For example, it is common for a patient to take more than one medication to control hypertension. The nurse’s role is to ensure the greatest therapeutic benefit with the least amount of harm by educating patients about safe medication use. Nurses must question the efficacy and safety of combinations of prescribed medications and advocate for the older adult to prevent adverse reactions. Older adults may also use over-the-counter or herbal medications. The mix of over-the-counter and herbal medications with prescription medications can also create adverse reactions.

For some older adults safely managing medications is complex and often becomes overwhelming. Some older adults take their medications incorrectly because they do not understand the administration instructions, thereby complicating a nurse’s assessment of effects and side effects. Medications that need to be taken more than once or twice a day are a concern because the patient may not remember to take them as scheduled. As a nurse you are in a position to assist older adult patients as they carry out this important self-care activity (see Chapter 31).

The cost of prescriptions can be prohibitive. You can advocate for patients who may need certain medications by working with pharmacies or drug companies to provide the needed medication at less cost. Often a generic medication that will provide the desired effect is available at a reduced cost.

Work collaboratively with older adults to ensure safe and appropriate use of all medications, both prescribed and over-the-counter. Teach an older adult the names of all medications that he or she is taking, when and how to take them, and desirable and undesirable effects. Explain how to avoid adverse effects and/or interactions of medications and how to establish and follow an appropriate self-administration pattern. Strategies for reducing the risk for an adverse medication effect in the older adult include reviewing the medications with the older adult at each visit; examining for potential interactions with food or other medications; simplifying and individualizing the medication regimen; taking every opportunity to inform the older adult and family about all aspects of medication use; and encouraging the older adult to question the physician, advanced practice nurse, and/or pharmacist about all prescribed medications and all over-the-counter medications.

When providers use medications to manage confusion, special care is necessary. The sedatives and tranquilizers sometimes prescribed for acutely confused older adults may cause or exacerbate confusion and increase risks for falls or other injuries. Carefully administer medications used to manage confused behaviors, taking into account age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), health care providers must treat the cause rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, use creative, nonpharmacological measures such as making the environment more meaningful, providing adequate light, encouraging use of assistive devices, or even calling friends or family members to let older adults hear reassuring voices.

Therapeutic Communication

Therapeutic communication skills enable you to perceive and respect the older adult’s uniqueness and health care expectations. Attentive nurses provide care in a timely fashion, meeting a patient’s expressed or unexpressed needs. A caring nurse expresses attitudes of concern, kindness, and compassion. Knowledgeable nurses not only demonstrate procedural competence but recognize needs and relay information skillfully. Patients accept and respect nurses who meet these expectations and communicate effectively about concern for the older adult’s welfare. However, you cannot simply enter an older adult’s environment and immediately establish a therapeutic relationship. First you have to be knowledgeable and skilled in communication techniques (see Chapter 24).

Touch

Touch is a therapeutic tool that you use to help comfort older adults. A pilot study by Wang and Hermann (2006) showed that agitation levels were significantly lower in demented older adults who received a healing touch intervention. Touch provides sensory stimulation, induces relaxation, provides physical and emotional comfort, orients the person to reality, shows warmth, and communicates interest. It is a powerful physical expression of a relationship.

Older adults are often deprived of touching when separated from family or friends. An older adult who is isolated, dependent, or ill; who fears death; or who lacks self-esteem has a greater need for touch. You recognize touch deprivation by behaviors as simple as an older adult reaching for the nurse’s hand or standing close to the nurse. Unfortunately older men are sometimes wrongly accused of sexual advances when they reach out to touch others. When you use touch, be aware of cultural variations and individual preferences (see Chapters 7 and 9). Touch should convey respect and sensitivity. Do not use it in a condescending way such as patting an older adult on the head. When you reach out to an older adult, do not be surprised if the older adult reciprocates.

Reality Orientation

Reality orientation is a communication technique that makes an older adult more aware of time, place, and person. The purposes of reality orientation include restoring a sense of reality; improving the level of awareness, promoting socialization; elevating independent functioning; and minimizing confusion, disorientation, and physical regression. Although you use reality orientation techniques in any health care setting, they are especially useful in the acute care setting. The older adult experiencing a change in environment, surgery, illness, or emotional stress is at risk for becoming disoriented. Environmental changes such as the bright lights, unfamiliar noises, and lack of windows in specialized units of a hospital often lead to disorientation and confusion. Absence of familiar caregivers is also disorienting. Using anesthesia, sedatives, tranquilizers, analgesics, and physical restraints with older patients increases disorientation. Anticipate and monitor for disorientation and confusion as possible consequences of hospitalization, relocation, surgery, loss, or illness and incorporate interventions based on reality orientation into the care plan.

The principles of reality orientation offer useful guidelines for communicating with acutely confused individuals. The key elements of reality orientation include frequent reminders of person, time, and place; the use of environmental aids such as clocks, calendars, and personal belongings; and stability of environment, routine, and staff. However, do not continue to reorient older adults with chronic cognitive impairment. Communication is always respectful, patient, and calm. Answer questions from the older adult simply and honestly with sensitivity and a caring attitude.

