Essentials of Gerontological Nursing

Essentials of
Gerontological Nursing
Meredith Wallace PhD, APRN-BC
New York
Essentials of
Gerontological Nursing
Copyright © 2008 Springer Publishing Company, LLC
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Library of Congress Cataloging-in-Publication Data

Wallace, Meredith, PhD, RN.
Essentials of gerontological nursing / Meredith Wallace.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8261-2052-6 (alk. paper)
ISBN-10: 0-8261-2052-0 (alk. paper)
1. Geriatric nursing. I. Title.
[DNLM: 1. Geriatric Nursing. WY 152 W192e 2007]
RC954.W25 2007
618.97'0231—dc22 2007025523
Printed in the United States of America by Bang Printing.

This book is dedicated to my loving grandfather Fiora “Bill”
Metall who engendered in me a love for older adults and a passion
for excellence in geriatric care.
Contents
Preface xiii
Acknowledgments xv
ONE The Graying of America 1

Issues of Aging 2
Government-Funded Health Care 3
Medical Concerns 4
Ageism—Facts and Myths of Aging 5
Myths 5
Ageism 10
Ethnogeriatrics and Health Care 11
Cultural Competence 14
Gerontological Nursing 19
Theories of Aging 22
Biological Theories 22
Psychological Theories 24
Moral/Spiritual Theories 24
Sociological Theories 25
Summary 26
TWO The Health Care Delivery System 29

Retirement 31
Challenges Within the Current Health Care
Delivery System 33
Financing Health Care 38
Medicare and Related Plans 38
Medicaid 65
Private Pay, or Fee for Service 68
vii
viii CONTENTS
Veteran’s Benefits 68
Long-Term Care Insurance 69
Payment Options for Older Adults Without
Resources for Health Care 71
Summary 72
THREE Normal Changes of Aging 75

Cardiovascular System 77
Respiratory System 88
Integumentary System 89
Gastrointestinal System 91
Constipation 92
Bowel Incontinence 93
Urinary System 94
Urinary Incontinence 94
Musculoskeletal System 96
Sexuality/Reproductive System 98
Changes in the Senses 100
Neurological Changes 102
Summary 103
FOUR Assessing Older Adults 105

Systematic Geriatric Assessment 106
Health History 110
Reminiscence and Life Review 112
Physical Assessment 112
Critical Components of a Comprehensive
Geriatric Assessment 115
Function 116
Cognition 117
Summary 118
FIVE Health Promotion 121

Primary Prevention 124
Alcohol Usage Among Older Adults 124
Smoking 125
Nutrition and Hydration 126
Risk Factors for Malnutrition 127
Failure to Thrive (FTT) 128
Interventions to Promote Nutrition 129
Exercise 130
Sleep 131
Fall Prevention 131
Restraint Usage 133
Adult Immunization 134
Contents ix
Influenza 134
Pneumonia 135
Tetanus and Diphtheria 135
Secondary Prevention 137
Cardiovascular Disease 137
Diabetes 138
Cancer 139
Summary 142
SIX Pathological Disease Processes in Older Adults 145

Musculoskeletal Disorders 147
Osteoarthritis 147
Osteoporosis 148
Cardiovascular and Respiratory Disorders 151
Hypertension 151
Congestive Heart Failure (CHF) 152
Angina and Myocardial Infarction (MI) 155
Obstructive Airway Diseases 157
Cerebral Vascular Accident (Stroke) 158
Diabetes Mellitus 160
Infectious Diseases 162
Influenza 162
Pneumonia 163
Sexually Transmitted Disease and Human
Immunodeficiency Virus/Acquired Immune
Deficiency Syndrome 165
Cancer 168
Parkinson’s Disease 170
Summary 172
SEVEN Medication Usage 175

Pharmacokinetics and Pharmacodynamics 177
Medication Absorption 178
Medication Distribution 180
Hepatic Metabolism 181
Renal Elimination 182
Medication Interactions 183
Medication–Disease Interactions 183
Medication–Nutrient Interactions 184
Generic Medications 185
Inappropriate Medications 185
Medication Adherence 187
Over-the-Counter and Illegally Obtained
Narcotics and Herbal Medications 190
Summary 194
x CONTENTS
EIGHT Cognitive and Psychological Issues in Aging 197

Delirium 198
Depression 205
Suicide 209
Dementia 210
Alzheimer’s Disease (AD) 210
Summary 216
NINE Ethical Issues of Aging and Independence 219

Ethical Principles 221
Autonomy 222
Beneficence 224
Nonmaleficence 224
Justice 225
Driving 226
Sexuality in Older Adults 229
Gambling 234
Summary 237
TEN Quality of Life Issues Among Older Adults 239

Quality of Life (QOL) 240
Elder Mistreatment 243
Pain 247
Grandparenting 248
Spirituality 249
Summary 252
ELEVEN Environments of Care 255

Home Care 256
Caregiving at Home 260
Acute Care 262
Skilled Nursing Facilities 263
Urinary Tract Infections 264
Pressure (Decubitus) Ulcers 272
Assisted Living 273
Continuing Care Retirement Communities 274
Homeless Older Adults 275
Summary 276
TWELVE End-of-Life Care 279

Advance Directives 280
Financial Planning for End of Life 283
Dimensions of End-of-Life Care 283
Physical Dimension 285
Contents xi
Psychological Dimension 288

Social Dimension 288
Spiritual Dimension 288
Communication 290
Grieving 291
Widowhood 291
Hospice Care 292
Summary 293
THIRTEEN Future Trends and Needs 295

America Continues to Gray 296
Changes in the Health Care Delivery System 300
Ethical, Legal, and Financial Issues Related
to Older Adults 302
Normal Changes of Aging 304
Wellness, Health Promotion, and Health
Education 305
Medication Management 305
Geriatric Assessment 307
Advances in Acute Illnesses and Chronic
Disease Management 307
Special Issues of Aging 309
Psychological and Cognitive Issues in Aging 309
Environments of Care 310
Spirituality and End-of-Life Care 311
Conclusion 311
Web Resources 313
Index 315
Preface
The current standards of living, nutrition, prevention and treatment of

infectious diseases, and progress in medical care have sharply increased
the survival rate for people born in the United States. Once people reach
adulthood, they are likely to survive to old age. In 1990, the number
of Americans age 65 and older was approximately 28 million, roughly
12% of the population. By the year 2030, that percentage is projected
to increase to more than 18% of the population. By the year 2020, the
over-65 population in Connecticut alone is expected to increase 28%
(ftp://ftp.hrsa.gov/bhpr/workforceprofiles/connecticut.pdf). In fact, the
fastest-growing age group in the country is that of adults age 85 and
older. According to Healthy People 2010, individuals currently aged 65
years can be expected to live an average of 18 more years than they did
100 years ago, for a total of 83 years. Those currently aged 75 years can
be expected to live an average of 11 more years, for a total of 86 years
(http://www.health.gov/healthypeople).
As a result of the increasing lifespan, diseases once regarded as
acute in duration and imposing imminent death are now chronic diseases
among older adults. The presence of disease among this population man-
dates quality nursing care. However, the poor perception of nursing and
lack of nurses with the knowledge and experience to care for older adults
clearly leaves older adults as an underserved population with a dubious
quality of care. In a study of college students, negative attitudes toward
the elderly were commonly found. However, intergenerational learning
experiences contributed to improving these attitudes. Thus, the author
recommended these experiences in order to change attitudes toward the
aged (Layfield, 2004).
This evidence points clearly to the fact that a large need exists to
provide quality geriatric nursing education to practicing nurses nation-
wide. Essentials of Gerontological Nursing is an effective compilation
of geriatric best practices needed to effectively care for older adults. It is
brief, yet comprehensive, in its approach to geriatric issues and will be
xiii
xiv PREFACE
a refreshing contribution to the currently existing literature that is more

heavily focused on theory, and less so on clinical practice.
REFERENCES
Layfield, K. D. (2004). Impact of intergenerational service learning on students’ stereotypes

toward older people in an introductory agricultural computing course. Journal of
Southern Agricultural Education Research, 54, 134–146.
Acknowledgments
The author wishes to gratefully acknowledge the many students who as-
sisted with this book. Thanks go to Kara Diffley for her contributions on
Parkinson’s Disease and her editorial assistance with this book; Patricia
Cino for her assistance with the sections on Alzheimer’s Disease; Jay Plano
for his assistance with the sections on diabetes; and George Flohr for his
assistance with the sections on congestive heart failure. Also, thanks go
to Paula Shevlin for her work on the Evidence-Based Practice boxes and
Lindsay Neptune for assisting with the case studies. Many thanks to the
Hartford Institute for Geriatric Nursing for generating so much of the
knowledge evident in this book and to Dr. Mildred O. Hogstel, who pro-
vided so much inspiration for this book and for compassionate geriatric
nursing care throughout her career.
xv
C H A P T E R O N E
The Graying of
America
Learning Objectives
1. Discuss the concept of the Graying of America.
2. Identify special issues of aging.
3. Discuss 10 myths of aging.
4. Discuss the concept of ageism and its relevance to nursing.
5. Define ethnogeriatrics and cultural competence.
6. Describe standards of gerontological nursing and education.
7. Identify the major theoretical categories of aging.
Mrs. Molina, an 85-year-old White female, comes to the walk-in clinic

with a chief complaint of dizziness and unsteady gait and states that she
fell 2 weeks ago. Her vitals signs are BP 80/50, P 90, R 20, T 99.5° F,
and she has no complaint of pain. She is 5’2” and weighs 90 lbs. You are
the RN doing her initial assessment. You ask her why she waited so long
to come in and she states “I haven’t driven a car in 15 years and I don’t
want to be a bother to my children—they are busy enough.” You then
ask her what she typically eats in a day, and she tells you, “I usually don’t
eat anything for breakfast, just a cup of coffee. For lunch I usually have
a bowl of soup, and then I make a little pasta for dinner.” She then says
that she has lost enjoyment in eating and cooking meals ever since her
husband passed away 6 months ago.
The story of Mrs. Molina is typical of commonly occurring health care

situations, and highlights the typical and complex aging older adult.
Whether one is a nurse, a street sweeper, or a nuclear engineer, it is impos-
sible to live in the United States today without hearing about the increas-
ing elder population. According to Healthy People 2010, individuals
1
2 ESSENTIALS OF GERONTOLOGICAL NURSING
aged 65 years can be expected to live an average of 18 more years than

they did 100 years ago, for a total of 83 years. Those aged 75 years can
be expected to live an average of 11 more years, for a total of 86 years
(http://www.health.gov/healthypeople). Older adults are expected to
represent approximately 20% of the population by the year 2030. This
unprecedented increase in the number of older adults in the United States
is known as the Graying of America. The Graying of America brings
about multiple issues and concerns for society, including how a majority
of older adults will be viewed and what resources will be available for
older adults to live healthy and happy lives.
There are many reasons why people are living longer. Advances in
medications to treat diseases, immunizations to prevent disease, and new
diagnostic techniques to assist in the early detection and treatment of
disease are among the major reasons for the increase in longevity. The
development of new medications occurs daily and aids in the treatment
of illnesses that once resulted in disability and death, such as heart dis-
ease and cancer. Moreover, the ability to prevent diseases such as measles,
mumps, rubella, chicken pox, and polio plays a great role in allowing chil-
dren and young adults to enter older adulthood. In addition, improved
economic conditions and nutrition, as well as a stronger emphasis on
health promotion, have undoubtedly resulted in decreases in both illness
and death among the population. Many theorists have questioned the
key ingredients to living a long life. In a qualitative study by Pascucci and
Loving (1997), centenarians (those who have survived to the age of 100
or older) stated that clean and moral living, described as avoiding drink-
ing and living independently, provided the rationale for their long lives.
Other centenarians reported that a good attitude was essential to a long
life. However, the majority of the 12 centenarians in the study had no
idea why they had lived so long. This chapter will discuss the rising older
population as well as special issues and myths of aging and the impact of
ageism on the population. The cultural diversity of the older population
will be explored with recognition of the need to develop cultural compe-
tence in order to appropriately care for older adults. Gerontological nurs-
ing education and history will be presented. The chapter will conclude
with a discussion of the various theoretical explanations for aging.
ISSUES OF AGING
The great advances in science, which have created a generation of older

adults that was previously nonexistent, are cause for celebration. How-
ever, the growth of the older population is not without issues that impact
society and nursing practice. One of the major issues discussed frequently
The Graying of America 3
in society includes the need for more health care for older adults. Older
adults, although living longer, tend to do so with several chronic illnesses
that are in need of long-term and consistent health care. Moreover, older
adults tend to have comorbid illnesses, or more than one disease at a
time. The Alliance for Aging Research (2002) reports that the average
older adult has three chronic medical conditions. The presence of illnesses
among populations is referred to as the population’s morbidity. When
these illnesses result in death, this is considered the population’s mortality.
These acute and chronic illnesses will be discussed later in Chapter 6.
The increasing lifespan of older adults makes it possible for an indi-
vidual to spend up to 40 years in older adulthood. Consequently, geron-
tologists have broken this stage of life into three segments: the young–old
includes adults aged 65 to 75, the middle–old includes those 75–85, and
those 85+ are the old–old. The division of older adults into segments
allows nurses to recognize the unique differences present in each stage
of older adulthood in order to provide more effective care. One of the
unique issues present for the young–old is the great impact of the baby
boom population on the nation’s resources. The first baby boomer will
turn 65 on January 1, 2011, and this population will provide the nation
with the largest elderly population in history. With the great use of health
promotion and health resources required by this population, society will
be challenged to maintain supply with demand. The middle–old and old–
old also have challenges including health and housing, as well as paying
for long-term and chronic care.
Government-Funded Health Care

