NCM 114 – GERONTOLOGICAL NURSING

INTRODUCTION TO GERONTOLOGICAL NURSING - Learning patience, tolerance,

understanding and basic nursing skills
Gerontological Nursing - Witnessing the terminal stages of
- used to called “Geriatric” disease and importance of skilled nursing
- a nursing sub-specialty for older patients care
- Preparing for the future
GERONTOLOGICAL NURSING VS. GERIATRIC NURSING - Recognizing the importance of
rehabilitation
Gerontological Geriatric - Being aware of the need to undertake
research

Focus on aging and Focus on medical care

the aged (old people) of the aged SCOPE AND STANDARDS OF GERONTOLOGICAL NURSING PRACTICE

SCOPE STANDARDS

Assessment Quality of Care

The history and development of Gerontological
Nursing is rich in diversity and experiences. Diagnosis Performance Appraisals
Outcome Identification Education
• Focus in increasing life expectancy
Planning Collegiality
• Increasing number of acute and chronic
health conditions Implementation Ethics
• Nurses provides disease prevention and Evaluation Collaboration
health promotion Research
• Promote positive aging
Research Utilization

HISTORY
DEFINITION REVIEW
- Specialty formed in the early 1960’s by ANA
- Standards for Geriatric Practice: Veterans • Ageism – discrimination based on age
Administration funded Geriatric Research • Old – people who are living for a long time
Education and Clinical Centers (GRECC) at
VA medical centers (1970’s) DEFINITION OF “OLD”
- Scope and Standards of Gerontological Chronological age
Nursing Practice (1980’s) - young-old: 65 – 74
- Established Hartford Foundation Institute of - middle-old: 75 – 84
Geriatric Nursing at NYU Division of Nursing - old-old (frail elderly): 85+
(1990’s)
• Cultural terms: elder, senior, older adult,
elderly
PIONEERS IN GERONTOLOGICAL NURSING
Biological age
Florence Nightingale
- First geriatric nurse
- Care of Sick Gentlewomen in Distressed PREVIOUS STEREOTYPES OF THE AGED
Circumstances - Television
Doreen Norton - Media
- focused career on care of the aged - Newspapers
- described advantages of learning - Film industry
geriatric care in basic education - Commercials in magazines and on TV
- Greeting card/birthday cards
NCM 114 – GERONTOLOGICAL NURSING
PRACTICE SETTINGS - Centered on holistic, interdisciplinary care to
help the dying “live until they die”
• Acute Care Hospital - Provide quality care until the last months,
• Long-Term Care weeks, days or hours of their life
- Assisted Living
- Intermediate Care Respite Care
- Subacute or Transitional Care - Provides care to give caregivers a break
- Skilled Care - Can be done in a daycare center, at home,
- Alzheimer’s Care or ALF’s
- Hospice
• Rehabilitation Continuing Care Retirement Community
• Community (CCRC)
- Home Health Care - Provides continuum of care from
- Foster Care or Group Homes independent living to skilled care all within a
- Independent Living single campus, with levels of care adjusted
- Adult Day Care to individual needs
- Patients can move seamlessly among
independent living, assisted living, skilled
CONTINUUM OF CARE
care, or long term care as their condition
Acute Care Hospitals warrants
- Often the point of entry into the healthcare
system Assisted Living Facilities
- Nurses care for older adults - Alternative for those who don’t feel safe
- Admits older people except in L&D, post- being alone
partum & pediatrics - For those who needs help with ADL’s
- May be connected to a LTCF
Acute Rehabilitation - Provides healthy meals, planned activities,
- Found in several settings including acute places to walk & exercise, and pleasant
care hospitals, subacute care (transitional surroundings
care), & LTCF’s
- Goals are to maximize independence, Foster Care or Group Homes
promote maximal function, prevent - For those who can do ADL’s but with
complications, & promote quality of life within issues safety that requires supervision
a person’s strengths & limitations - Offers more personalized supervision in
a smaller, more family like environment
Home Health Care
- For home-bound due to severity of illness or Green House Concept
immobility - Primary purpose is to serve as a place
- Usually done by a visiting nurse where elders can receive assistance and
support with ADL’s & clinical care without
Long Term Care Facility the assistance becoming the focus of
- Referred to as nursing homes existence
- Provides support to persons of any age who - Older people retain control of ADL’s
lost some or all capacity for self-care
- Nurses provide planning & oversee Adult Daycare
residents - For older adults who are unable to
→ Maintain the functional & nutritional remain at home unsupervised
status of residents while preventing - Used by family members who care for the
complications of impaired mobility older person in their homes
Hospice - Community based program designed to
- To care for the dying and their families meet the needs of functionally and/or
cognitively impaired adults through
NCM 114 – GERONTOLOGICAL NURSING
individual plan of care in protective Malignant neoplasms,
5.11%
setting all forms
- Programs may be sponsored to provide COPD 3.42%
socialization, meals, & therapeutic
activities Tuberculosis, all forms 3.04%

