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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

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Nursing Fundamentals [Internet].

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Chapter 19 Care of the Older Adult

19.1. CARE OF THE OLDER ADULT INTRODUCTION

Learning Objectives

  • Consider all aspects of diversity, including age
  • Differentiate between normal and abnormal findings for older adults
  • Detail specific adaptations in patient care to accommodate the needs of older adults

The needs of the older adult population will continue to influence health care through this century. The aging “baby boomer” population, along with an increased average life span of Americans, has led to an increased number of older adults and is only expected to grow. The U.S. Census Bureau projects that 1 in 5 Americans will be over the age of 65 by 2030, and by 2034, the number of older individuals will outnumber children for the first time in U.S. history.[1]

Each individual ages in their own way, and the physical, psychosocial, and cognitive health of older individuals varies widely. Because of this broad scope of health and illness in the aging population, providing nursing care that meets the needs of each older adult can be challenging. Additionally, although there are common physiological changes that occur with aging, many individuals ignore symptoms by erroneously attributing them to the aging process. For example, many older adults mistakenly believe that pain from arthritis is a normal part of growing older and do not seek treatment, resulting in decreased physical activity that puts them at increased risk for developing chronic disease. Providing individualized nursing care and patient education to older adults can promote effective preventative health care and self-management that maintains and enhances their quality of life.[2] Let’s begin by reviewing basic concepts related to the aging process.

References

1.
United States Census Bureau. (2018, March 13). Older people projected to outnumber children for the first time in U.S. history. https://www​.census.gov​/newsroom/press-releases​/2018/cb18-41-population-projections.html ↵.
2.
Sarkisian C. A., Hays R. D., Berry S., Mangione C. M. Development, reliability, and validity of the expectations regarding aging (ERA-38) survey. The Gerontologist. 2002;42(4):534–542. ↵ [PubMed: 12145381] [CrossRef]

19.2. BASIC CONCEPTS

Ageism

Gerontology is the study of the social, cultural, psychological, cognitive, and biological aspects of aging. There are many stereotypes and negative attitudes about aging adults that persist in the US and around the world. This bias can be linked to a general lack of knowledge about the aging process and misunderstandings about older adults. Because of these influences, many individuals have anxiety about aging that can lead to negative stereotypes of older individuals called ageism.[1]

Ageism among nurses and other health care professionals puts older people at risk. Research has demonstrated that ageism in health care negatively impacts older adults’ overall health, well-being, and quality of care received. Ageism results in increased risks of mortality, poor functional health, and slower recovery times from illness. Negative perceptions about aging can also lead to poor mental health and depression.[2] As you read this chapter, think about your own attitudes about aging and how these beliefs may impact the care you provide.

Integrity Versus Despair

Aging individuals must continually adjust to changes in health and physical strength, lifestyle changes as a result of retirement, the loss of significant others, and changing roles and relationships with family members and friends. As a result, older individuals may find it difficult to accept the changes associated with aging. Nurses can support older adults in maintaining a positive self-image and outlook by considering Erikson’s theory of development. Erikson’s theory of development describes the stage of older adulthood as “Integrity versus Despair.” This stage begins at approximately age 65 and ends at death. During this stage, older adults reflect on their accomplishments and the person they have become. If they feel they have led a successful life, they often feel satisfied and develop a sense of integrity. Conversely, individuals who feel unsuccessful or do not feel they achieved their life goals often feel unsatisfied and may experience hopelessness and despair that can lead to depression. Nurses can assist older adults in developing a sense of integrity by encouraging the patient to reminiscence about previous positive life events and relationships and cultivate a positive mindset of guiding the next generation.[3]

Many older adults, especially those with declining health due to chronic disease, acknowledge that changes in their health status and mobility threaten the autonomy and independence they previously experienced throughout adulthood. As a result, many older adults strive to be autonomous so they are not overly reliant on others for their daily care. They often engage in self-management activities in response to changes in their health and physical strength, ranging from simple daily tasks, such as medication management, to more complex tasks, such as relocating to new residences that are better suited to their changes in physical and mental health. Research has found that when older adults are faced with declines in their physical health and/or cognitive abilities, they often draw upon experiences and skills acquired in earlier adulthood for the purpose of self-managing their new conditions. They reflect on their resilience used to overcome significant challenges faced in earlier adulthood and then apply skills and knowledge gained through previously productive activities to managing their new health changes. However, not all older adults have sufficient personal and external resources to devote towards successful self-management of their health conditions. Nurses can assist older adults by personalizing health self-management strategies that emphasize their existing skill sets and knowledge.[4]