A major issue resulting from the increasing life span is how to pay for the
many health care problems of older adults. Medicare, the current federal
insurance plan for adults over the age of 65 and for those with disabili-
ties, is experiencing great difficulty in paying for the rising medical costs
consistent with the increasing population. When Medicare was originally
developed, the basis for funding was a lower life span and lower medical
costs. With people living longer and health care costs rising there is a
growing budget deficit as payments continue to be made on behalf of
Medicare recipients. Furthermore, the current Medicare coverage does
not provide for long-term nursing home care or prescription drug cover-
age under traditional Medicare plans, although drug coverage plans may
be purchased. Recently, the Medicare Prescription Drug Improvement and
Modernization Act of 2003 approved prescription discount drug cards
for Medicare recipients. These cards are available to over 7 million of
Medicare’s 41 million participants. Older adults must apply to be eligible
for the discount cards, and a minimum fee may be charged depending
CѢlѡѢџюl FќѐѢѠ
Older adults who have immigrated to the United States to live their later
lives with their adult children may not have paid into the U.S. Social Secu-
rity system, and, therefore, they must either buy into Medicare or become
eligible for Medicaid. However, legislation passed in 1990 made it more
difficult for older adults who were not citizens of the United States to
access Medicaid. Nurses caring for older adults from various cultural back-
grounds should question ability to pay for medication in order to decrease
nonadherence to suggested health care strategies.
on their income. The cards provide discounts on some drugs, but not all.
The American Journal of Nursing (“Pick a Card,” 2004) reports that
older adults with higher incomes may save more by using other prescrip-
tion drug plans. Moreover, Social Security payments, which are a form of
income for older adults who are no longer working, were designed based
on a much shorter lifespan as well. Social Security payments continuing
into unexpected eighth and ninth decades of life are causing the social
security system to explore alternative methods. For more information on
the health care delivery system implications surrounding the increasing
aging population, see Chapter 2.
MEDICAL CONCERNS
Medical problems are very common among older adults. As stated ear-
lier, it is not uncommon for older adults to have several chronic medical
conditions at the same time. As a result of these medical illnesses, older
adults experience a variety of problems with activities of daily living
(ADLs), which include bathing, dressing, eating, toileting, continence,
and transferring. These problems often impact older adult’s ability to
live independently, because their functional decline may prevent them
from bathing on a regular basis, preparing food for themselves, or paying
their bills on time, which all affect the individual’s quality of life. When
this occurs, older adults have several housing options. Many older adults
move in with siblings or children. Others may consider subsidized or pri-
vately owned and operated housing alternatives, such as senior housing,
assisted-living facilities, continuing care retirement communities, or nurs-
ing homes. Each of these environments of care provide some supervision
and services to help the older adult to live as independently as possible.
More information about these environments of care and the services they
provide are available in Chapter 11.
AGEISM—FACTS AND MYTHS OF AGING
When nursing students enter educational programs they are often asked
with which populations they would like to work. Most students answer
that they wish to work with children and babies. Some students respond
that they would like to work in maternity. Very few (if any) students
reply that they came to nursing school to work with older adults. In
fact, the society that currently exists in the United States is extremely
youth-oriented. This means that older adults are not always considered
and respected for their unique needs and contributions to society. Beliefs
about older adulthood in the United States are perpetuated by myths of
aging. The following section reports on the top 10 myths of aging and
discusses why they are untrue of today’s population of older adults.
Myths
Myth #1: Older adults are of little benefit to society. Older adults are
often viewed as sick people in hospital units and nursing homes. As they
lie in beds and consume medications and resources, it is hard to imagine
what benefit they are to society, and thus they are often considered to be
a burden. However, the rate of disability among older adults is continu-
ing to decline steadily. Moreover, it is important to remember that the
same older adults for whom nurses care are mothers and fathers, grand-
mothers and grandfathers, aunts, uncles, brothers, sisters, and friends. To
those with whom they are in relationships, they are of great benefit, as
they provide and receive love, care, and support. These same older adults
function in professional roles as teachers, administrators, physicians,
nurses, and clergy. Consequently, they are of great benefit to those they
serve in these roles. Instead of viewing older adults as a burden, take the
time to speak with them about their lives. Ask older adults about their
favorite memories or regrets. Don’t be afraid to ask for advice. When
given the opportunity, it is likely that nurses as well as the rest of society
will learn a lot from older adults.
Myth #2: Older adults are a drain on society’s resources. As many
older adults retire in their late years and collect Social Security payments
and Medicare, it is assumed that they are overutilizing their resources. In
fact, increasing Social Security payments over decades of life and Medi-
care reimbursement for rising health care costs are a significant problem
for U.S. citizens. However, older adults who received Social Security and
Medicare paid into the system from which they are now drawing. More-
over, while many older adults retire, many others do not. In 2002, 13.2%
of older Americans were working, or actively seeking work. A Gallup
poll of 986 older adults reported that, of the total sampled, only 15% of
older adults wished to retire; the vast majority wanted to work as long as
possible. Mandatory retirement ages and work discrimination have often
forced reluctant older adults into retirement. In addition, many older
adults who are retired spend a great deal of time in unpaid volunteer
work, which saves employer’s costs. Moreover, many retired older adults
have taken on the role of custodial grandparents, relieving the states from
having to pay for the full cost of foster care from a nonrelative. The 1990
Census reported that grandparents raising grandchildren had risen 44%
over the previous decades. While it is true that the rising lifespan of U.S.
citizens is resulting in a greater amount of expenditures on the behalf
of older adults, this is not always a result of their choosing, and a great
majority of the retired older adults are significantly contributing to soci-
ety in ways other than traditional employment.
Myth #3: Older adults are cranky and disagreeable. When asked
about initial impressions of older people, many nursing students report
that older adults are cranky, disagreeable, and generally unlikable peo-
ple. This myth plays an instrumental role in the lack of gerontological
nurses. While it is true that there are many cranky and disagreeable older
adults, it is important to note that there is an equal number of cranky
and disagreeable younger adults. Moreover, the continuity theory sup-
ports that individuals move through their later years attempting to keep
things much the same and using similar personality and coping strategies
to maintain stability throughout life. Consequently, the coping strategies
seen among older adults may be very similar to their younger character-
istics. If there appears to be more difficult patients among older adults,
it may be because older adults tend to approach their later years sicker
than the younger population. Anyone who has ever been sick can report
that being sick can make you cranky. When working with difficult older
adults, remember that negative interactions with nurses may likely be a
symptom of their illness, rather than a characteristic of aging. Like any
other symptom, it is essential to identify the cause and treat it. In so
doing, the older adult’s personality will be allowed to shine through, and
they will likely treat you with the respect due to a caring and concerned
professional.
Myth #4: You can’t teach old dogs new tricks. Patient teaching is
a major component of the nursing role, regardless of which population
is receiving care. This is true for older adults as well. While it is easy
to think that 60 to 80 years of poor health behaviors such as drink-
ing, smoking, or poor nutrition are impossible to break, this is simply
not true. In working with the older adult population, a large amount of
care will be directed toward managing pathological diseases of aging that
resulted from poor health practices acquired early in life and continued
into older adulthood. But, this does not mean that these diseases cannot
be treated, managed, and in some cases cured. Older adults are never too
old to improve their nutritional level, start exercising, get a better night’s
sleep, stop drinking and smoking, and improve their overall health and
safety. The Surgeon General recently stated that the health risks of smok-
ing may be reduced among all age groups and recommends that “geriatri-
cians should counsel their patients who smoke, even the oldest, to quit”
(U.S. Department of Health and Human Services, 2004). Moreover, older
adults may still benefit from health promotion activities, even in their
later years. In fact, health promotion is as important in older adulthood
as it is in childhood. Further support to refute the myth that you can’t
teach old dogs new tricks may be found in the record number of older
adults increasing their education. Older adults are increasingly return-
ing to school and increasing their level of education. Many colleges and
universities allow older adults to attend classes for low or no charge. In
fact, 17% of older adults have a bachelor’s degree or more. Keeping intel-
lectually active is regarded as a hallmark of successful aging.
Myth #5: Older adults are all senile. The word senile was commonly
used many years ago to describe older adults who were experiencing
cognitive impairment. More recently this word has been replaced by the
word dementia, which describes a number of illnesses that result in cogni-
tive impairment. Becoming senile or demented as one grows older is of
large concern to the aging population and their families and is the focus
of a great deal of study in the older population. It is commonly believed
that older adults will develop dementia as they age. However, this is
always the case, as many older adults live well into their 10th decade as
sharp as they were in their 20s and 30s. Memory losses are common in
older adulthood, but are often falsely labeled as dementia. Dementia is
not a normal change of aging, but a pathological disease process. In fact,
dementia is a general term used to describe over 60 pathological cogni-
tive disorders that develop as a result of disease, heredity, lifestyle, and
perhaps environmental influences. Dementia is a chronic loss of cognitive
function that progresses over a long-period of time. Alzheimer’s disease
(AD) is the most common cause of dementia among older adults, making
up about 50% of all dementia diagnoses. There are approximately 4.5
million U.S. residents with Alzheimer’s disease. Dementia is a devastating
occurrence for both older adults and loved ones. Much research is being
conducted on the prevention, diagnosis, early detection, and treatment of
AD and related dementias.
Myth #6: Depression is a normal response to the many losses older
adults experience with aging. Older adults have the highest rates of depres-
sion within the U.S. population. The frequent occurrence of loss among
the older population was once used to explain the large incidence of
depression among older adults. While it is true that situational life events,
such as retirement, relocation, loss of spouse, financial constraints, and

illness, play a role in the development or severity of depression, recent
research on depression indicates that there is more to the development
of depression than the experience of loss. In fact, the nature versus nur-
ture controversy has uncovered the role of physiological factors in the
development of depression among older adults. Because of the many
physiological changes in older adults, this population is more suscep-
tible to the effects of pathophysiology than any other age group. In fact,
depression rates are highest among older adults with coexisting medical
conditions. Moreover, 12% of older persons hospitalized for problems
such as hip fracture or heart disease are diagnosed with depression. Rates
of depression for older people in nursing homes range from 15% to 25%.
Other factors that must be considered in assessing and managing depres-
sion are the presence of alcohol or drug abuse, past suicide attempts, and
family history of depression and suicide.
Myth #7: Older adults are no longer interested in sex. It is com-
monly believed that older adults no longer have any interest or desire to
participate in sexual relationships. Because sexuality is mainly considered
a young person’s activity, often associated with reproduction, society
doesn’t usually associate older adults with sex. In the youth-oriented soci-
ety of today, many consider sexuality among older adults to be distasteful
and prefer to assume sexuality among the older population doesn’t exist.
However, despite popular belief, sexuality continues throughout the lives
of older adults. A survey of 1,709 older adults by the American Associa-
tion of Retired Persons (1999) found that almost 39% had participated
in sexual activity over the past week. The need to continue sexuality
and sexual function should be as highly valued as other physiological
needs. But for multiple reasons, most of society believes that sexuality
is not part of the aging process. Consequently, nurses and other health
care providers do not assess sexuality and few intervene to promote the
sexuality of the older population. Reasons for nurses’ lack of attention
to sexuality of older adults include lack of knowledge, as well as general
inexperience and discomfort.
Myth #8: Older adults smell. The age-old belief that older adults
have poor personal hygiene has impacted the mind of many nursing
students and health care providers of today. Moreover, the age-old recol-
lection of nursing homes that smell of urine remains strong among those
who may have visited such a home in the past. This myth plays a part
in the opinion of older adults as a desirable population with whom to
work. While it is true that there are older adults who have bad personal
hygiene, this is definitely not the majority of the population. In fact, the
number of sweat glands actually diminishes as people age, leading to
less perspiration among older adults. Urinary and bowel incontinence,
or the involuntary loss of urine and feces, occurs more commonly among
older adults, but these are pathological changes of aging and are highly
treatable. If an older adult smells of urine or feces, this is likely because
they are very ill and their illnesses are not being effectively managed.
Increased attention to older adult’s care will likely result in improved
management of hygiene, incontinence, and associated disorders.
Myth #9: The secret to successful aging is to choose your parents
wisely. This comical phrase from the popular work of Rowe and Kahn on
successful aging (1997) leads society to believe that little can be done to
slow the aging process, because it is all set out in a nonmodifiable genetic
plan dictated by lineage. This myth is dangerous, because it leads older
adults and caregivers to believe that little can be done to slow or com-
pensate for normal changes of aging or to prevent and treat pathological
medical problems. While genetics certainly are responsible for some of the
aging process, they become less and less important as older adults age. As
life continues, the role of environment and health behaviors significantly
replaces the role of genetics in determining the onset of normal and patho-
logical aging. Rowe and Kahn (1997) report that approximately one-third
of physical aging and one-half of cognitive function is a result of genetic
input from parental influences. That leaves two-thirds of physical aging
and one-half of cognitive function to be influenced by environmental fac-
tors and health behaviors. Consequently, there is a lot that individuals can
do to prevent the onset of both normal and pathological aging processes.
Myth #10: Because older adults are closer to death, they are ready
to die and don’t require any special consideration at end of life. When
society learns of the death of a young child or adult, the level of grief and
astonishment for the loss of a young life is extraordinary and difficult
to contain. This grief and astonishment often is associated with a life
that was too short, or taken too suddenly. However, when individuals
in society and health care workers learn of the death of an older adult,
or have the opportunity to work with an older adult at the end of life, it
is often assumed that the older adult is prepared for their death because
of their advanced age. This myth often leads health care professionals
to offer less than aggressive treatment for disease and to neglect essen-
tial components of end-of-life care for the older adult. It is important to
remember that while death among older adults may occur after a long
life, older adults are not necessarily ready for death. They require equal
and specialized attention to physical, psychological, social, and spiritual
tasks at the end of life. End of life is often a difficult time for many
older adults, but it also presents the opportunity to complete important
development tasks of aging, such as mending fences with loved ones, dis-
engaging from social roles, and transcending from this life into another
existence. Nurses may play an important role in helping older adults to
complete these development tasks that can make the difference between
experiencing a good or bad death.
Ageism
Many of the residents of the United States believe these myths of aging
and allow them to be unchallenged in their perception of older adults.
These myths of aging perpetuate ageism in today’s society. Ageism is
defined as a negative attitude or bias toward older adults, resulting in the
belief that older people cannot or should not participate in societal activi-
ties or be given equal opportunities afforded to others (Holohan-Bell &
Brummel-Smith, 1999).
The presence of ageism in today’s society is of great concern to nurses
working with older adults. Ageism affects the medical care of older adults
and their access to services. It has the power to rob older adults of their
dignity and respect and often forces older adults to abandon hopes of con-
tributing to society. The danger of ageism also lies in its ability to influ-
ence policies and care decisions for older adults. Traxler (1980) proposed
four reasons for the development of ageism in society, including: (a) fear
of death in Western society, (b) emphasis on the youth culture, (c) poor
economic potential, and (d) past research that focused attention on dis-
ability and chronicity of older adults. The following examples illustrate
ageism in action.
In order to fight ageism and protect against its many harmful con-
sequences, it is essential to re-examine the role of older adults in society.
Some important facts are coming to light to dispel the myths and reframe
the experience of aging. For nurses it is essential to identify ageism and
mitigate its ability to influence policies and care decisions that will affect
the quality of life of older adults. In so doing, nurses play an instrumental
role in preventing the consequences of aging on older adults. This includes
making sure that older adults are not discriminated against in selection
for medical procedures or resources. Older adults as a group have taken
great action to prevent the effects of ageism on health care policy. As one
of the most influential and persuasive cohorts present in today’s society,
older adults have formed two large and influential national organizations
that provide them with representation concerning legislative issues and
resources for successful aging: the American Association of Retired Per-
sons (AARP) and the National Council on Aging (NCOA). These groups
are also good sources of information for students interested in exploring
issues of aging.
AARP is a very important and influential organization for individuals
aged 50 and older (Hogstel, 2001). The organization has substantial influ-
ence on policy making at the federal and state levels. Currently, AARP has
36 million members, which represents over 50% of older adults. The

membership is growing quickly, with a new member joining AARP
every 11 seconds. The name is misleading, as many of the members of
AARP are not retired. The annual membership rates are reasonable, and
the organization is open to all who are interested. AARP’s vision is to
“shape and enrich the experience of aging for each and every member of
society.” It is a nonprofit, nonpartisan organization whose primary goal
is to help older people live with independence, dignity, and purpose.
AARP offers a wide range of services, program and volunteer opportu-
nities, and benefits to its members. Millions of people are helped each
year through its free or low-cost programs, such as tax counseling and
driver’s training programs. The organization publishes informational
bulletins and newsletters on topics of interest to older adults. An impor-
tant component of the organization is its lobbying ability and influence
on legislative issues of importance to older adults. With the assistance of
AARP, the rights of older adults continue to be heard loudly on Capitol
Hill.
The NCOA is another nonprofit organization that plays an influen-
tial role in providing information, technical assistance, and research in the
field of aging. It maintains a national information clearinghouse related
to aging, plans conferences on aging issues, conducts research on aging,
supports demonstration programs related to aging, and keeps a compre-
hensive library of materials associated with every aspect of aging.
ETHNOGERIATRICS AND HEALTH CARE
Scommegna (2007) predicts an unprecedented shift in the cultural back-

ground of the U.S. population. It is reported that the White population
of adults over 65 is expected to decrease from approximately 87% to
75% of all older adults in the years 1990–2030. In turn, the percentage
of Black older adults is expected to rise from 8% to 9%; the percentage
of Asian older adults is expected to increase from 1.4% to 5%; and the
percentage of Hispanic older adults is expected to increase from 3.7%
to 10.9%. These statistics are important because they predict a change
in the manner in which traditional Western medicine is accepted in this
country.
The United States currently functions under a health care system
known popularly as the Western biomedical model. This model forms the
basis of beliefs about health care in the United States. The model is based
on scientific reductionism and characterized by a mechanistic model of
the human body, separation of mind and body, and disrespect of spirit or
soul. In practice, this model is revealed commonly through the treatment
of medical problems with little respect for the impact of treatment on