Diabetes mellitus 2.74%

ROLES OF THE GERONTOLOGICAL NURSE GI ulcers & other GI
1.42%
diseases
• Provider of Care
Nephritis, nephrotic
1.19%
• Teacher syndrome, nephrosis

• Manager
THEORIES OF AGING
• Advocate
SOCIOLOGICAL THEORIES
• Research Consumer - Changing roles, relationships, status
and generational cohort impact the
older adult’s ability to adapt.
DEMOGRAPHICS OF AGING IN THE PHILIPPINES
• Activity Theory
PHILIPPINE DEMOGRAPHICS
- Havighurst and Albrecht (1953)
• 2018: 8,013,059 Filipinos over 60 years old - Conceptualized activity engagement &
positive adaptation to aging
(8.2%) - Remaining occupied and involved is a
• 5,082,049 will be 65 years old and older necessary ingredient to satisfying late
life
- Associates activity as a means to
prolong middle age & delay the negative
PROJECTIONS
effects of old-age
• Philippines will enjoy the benefits of a young
population until 2030
• Disengagement Theory
• Growth: 4.9% (2020)
- Cumming & Henry (1961)
5.6% (2025) - Contrast to activity theory
- Conceptualized that aging is
6.3% (2030) characterized by gradual
disengagement from society and
WHY THE RECENT INCREASE IN NUMBER OF OLDER relationship
ADULTS? - Withdrawal from society & relationship
Increased life expectancy Average age: 68.5 (2017) to serves to maintain social equilibrium &
74 (2018) • Fertility promote internal reflection
- Outcome is a new equilibrium ideally
satisfying to both individual and society

• Subculture Theory
MORTALITY AND MORBIDITY IN OLDER - Rose (1965)
ADULTS - Views older adults as a unique
subculture within society formed as a
Cardiovascular defensive response to society’s negative
18.56%
diseases, all forms attitudes & the loss of status that
Pneumonia 6.21% accompanies aging
NCM 114 – GERONTOLOGICAL NURSING
- Conceptualized that the elderly prefer to - Activity & participation must be the
segregate from society in an aging result of one’s own choices which differs
subculture sharing loss of status and from one person to another, & control
societal negativity regarding the aged. over one’s life in all situation is essential
- Health and mobility are key for the person’s adaptation to aging
determinants of social status
PSYCHOLOGICAL THEORIES
• Continuity Theory - Explain aging in terms of mental processes,
- Havighurst, Neugarten & Tobin (1968) emotions, attitudes, motivation and
- Suggests that personality is well- personality development that is
developed by the time one reaches old- characterized by life stage transitions
age & tends to remain consistent across
life span • Human Needs Theory
- Past coping patterns occur as older - Maslow (1954)
adults adjust to physical, financial, & - Five basic needs motivate human behavior
social decline and contemplate death in a life-long process toward need fulfilment
- The needs are prioritized such that more
basic needs take precedence before the
• Age Stratification Theory complex needs
- Riley and associates (1972)
• Theory of Individualism
- Society is stratified by age groups that
are the basis for acquiring resources, - Jung (1960)
roles, status, & deference from others. - Personality consists of an ego and personal
- Age cohorts are influenced by their and collective unconsciousness that views
historical contexts& share similar life from a personal or external perspective.
experiences, beliefs, attitudes, & Older adults search for life meaning & adapt
expectations of life course transitions to functional & social losses