Validation Therapy

Validation therapy is an alternative approach to communication with a confused older adult. Whereas reality orientation insists that the confused older adult agree with our statements of time, place, and person, validation therapy accepts the description of time and place as stated by the confused older adult. Older adults with dementia are less likely to benefit and more likely to become agitated by a caregiver’s insistence on the “correct” time, place, and person. In validation therapy you do not challenge or argue with statements and behaviors of the confused older adult. They represent an inner need or feeling. For example, the person might insist that the day is actually a different day because of high anxiety. The appropriate nursing intervention is to recognize and address that inner need or feeling. Validation does not involve reinforcing the confused older adult’s misperceptions; it reflects sensitivity to hidden meanings in statements and behaviors. By listening with sensitivity and validating what the patient is expressing, you convey respect, reassurance, and understanding. Validating or respecting confused older adults’ feelings in the time and place that is real to them is more important than insisting on the literally correct time and place.

Reminiscence

Reminiscence is recalling the past. Many older adults enjoy sharing past experiences. As a therapy, reminiscence uses the recollection of the past to bring meaning and understanding to the present and resolve current conflicts. Looking back to positive resolutions of problems reminds the older adult of coping strategies used successfully in the past. Reminiscing is also a way to express personal identity. Reflection on past achievements supports self-esteem. For some older adults the process of looking back on past events uncovers new meanings for those events.

During the assessment process use reminiscence to assess self-esteem, cognitive function, emotional stability, unresolved conflicts, coping ability, and expectations for the future. For example, have a patient talk about a previous loss to assess coping. You can also reminisce during direct care activities. Taking time to ask questions about past experiences and listening attentively conveys to an older adult your attitudes of respect and concern.

Although many use reminiscence in a one-on-one situation, it is also used as a group therapy for cognitively impaired or depressed older adults. The nurse organizes the group and selects strategies to start a conversation. For example, the nurse asks the group to discuss family activities or childhood memories. He or she adapts the group’s size, structure, process, goals, and activities to meet its members’ needs.

Body-Image Interventions

The way that older adults present themselves influences body image and feelings of isolation (Chapter 33). Some physical characteristics of older adulthood such as distinguished-looking gray hair are socially desirable. Other features such as a lined face that displays character or wrinkled hands that show a lifetime of hard work are also impressive. However, too often society sees older people as incapacitated, deaf, obese, or shrunken in stature. Consequences of illness and aging that threaten the older adult’s body image include invasive diagnostic procedures, pain, surgery, loss of sensation in a body part, skin changes, and incontinence. The use of devices such as dentures, hearing aids, artificial limbs, indwelling catheters, ostomy devices, and enteral feeding tubes also affects body image.

The nurse needs to consider the importance to the older adult of presenting a socially acceptable image. When older adults have acute or chronic illnesses, the related physical dependence makes it difficult for them to maintain body image. You influence the older adult’s appearance by helping with grooming and hygiene. It takes little effort to help the older adult comb hair, clean dentures, shave, or change clothing. He or she does not choose to have an objectionable appearance. Be sensitive to odors in the environment. Odors created by urine and some illnesses are often present. By controlling odors you may prevent visitors from shortening their stay or not coming at all.

Preparing for Clinical Practice

Mrs. Kaven is an 81-year-old woman who is admitted to the hospital following emergency surgery for a hip pinning of a hip fracture secondary to a fall at her home. Her other medical problems are hypertension, hypothyroidism, and anxiety disorder for which she takes a diuretic and thyroid replacement medication. She has had bilateral knee replacements in the past. Her home is “handicap” friendly. She is a retired bookkeeper, a widow living independently at her home, and usually very active. She drives, plays cards weekly with her friends, and participates in church activities twice a week. She hires help for household cleaning and yard work. She wears glasses, has uncorrected cataracts, and uses a cane.

You are assigned to care for her on her first postoperative day after the hip pinning. You learn in report that Mrs. Kaven has been receiving opioids for postoperative pain, with her last pain rating a 5 on a scale of 0 to 10. She has intravenous fluids for hydration for the first 24 hours. She has an indwelling urinary catheter. The night nurse reports that Mrs. Kaven was restless all night and slept very little and that she had even tried to get out of bed. You enter Mrs. Kaven’s room and find her picking at the air and talking to herself as she tries to eat her breakfast. She is not wearing her glasses. She is oriented to self only. As you do your shift assessment, you recognize that she is delirious.

 Answers to Clinical Application Questions can be found on the Evolve website.

Are You Ready to Test Your Nursing Knowledge?

Answers: 1. 4; 2. 2, 3, 5; 3. 2; 4. 3; 5. 4; 6. 4; 7. 3; 8. 2, 3, 5; 9. 2; 10. 3; 11. 1, 4; 12. 2, 4; 13. 4; 14. 3; 15. 2, 5, 6.