the older adult’s life. For example, expensive medications are often pre-
scribed for older adults with little thought as to how they could possibly
be purchased on a fixed income. For many years, this model has been
accepted by the older residents of the United States, and it continues to
be utilized widely throughout the country. The recent increase in cultu-
ral diversity in the United States presents an unprecedented challenge to
this model and the way in which health care has been practiced in the
United States. However, this challenge also represents the opportunity to
improve health care services to the entire population.
As each culture brings different explanations of disease origins
and treatments, the traditional manner in which health is understood,
maintained, or improved will likely be altered as new culture beliefs
challenge traditional understanding. This has the potential to change
health care practice as we know it. Improved understanding of cul-
tures will allow a greater integration of mind, body, and spirit. This has
already impacted health care as evidenced by the increased emphasis
on spirituality in health care settings. O’Brien (2004) reports that the
Eѣіёђћѐђ-BюѠђё Pџюѐѡіѐђ
Title of Study: Developing a Multisite Project in Geriatric and/or Geronto-

logical Education With Emphasis in Interdisciplinary Practice and Cul-
tural Competence
Authors: Browne, C., Braun, K., Mokuau, N., McLaughlin, L.
Purpose: A curriculum development project was designed to increase the
number of professionals trained in geriatric and/or gerontological social
work in Hawaii.
Methods: A 4-segment project that included: (1) developing, implement-
ing, and testing a curriculum based on standardized learning competen-
cies designated by project participants; (2) providing advanced training
in aging, cultural competence, and interdisciplinary practice to social
work professionals and masters degree students; (3) revising the cur-
riculum to support such competencies; (4) producing a practicum hand-
book.
Findings: The above purposes were accomplished. This project is replicable
in other communities and universities.
Implications: Although developed for the state of Hawaii, this project is
replicable, and the curriculum is adaptable to other sites in need of more
knowledgeable and skilled persons who work with the diverse older
populations.
The Gerontologist, Vol. 42, No. 5, 698–704.
connection of mind, body, and spirit has been shown to enhance the
health and spiritual well-being among older adults. In addition, alterna-
tive and complementary health care practices are more commonly seen
in the clinical area.
Economically, culture also has an impact on health care. For exam-
ple, there are older adults who have immigrated to the United States to
live their later lives with their adult children. They may not have paid into
the U.S. Social Security system, and, therefore, they must either buy into
the Medicare system or become eligible for Medicaid. Medicaid, a com-
bination federal and state program, varies from state to state and funds
health care, including nursing home care for low income older adults.
However, legislation passed in the 1990s made it more difficult for older
adults who were not citizens of the United States to access Medicaid,
which means that noncitizen older adults may not have any method with
which to pay for health care.
It is imperative that health care providers become aware of the cul-
tural diversity of the population and identify the cultural beliefs that
empower health care decisions of older adults. In order to fully under-
stand how cultural shifts in society affect the way in which health care is
accessed and accepted in society, it is first necessary to understand a few
terms. Increasing understanding of the great cultural shifts in society will
have a substantial impact on the ability to provide health care to older
adults from all cultural backgrounds. The term culture refers to the way
of life of a population, or part of a population. Culture is usually used
to discuss different societies or national origins. However, culture also
reflects differences in groups according to geographic regions or other
characteristics that comprise subgroups within a nation. Acculturation is
defined as the degree to which individuals have moved from their origi-
nal system of cultural values and beliefs toward a new system. The term
ethnogerontology is the study of the causes, processes, and consequences
of race, national origin, culture, minority group status, and ethnic group
Cultural Focus
Scommegna (2007) reports that there is an unprecedented shift in the cul-

tural backgrounds of the U.S. population. The shift in cultural backgrounds
in the United States also predicts a change in the manner in which tradi-
tional Western medicine is accepted in this country. Consequently, cultur-
ally competent care is essential among nurses caring for older adults, and
improved understanding regarding complementary and alternative therapy
is necessary.
status on individual and population aging in the three broad areas of

biological, psychological, and social aging. The goal in providing excel-
lent nursing care for older adults of all cultural backgrounds is cultural
competence.
Cultural Competence
Cultural competence refers to the ability of nurses to understand and
accept the cultural backgrounds of clients and provide care that best meets
the client’s needs—not the nurse’s needs. Examples of cultural competence
include the nurse’s ability to discuss appropriate foods associated with
healing with a hospitalized older adult and procure those foods to aide
in the healing process. Another example is sharing in prayer with an
older adult. Questioning older adults about their ability to pay for their
medications or health care also shows an increased integration of mind,
body, and spirit and is an example of cultural competence. Becoming
culturally competent is not an easy task and requires great work. Purnell
(2000) and Campinha-Bacote (2003) identify stages of cultural compe-
tence. The first stage, unconscious incompetence, is common to begin-
ning nurses and is manifested by the assumption that everyone is the
same. Following this stage, conscious incompetence occurs as the nurse
begins to understand the vast differences between patients from many
cultural backgrounds, but lacks the knowledge to provide competent
care to culturally diverse patient populations. Conscious competence is
the stage when knowledge regarding various cultures is actively obtained,
but this knowledge is not easily integrated into practice, because the nurse
is somewhat uncomfortable with culturally diverse interventions. The
final stage, unconscious competence, occurs when nurses naturally inte-
grate knowledge and culturally appropriate interventions into practice
(Campinha-Bacote, 2003).
Developing cultural competence is increasingly challenging to nurses
who were not exposed to a large variety of cultural backgrounds during
childhood or early adulthood. However, with attention to several steps,
cultural competence can be developed. An integral step toward cultural
competence is to examine personal beliefs and the impact of these beliefs
on professional behavior. This may best be accomplished by conducting
a personal cultural assessment on oneself. The following questions may
be helpful in guiding this assessment:
• What are your own cultural backgrounds, attitudes, and beliefs?

• Where did you get them?
• What behaviors do you have that come from your cultural back-
ground?
• Which of these behaviors are different from those of others around

you or in your care?
These questions may be used individually or administered to a col-

league to help uncover personal beliefs that may bias or interfere with
the development of cultural competence. Once these biases are identified,
they must be set aside and not allowed to interfere with the care of older
adults.
Following the identification of cultural biases that may impact care,
it is essential to acquire knowledge regarding population-specific, health-
related cultural values, beliefs, and behaviors. These practices are often
rooted in deep religious beliefs and may stand in stark contrast to the
biomedical model. In addition, it is also important to explore disease
incidence, prevalence, and mortality rates among cultural groups. Table
1.1 provides examples of some commonly held health care practices of
the dominant cultural groups in the United States. These practices often
have an influence on all aspects of health care.
It is important to remember that although older clients may be part
of a specific cultural group, they may have acculturated to a certain
degree during their time in the United States. Therefore, a cultural history
is an essential next step in determining the basis of the client’s health care
beliefs and practices. Some health care facilities have begun to add cul-
tural assessment questions to client’s admission assessment. Sample ques-
tions to guide the assessment may be found in the Cultural Focus box. In
conducting the assessments, approach all older adults with dignity and
respect and always use a client’s formal title (Mr., Mrs., Dr.). It is appro-
priate to ask the older adult how they would like to be addressed. If the
older client speaks a language with which the nurse is not familiar, deter-
mine if the older adult client would like an interpreter or whether a fam-
ily member would like to communicate the individual’s needs for them.
It is important to note that the fast pace in which the American culture
operates may be seen as a sign of disrespect to older adults from different
cultural backgrounds. A quick approach to patient care, which is often
essential in busy health care climates, often is perceived as uncaring and
hasty. Recognizing this allows for nurses to approach the clients more
slowly and with great attention to care giving and detail. The amount
of personal space, the comfort with eye contact, and the use of physical
gestures, such as hand-shaking, should also be assessed to determine the
older adult’s comfort with these common social norms.
Two common issues in the care of older adults from various cultural
backgrounds have to do with the use of complementary and alternative
therapy (CAM) and end-of-life care. The Gerontological Society of Amer-
ica (2004) reports that one-third of older adults used alternative medicine
TABLE 1.1 Health Care Practices of Dominant Cultural Groups
African Latin
Belief Native Americans Americans Asian Americans Americans
Origin of Belief Health beliefs and African traditions are Classical Chinese medicine Most Latino Americans
views of death are often integrated with influenced traditions in practice the biomedical
older than the American Indian, Japan (Kampo), Korea model, but among some
country and vary Christian, and other (Hanbang), and Southeast elders there may be remi-
by tribe. European traditions. Asia. In parts of Asia, niscences of other beliefs.
Many African Taoism and Buddhism
16
Americans grew have influenced the
up with little health healing traditions.
care.
Focus of Health Great emphasis on Interaction of Characterized by need for Religion is an important
mind–body–spirit multiple causes of balance between yin and component of health.
integration. health as opposed yang to preserve health.
to just physical. Interaction of basic ele
ments of the environment
(e.g., water, fire earth,
metal, and wood).
View of Illness Sometimes seen as a Illness may be seen as Illness is viewed as a threat Illness may be multidi-
result of an individu- the result of a physical to the soul. mensional in nature.
al’s offenses. cause, such as
infection, weather,
and other environmen-
tal factors, or from sin
or great offense.
Components of Care Use of herbs from Power of religion, The use of herbs and diet An interaction of the
Needed for Healing native plants, Christian in some may be seen as a method biomedical model with
spiritual healing, cases; and use of of unblocking the free flow complementary and alter-
harmony with herbs, or “root work- of qi (chi), or vital energy, native therapies provides
environment; ritual ing.” The use of through meridians in the the framework for health
17
purification healers is rarely seen. body. Acupuncture, tai chi, care.
ceremony may be Home remedies may moxibustion, and cupping
needed to heal. be used. Experiences are also used frequently.
of segregation and Illness should be addressed
memories of the not only through medicine,
Tuskegee experiment but also through social and
may make older psychological means.
African Americans
skeptical and
distrustful of health
care providers
Gratefully adapted from the Stanford Geriatric Education Center’s Core Curriculum in Ethnogeriatrics.
Cultural Focus
Sample Cultural History Questions

1. In what country were you born?
2. How long have you (or your ancestors) been in this country?
3. What language did you first learn to speak?
4. What language is used at home?
5. How do you identify yourself (in terms of your ethnic/racial back-
ground, heritage, or culture)?
6. What is important for others to know and understand about your
background or culture?
7. How has your background or culture influenced who you are
today?
8. What is the role of spirituality, faith, or religion in your life? Do you
identify with any formal religion/belief system?
9. What customs or traditions are important to you/your family?
10. What does your culture/religion/heritage teach you about aging/
growing older/elders or older people?
11. What has been the biggest adjustment for you/your family about life
in this country?
Source: Standford Geriatric Education Center Ethnogeriatric Core Curriculum
in 2002. The use of CAM will be discussed in greater detail in Chapter 7.

Different cultural backgrounds also show great diversity in acceptance of
and discussions about death. These issues impair the appropriate use of
advance directives. There are also diverse cultural rituals and traditions
at the time of death that must be respected. Cultural considerations at
end of life will be discussed in more detail in Chapter 12.
The final step in the acquisition of cultural competence is the devel-
opment of skills for working with culturally diverse populations. This
involves gaining knowledge about how to work with culturally diverse
populations and consistently using those skills with older adults. The
U.S. Department of Health and Human Services (DHHS) provides rec-
ommended suggestions for the integration of cultural competence into
various environments of care. These recommendations are detailed in
Chapter 11.
The culturally competent nurse consistently recognizes the great
cultural diversity in the population and approaches care of older adults
with an open and accepting attitude toward diverse health care practices.
Increased respect for culture is evident during assessments, and infor-
mation is gathered regarding cultural beliefs and practices. A greater
integration of mind, body, and spirit as well as the use of alternative
Cultural Focus
The fast pace in which the American culture operates may be seen as a
sign of disrespect to older adults from different cultural backgrounds. A
quick approach to patient care, which is often essential in busy health care
climates, often is perceived as uncaring and hasty. Recognizing this allows
for nurses to approach the clients more slowly and with great attention to
caregiving and detail.
and complementary therapies is practiced, and great respect toward the

special needs of culturally diverse clients at the end of life is paid. Con-
ducting cultural assessments, utilizing translator services in facilities, and
providing culturally competent care are integral components to develop-
ing culturally competent institutions and ultimately improving care of
older adults.
GERONTOLOGICAL NURSING
The increased numbers of older adults in the United States undoubtedly has
a major impact on the demand of this population on the health care sys-
tem. The Alliance for Aging Research (2002) reports that the average older
adult has three chronic medical conditions. Consequently, more nurses are
needed to care for the increasing number of older adults with chronic ill-
ness. It is commonly assumed that any nurse can take care of older adults.
However, with the increasing population of older adults there has been an
increase in the amount of specialized geriatric nursing knowledge needed
to care for this population. Not only are more nurses needed to care for
older adults, but nurses competent in the care of older adults will be needed
to meet the enhanced needs of the older population. Rosenfeld, Bottrell,
Fulmer, and Mezey (1999) report that “Today, a nurse’s typical patient is
an older adult,” and “it behooves the nursing community to ensure that
every nurse graduating from a baccalaureate nursing program has a defined
level of competency in care of the elderly” (p. 84).
Despite the increased need, as well as the substantial growth in geri-
atric nursing science, the field of gerontological nursing has been slow
to gain recognition as a nursing specialty. While more and more nurs-
ing programs are offering courses in geriatric nursing or integrating best
geriatric nursing practices throughout programs, geriatric nursing is still
not a popular specialty area among nursing students. Moreover, there is
currently a nursing shortage that affects all areas of care, including older
adults. The overall shortage of nurses along with the increase in older
adults requiring care has resulted in a critical shortage of nurses prepared

to care for older adults. A recent article in the American Journal of Nurs-
ing challenges whether or not nurses are prepared to meet the needs of
this increased population of older adults (Stotts & Dietrich, 2004).
The terms geriatric nursing, gerontological nursing, and gerontic
nursing have been used interchangeably to describe the role of nursing
care of older adults. However, these terms have different meanings. Geri-
atric nursing refers to the nursing care of older people with health prob-
lems, or those requiring tertiary care. Gerontological nursing includes
health promotion, education, and disease prevention (primary and sec-
ondary care). Gerontic nursing, although not a commonly known term,
encompasses both of these aspects (Hogstel, 2001). The past several
decades have seen a great increase in gerontological nursing knowledge.
Rauckhorst (2003) reports that these changes began in 1966 when the
American Nurses Association (ANA) first recognized geriatric nursing as
a specialty. Standards to guide the practice of gerontological nursing were
first published by the ANA in 1976 and later revised in 1987 and 1995.
The educational foundation in gerontological nursing has expanded
greatly over the past two decades. Many more associate, baccalaureate,
and certificate programs in nursing contain geriatric content than previ-
ously. The development and integration of geriatric content into nursing
programs was greatly supported by the Kellogg, Robert Wood Johnson,
and John A. Hartford foundations. However, despite the great progress
in gerontological nursing, Kovner, Mezey, and Harrington (2002) report
that 58% of baccalaureate nursing programs do not have geriatric-cer-
tified faculty. Gilje, Lacey, and Moore (2007) report that only slightly
more than half of baccalaureate programs surveyed offered a stand-alone
geriatric course.
The development of the first post-master’s certificate and graduate pro-
grams in gerontological nursing were witnessed in the mid-1970s. These
original 141 advanced programs were supported by the U.S. Public Health
Service (USPHS) and cost taxpayers approximately $17 million (Hogstel,
2001). Currently, there are many graduate and post-master’s certificate
programs in gerontological nursing available to assist nurses in develop-
ing increased knowledge regarding the specialized needs of older adults.
Graduates of these programs may practice as geriatric nurse practitioners
and geriatric clinical nurse specialists to work in clinics, hospitals, home
care, and nursing homes. It is important to note that the educational pro-
grams provide the education and certificate or diploma in the specialty
program. However, in order to utilize these specialty titles, qualified
nurses must pass an examination offered by the American Nurses Cre-
dentialing Center (ANCC). A nurse with an Associate’s or Baccalaureate
degree and no advanced graduate credits, 1,500 clinical practice hours
Evidence-Based Practice
Title of Study: Gerontological Nursing Content in Baccalaureate Nursing