• Person-Environment Fit Theory • Stages of Personality Development

- Lawton (1982) - Erikson (1963)
- Introduced functional competence in - Personality develops in 8 sequential stages
relationship to the environment with corresponding life tasks. The 8th
- Conceptualized that function is affected phase, Integrity vs. Despair, is
by ego strength, mobility, health, characterized by evaluating life
cognition, sensory perception & the accomplishments; struggles including
environment letting go, accepting care, detachment, &
- Competency changes one’s ability to physical & mental decline
adapt to environmental needs - Peck (1968) refined the 8th phase into
three challenges
• Gerotranscendence o Ego differentiation vs. work role
- TheoryTornstam (1994) reoccupation
- Proposed that aging individuals undergo o Body transcendence vs. body
a cognitive transformation from a preoccupation
materialistic, rational perspective toward o Ego transcendence vs. ego
oneness with the universe preoccupation
- Successful transformations include a
more outward or external focus, • Life Course (Life Span) Paradigm
accepting impending death without fear, - Bühler (1933)
an emphasis of substantive - Blend key elements in psychological
relationships, intergenerational theories (life stages, tasks, & personality
connectedness & spiritual unity with the development) with sociological concepts
universe
NCM 114 – GERONTOLOGICAL NURSING
(role behavior & interrelationship between • Programmed Theory
individual & society)
- Cells divide until they are no longer able to;
- Life course is unique to each individual
this triggers apoptosis or cell death
- Divided into stages with predictable patterns
- Structured based on one’s role,
relationships, internal values, & goals • Gene/Biological Clock Theory
- Goal achievement is associated with life
satisfaction - Cells have a genetic programmed aging
code
• Selective Optimization with Compensation
Theory
• Neuroendocrine Theory
- Baltes (1987)
- Individual copes with the functional losses - Problems with the Hypothalamus-Pituitary-
of aging through Endocrine Gland Feedback System causes
activity/role selection, optimization, & disease; increased insulin growth factor
compensation increase aging
- Critical life points are morbidity, mortality, &
quality of life • Immunological Theory
- Facilitates successful aging
- Aging is due to faulty immunological
function which is linked to general well
BIOLOGICAL THEORIES being

• Stochastic Theories
- Based on random events that cause cellular NURSING THEORIES OF AGING
damage that accumulates as organism ages • Functional Consequences Theory
• Nonstochastic Theories - Environmental and biopsychosocial
- Based on genetically programmed events consequences impact functioning. Nursing’s
caused by cellular damage that accelerates role is to minimize age associated disability
aging of the organism in order to enhance safety and quality of
living
• Free Radical Theory
• Theory of Thriving
- Membranes, nucleic acids, and proteins are
damaged by free radicals which causes - Failure to thrive results from a discord
cellular injury and aging between the individual and his or her
environment or relationships. Nurses
• Orgel/Error Theory identify and modify factors that contribute to
disharmony among these elements
- Errors in DNA and RNA synthesis occur
with aging
• Wear & Tear Theory COMMUNICATION
- Cells wear out and cannot function with - It is an important skill that allows us to
aging survive in and interact with our world
• Connective Tissue/Cross-Link Theory - We express our needs and wishes,
understand needs and wishes of others,
- With aging proteins impede metabolic negotiate adversity, and convey our feelings
processes and cause trouble with getting
nutrients to cells and removing cellular
waste products The ability to communicate depends on
physiological and psychological processes
NCM 114 – GERONTOLOGICAL NURSING
- uses non-verbal gestures & facial
PHYSICAL PSYCHOLOGICAL expressions

Listening Attention
Speaking Memory  SPEECH
Gesturing Self-awareness - primary form of communication
Reading Organization
- requires both visual & auditory input,
Writing Reasoning
motor output, & central processing
Touching
- involves articulation & pronunciation
Moving
 DISABILITY
- plays a major role in affecting
communication