Other Considerations

Retirement

In addition to the physiological changes that occur with aging, older adults vary in their level of activity. For example, many older adults continue working into their seventies and beyond. Individuals may choose to continue to work because of their sense of purpose or because of a need for income. Some older individuals experience a loss of identity when they retire because their work role was an important aspect of their life. Retirement can bring a sense of freedom and adventure, as well as a need to find new identity and purpose.

Social Isolation

Retirement and the loss of daily interaction with coworkers, as well as death of family members and friends, can lead to social isolation in the aging population. Social support impacts a person’s health and quality of life and should be included as part of the assessment. It is helpful for nurses to be familiar with community resources that provide socialization opportunities and provide referrals for patients in need of additional services.

Modified Living Environment

Although many aging adults live in assisted living facilities or skilled nursing centers, many older adults prefer to live at home. Modifications may be needed to the home environment to promote safety and independence. For example, grab bars, elevated toilet seats, and other modifications may be needed in the bathroom, along with good lighting, minimization of clutter, and removal of rugs throughout the home. Assessment of the home environment for safety and ease of mobility is an important aspect of home care nursing.

If an older adult requires more care than family members are able to provide at home, nurses provide valuable information about available care options and make referrals to social workers and case managers. There are a wide variety community-based resources to enhance care for older adults. Local aging and disability resource centers (ADRCs) can help facilitate referrals based on specific needs of the older adult. Examples of other resources include adult day centers, home health agencies that provide personal care and nursing assistance, community-based residential facilities (CBRFs), and residential care apartment complexes (RCACs). If an older adult requires 24-hour nursing care, placement in a nursing home (also referred to as a skilled nursing facility) may be required. Use the following hyperlink to read more information about nursing home resources provided by the Centers for Medicare and Medicaid (CMS).

Learn more about nursing home resources by reviewing the Nursing Home Resource Center provided by the Centers for Medicare and Medicaid (CMS).

References

1.
Merz C. C., Stark S. L., Morrow-Howell N. L., Carpenter B. D. When I'm 64: Effects of an interdisciplinary gerontology course on first-year undergraduates' perceptions of aging. Gerontology & Geriatrics Education. 2016;39(1):35–45. ↵ [PMC free article: PMC4988946] [PubMed: 26886151] [CrossRef]
2.
Burnes D., Sheppard C., Henderson C. R., Wassel M., Cope R., Barber C., Pillemer K. Interventions to reduce ageism against older adults: A systematic review and meta-analysis. American Journal of Public Health. 2019;109(8):e1–e9. ↵ [PMC free article: PMC6611108] [PubMed: 31219720] [CrossRef]
3.
This work is a derivative of StatPearls by Orenstein and Lewis and is licensed under CC BY 4.0 ↵.
4.
Perry T. E., Ruggiano N., Shtompel N., Hassevoort L. Applying Erikson's wisdom to self-management practices of older adults: Findings from two field studies. Research on Aging. 2014;37(3):253–274. ↵ [PMC free article: PMC4318792] [PubMed: 25651571] [CrossRef]

19.3. APPLYING THE NURSING PROCESS

Applying the Nursing Process: Assessment

When performing a comprehensive assessment on an older adult, the findings are used to establish their baseline status of physical, cognitive, psychosocial, and spiritual well-being. It is appropriate to consider the potential impact of declining strength and physical functioning on their psychological status using Erikson’s developmental stage of “Integrity versus Despair.” It is also important to consider the impact of chronic disease on their ability to function and complete Activities of Daily Living (ADLs). Many older adults who are able to perform ADLs without assistance consider themselves healthy.

When performing an assessment on an older adult, modification of communication techniques may be required, as discussed in the “Sensory Impairments” and “Cognitive Impairments” chapters. It is important to allow adequate time for older individuals to reply to questions thoughtfully and to move through the requests contained in a physical assessment comfortably.