Programs: Findings From a National Survey
Authors: Bottrell, M., MPH; Fulmer, T., PhD, RN, FAAN; & Mezey, M. D.,
EdD, RN, FAAN
Purpose: To provide a baseline of the current status of geriatric content in
the baccalaureate curriculum in nursing programs.
Methods: This article is based upon a survey that was conducted in 1997
with a universe of baccalaureate nursing programs with n = 598. The
findings are based on a respondent pool of 480 programs (80.3%). This
survey covered curriculum, content, faculty preparation, and how pro-
grams define their needs for the future. The data analysis included the
identification of baccalaureate nursing programs with exemplary offer-
ings in gerontological care.
Findings: The survey indicates that, at present, nursing students are not
being adequately prepared to care for the elderly. This study shows that
the size of the full-time and part-time faculty varied dramatically in bac-
calaureate nursing programs, with some programs having stand-alone
courses and others integrated courses. Overloaded curriculums were
seen as a barrier to entering gerontology into the curriculum. Three
other “barriers” were reported; these included a lack of interest among
students, a lack of role models/preceptors in clinical settings, and a lack
of clearly articulated gerontological curricula.
Implications: The study indicates a need for more instruction regarding the
care of older adults. It calls for a concerted effort to assure that bacca-
laureate nursing programs offer their students the courses and clinical
experiences necessary for quality care for the elderly. It suggests that
the number and focus of questions on the National Council Licensure
Examination-Registered Nurse reflect the knowledge base necessary for
the care of the elderly. It also suggests that professional organizations
should revise their standards for programs to reflect the importance of
preparation for care of the elderly. It also cites the need for revised cur-
riculum to reflect courses that will teach the skills to meet the needs of
the aging society.
Journal of Professional Nursing, Vol. 21, No. 5, 268–275.
in geriatric nursing, and 30 continuing education hours may sit for Geri-
atric Nurse Certification through ANCC (http://www.nursingworld.org/
ancc/) as well. Certification programs designed to provide the 30 continu-
ing education hours are often available at local hospitals, colleges, and
universities and on the World Wide Web.
Currently there are several organizations that specialize in geriatric
nursing. The National Gerontological Nursing Organization (NGNO)
was developed in 1984 to support the growth of knowledge related to

gerontological nursing science (Hogstel, 2001). The Gerontological Soci-
ety of America (GSA), the American Society of Aging (ASA), and the
American Geriatrics Society (AGS) are multidisciplinary organizations
that support aging knowledge and research. These groups have increas-
ing numbers of nurse members with a special interest in the development
and dissemination of gerontological nursing knowledge.
THEORIES OF AGING
Prior to the middle of the twentieth century, the cause of death listed on
many older adults’ death certificates was old age. It was thought that at
some later point in life, the body just gave out. The growth in scientific
medical and gerontological knowledge over the past century has chal-
lenged this popular view. In fact, advances in the study of older adults
have made society question whether there are more appropriate physi-
ological, social, or psychological reasons why people die. At the 55th
annual meeting of the Gerontological Society of America, a presentation
by Butler and Olshansky (2002) continued to debate, “Has anyone ever
died of old age?”
Despite the continuing debate, the question remains: in the absence
of illness, why do people die? The results of efforts to answer this ques-
tion are derived from theories of aging. Biological theories explain that
the reason people age and die is because of changes in the human body.
Psychological theories support the idea that an older adult’s life ends
when they have reached all of their developmental milestones. For exam-
ple, Maslow’s Hierarchy of Needs states that a person’s final stage is
self-actualization. From a psychological viewpoint, once an older adult
reaches self-actualization, they approach the end of life. Moral/spiritual
theories support the idea that once an older individual finds spiritual
wholeness, this transcends the need to inhabit a body, and they die. Soci-
ological theories explain that when an older adult’s usefulness in roles
and relationships ends, end of life occurs.
Biological Theories
Two of the main biological categories are feature and defect theories.
Feature theory is consistent with the work of Hayflick (2007) commonly
known as the “Hayflick limit.” The Hayflick limit essentially states
that cells will divide for a finite number of times, and once they have
reached this limit, the cells shrink, disperse, and eventually die, result-
ing in death of the body. The Hayflick limit relies heavily on the science
of “programmed cell death” or “apoptosis.” The manner and timeline

of apoptosis is the subject of a great deal of research surrounding the
aging process. Feature theory expands the work of Hayflick and focuses
heavily around apoptosis. This theory purports that the aging process
is contained in the design of human beings. In other words, theorists
who support this theory believe that how a person ages is genetically
predetermined. Consistent with this theory, little can be done to alter the
aging process, despite interventions taken to promote health and pre-
vent illness. The main purpose of aging, according to feature theory, is to
improve or perfect human beings. Supporters of the feature theory look
to the wide variation in lifespan among people in similar environments to
support the theory. For example, two people who grow up and live their
lives in the same town, performing similar jobs and having similar fami-
lies may die at vastly different ages as a result of their genetic make-up.
An adaptation of this theory is commonly known as programmed senes-
cence theory. This theory states that while the aging process is depen-
dent on genetic make-up, there is an ordered switching on and off of
certain genes. The aging process, according to programmed senescence
theory, begins when age-associated deficits are manifested. For example,
aging could be thought to begin when an adult develops hip pain as the
early sign of osteoarthritis. Further expansion of genetic theories known
as longevity and senescence theory are currently being researched. Perls
(2001) is studying genetic backgrounds of elderly people to differenti-
ate between the genetics of longevity and exceptional longevity. This
researcher is attempting to find differences in genetic make-up between
those families that live to old age and groups of family members that live
to very old age, that is, well into their nineties and hundreds.
The defect theory is a biological theory that is somewhat the oppo-
site of feature theory. According to the defect theory, the breakdown and
losses that occur with aging are accidents or mistakes. Defect theories
lead researchers to believe that the cause of death of older adults gener-
ally results from a wearing out of the body, or an accumulation of muta-
tions in DNA that can no longer be withstood. Further research is actively
being conducted on this theory and the role of shortening of telomeres in
the process of DNA replication during cell division. In contrast to feature
theory, defect theory supports the work of health promotion and illness
treatment and management as an important manner in which to prolong
life. Examples of defect theory in action are seen among the large num-
bers of older adults who survive years after treatment for aggressive can-
cers or cardiac disease. Recent work related to the defect theory shows
great support for the influence of caloric restriction on the aging process
(http://www.azinet.com/aging/). Caloric restriction was originally con-
ceived by Pearl (1928) as a manner in which to optimize metabolism to
expand life. This theory, which has repeatedly been tested, revealed that
when mice and rats were fed a calorie-restricted but nutritious diet, they
lived about 50% longer than rats fed regular diets. Moreover, the study
showed that the study rats were more active and youthful. This translates
to about a 30% increase in longevity for human beings or 10 to 15 years
of added human life.
Psychological Theories
Psychological theories support the idea that an older adult’s life ends when
they have reached all of their developmental psychological milestones.
Theories focusing on the psychological dimension include Maslow’s
Hierarchy of Needs. This theory states that an individual goes through
a series of developmental steps through life commencing with the need
to obtain safety and fulfill biological needs such as food and water. The
steps become progressively more challenging until the final stage in a
person’s life, known as self-actualization. According to Maslow’s theory,
self-actualization is obtained when a person develops an understanding
of themselves within the world and accepts who they have become. From
a psychological viewpoint, once an older adult reaches self-actualization,
they have reached the final stage of life. Other theories within the psy-
chological dimension include Erikson’s stages of development (1997).
Erikson theorizes that within each stage of life, individuals must success-
fully encounter and resolve a problem or crisis in order to move on to the
next stage. Within the final stage, ego integrity versus despair, the older
adult must successfully master changes in health, loss of loved ones, and
resolution of role changes such as no longer being a parent, employee,
or friend.
Moral/Spiritual Theories
Moral/spiritual theories support the idea that once an older individual
finds spiritual wholeness, this transcends the need to inhabit a body, and
the person approaches the end of life. Theories that fall within this cate-
gory include Kohlberg’s stages of moral development (Lind, Hartman, &
Wakenhut, 1985) and more recently, Tornstam’s (1994) theory of gero-
transcendence. Kohlberg’s theory of moral development states that an
individual goes through a series of moral reasoning activities that become
progressively more sophisticated throughout life. The most sophisticated
and final step is post-conventional reasoning, which is not reached by many
individuals. According to Kohlberg’s theory, post-conventional reasoning
is obtained when universality with the world is present and sense of higher
consciousness is achieved. This stage is dependent on social interaction
and is obtained when a person develops an understanding of themselves

within the world and accepts who they have become. From a moral per-
spective, once an older adult reaches post-conventional reasoning, they have
reached the final stage of life and are therefore prepared for the end of life.
Tornstam’s theory of gerotranscendence supports a movement to-
ward older adulthood throughout all stages of life, including childhood.
Tornstam’s theory builds upon previous work by Carl Jung. According to
the theory of gerotranscendence the movement toward the aging process
results in greater satisfaction with life, resulting in greater maturity and
improved understanding of the world and the individual’s position within
it. The steps toward attaining this enhanced perspective involve self-reflec-
tion and a progression toward selflessness, as well as an interconnectedness
and communication with the past and things beyond this world. Gerotran-
scendence often finds older adults with a decreased need to be with others,
as individuals become increasingly more comfortable being alone.
Sociological Theories
Sociological theories explain that aging results as older adult’s usefulness
in roles and relationships changes or declines. Sociological theories to
support this process include disengagement theory. This theory, which
was among the first of sociological theories to explain aging, states that
as relationships change or end for older adults, either through the process
of retirement, disability, or death, a gradual withdrawing of the older
adult is evidenced. Less involvement in activities is seen, and while new
relationships may be formed these relationships are not as integral to life
as previously necessary. Also within the sociological dimension is activity
theory. This theory states that social activity is an essential component
of successful aging. Consequently, when social activity is halted because
of death of loved ones, changes in relationship, or illness and disabilities
that affect relationships, aging is accelerated and death becomes nearer.
The focus of activity theory is the relationship between activity and self-
concept. In other words, social activity and role relationships are integral
to the self-concept and harmful when disrupted or stopped. To avoid this,
new roles must be developed to replace lost roles. For example, within
this theory, the loss of job roles through retirement could be replaced
with appropriate recreational or volunteer activities to avoid the harmful
effects of the job loss on self-concept. A final theory within the socio-
logical perspective is the continuity theory. This theory referred to earlier
in the chapter supports that individuals move through their later years
attempting to keep things much the same and using similar personal-
ity and coping strategies to maintain stability throughout life. Within
this theory, one can look to past experiences of an older adult to predict
Critical Thinking Case Study
A 64-year-old White male had been healthy for most of his life. He was a
teacher and an upstanding father who was active in the church and commu-
nity. However, after experiencing signs of Coronary Artery Disease (CAD),
he underwent a Coronary Artery Bypass Graft (CABG). What should have
been an unremarkable recovery was tainted with many complications, and
he required permanent residence in a nursing home approximately 1 hour
away from his home, wife, and grown children. Within 1 month of admis-
sion, he died.
1. What theories of aging could be used to help explain why this client
died when he did?
2. What factors may have contributed to this man’s premature death?
3. Do you think any one theory explains the aging process and the
cause of death among older adults, or do you feel a combination of
theories is more useful? Why?
how they will encounter current and future stressors. For example, if
an individual became greatly distressed after the loss of a friend in their
forties, it is likely that they will experience similar distress to other losses
in life. However, this theory also supports that past reflection on life and
future goal setting are helpful in changing past dysfunctional strategies.
SUMMARY
Olshansky, Carnes, and Desquelles (2001) report that
There are no lifestyle changes, surgical procedures, vitamins, antioxi-

dants, hormones or techniques of genetic engineering available today
with the capacity to repeat the gains in life expectancy that were
achieved during the 20th century. The next quantum leap in life expec-
tancy can occur only by adding decades of life to people who have
already lived 70 years or more. (p. 1491)
This statement summarizes the great advances in aging that have

resulted in the emergence of a population that was nonexistent a cen-
tury ago. The presence of older adults in society is of great benefit to
the many children and grandchildren, spouses, siblings, and friends
who receive love, care, and support from their older loved one. More-
over, nurses can receive much benefit from learning about the lives
of older adults. However, the emergence of this large population is not
without issues that need to be addressed. The presence of multiple medi-

cal illnesses and the subsequent need for health care, the means to pay
for health care, and the ability to provide housing for older adults when
illness impacts their functional status are among the issues that concern
nursing for older adults. Myths of aging are prevalent among society,
and this chapter provided information to dispel these myths and combat
ageism. Finally, the evolution of gerontological nursing education and
theories of aging were discussed to complete this introduction on the
Graying of America.
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New York Academy of Science, (1100), 1–13.
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executivesummary.pdf
C H A P T E R T W O
The Health Care

Delivery System
Learning Objectives
1. Identify the impact of retirement on aging and ability to pay for
health care.
2. Identify challenges for older adults within the current health care
delivery system.
3. Describe the basic elements of payment for health services for
older adults.
4. Identify the essential elements of Medicare as the primary payer
system of older adults.
5. Discuss Medicaid, veteran’s benefits, long-term care insurance,
and other payment methods for older adult health care.
6. Identify resources for health care for older adults without health
insurance.
Mr. Jackson is an 80-year-old man with moderate to severe dementia. He

has been living with his 55-year-old daughter and her family for the past
5 years. Over the past year his cognition has declined quite rapidly, and
he has required considerably more attention and supervision in order to
ensure his safety. The client’s daughter states that a month ago he left the
house and was found walking down the middle of a busy street, and he
appeared very scared and confused. Recently, the client has also become
verbally abusive toward his son-in-law.
His daughter is concerned about his safety when he is left alone, but
she states that financially both she and her husband need to keep their
full-time jobs. The family has discussed the possibility of visiting nurse
services and assisted-living facilities, but they are unsure of how they
29
would pay for such services. They come to you for counseling on their
options, as well as to obtain more information on eligibility requirements
for Medicare and Medicaid.
The story of Mr. Jackson is typical of today’s older adult. It is logical to

assume that the highly scientific and timely interventions that are used
to treat and cure disease in today’s society are available to everyone.
Many citizens and health care workers operate under the assumption
that if something is available, it is available to all. Unfortunately, this is
not the case. While the health care delivery system has improved vastly
over the past century, many of the currently available interventions to
detect disease early and treat disease effectively are not available to older
adults because they are not able to pay for these costly interventions. A
considerable amount of time is spent in nursing and medical schools on
illness assessment, management, and treatment. For example, if a patient
presents to the primary care provider with undiagnosed abdominal pain
and rectal bleeding, they may likely be sent for a Magnetic Resonance
Imaging (MRI) study to determine the cause of the symptoms. Few
providers realize that this particular test costs in excess of $1,000 and
may not be covered by insurance. In fact, very little time is spent on how
to access and obtain care for patients in medical and nursing education
programs. Little, if any, time is spent on how to assist patients without
health insurance to obtain greatly needed health care.
The sad reality is that while medical science and nursing interven-
tions have greatly increased in effectiveness over the past century, this
enhanced science is not available to everyone. Consequently, many older
adults are not able to access needed health care and remain part of an
underserved population. The most common barrier to effective health
care is the inability to pay for it. Among older adults, the inability to
receive effective health care may also result from a lack of transportation
to health care providers. Another barrier is the lack of primary providers
of geriatric care.
There are several primary health care payment systems for older
adults in the United States. The most widely used are Medicare and
Medicaid. However, these two payment mechanisms are not available
to all older adults. Medicare is the federally funded insurance program
for older adults. Older adults who have not paid into the U.S. Social
Security system, either because they were never employed or because they
immigrated into the United States as older adults, must either buy into
the Medicare system or become eligible for Medicaid. Medicaid, a com-
bination federal and state payment system, varies from state to state, but
it funds health care, including nursing home care for low income older
adults. Legislation passed in the 1990s made it more difficult for older
noncitizen immigrants to access Medicaid.
The Health Care Delivery System 31
This chapter will explore the financial issues related to health care
among older adults including the impact of retirement on aging and health
care. The Medicare system will be explored in depth, including historical
changes to this system and the effects of these changes on the delivery of
health care to older adults. Other reimbursement programs for health
care will also be discussed in order to prepare students to understand the
basic elements of these systems and viability of these systems for older
adults. The primary systems that will be discussed include: (a) Medic-
aid payment systems, (b) long-term care, (c) private and fee for service,
and (d) veterans services for payment of health care. Finally, the chapter
will conclude with an exploration of payment options for those without
access to these systems.
RETIREMENT
While older adults are generally considered to be retired, many older

adults are working longer and having second careers. Some older adults
continue to work because of the income it provides. Others work for the
social and intellectual stimulation provided by employment. Other older
adults feel that working helps them to contribute to society. In 2002,
13.2% of older Americans were working, or actively seeking work.
Eѣiёђћѐђ-BюѠђё Pџюѐѡiѐђ
Title of Study: Predictors of Perceptions of Involuntary Retirement