SENSORY MODALITIES INVOLVED IN

COMMUNICATION NORMAL & PATHOLOGICAL
AGE-RELATED CHANGES THAT AFFECT
 VISION COMMUNICATION
- 70% of all information coming  The number of individuals with sensory
through the eyes deficits increases with age
- visual information makes interaction
sensible & add meaning to verbal
messages
VISION (age-related changes in the eyes)
 The Lens
 HEARING ▪ Changes in color (yellowed or
amber; opaque)
- reception of communication ▪ Begins to change after age of 40
- major source of communication is
the content of auditory information  The Iris & Pupil
- The non-verbal auditory information ▪ Slower pupillary reflex at age 50
includes the pitch (tone) and timber ▪ Pupil does not dilate completely
(quality) (senile miosis)
▪ At age 60, 70% less
 TOUCH accommodation of light

- substitute for sight TYPICAL VISION PROBLEMS

- conveys meaning for anger or love  Poor visual acuity
- may communicate danger
 Presbyopia

 OLFACTION & GUSTATION  Sensitivity to light & glare

- may trigger feelings or memories  Senile miosis

(Olfaction)
 Problems with color contrast
- may convey meanings (Gustation)

 MOVEMENT BEHAVIORAL CUES TO VISUAL DEFECTS

- provides important information on  Adjustment of distance
environment
- elicits information if used with other  Squinting or focusing
senses  Difficulties in ADL’s
NCM 114 – GERONTOLOGICAL NURSING

COMMON VISUAL DISEASES

 Macular Degeneration

HEARING (age-related changes in hearing)

 Diabetic Retinopathy TYPES OF HEARING LOSS

 Conductive Problems (outer to inner)
- Reduction of sound transmission

 Sensorineural Problems (inner to cortex)

- Caused by genetics & acquired
factors

 Mixed Hearing Loss

 Glaucoma - Mixture of sensorineural &
conductive

PATHOLOGICAL CHANGES TO HEARING

 Persistent exposure to noise pollution
- Damage due to
environmental noise or
pressure changes
- Can be temporary or
 Senile Cataracts permanent
- Can result to tinnitus
 Exposure to ototoxic substances
- Medications
- Poisons
 Medical conditions
- Acute trauma

 Retinal Detachment - Cardiovascular diseases (smoking)

- Chronic viral or bacterial infection
NCM 114 – GERONTOLOGICAL NURSING
- Measles, mumps, or meningitis - May lead to anarthria (severe form)
 Verbal Apraxia
INDICATIONS OF HEARING LOSS - A neurological disorder caused by
damage to the parietal lobe which
 Inattentiveness / inappropriate responses
results in difficulties executing mouth &
 Repetitions speech movements

 Complains of “mumbling” - Person has intention & capacity to move

muscles for speech, but have no
 Increased reaction to loud sounds volitional control over the muscles
 Increased or unusually loud speech  Aphasia
 Tilting / cocking of head - Most common speech disorder usually
 Volume up following after stroke (left hemisphere)
- Inability to express or understand the
meaning of words
2 Types of Aphasia
COMMUNICATION TIPS
1. Receptive (fluent) aphasia
 Do not shout
- inability to comprehend spoken or written
 Use touch or visual cues language but intact expressive ability
- due to damage in the Wernicke’s area
 Use gestures or objects
(meaning)
 Limit background noise
2. Expressive (non-fluent) aphasia
- inability to produce language but intact
SPEECH AND LANGUAGE language comprehension
- due to damage in the Broca’s area
 NORMAL AGING CHANGES (speech production)
 Decreased respirations
 Change in laryngeal structure COMMUNICATION TIPS

 Reduced saliva  Low distractions

 Loss of teeth  Position yourself in close proximity

 Decreased elasticity & muscle tone  Use multiple forms of communications

 Cognitive changes  Use short uncomplicated sentences

PATHOLOGICAL CHANGES TOUCH / SOMATOSENSORY SYSTEM

 Dysarthria  The skin responds to external stimuli

- Disturbed articulation due to  Interpreted as softness, pain, or heat

disturbance in control of speech  Reduction in tactile and vibration sensation;
muscle decreased sensitivity to warm or cold stimuli
- May be related to stroke, brain  Sensitivity is reduced more in the fingertips
tumors, degenerative & metabolic than in other location
diseases, or toxins
NCM 114 – GERONTOLOGICAL NURSING
 Somatosensory information plays an - Postural instability
important role in ensuring safety
- Impaired balance & coordination
 Other symptoms may include:
IMPACT OF SOMATOSENSORY DEFICITS ON
- Memory problems
COMMUNICATION
- Depression
 Imposes danger due to loss of sensation
- Hallucinations
 May use other senses to identify
characteristics & quality of objects - Mild vision loss
 Can cause other forms of disorders