It is helpful to use an evidence-based tool to assess for frequent needs of older adults, such as the Fulmer SPICES tool. The SPICES tool focuses on areas of common problems for aging individuals and can lead to early intervention and treatment. The SPICES tool includes assessment of the following:

S: Sleep Disorders

P: Problems with Eating or Feeding

I: Incontinence

C: Confusion

E: Evidence of Falls

S: Skin Breakdown[1]

Read more details about using the SPICES tool.

Several free assessment tools for common issues in older adults are located at The Hartford Institute of Geriatric Nursing website. Use the hyperlink in the following box to explore available tools.

Download free assessment tools from the “Try This: Series” at the Hartford Institute of Geriatric Nursing.[2]

Unexpected Findings

While cognitive impairment and memory deficits are not considered normal aspects of aging, there are common expected physiological changes that occur with aging. Nurses should be familiar with these expected findings so that deviations from the expected can be adequately addressed. See Table 19.3 for a comparison of expected versus unexpected findings in an older adult that require notification of the health care provider.[3]

Table 19.3

Table 19.3

Expected Versus Unexpected Findings[4]

Health Promotion

One of the goals of Healthy People 2030 is to improve the health and well-being for older adults. It is estimated that by 2060 almost a quarter of the U.S. population will be age 65 or older. Older adults are at higher risk for chronic health problems like diabetes, osteoporosis, and Alzheimer’s disease. In addition, 1 in 3 older adults fall each year, with falls being a leading cause of injury for this age group. Older adults are also more likely to go to the hospital for infectious diseases such as pneumonia that is a leading cause of death for this age group. Nurses can ensure older adults get preventive care, including vaccines to protect against the flu and pneumonia, to help them stay healthy. Other goals for older adults established by Healthy People 2030 include early detection of dementia with appropriate intervention; decreased hospitalization for urinary infections, falls, and pneumonia; decreased incidence of medication-related safety issues; improved physical activity; improved oral health; decreased complications of osteoporosis; and reduced vision loss from macular degeneration.[5]

Nurses can advocate for improved health care for older adults while actively involving them in decisions about their care and promoting their quality of life. Common areas of health promotion for older adults include nutrition, physical activity, safe medication use, and psychosocial well-being.

Nutrition

Heart disease, cancer, chronic lung disease, and stroke are the leading causes of death in older adults. Nurses can provide patient education that focuses on good nutrition, physical activity, smoking cessation, and moderate alcohol use to promote improved health outcomes.[6] However, nutrition can pose special challenges for the older adult. Chewing can be a problem if there are difficulties with dentition. Lack of oral care, missing teeth, or poorly fitting dentures can cause individuals to avoid intake of healthy foods. Regular dental care should be encouraged when working with older adults. Finances often impact nutritional intake when older adults have difficulty meeting their basic needs of housing, food, and health care. Additionally, the inability to plan, shop, and prepare meals because of activity intolerance, cognitive impairments, or physical limitations can impact nutrition. Nurses can initiate referrals to social workers or case managers for assistance with financial or health care concerns, as well as promote community resources such as Meals on Wheels or senior citizen meal site centers. Assisting individuals to meet their nutritional needs is an important aspect of health promotion.

Read more about promoting good nutrition in the “Nutrition” chapter.

Physical Activity

Physical activity is important throughout the life span. Older individuals may be limited in their ability to engage in physical activity due to various factors such as physical limitations, pain, and fear of falling. Musculoskeletal problems, such as impaired balance and arthritis, can impair an individual’s ability to walk or participate in regular exercise. Helping older adults find appropriate ways to maintain activity is an important nursing intervention. Nurses can advocate for the older adult by encouraging them to regularly attend health care checks with their provider and discuss concerns that limit their activity. They should be reassured that pain is not considered a normal part of aging and can be effectively treated so they can maintain physical activity comfortably.

Read more about promoting activity and joint range of motion in the “Mobility” chapter.

Safe Medication Use

Because of the increased incidence of chronic disease, many older adults take multiple medications to manage their symptoms and conditions. Polypharmacy, the use of many medications, increases a person’s risk of adverse medication effects. Older adults may be prescribed medications by multiple providers, and they can become confused when attempting to safely manage their daily medication use. There are also changes in absorption, distribution, metabolism, and excretion of drugs as an individual ages that impact the safe use of any medications.