Authors: Szinovacz, M., Davey, A.
Purpose: To investigate situations in which retirees perceive their retire-
ment as “forced.”
Methods: Waves 1–4 on the Health and Retirement Survey were used for
analyses (N = 1, 160; 572 men and 588 women). Background factors,
choice and restricted choice conditions, and retirement contexts on per-
ceptions of forced retirement were estimated using logistic regression
models.
Findings: It was found that nearly one-third of workers perceive their
retirement as “forced.” Restricted choice through health limitations,
job displacement, care obligations, marital status, race, assets, benefits,
job tenure, and off-time retirement were also reflected.
Implications: Personal and policy implications are needed relating to forced
retirement. Employment programs are necessary to assist persons to find
alternate employment once “forced” into retirement.
In fact, a recent study by the Pew Research Center (2006) found that
the majority of older adults plan to retire at age 61, but 77% expect to
work for pay after retirement. Moreover, the traditional view of retire-
ment at 65 to pursue a life of leisure is becoming outdated as a result of
the expanding lifespan.
Some older people prefer and need to continue to work throughout
their older years. Work options may be full-time or part-time. Some older
adults continue to perform work similar to what they had previously
done, but others change careers. Currently, there is no mandatory retire-
ment age for U.S. residents.
Continued employment in older adulthood fills many needs. These
needs are physical, psychological, social, and financial. For example, con-
tinued work helps to provide extra income and socialization. As of January
1, 2000, Social Security recipients age 65 through 69 can earn as much as
they wish and still receive their full Social Security benefits. Prior to this leg-
islation being passed, individuals age 65 through 69 had $1 deducted from
their Social Security benefit for every $3 they earned (Hogstel, 2001).
For those who have chosen retirement, the continually increasing
lifespan means that older adults can spend an average of 30 years not
working. Rosenkoetter (2000) provides several theories to help understand
retirement. For those who view it positively, retirement may be peaceful
and less stressful than previous years. For these individuals, retirement
can be filled with hobbies and travel. But, for others retirement can be
difficult and filled with financial struggle and ill health. Older adults are
not always prepared financially for retirement, and many older adults
live on limited incomes.
It is important to note that when older adults retire, the health care
insurance available through employers may be terminated. While some
employers maintain health insurance coverage, others do not. This will
force the older adult to become a Medicare recipient. Medicare provides
limited benefits, as will be seen later in this chapter. These limitations
often place financial demands on older individuals that when combined
with lowered income post-retirement, makes paying for health care and
other expenses difficult. Financial planning during the young and healthy
years is the ideal way for older adults to be able to retire when desired and
to live at an optimal income level. This can be facilitated through con-
sultations with attorneys and financial planners throughout the working
years. However, this is not always done. Often when older adults retire,
they find themselves on fixed incomes with insufficient financial resources
for the future.
Continuing to work in later years has both advantages and dis-
advantages. While work provides a daily structure for activities, social in-
volvement, and the possibility of health benefits, it also prevents travel,
Mr. Robertson, an 80-year-old man, has worked as a mechanical engineer

for the same company for 45 years. He very much enjoys his position and
utilizes the company’s health insurance to pay for his health care. Yet, his
blood pressure is unstable requiring frequent medications and monitoring.
He has recently been diagnosed with Type 2 diabetes mellitus. Because
he requires frequent medical appointments, these medical conditions often
interfere with his workday. While he is well over retirement age and finan-
cially stable, he does not want to leave his current position.
1. What factors should be considered in Mr. Robertson’s decision to
retire or not?
2. What are the pros and cons of retirement in Mr. Robertson’s case?
3. How will Mr. Robertson’s retirement affect his medical care?
4. What alternatives to retirement are there for Mr. Robertson?
time with family and grandchildren, as well as other opportunities for

volunteering and participating in hobbies. Moreover, as adults age, the
incidence of chronic illnesses increases. The average older adult has three
chronic illnesses. These illnesses usually require daily management, such
as the use of medication, and the presence of pain, fatigue, or side-effects
of medication may negatively impact the individual’s quality of work.
The need to visit health care providers may interfere with a traditional
work schedule. Lower quality of work and greater absences may lessen
the individuals chance of promotion within competitive work environ-
ments. While some employers understand these special needs, others do
not and will look to replace the older adult with a younger, healthier
worker.
CHALLENGES WITHIN THE CURRENT HEALTH

CARE DELIVERY SYSTEM
There have been many changes in the health care delivery system in
the United States in the last 10 years. These changes include the devel-
opment of new medications, treatment for early-diagnosed disease,
improved surgical techniques, and enhanced diagnostic capabilities. For
example, new generations of antidepressant medications, cholesterol
lowering agents (statins), and blood pressure management medications
have all evolved over the last decade. These improvements have played
an instrumental role in preventing death and disability among adults
who are fortunate enough to benefit from these new interventions.
Changes and improvements in health care treatments have been dra-

matic and continuous for decades. Moreover, these changes continue to
evolve everyday, and progress is not likely to be slowed in the future. In
other words, the vast improvements in health care will likely continue
for centuries resulting in unprecedented improvements in both morbid-
ity and mortality.
These great improvements in health care, while cause for celebration,
come with a price tag. In many cases, this price tag is exceptionally
high and exceeds most people’s budgets. Often health care profession-
als do not consider the high price of new technological improvements
when prescribing care or medications. However, as a result of these
technological advancements, health care costs continue to increase with
each passing decade (Hogstel, 2001). The Federal Interagency Forum on
Age-Related Statistics (2004, p. 14) reports that most older adults are
retired from work.
Changes in health care expenditures have had a great impact on
the ability to access health care, because individuals must pay the rising
cost of insurance and/or out of pocket health care expenditures. In the
case of Medicare-eligible older adults, some of these expenses may be
paid for, but many are not. Medicare reimburses health care provid-
ers and facilities for the cost of some medical expenditure, but not
all older adults are eligible for Medicare, and Medicare does not pay
for all health care costs. For example, most outpatient prescription
medications are expensive and not covered by traditional Medicare
plans. Moreover, complementary and alternative therapies (CAM),
such as herbal supplements, are usually over the counter and not cov-
ered by any insurance. These herbal medications, while rising in popu-
larity among all older cultural groups, may be the primary healing
source among some Asian, Hispanic, and other cultures. Depending on
the health status of the older adult, the cost of medications alone may
be enough to bankrupt them. In attempts to provide increased medica-
tion coverage for Medicare recipients, a new Medicare prescription
drug benefit has recently become available. This program, titled the
Medicare Prescription Drug Improvement and Modernization Act of
2003, approved prescription discount drug cards for Medicare recipi-
ents. These cards are available to over 7 million of Medicare’s 41 mil-
lion participants. Older adults must apply to be eligible for the discount
cards, and a fee of $30 may be charged depending on the individual’s
income. The cards provide discounts on some medications, but not
all. The American Journal of Nursing (“Pick a Card,” 2004) reports
that other available prescription drug plans may benefit higher income
older adults more than the Medicare plan.
Mrs. O’Brien is a 79-year-old immigrant from Ireland. She came to this

country 1 year ago to live with her adult daughter. One week ago, her
daughter found her unconscious in the bathroom of her home. She was
brought to the emergency room with an elevated blood sugar level. She
was diagnosed with diabetes mellitus and sent home with a prescription
for insulin and a follow-up appointment in 2 weeks. Mrs. O’Brien is hav-
ing great difficulty learning to fill and inject the insulin. Her daughter can
prefill the syringes before she leaves for work, but she does not return in
time to administer the evening dosage. As Mrs. O’Brien is an immigrant,
she is not qualified for Medicare, and she has not yet applied for Medicaid
assistance. Mrs. O’Brien needs help in learning about her new disease and
treatment.
1. What type of insurance might Mrs. O’Brien be eligible for, given her
immigrant status?
2. If Mrs. O’Brien is not eligible for Medicare, how would you suggest
Mrs. O’Brien pay for her health care?
3. In your geographic area, are there services available to assist older
adults such as Mrs. O’Brien to receive needed care?
4. In light of the increasingly diverse older adult population, what changes
do you feel are necessary in the U.S. health care delivery system?
The lack of reimbursement for medications and treatments for illness

and the inability to pay out of pocket for these expensive treatments has
resulted in an increase in the rates of noncompliance or nonadherence to
medication regimes. It is reported that about one-half of all patients take
the medications as prescribed upon leaving the physician’s office. The other
half take the medications incorrectly or not at all. One-third of those who
take the medications incorrectly do not take it at all, one-third take the
medication sporadically, and one-third do not even fill the prescription.
Compliance and adherence, while defined differently, are similar and are
used interchangeably within health care professions. Compliance is defined
as the degree to which a patient follows a recommended treatment regimen.
For example, if the physician tells the patient to take medication to control
blood pressure, it is assumed that the patient will do what the physician says
they should do. Adherence is defined as the degree to which behavior corre-
sponds to a recommended therapeutic regimen. In this case, if the physician
feels a medication might help the patient to maintain blood pressure con-
trol, the physician would recommend the administration of medication, and
the patient’s daily intake of the medication would be considered adherent.
Noncompliance rises in correlation with the increase in chronic ill-

ness commonly seen among older adults. As the older adult is asked to
commit more time and resources to maintaining health, they are less
likely to adhere closely to the recommended regimen. It is also impor-
tant to note that older adults from various cultural backgrounds may be
nonadherent to medication and treatment regimes because such plans
conflict with their cultural healing beliefs. In order to promote maximum
adherence, it is essential that nurses educate the patient on the recom-
mended treatment regimen and assess the patient’s understanding, will-
ingness, and capability to comply. In so doing, it is estimated that up
to 23% of nursing home admissions, 10% of hospital admissions, and
many physician visits, diagnostic tests, and unnecessary treatments could
be avoided.
Reimbursement of health care has also changed as a result of increas-
ing costs. Allowable expenses under Medicare and Medicaid plans, as
well as private insurance, have diminished in many cases and have been
removed altogether in other cases. For example, at a point in the early
1990s, Medicare reimbursement for home care was very flexible, allow-
ing clients many weeks to meet their health care goals after discharge
from an acute care facility. In these cases, nurses could visit clients 2 or 3
times a week to provide wound care, medication teaching, and evaluation
of health status. However, changes in the Medicare allowable expenses
for home care have resulted in a lack of reimbursement for home care.
Currently, home care nurses are given few visits to assist older adults to
meet health care goals and then are mandated to discharge them because
of lack of reimbursement. Moreover, future changes are possible and will
continue to affect the way older people receive health care. These changes
in health care expenditures have also had a great impact on the methods
of health care delivery over the past several decades. In response to the
increasing costs of health care, increased amounts of the federal and state
funds must be budgeted to pay for rising health care costs.
Cultural Fќcus
Complementary and alternative therapies (CAM), such as herbal supple-

ments, are usually over the counter and not covered by any insurance.
These herbal medications, while rising in popularity among all older cul-
tural groups, may be the primary healing source among some Asian, His-
panic, and other cultures. Awareness of the use of CAM therapies allows
nurses to assess for the interaction of these therapies with traditional medi-
cations.
Methods of health care delivery have also changed as a result of

the increasing cost of health care. The dramatic changes in the health
care delivery system in the past several decades have had a profound
impact on the availability of health care to older adults. Consequently,
Kane (2002) reports that “Geriatricians are in danger of extinction”
(p. M803).
Decreased Medicare payments to hospitals, home health agencies,
and nursing homes and decreased coverage of outpatient rehabilitation
services have caused a reduction in the numbers of nurses available, qual-
ified, and willing to provide care to older adults It is not clear whether
or not the health care community will be prepared to manage the needs
of an increasing population of older adults (Stotts & Dietrich, 2004). In
addition, many physicians, nurses, nurse practitioners, and others are not
aware of the specialized care needs of older adults. As noted in Chapter 1,
gerontology is a fairly new science. Only recently have medical and nurs-
ing programs begun to provide specialized education on the needs of
older adults. A reduction in qualified nursing staff has the potential to
decrease the number of programs designed to provide geriatric health
care.
Another problem with obtaining health care for older adults includes
lack of transportation. Transportation to physician’s offices, clinics, and
other health care services is a major problem for those who can no lon-
ger drive or afford to maintain a car. While van services are available in
many communities to transport older adults to medical appointments
and health-related visits, they are not universally available. Moreover,
these van services usually require advanced scheduling on a first-come,
first-serve basis. Often, older adults must wait for extended amounts of
time at the health care facility or physician’s office for the van to return
to bring them home, extending a short appointment to a day-long outing.
Some older adults may have the option of public transportation, such
as buses or subway systems, to travel to their medical appointments,
and these systems have increased accessibility to accommodate chronic
disabilities among older adults. However, long walks to the stations may
prevent older adults from using this system, and smaller communities
may not even offer public transportation. These barriers often force older
adults to delay medical treatment for health-related issues.
Clearly, the many changes in the health care delivery system present
challenges for older adults in receiving adequate health care. In the afflu-
ent United States, it is often assumed that anyone who needs health care
can get it. But, clearly this is not the case, and there are many challenges to
the current health care delivery system, including the high cost of health
care and the lack of insurance of many U.S. citizens. These issues, as well
as lack of providers and transportation, may lead to noncompliance
Cultural Fќcus
Older adults with diverse cultural backgrounds may be nonadherent to

medication and treatment regimes because such plans conflict with their
cultural healing beliefs. Assessment of a client’s cultural backgrounds and
health care beliefs will ensure that recommended treatments are consistent
with values and adhered to most effectively.
or nonadherence to health care regimens and may prevent much of the

population from accessing health care. Consequently, many older adults
avoid health care providers and neglect health care in order to have
money to eat, live in their house or apartment, and pay their bills.
FINANCING HEALTH CARE
Health care for older adults is primarily paid for by the following
methods: (a) Medicare and related plans; (b) Medicaid; (c) private pay,
or fee for service; (d) veteran’s benefits; and (e) long-term care insurance.
Each of these payment systems has specific eligibility criteria as well as
inclusions and exclusions. In many cases, more than one system is used to
pay for the health care service. The following section provides a discus-
sion of each of these payment programs and their ability to pay for health
care costs of older adults.
Medicare and Related Plans