HOW PARKINSON’S DISEASE AFFECT

COMMUNICATION
COMMUNICATION TIPS
 Speech may become slurred, soft, hoarse,
 Use verbal explanations to describe
or have an inappropriate rhythm
physical activities
 Writing may become smaller, shaky, and
 Encourage older adults to revert to other
difficult to read
activities that capitalize on their current
strength and abilities  Facial expression may be lost

MOVEMENT DISABILITY
 An important ability that fosters  A decrease in the performance of ADLs and
independence and promotes interaction & IADLs independently can have a negative
understanding of the environment impact on the older adult’s quality of life
 It is a function of many variables:
- Posture ACTIVITIES OF DAILY LIVING / INSTRUMENTAL
- Balance ACTIVITIES OF DAILY LIVING
- Flexibility
- Tone  ADLs are basic tasks one perform to survive
- Strength  Impairment in ADLs are more severe
- Sensory integration
- Reflexes  IADLs are more complex tasks
- Motor planning
 ADLs & IADLs are used to assess functioning
 Impairment is most common among
MOVEMENT DISORDER IN OLDER ADULTS
elderlies
 Parkinson’s Disease
 A chronic neurodegenerative condition
RISK FACTORS FOR IMPAIRMENT OF ADLs
characterized by impairment of the nerves
AND IADLs
that control movement
 Age
 Major symptoms include:
 Gender – female
- Tremors
 Chronic diseases
- Rigidity & stiffness
 Cognitive impairment
- Slowness of movement
NCM 114 – GERONTOLOGICAL NURSING
 Lack of exercise Mental flexibility
Rapid naming ability
 Subjective health problems Long term memory
 Low socioeconomic status
PATHOLOGICAL COGNITIVE CHANGES –
DELIRIUM
MEASURING ADLs/IADLs
 Common in hospital settings
 Presence or absence of medical diagnosis
 Prevalent in the terminally ill
 Self-report
 Definition (accdg. to DSM-MHD)
 Direct observation
- Disturbance of consciousness with
reduced ability to focus, sustain, shift
attention
COMPENSATING FOR ADL/IADL IMPAIRMENT
- A change in cognition or
 Assistive devices
development of perceptual
 Easy to wear clothing disturbance that is not better
accounted for by a preexisting,
 Handrails
established or evolving dementia
 Ready to cook meals
- Disturbance develops over a short
period of time and tends to fluctuate
over the course of the day
PHYSIOLOGICAL CHANGES IN
COMMUNICATION - There is evidence from history,
physical examination or laboratory
- COGNITIVE CHANGES findings that the disturbance is
caused by several different possible
TWO TYPES OF INTELLIGENCE events