The American Geriatrics Society maintains a list of medications to potentially avoid or use with caution in older adults because of the risk for harm. This list is called “AGS Beers Criteria.” Updated reports are published in the Journal of the American Geriatric Society.

Read a free PDF of the 2012 Beers Criteria including rationale for why the listed medications may be inappropriate for older adults. Go to the American Geriatric Society website to view the most current ABG Beers Criteria.

In addition to cautiously using medications listed on the ABG Beers Criteria list with older adults, nurses can promote other safety strategies with medications. For example, older adults should have all of their medications prescribed from multiple providers filled at the same pharmacy to check for interactions and replications. It is also helpful to use a daily pill dispenser to ensure medications are taken as prescribed.

Nurses should also perform medication reconciliation during all clinic visits and on admission to health care agencies to review the patient’s current use of all medications.

Read more about medication reconciliation in the “Preventing Medication Errors” section of the “Legal/Ethical” chapter in Open RN Nursing Pharmacology.

Psychosocial Well-Being

As individuals age, they often experience loss of significant others, family members, and friends. These losses create increased risk for social isolation and depression. Poor mobility and transportation issues can also add to social isolation. As male older adults experience multiple losses, their risk for suicide increases.[7] Nurses can provide information about community resources and outreach programs to promote social interaction for individuals experiencing isolation.

Older adults experience risk for other safety issues, such as elder abuse and financial exploitation. Read more about safety considerations for older adults in the “Safety” chapter.

Aging individuals continue to have sexual needs, and this aspect of their overall health should not be ignored. Assessment of these needs allows the nurse to integrate these aspects into the patient’s plan of care and make appropriate referrals when necessary.

Adapting Patient Education

As discussed throughout this chapter, there are many considerations when working with the older adult population and promoting optimal health and quality of life. It is also important to modify patient education methods depending on the individual’s knowledge, skills, and abilities. For example, some older adults readily engage in using electronic technology, but others have low digital literacy or experience difficulty when accessing electronic health resources. Nurses should adapt patient education to the needs of the individual and provide verbal, written, or electronic resources as needed, while considering any sensory, cognitive, or functional impairments. The ultimate goal of health promotion and patient education is to improve their understanding, motivation, and engagement in self-management and promote their quality of life.

References

1.
Fulmer, T. (2019). Fulmer SPICES: An overall assessment tool for older adults. The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing. https://hign​.org/sites​/default/files/2020-06​/Try%20This%20General​%20Assessment%201.pdf ↵.
2.
The Hartford Institute for Geriatric Nursing, New York University, Rory Meyers College of Nursing. https://hign​.org/consultgeri-resources​/try-this-series ↵.
3.
Boss G. R., Seegmiller J. E. Age-related physiological changes and their clinical significance. The Western Journal of Medicine. 1981;135(6):434–440. ↵ [PMC free article: PMC1273316] [PubMed: 7336713]
4.
Boss G. R., Seegmiller J. E. Age-related physiological changes and their clinical significance. The Western Journal of Medicine. 1981;135(6):434–440. ↵ [PMC free article: PMC1273316] [PubMed: 7336713]
5.
6.
Centers for Disease Control and Preventive Medicine. (2021, March 1). Leading causes of death. https://www​.cdc.gov/nchs​/fastats/leading-causes-of-death.htm ↵.
7.
Centers for Disease Control and Prevention (n.d.) Injury Prevention and Control. https://www​.cdc.gov/injury/index.html ↵.

19.4. LEARNING ACTIVITIES

Learning Activities

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

1.

Mr. Yang is an 87-year-old patient admitted to the medical surgical floor due to a recent fall at home. His wife reports that the patient has become increasingly frail and unsteady. Utilizing the SPICES tool, develop a list of assessment questions for Mr. Yang to determine potential problems and subsequent interventions.

Image ch19careolderadult-Image001.jpg

XIX GLOSSARY

Ageism

Negative stereotypes of older individuals.

Gerontology

The study of the social, cultural, psychological, cognitive, and biological aspects of aging.

SPICES tool

Focuses on areas of common problems for aging individuals and can lead to early intervention and treatment.

Copyright Notice

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

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