Most older adults are Medicare beneficiaries and receive health care
accordingly. To be eligible to receive Medicare, older adults must have
contributed to Social Security and/or the Medicare system earlier in life
or had a spouse who worked and contributed to these systems (Hogstel,
2001). Younger individuals may also be eligible for Medicare if they
contributed to Social Security earlier in life and then developed a dis-
ability that prevents them from working. This includes individuals with
end-stage renal disease (ESRD) who are receiving dialysis treatments and
other younger adults with disabilities such as amyotrophic lateral sclero-
sis (ALS), Parkinson’s disease (PD), or other adult onset neurodegenera-
tive diseases.
Although Medicare, as a national health insurance program, was put
into effect by President Johnson in July, 1965, the program was originally
conceived several decades earlier by the Roosevelt administration, within
the context of its vision for universal health care in the United States.
Be that as it may, Medicare was one of several programs established to

improve health care for the nation’s poorest, oldest, and often sickest
citizens. Health insurance plans, which also became more widely avail-
able, were primarily offered to working people through their employ-
ers. Older, often retired adults were not be eligible for these plans unless
they purchased them privately and paid the full premiums by themselves.
However, because older adults were considered poor health risks based
on their age and an increasing need for expensive health care, private
insurance premiums were quite high—if older adults were eligible for this
kind of insurance at all.
Medicare is highly regulated, with health care delivery provided
by private physicians, hospitals nurses, nurse practitioners, and vari-
ous health care facilities. Private physicians currently treating Medicare
patients receive 80% of the usual customary and reasonable (UCR) fee
for health care services if they accept Medicare assignment. If they do not,
they can charge no more than 115% of the Medicare allowed amount,
with the client required to pay the 20% remaining UCR and any other
costs up to 115% (Hogstel, 2001). Needless to say, physicians are often
hesitant to accept the low reimbursement for older adults available from
Medicare, and patients are hesitant to receive care from physicians that
do not accept Medicare assignment because of the need to finance the
co-pay. There is thus a shortage of primary care physicians to treat the
health care needs of older adults.
Medicare has two parts. Part A provides for hospital insurance for
older adults. In the event that an older adult requires hospitalization,
Medicare Part A pays for the hospital stay. In addition, Medicare Part A
pays for short-term nursing home or home care visits after hospitaliza-
tion. Medicare Part A also pays for hospice care, which is discussed in
Chapter 12. Generally, there is no premium for this insurance. If older
adults meet the eligibility for Medicare, they are automatically enrolled
in Part A.
Medicare Part B pays for visits to physicians and nurse practitioners
and other health care expenditures, such as X-rays, physical and occu-
pational outpatient therapy, and laboratory tests. Monthly premiums for
Part B are based on your income and, as of June 2007, range from $93.50
to $161.40. The amount is usually deducted from the recipient’s monthly
Social Security checks. Medicare Part B also requires recipients to pay a
deductible, which is currently the first $131 yearly for Part B-covered ser-
vices or items. This deductible is likely to increase annually. Coverage of
Medicare for health care needs of older adults is detailed in Table 2.1.
The Medicare traditional plan, which includes Parts A and B, has
undergone a great deal of scrutiny since its inception in 1965. The
chief concern among older adults and providers is the limited amount
TABLE 2.1 Coverage of Medicare for Health Care Needs of Older Adults
Service or Supply What is covered, and when?
Acupuncture Medicare doesn’t cover acupuncture.
Ambulance Medicare covers limited ambulance services. If you need to go to a hospital or skilled nursing facility (SNF),
Services ambulance services are covered only if transportation in any other vehicle would endanger your health. Medi-
care helps pay for necessary ambulance transportation to the closest appropriate facility that can provide the
care you need. If you choose to go to another facility farther away, Medicare payment is based on how much it
would cost to go to the closest appropriate facility. All ambulance suppliers must accept assignment.
Medicare generally doesn’t pay for ambulance transportation to a doctor’s office.
Air ambulance is paid only in the most severe situations. If you could have gone by land ambulance without
40
serious danger to your life or health, Medicare pays only the land ambulance rate, and you are responsible for
the difference.
Ambulatory Medicare covers services given in an Ambulatory Surgical Center for a covered surgical procedure.
Surgical Centers
Anesthesia Medicare covers anesthesia services along with medical and surgical benefits. Medicare Part A covers anesthesia
you get while in an inpatient hospital. Medicare Part B covers anesthesia you get as an outpatient.
Artificial Limbs Medicare helps pay for artificial limbs and eyes. For more information, see Prosthetic Devices.
and Eyes
Blood Medicare doesn’t cover the first three pints of blood you get under Part A and Part B combined in a calendar
year. Part A covers blood you get as an inpatient, and Part B covers blood you get as an outpatient and in a
freestanding Ambulatory Surgical Center.
Bone Mass Medicare covers bone mass measurements ordered by a doctor or qualified practitioner who is treating you if
Measurement you meet one or more of the following conditions:
Women
• You are being treated for low estrogen levels and are at clinical risk for osteoporosis, based on your medical
history and other findings.
Men and Women
• Your X-rays show possible osteoporosis, ostcopenia, or vertebrae fractures.
• You are on prednisone or steroid-type drugs or are planning to begin such treatment.
• You have been diagnosed with primary hyperparathyroidism.
• You are being monitored to see if your osteoporosis drug therapy is working.
The test is covered once every two years for qualified individuals and more often if medically necessary.
Braces (arm, leg, Medicare covers arm, leg, back, and neck braces. For more information, see Orthotics.
41
back, and neck)
Breast Prostheses Medicare covers breast prostheses (including a surgical brassiere) after a mastectomy. For more information,
see Prosthetic Devices.
Canes/Crutches Medicare covers canes and crutches. Medicare doesn’t cover canes for the blind. For more information, see
Durable Medical Equipment.
Cardiac Rehabili- Medicare covers comprehensive programs that include exercise, education, and counseling for patients whose
tation Programs doctor referred them and who have 1) had a heart attack in the last 12 months, 2) had coronary bypass sur-
gery, 3) stable angina pectoris, 4) had heart valve repair/replacement, 5) had angioplasty or coronary stenting,
and/or 6) had a heart or heart-lung transplant. These programs may be given by the outpatient department of a
hospital or in doctor-directed clinics.
Cardiovascular Medicare covers screening tests for cholesterol, lipid, and triglyceride levels every five years.
Screening Ask your doctor to test your cholesterol, lipid, and triglyceride levels so he or she can help you prevent a heart
attack or stroke.
(continued)
TABLE 2.1 Coverage of Medicare for Health Care Needs of Older Adults (Continued)
Chemotherapy Medicare covers chemotherapy for patients who are hospital inpatients, outpatients, or patients in a doctor’s
office or freestanding clinics. In the inpatient hospital setting, Part A covers chemotherapy.
In a hospital outpatient setting, freestanding facility, or doctor’s office, Part B covers chemotherapy.
Chiropractic Medicare covers manipulation of the spine if medically necessary to correct a subluxation (when one or more
Services of the bones of your spine moves out of position) when provided by chiropractors or other qualified providers.
Clinical Trials Medicare covers routine costs, like doctor visits and tests, if you take part in a qualifying clinical trial. Clinical
trials test new types of medical care, like how well a new cancer drug works. Clinical trials help doctors and
researchers see if the new care works and if it is safe. Medicare doesn’t pay for the experimental item being
investigated, in most cases.
42
Colorectal Cancer Medicare covers several colorectal cancer screening tests. Talk with your doctor about the screening test that is
Screening right for you. All people age 50 and older with Medicare are covered. However, there is no minimum age for
having a colonoscopy.
Colonoscopy: Medicare covers this test once every 24 months if you are at high risk for colorectal cancer. If
you aren’t at high risk for colorectal cancer, the test is covered once every 120 months, but not sooner than 48
months after a screening sigmoidoscopy.
Fecal Occult Blood Test: Medicare covers this lab test once every 12 months.
Flexible Sigmoidoscopy: Medicare covers this test once every 48 months for people 50 and older.
Barium Enema: Once every 48 months (high risk every 24 months) when used instead of a flexible sigmoidos-
copy or colonoscopy.
Commode Chairs Medicare covers commode chairs that your doctor orders for use in your home if you are confined to your
bedroom. For more information, see Durable Medical Equipment on page 46.
Cosmetic Surgery Medicare generally doesn’t cover cosmetic surgery unless it is needed because of accidental injury or to improve
the function of a malformed part of the body. Medicare covers breast reconstruction if you had a mastectomy
because of breast cancer.
Custodial Care Medicare doesn’t cover custodial care when it’s the only kind of care you need. Care is considered custodial
(help with activi- when it’s for the purpose of helping you with activities of daily living or personal needs that could be done
ties of daily living, safely and reasonably by people without professional skills or training. For example, custodial care includes
like bathing, help getting in and out of bed, bathing, dressing, eating, and taking medicine.
dressing, using the
bathroom, and
eating)
Dental Services Medicare doesn’t cover routine dental care or most dental procedures such as cleanings, fillings, tooth extrac-
tions, or dentures. Medicare doesn’t pay for dental plates or other dental devices. Medicare Part A will pay for
certain dental services that you get when you are in the hospital.
43
Medicare Part A can pay for hospital stays if you need to have emergency or complicated dental procedures,
even when the dental care itself isn’t covered.
Diabetes Screening Medicare covers tests to check for diabetes. These tests are available if you have any of the following risk fac-
tors: high blood pressure, dyslipidemia (history of abnormal cholesterol and triglyceride levels), obesity, or a
history of high blood sugar. Medicare also covers these tests if you have two or more of the following charac-
teristics:
• age 65 or older,
• overweight,
• family history of diabetes (parents, brothers, sisters),
• a history of gestational diabetes (diabetes during pregnancy) or delivery of a baby weighing more than 9
pounds.
Based on the results of these tests, you may be eligible for up to two diabetes screenings every year.
(continued)
Diabetes Supplies Medicare covers some diabetes supplies, including

and Services • blood glucose test strips,
• blood glucose monitor,
• lancet devices and lancets, and
• glucose control solutions for checking the accuracy of test strips and monitors.
There may be limits on how much or how often you get these supplies.
For more information, see Durable Medical Equipment on page 32.
Here are some ways you can make sure your Medicare diabetes medical supplies are covered:
• Only accept supplies you have ordered. Medicare won’t pay for supplies you didn’t order.
• Make sure you request your supply refills. Medicare won’t pay for supplies sent from the supplier to you
44
automatically.
• All Medicare-enrolled pharmacies and suppliers must submit claims for glucose test strips. You can’t send in
the claim yourself.
Medicare doesn’t cover insulin (unless used with an insulin pump), insulin pens, syringes, needles, alcohol
swabs, gauze, eye exams for glasses, and routine or yearly physical exams. If you use an external insulin pump,
insulin and the pump could be covered as durable medical equipment. There may be some limits on covered
supplies or how often you get them. Insulin and certain medical supplies used to inject insulin are covered
under Medicare prescription drug coverage.
Therapeutic Shoes or Inserts: Medicare covers therapeutic shoes or inserts for people with diabetes who have
severe diabetic foot disease. The doctor who treats your diabetes must certify your need for therapeutic shoes
or inserts. The shoes and inserts must be prescribed by a podiatrist or other qualified doctor and provided by a
podiatrist, orthotist, prosthetist, or pedorthist. Medicare helps pay for one pair of therapeutic shoes and inserts
per calendar year. Shoe modifications may be substituted for inserts. The fitting of the shoes or inserts is cov-
ered in the Medicare payment for the shoes.
Medicare covers these diabetes services:
• Diabetes Self-Management Training: Diabetes outpatient self-management training is a covered program
to teach you to manage your diabetes. It includes education about self-monitoring of blood glucose, diet,
exercise, and insulin.
If you’ve been diagnosed with diabetes, Medicare may cover up to 10 hours of initial diabetes self-management
training. You may also qualify for up to two hours of follow-up training each year if
• it is provided in a group of 2 to 20 people,
• it lasts for at least 30 minutes,
• it takes place in a calendar year following the year you got your initial training, and
• your doctor or a qualified non-physician practitioner ordered it as part of your plan of care.
• Some exceptions apply if no group session is available or if your doctors or qualified non-physician practi-
tioner says you have special needs that prevent you from participating in group training.
• Yearly Eye Exam: Medicare covers yearly eye exams for diabetic retinopathy.
• Foot Exam: A foot exam is covered every 6 months for people with diabetic peripheral neuropathy and loss of
45
protective sensations, as long as you haven’t seen a foot care professional for another reason between visits.
• Glaucoma Screening: Medicare covers glaucoma screening every 12 months for people with diabetes or a
family history of glaucoma, African Americans age 50 and older, or Hispanics age 65 and older.
• Medical Nutrition Therapy Services: Medical nutrition therapy services are also covered for people with
diabetes or kidney disease when referred by a doctor. These services can be given by a registered dietitian or
Medicare-approved nutrition professional and include a nutritional assessment and counseling to help you
manage your diabetes or kidney disease.
For more information, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
Diagnostic Tests, Medicare covers diagnostic tests like CT scans, MRIs, EKGs, and X-rays. Medicare also covers clinical diag-
X-rays, and Lab nostic tests and lab services provided by certified laboratories enrolled in Medicare. Diagnostic tests and lab
Services services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare doesn’t
cover most routine screening tests, like checking your hearing.
Some preventive tests and screenings are covered by Medicare to help prevent, find, or manage a medical prob-
lem. For more information, see Preventive Services.
(continued)
Dialysis (Kidney) Medicare covers some kidney dialysis services and supplies, including the following:
• Inpatient dialysis treatments (if you are admitted to a hospital for special care).
• Outpatient maintenance dialysis treatments (when you get treatments in any Medicare-approved dialysis facility).
• Certain home dialysis support services (may include visits by trained dialysis workers to check on your home
dialysis, to help in dialysis emergencies when needed, and check your dialysis equipment and hemodialysis
water supply).
• Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, and
topical anesthetics.
• Erythropoiesis–stimulating agents (such as Epogen®, Epoetin alfa), or Darbepoetin alfa (Aranesp®) are drugs
used to treat anemia if you have end-stage renal disease. For more information, see Prescription Drugs.
• Self-dialysis training (includes training for you and the person helping you with your home dialysis treatments).
46
• Home dialysis equipment and supplies (like alcohol, wipes, sterile drapes, rubber gloves, and scissors).
Doctor’s Office Medicare covers medically necessary services you get from your doctor in his or her office, in a hospital, in a
Visits skilled nursing facility, in your home, or any other location. Routine annual physicals aren’t covered, except the
one-time “Welcome to Medicare” physical exam. Some preventive tests and screenings are covered by Medi-
care. See Preventive Services, and Pap Test/Pelvic Exam.
Drugs See Prescription Drugs (Outpatient).
Durable Medical Medicare covers Durable Medical Equipment (DME) that your doctor prescribes for use in your home. Only
Equipment (DME) your own doctor can prescribe medical equipment for you.
Durable Medical Equipment is
• (long lasting) durable,
• used for a medical reason,
• not usually useful to someone who isn’t sick or injured, and
• used in your home.
The Durable Medical Equipment that Medicare covers includes, but isn’t limited to the following:
• Air-fluidized beds
• Blood glucose monitors
• Canes (canes for the blind aren’t covered)
• Commode chairs
• Crutches
• Dialysis machines
• Home oxygen equipment and supplies
• Hospital beds
• Infusion pumps (and some medicines used in infusion pumps if considered reasonable and necessary)
• Nebulizers (and some medicines used in nebulizers if considered reasonable and necessary)
• Patient lifts (to lift patient from bed or wheelchair by hydraulic operation)
• Suction pumps
• Traction equipment
47
• Walkers
• Wheelchairs
Make sure your supplier is enrolled in Medicare and has a Medicare supplier number. Suppliers have to meet strict
standards to qualify for a Medicare supplier number. Medicare won’t pay your claim if your supplier doesn’t have
one, even if your supplier is a large chain or department store that sells more than just durable medical equipment.
Emergency Room Medicare covers emergency room services. Emergency services aren’t covered in foreign countries, except in
Services some instances in Canada and Mexico. For more information, see Travel.
A medical emergency is when you believe that your health is in serious danger. You may have an injury or ill-
ness that requires immediate medical attention to prevent a severe disability or death.
When you go to an emergency room, you will pay a copayment for each hospital service, and you will also pay
coinsurance for each doctor who treats you.
Note: If you are admitted to the hospital within three days of the emergency room visit for the same condition,
the emergency room visit is included in the inpatient hospital care charges, not charged separately.
(continued)
Equipment See Durable Medical Equipment.