 Fluid Intelligence  It could easily be misinterpreted as any

number of disorders including psychotic
 Acquisition of new information disorders, dementia and mood disorders
with psychotic features
 Crystallized Intelligence
- Good to excellent recovery if
 Accumulation of knowledge over
correctly identified but unlikely in the
life span
geriatric population
- It is associated with increased risk of
FLUID INTELLIGENCE vs. CRYSTALLIZED developing medical complications
INTELLIGENCE and functional decline
CRYSTALLIZED
FLUID INTELLIGENCE
INTELLIGENCE  Can be life threatening leading to coma,
seizures and eventual death
Decline over time  Clients with delirium often experiences
Remain stable
hallucinations
Information processing
Verbal comprehension
speed - Tends to be disoriented and
Divided attention Verbal expression confused
Sustained attention Vocabulary
Visuospatial tasks Wisdom  Communications is often fraught with
Abstraction Expertise misinterpretation and inappropriate
responses
NCM 114 – GERONTOLOGICAL NURSING
 The most common type of Dementia in
older adults 60 years & up (50%-60%)
GUIDELINES FOR COMMUNICATION
 This is one disease that has no definite
 Keep discussions simple and questions
diagnosis until after autopsy; disease of
concise
“rule out”
 Use large-print calendars and clocks to
 Progression of dementia in 3 stages
assist with orientation to time
 Pictures of family members and loved ones
3 STAGES OF DEMENTIA TYPE ALZHEIMER’S
 Well-lit place
 Stage 1 (2-4 years leading up to and
 Frequent reassurance
including diagnosis)
 No restraints
 Progressive memory loss & confusion
 Distraction and soothing conversation
 Mood & personality changes
 Loss of spontaneity & initiative
PATHOLOGICAL COGNITIVE CHANGES –
 Decreased concentration abilities
DEMENTIA
 Impaired judgment & thinking
 A progressive illness that impairs social and
occupational functioning
 Criteria for Dementia:
- Cannot recall new or previously  Stage 2 (2-8 years)
learned information
 Increasing memory loss & confusion
- Memory problems must be present
 Poor impulse control with frequent
- With one or more of the following: outbursts

• Apraxia (impaired movement)  May display aggressive behavior

• Aphasia (inability to comprehend)  Hallucinations or delusions

• Agnosia (inability to interpret)  Aphasia & confabulations

• Disturbed executive functioning  Agraphia & agnosia

 Wandering & restlessness

TYPES OF DEMENTIA  Hyperorality

 Irreversible Dementia
 Inability to cure or reverse the  Stage 3 (1-3 years)
symptoms with medical or  Loss of weight or binge eating
psychological treatment
 Loss of self-care skills
 Reversible Dementia (Pseudodementias)
 Incontinence
 Potential for reversibility depending
on etiology and treatment availability  Progressive decrease in ability to
respond to environmental stimuli
 Multiple physical health problems &
ALZHEIMER’S DISEASE eventual death
NCM 114 – GERONTOLOGICAL NURSING
 Risk of suicide is common/highest among
older Caucasian men
IMPACT OF DEMENTIA ON COMMUNICATION
 May also affect family members &
 Early stages
caregivers of depressed elders
 Frustrations, embarrassment, & can
be upset about inability to
communicate
 Reduction in social contact &
reduced feelings of self-worth
SYMPTOMS OF DEPRESSION
 Moderate to severe
 Sadness
 Agitation
 Anhedonia
 Easy irritability
 Significant weight loss or gain
 Increased or decreased sleep
COMMUNICATION TIPS
 Psychomotor agitation or retardation
 Be calm, reassuring & confident
 Fatigue or loss of interest
 Get the person’s attention before starting a
 Feelings of worthlessness or guilt
conversation
 Impaired ability to concentrate or think
 Orient the person to yourself and the
person’s name  Recurrent thoughts of death or suicide
ideation or attempts
 Reduce or eliminate background noise
 Provide clear and simple instructions for
tasks UNIQUE CHARACTERISTICS IN ELDERLY
 Frequently remind the person of the task he  Multiple medical conditions
is doing
 Life transitions & change in status and role
 Use concrete or familiar words
 Loss of family members & friends
 Encourage discussion of significant life
events
 Establish familiar environment What causes Depression in older
adults?

PSYCHOLOGICAL CHANGES IN  Chemical changes in the brain &

COMMUNICATION chemical imbalance
- MENTAL ILLNESS  Experiences of helplessness
 Negative views of oneself, the world
DEPRESSION and others
 A very serious condition associated with
increased risk of death, a greater number of
 Exposure to severe and prolonged
medical conditions, higher healthcare costs, stress
& longer hospital stays
 Or maybe…some combination of all
these explanations
NCM 114 – GERONTOLOGICAL NURSING
TREATMENT OF DEPRESSION
 Medications
 Anti-depressants
 Talk therapy
 Psychiatrists or
Psychologists
 Electroconvulsive therapy
 Electrical shock

IMPACT ON COMMUNICATION
 Loss of inclination to interact (withdrawn)
 Social isolation\

NURSE’S ROLE
 Self-awareness
 Encourage the elder to engage in minor
activities
 Be respectful & understanding
 Offer your availability for communication
 Use memory aids