Eye Exams Medicare doesn’t cover routine eye exams.
Medicare covers some preventive eye tests and screenings:
• See yearly eye exams under Diabetes Supplies and Services on page 25.
• See Glaucoma Screening.
• See Macular Degeneration.
Eyeglasses/Contact Generally, Medicare doesn’t cover eyeglasses or contact lenses.
Lenses However, following cataract surgery with an implanted intraocular lens, Medicare helps pay for corrective
lenses (spectacles or contact lenses) provided by a licensed and Medicare-approved opthalmologist. Services
provided by a licensed and Medicare-approved opthalmologist may be covered, if they are authorized to pro-
48
vide this service in your state.
Important:
• Only standard frames are covered.
• Lenses are covered even if you had the surgery before you had Medicare.
• Payment may be made for lenses for both eyes even though cataract surgery involved only one eye.
Eye Refractions Medicare doesn’t cover eye refractions.
Flu Shots Medicare covers one flu shot per flu season. You can get a flu shot in the winter and the fall flu season of the
same calendar year. All people with Medicare are covered.
Foot Care Medicare generally doesn’t cover routine foot care.
Medicare Part B covers the services of a podiatrist (foot doctor) for medically necessary treatment of injuries or
diseases of the foot (such as hammer toe, bunion deformities, and heel spurs).
See Therapeutic Shoes and Foot Exam under Diabetes Supplies and Services starting.
Glaucoma Medicare covers glaucoma screening once every 12 months for people at high risk for glaucoma. This includes
Screening people with diabetes, a family history of glaucoma, African Americans age 50 and older, or Hispanic Americans
age 65 and older. The screening must be done or supervised by an eye doctor who is legally allowed to do this
service in your state.
Health Education/ Medicare generally doesn’t cover health education and wellness programs. However, Medicare does cover
Wellness Programs medical nutrition therapy for some people and diabetes education for people with diabetes.
Hearing Exams/ Medicare doesn’t cover routine hearing exams, hearing aids, or exams for fitting hearing aids.
Hearing Aids In some cases, Medicare covers diagnostic hearing exams.
Hepatitis B Shots Medicare covers this preventive service (three shots) for people at high or medium (intermediate) to high risk
for Hepatitis B.
Your risk for Hepatitis B increases if you have hemophilia, end-stage renal disease (permanent kidney failure
requiring dialysis or a kidney transplant), or a condition that lowers your resistance to infection. Other factors
may also increase your risk for Hepatitis B. Check with your doctor to see if you are at high to medium risk for
49
Hepatitis B.
Home Health Care Medicare covers some home health care if the following conditions are met:
1. Your doctor decides you need medical care in your home and makes a plan for your care at home, and
2. You need reasonable and necessary part-time or intermittent skilled nursing care and home health aide
services, and physical therapy, occupational therapy, and speech-language pathology ordered by your doc-
tor and provided by a Medicare-certified home health agency. This includes medical social services, other
services, durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers), and medical
supplies for use at home.
3. You are homebound. This means you are normally unable to leave home and that leaving home is a major
effort. When you leave home, it must be infrequent, for a short time. You may attend religious services. You
may leave the house to get medical treatment, including therapeutic or psychosocial care. You can also get
care in an adult day care program that is licensed or certified by your state or accredited to furnish adult day
care services in your state, and
(continued)
4. The home health agency caring for you must be approved by Medicare.
Medicare covers durable medical equipment (such as wheelchairs, hospital beds, oxygen, and walkers).
Note for Women with Osteoporosis: Medicare helps pay for an injectable drug for osteoporosis in women who
have Medicare Part B, meet the criteria for the Medicare home health benefit, and have a bone fracture that a
doctor certifies was related to post-menopausal osteoporosis. You must also be certified by a doctor as unable
to learn or unable to give yourself the drug by injection, and that family and/or caregivers are unable or unwill-
ing to give the drug by injection.
Medicare covers the visit by a home health nurse to give the drug.
Hospice Care Medicare covers hospice care if
• you are eligible for Medicare Part A,
50
• your doctor and the hospice medical director certify that you are terminally ill and probably have less than
six months to live,
• you accept palliative (care to comfort) instead of care to cure your illness,
• you sign a statement choosing hospice care instead of routine Medicare-covered benefits for your terminal
illness, and
• you get care from a Medicare-approved hospice program.
Medicare allows a nurse practitioner to serve as an attending doctor for a patient who elects the hospice ben-
efit. Nurse practitioners are prohibited from certifying a terminal diagnosis.
Respite Care: Medicare also covers respite care if you are getting covered hospice care. Respite care is inpatient
care given to a hospice patient so that the usual caregiver can rest. You can stay in a Medicare-approved facil-
ity, such as a hospice facility, hospital or nursing home, up to five days each time you get respite care.
Medicare will still pay for covered services for any health problems that aren’t related to your terminal illness.
Hospital Bed See Durable Medical Equipment.
Hospital Care Medicare covers inpatient hospital care when all of the following are true:
(Inpatient) for • A doctor says you need inpatient hospital care to treat your illness or injury.
Outpatient • You need the kind of care that can be given only in a hospital.
Services. • The hospital is enrolled in Medicare.
• The Utilization Review Committee of the hospital approves your stay while you are in the hospital.
• A Quality Improvement Organization approves your stay after the bill is submitted.
Medicare-covered hospital services include the following: a semiprivate room, meals, general nursing, and other
hospital services and supplies. This includes care you get in critical access hospitals and inpatient mental health
care. This doesn’t include private-duty nursing, a television, or telephone in your room. It also doesn’t include a
private room, unless medically necessary.
Implantable Car- Medicare covers defibrillators for many people diagnosed with congestive heart failure.
diac Defibrillator
51
Kidney (Dialysis) See Dialysis.
Lab Services Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they
are provided by a Clinical Laboratory Improvement Amendments (CLIA)–certified laboratory enrolled in Medi-
care. For more information, see Diagnostic Tests.
Macular Degen- Medicare covers certain treatments for some patients with age-related macular degeneration (AMD) like ocular
eration photodynamic therapy with verteporfin (Visudyne®).
Mammogram Medicare covers a screening mammogram once every 12 months (11 full months must have gone by from the
(Screening) last screening) for all women with Medicare age 40 and older. You can also get one baseline mammogram
between ages 35 and 39.
(continued)
Mental Health Medicare covers mental health care given by a doctor or a qualified mental health professional. Before you get
Care treatment, ask your doctor, psychologist, social worker, or other health professional if they accept Medicare
payment.
Inpatient Mental Health Care: Medicare covers inpatient mental health care services. These services can be
given in psychiatric units of a general hospital or in a specialty psychiatric hospital that cares for people with
mental health problems. Medicare helps pay for inpatient mental health services in the same way that it pays
for all other inpatient hospital care.
Note: If you are in a specialty psychiatric hospital, Medicare only helps for a total of 190 days of inpatient care
during your lifetime.
Outpatient Mental Health Care: Medicare covers mental health services on an outpatient basis by either a
doctor, clinical psychologist, clinical social worker, clinical nurse specialist, or physician assistant in an office
52
setting, clinic, or hospital outpatient department.
Partial Hospitalization: Partial hospitalization may be available for you. It is a structured program of active
psychiatric treatment that is more intense than the care you get in your doctor or therapist’s office. For Medi-
care to cover a partial hospitalization program, a doctor must say that you would otherwise need inpatient
treatment.
Medicare covers the services of specially qualified non-physician practitioners such as clinical psychologists,
clinical social workers, nurse practitioners, clinical nurse specialists, and physician assistants, as allowed by
state and local law for medically necessary services.
Nursing Home Most nursing home care is custodial care. Generally, Medicare doesn’t cover custodial care. Medicare Part A
Care only covers skilled nursing care given in a certified skilled nursing facility (SNF) or in your home (if you are
homebound) if medically necessary, but not custodial care (such as helping with bathing or dressing).
Nutrition Therapy Medicare covers medical nutrition therapy services, when ordered by a doctor, for people with kidney disease
Services (Medical) (but who aren’t on dialysis) or who have a kidney transplant, or people with diabetes. These services can be
given by a registered dietitian or Medicare-approved nutrition professional and include nutritional assessment,
one-on-one counseling, and therapy through an interactive telecommunications system. See Diabetes Supplies
and Services.
Occupational See Physical Therapy/Occupational Therapy/Speech-Language Pathology.
Therapy
Orthotics Medicare covers artificial limbs and eyes, and arm, leg, back and neck braces.
Medicare doesn’t pay for orthopedic shoes unless they are a necessary part of the leg brace. Medicare doesn’t
pay for dental plates or other dental devices.
See Diabetes Supplies and Services (Therapeutic Shoes).
Ostomy Supplies Medicare covers ostomy supplies for people who have had a colostomy, ileostomy, or urinary ostomy. Medicare
53
covers the amount of supplies your doctor says you need, based on your condition.
Outpatient Hospi- Medicare covers medically necessary services you get as an outpatient from a Medicare-participating hospital
tal Services for diagnosis or treatment of an illness or injury.
Covered outpatient hospital services include
• services in an emergency room or outpatient clinic, including same-day surgery,
• laboratory tests billed by the hospital,
• mental health care in a partial hospitalization program, if a doctor certifies that inpatient treatment would be
required without it,
• X-rays and other radiology services billed by the hospitals,
• medical supplies such as splints and casts,
• screenings and preventive services, and
• certain drugs and biologicals that you can’t give yourself.
(continued)
Oxygen Therapy Medicare covers the rental of oxygen equipment. Or, if you own your own equipment, Medicare will help pay
for oxygen contents and supplies for the delivery of oxygen when all of these conditions are met:
• Your doctor says you have a severe lung disease or you’re not getting enough oxygen and your condition
might improve with oxygen therapy.
• Your arterial blood gas level falls within a certain range.
• Other alternative measures have failed.
Under the above conditions Medicare helps pay for
• systems for furnishing oxygen,
• containers that store oxygen,
• tubing and related supplies for the delivery of oxygen, and
• oxygen contents.
54
If oxygen is provided only for use during sleep, portable oxygen wouldn’t be covered.
Portable oxygen isn’t covered when provided only as a backup to a stationary oxygen system.
Pap Test/Pelvic Medicare covers Pap tests and pelvic exams (and a clinical breast exam) for all women once every 24 months. Medi-
Exam care covers this test and exam once every 12 months if you are at high risk for cervical or vaginal cancer or if you
are of childbearing age and have had an abnormal Pap test in the past 36 months. If you have your Pap test, pelvic
exam, and clinical breast exam on the same visit as a routine physical exam, you pay for the physical exam. Routine
physical exams aren’t covered by Medicare, except for the one-time “Welcome to Medicare” physical exam.
Physical Exams Routine physical exams aren’t generally covered by Medicare.
(routine) (“One- Medicare covers a one-time review of your health, as well as education and counseling about the preventive services
time Welcome to you need, including certain screenings and shots. Referrals for other care, if you need them, will also be covered.
Medicare” physi- Important: You must have the physical exam within the first six months you have Medicare Part B (deductibles
cal exam) and coinsurance apply).
Physical Therapy/ Medicare helps pay for medically necessary outpatient physical and occupational therapy and speech-language
Occupational pathology services when
Therapy/ • your doctor or therapist sets up the plan of treatment, and
Speech-Language • your doctor periodically reviews the plan to see how long you will need therapy.
Pathology
You can get outpatient services from a Medicare-approved outpatient provider such as a participating hospital
or skilled nursing facility, or from a participating home health agency, rehabilitation agency, or a comprehen-
sive outpatient rehabilitation facility. Also, you can get services from a Medicare-approved physical or occu-
pational therapist, in private practice, in his or her office, or in your home. (Medicare doesn’t pay for services
given by a speech-language pathologist in private practice.) In 2007, there may be limits on physical therapy,
occupational therapy, and speech-language pathology services. If so, there may be exceptions to these limits.
Pneumococcal Medicare covers the pneumococcal shot to help prevent pneumococcal infections. Most people only need this
Shot preventive shot once in their lifetime. Talk with your doctor to see if you need this shot.
Prescription Drugs Part B covers a limited number of outpatient prescription drugs. Your pharmacy or doctor must accept assign-
55
(Outpatient) Very ment on Medicare-covered prescription drugs.
Limited Coverage Part B covers drugs that aren’t usually self-administered when you are given them in a hospital outpatient
department.
You can get comprehensive drug coverage by joining a Medicare drug plan (also called “Part D”). For more
information.
The following outpatient prescription drugs are covered:
• Some Antigens: Medicare will help pay for antigens if they are prepared by a doctor and given by a properly
instructed person (who could be the patient) under doctor supervision.
• Osteoporosis Drugs: Medicare helps pay for an injectable drug for osteoporosis for certain women with
Medicare. See note for women with osteoporosis, under Home Health Care.
• Erythropoisis–stimulating agents (such as Epogen,® Epoetin alfa, or Darbepoetin alfa Aranesp®): Medicare
will help pay for erythropoietin by injection if you have end-stage renal disease (permanent kidney failure)
and need this drug to treat anemia.
(continued)
• Blood Clotting Factors: If you have hemophilia, Medicare will help pay for clotting factors you give yourself
by injection.
• Injectable Drugs: Medicare covers most injectable drugs given by a licensed medical practitioner, if the drug
is considered reasonable and necessary for treatment.
• Immunosuppressive Drugs: Medicare covers immunosuppressive drug therapy for transplant patients if
the transplant was paid for by Medicare (or paid by private insurance that paid as a primary payer to your
Medicare Part A coverage) in a Medicare-certified facility.
• Oral Cancer Drugs: Medicare will help pay for some cancer drugs you take by mouth if the same drug is
available in injectable form.
Currently, Medicare covers the following cancer drugs you take by mouth:
56
• Capecitabine (brand name Xeloda®)
• Cyclophosphamide (brand name Cytoxan®)
• Methotrexate
• Temozolomide (brand name Temodar®)
• Busulfan (brand name Myleran®)
• Etoposide (brand name VePesid®)
• Melphalan (brand name Alkeran®)
As new cancer drugs become available, Medicare may cover them.
• Oral Anti-Nausea Drugs: Medicare will help pay for oral anti-nausea drugs used as part of an anti-cancer
chemotherapeutic regimen. The drugs must be administered within 48 hours and must be used as a full thera-
peutic replacement for the intravenous anti-nausea drugs that would otherwise be given.
Medicare also covers some drugs used in infusion pumps and nebulizers if considered reasonable and necessary.
Preventive Services Medicare covers the following preventive services:
• Bone Mass Measurement.
• Cardiovascular Screening Blood Tests.
• Colorectal Cancer Screening.
• Diabetes Screenings.
• Glaucoma Screening.
• Mammogram Screening.
• Nutrition Therapy Services.
• Pap Test/Pelvic Exam.
• Prostate Cancer Screening.
• Shots on page 52 including
- flu shot,
- pneumococcal shot, and
- Hepatitis B shot.
57
• Smoking Cessation Counseling.
• One-time “Welcome to Medicare” physical exam.
Prostate Cancer Medicare covers prostate screening tests once every 12 months for all men age 50 and older with Medicare
Screening (coverage begins the day after your 50th birthday). Covered tests include the following:
• Digital Rectal Examination
• Prostate Specific Antigen (PSA) Test
Prosthetic Devices Medicare covers prosthetic devices needed to replace an internal body part or function. These include Medi-
care-approved corrective lenses needed after a cataract operation (see Eyeglasses/Contact Lenses), ostomy bags
and certain related supplies (see Ostomy Supplies), and breast prostheses (including a surgical brassiere) after a
mastectomy (see Breast Prostheses).
Radiation Therapy Medicare covers radiation therapy for patients who are hospital inpatients or outpatients or patients in free-
standing clinics.
(continued)
Religious Non- Medicare doesn’t cover the religious portion of RNHCI care. Medicare covers inpatient nonmedical care when
medical Health the following conditions are met:
Care Institution • The RNHCI has agreed and is currently certified to participate in Medicare, and the Utilization Review Com-
(RNHCI) mittee agrees that you’d require hospital or skilled nursing facility care if it weren’t for your religious beliefs.
• You have a written agreement with Medicare indicating that your need for this form of care is based on your
religious beliefs. The agreement must also indicate that if you decide to accept standard medical care you
may have to wait longer to get RNHCI services in the future. You’re always able to access medically neces-
sary Medicare Part A services.
• The care provided is reasonable and necessary.
58
Respite Care Medicare covers respite care for hospice patients (see Hospice Care).
Second Surgical Medicare covers a second opinion before surgery that isn’t an emergency. A second opinion is when another
Opinions doctor gives his or her view about your health problem and how it should be treated. Medicare will also help
pay for a third opinion if the first and second opinions are different.
Shots (Vaccina- Medicare covers the following shots:
tions) Flu Shot: Once per flu season. You can get a flu shot in the fall and the winter flu seasons of the same year.
Hepatitis B Shot: Certain people with Medicare at medium to high risk for Hepatitis B.
Pneumococcal Shot: One shot may be all you ever need. Ask your doctor.
Skilled Nursing Medicare covers skilled care in a skilled nursing facility (SNF) under certain conditions for a limited time.
Facility (SNF) Skilled care is health care given when you need skilled nursing or rehabilitation staff to manage, observe, and
Care evaluate your care. Examples of skilled care include changing sterile dressings and physical therapy. Care that
can be given by non-professional staff isn’t considered skilled care. Medicare covers certain skilled care services
that are needed daily on a short-term basis (up to 100 days).
Supplies (you use Medicare generally doesn’t cover common medical supplies like bandages and gauze.
at home) Supplies furnished as part of a doctor’s service are covered by Medicare, and payment is included in Medicare’s
doctor payment. Doctors don’t bill for supplies.
Medicare covers some diabetes and dialysis supplies. See Diabetes Supplies and Services on page 25 and Dialy-
sis (Kidney).
For items such as walkers, oxygen, and wheelchairs, see Durable Medical Equipment.
Surgical Dressings Medicare covers surgical dressings when medically necessary for the treatment of a surgical or surgically treated
wound.
60
Therapeutic Shoes See Diabetes Supplies and Services (Therapeutic Shoes).
Transplants (Doc- Medicare covers doctor services for transplants, see Transplants (Facility Charges).
tor Services)
Transplants (Facil- Medicare covers transplants of the heart, lung, kidney, pancreas, intestine/multivisceral, bone marrow, cornea,
ity Charges) and liver under certain conditions and, for some types of transplants, only at Medicare-approved facilities.
Medicare only approves facilities for kidney, heart, liver, lung, intestine/multivisceral, and some pancreas trans-
plants. Bone marrow and cornea transplants aren’t limited to approved facilities. Transplant coverage includes
necessary tests, labs, and exams before surgery. It also includes immunosuppressive drugs (under certain condi-
tions), follow-up care for you, and procurement of organs and tissues. Medicare pays for the costs for a living
donor for a kidney transplant.
Transportation Medicare generally doesn’t cover transportation to get routine health care. For more information, see Ambu-
(Routine) lance Services.
Travel Outside of Medicare generally doesn’t cover health care while you are traveling outside the United States. Puerto Rico,
the United States the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands are considered part of the
(Health Care United States. There are some exceptions. In some cases, Medicare may pay for services that you get while on
Coverage During board a ship within the territorial waters adjoining the land areas of the United States.
Travel) In rare cases, Medicare can pay for inpatient hospital services that you get in a foreign country. Medicare can
pay only under the following circumstances:
1. You are in the United States when a medical emergency occurs and the foreign hospital is closer than the
nearest United States hospital that can treat the emergency.
2. You are traveling through Canada without unreasonable delay by the most direct route between Alaska and
another state when a medical emergency occurs and the Canadian hospital is closer than the nearest United
States hospital that can treat the emergency.
3. You live in the United States and the foreign hospital is closer to your home than the nearest United States
61
hospital that can treat your medical condition, regardless of whether an emergency exists.
Medicare also pays for doctor and ambulance services you get in a foreign country as part of a covered
inpatient hospital stay.
Walker/Wheel- Medicare covers power-operated vehicles (scooters), walkers, and wheelchairs as durable medical equipment
chair that your doctor prescribes for use in your home. For more information, see Durable Medical Equipment.
Power Wheelchair: You must have a face-to-face examination and a written prescription from a doctor or other
treating provider before Medicare helps pay for a power wheelchair.
X-rays Medicare covers medically necessary diagnostic X-rays that are ordered by your treating doctor. For more
information, see Diagnostic Tests.
Source: U.S. Department of Health & Human Services Centers for Medicare & Medicaid Services (2007). Your Medicare benefits. Retrieved
September 2, 2007 from http://www.medicare.gov/Publications/Pubs/pdf/10116.pdf.
of reimbursement for increasingly common chronic illnesses. From a

government perspective, providing increased Medicare coverage to a
growing population of older adults is problematic.
In an attempt to resolve some of these issues, numerous changes
and additions to the traditional Medicare plan have evolved, including
Medigap: a private (nongovernmental) health insurance that Medicare
recipients can purchase in order to help pay for expenditures not cov-
ered by Medicare (Hogstel, 2001). Some expenses covered by Medigap
include Medicare deductibles, co-pays (the additional amount of money
that the patient must pay the health care provider), health care outside
the United States, and medications. Currently, within Medigap, there are
10 standard plans that cover some of the essentials here, such as deduct-
ibles. However, each Medigap plan may also have additional benefits,
exclusions, premiums, and coverage (Hogstel, 2001).
Although many traditional Medicare recipients purchase a Medigap
policy, older Medicare patients sometimes cannot afford the monthly
premiums for these supplemental plans. Sorting through payment issues
associated with traditional Medicare and Medigap plans is often trou-
blesome for many older adults, especially those with limited education,
literacy, and experience in managing administrative matters. More-
over, older adults from multiple cultures may have language barriers
that make it more difficult to understand the complex Medicare and
Medigap systems.
Another attempt to improve Medicare coverage and lower health
care costs is Medicare Managed Care, which began as a strong move-
ment in the early 1990s to lower the administrative costs associated with
Medicare (Hogstel, 2001). Medicare recipients were asked to select a
health maintenance organization (HMO) through which to receive their
health care, and health care received through these HMOs would be paid
for by Medicare. Unfortunately for the HMOs, older adults used consid-
erably more health care services than Medicare reimbursements covered.
As a result, HMOs lost money and, by 2000, many had withdrawn from
the Medicare Managed Care business. While there are still HMOs servic-
ing older adults in the United States, many other HMOs no longer take
older adult Medicare clients.
The increase in health care costs between 1970 and 1980, resulted in
changes in legislation surrounding how hospitals received reimbursement
for Medicare patients. Before 1983, hospitals provided necessary care
to older adults, and then, with care completed, the hospital submitted
an invoice to Medicare, receiving payment for all Medicare-eligible
services rendered. After this time, a prospective payment system (PPS)
was implemented that calculated reimbursable costs based on the older
patient’s diagnosis and placed financial limits on the amount that could
be reimbursed to the hospital for the older adult’s stay (Hogstel, 2001).
This system, known as defined diagnostic related groups (DRGs), forced
hospitals to find more efficient ways to provide care to older adults. New
technology has greatly assisted this effort and has played a substantial
role in decreasing the hospital stays of older adults. Moreover, improve-
ments in outpatient rehabilitation, home care, and short-term stays in
skilled nursing facilities have provided alternatives to care that tradition-
ally could only be found in the hospital setting. To illustrate this, consider
an older adult patient admitted to the hospital with pneumonia. Prior to
the implementation of the PPS and DRG systems, the patient would have
remained in the hospital until complete healing and rehabilitation were
assured, as long as two weeks if necessary. Currently, this same client may
be treated at home with antibiotics or admitted for only a short period
of time if intravenous therapy and intensive respiratory therapy are indi-
cated. This change in health care delivery has some positive benefits for
patients, who often meet health care goals more effectively at home and
are free from the risks of hospitalization, such as nosocomial infections.
However, should a problem arise, the availability of geriatric-educated
nurses and physicians is much higher in the hospital setting than in these
alternative locations.
As mentioned, the need for hospitals to deliver care more efficiently
in response to the implementation of the PPS and DRG systems resulted
in shorter hospital stays. Despite this movement, older adults continue
to require care that is often delivered at home. As a result of these
changes in the late 1980s and well into the 1990s, home care expe-
rienced tremendous growth. With an average of 95% of older adults
living at home, and each with approximately three chronic illnesses, the
need for nursing care at home is substantial. However, while the num-
ber of home care agencies grew greatly, so did the amount of fraudu-
lent claims to the Medicare system (Hogstel, 2001). Offenders were
prosecuted, but the cost to the home care system resulted in the closing
Cultural Focus
Sorting through payment issues associated with traditional Medicare and

Medigap plans is often troublesome for many older adults, especially those
with limited education, literacy, and experience in managing administrative
matters. Moreover, older adults from multiple cultures may have language
barriers that make it more difficult to understand the complex Medicare
and Medigap systems. Awareness of these difficulties allows nurses to pro-
vide assistance in sorting out these complicated issues and ensuring access
to health care.
Eѣidence-Based Practice
Title of Study: The Impact of the 1997 Balanced Budget Amendment’s

Prospective Payment System on Patient Case Mix and Rehabilitation
Utilization in Skilled Nursing
Authors: Yip, J., Wilber K., Myrtle, R.
Purpose: To study the impact of the 1997 Balanced Budget Amendment’s
prospective payment system (PPS) and whether that impact varies in the
post-acute prospective payment system on Medicare-funded rehabilita-
tion services in skilled nursing facilities (SNFs).
Methods: Interviews of 214 Medicare beneficiaries admitted to 3 SNFs in
southern California. Comparisons were made between patients’ admis-
sion characteristics and therapy utilization among those receiving post-
acute rehabilitation before and after the implementation of PPS.
Findings: Those admitted after PPS implementations were more likely to
have orthopedic problems, stroke, or poorer self-reported health. Their
rehabilitation stay was shorter, and they received less therapy. Those in
managed care had less reduction in treatment after SNF-PPS implemen-
tation than those in fee-for-service.
Implications: In this study, following SNF-PPS implementation, rehabilita-
tion treatment levels were reduced. Changes in Medicare managed care
were comparatively modest, whereas there were significant changes in
intensity and duration of physical and occupational therapies in Medi-
care fee-for-service.
of almost half of the home care agencies and a more highly regulated
system of reimbursement. Hogstel (2001) reports that no new home
health agencies were allowed to open and those remaining continued
to operate under strict regulations. The closure and merger of many
home health care agencies created a shortage of services and providers
for home-bound elderly.
It is important to note that this change in Medicare payment to hos-
pitals was the impetus for private health care insurance programs to insti-
tute a PPS system as well. Consequently, it is not only the elderly who
are discharged sicker and quicker, but children, new mothers and infants,
and other members of the population are also discharged sooner than
they would have been previously. Hospitals also made a change in staff-
ing patterns and attempted to replace nurses with unlicensed assistive
personnel (UAP) as a means to remain viable in a declining reimburse-
ment environment. This change caused great concern about the quality of
care in hospitals. While there are certainly positive aspects of this change
in health care delivery, such as the ability to meet health care goals more
effectively at home and the ability to remain free from the risks of hos-
pitalization, such as nosocomial infections, should a problem arise, the
need to transport to a facility with appropriate resources may be neces-
sary, and the delay in accessing these services could increase both mor-
bidity and mortality. This raises additional concerns for older adults who
may be discharged home with no one to care for them in the immediate
postoperative period.
In further attempts to repair the problems inherent in the Medicare
system, three newer alternatives have evolved as alternative options in
addition to the traditional Medicare plan. Medicare now offers (a) pre-
ferred provider organization plans (PPOs), (b) private fee-for-service
plans, and (c) specialty plans. PPOs provide discounts to older adults
who choose primary care providers and specialists who have agreed to
accept Medicare assignment for patients. This saves Medicare money and
provides older adults with an alternative health care provider based on
costs. For example, an older adult may have had a relationship with a
particular physician who chooses not to accept Medicare assignment. In
this case, the older adult can still maintain the physician as their primary
health care provider, but they must pay extra for visits to this physician.
Medicare fee-for-service plans contract with private providers to allow
older adults to go to any Medicare-approved doctor or hospital that is
willing to take them. Benefits of these plans are often improved cover-
age, such as extra hospital days. However, providers must work with
private insurance plans directly to determine coverage for the health care
expenditures. Moreover, an additional premium may be involved, and
there may be additional costs, such as higher co-pays. In addition, private
insurance companies may choose to terminate coverage at the end of each
year. Medicare is currently in the process of developing a variety of spe-
cialty plans to meet the diverse and comprehensive needs of older adults.
More information on these plans will be available as they develop.
Medicaid
Medicaid is another national health insurance program to improve health
care for low-income citizens of the United States, including older adults
(Hogstel, 2001). However, while Medicare is regulated and administered
by the federal government, Medicaid is administered by individual states.
Consequently, the coverage is variable according to state regulations and
coverages. Medicaid also has expanded coverage to include children and
adults younger than 65 regardless of health status. Medicaid eligibility is
based on specific income and asset guidelines established by individual
states. Older adults who are attempting to qualify for Medicaid generally
have very limited financial resources and assets (Hogstel, 2001). For older
adults with limited assets and income, Medicaid may supplement current
Medicare benefits and pay for health care expenses not covered by Medi-
care, including medications, extended hospital or nursing home stays, and
durable medical equipment. For older adults with both Medicare and Med-
icaid coverage, Medicare is the primary payment system, and Medicaid is
secondary. The Centers for Medicare and Medicaid Services (2005) estimates
that approximately 6.5 million Medicare recipients also have Medicaid.
Medicaid was enacted in 1965 by the same legislation as Medicare
and is also known as Title XIX of the Social Security Act. Unlike Medi-
care, which is funded and administered through the federal government,
Medicaid is a joint partnership between federal and state governments
aimed at assisting states to provide medical assistance to low income
individuals. The Centers for Medicare and Medicaid Services (2005)
reports that Medicaid is currently the greatest source of funding for
health-related services for America’s poor population.
While changes and revisions have resulted within Medicare since
its inception, many changes have also occurred within the Medicaid sys-
tems. However, because Medicaid is jointly funded by each individual
state, there is great variability in covered medical expenses throughout the
country. Each state establishes eligibility guidelines, allowable expenses,
how much will be paid for these expenses, and how the program will be
run within that state. Thus, there are as many different Medicaid pro-
grams as there are states. Because of the variability in guidelines, an older
adult could be eligible for Medicaid in one state and not another. In addi-
tion, an older adult may have a particular medical expense paid for under
one state’s Medicaid plan and find that it is not an allowable health care
expense in another. To further complicate the variability in Medicaid,
state governments have the authority to change Medicaid eligibility and
guidelines to meet annual state budget requirements. This means that
while an older adult may be eligible one year, they may be ineligible the
following year; or a particular procedure or expense may be covered one
year, but may not be covered the following year.
To receive the federal portion of funds within Medicaid, states are
required to include in the program individuals who receive certain federal
assistance programs. Generally speaking, eligibility for Medicaid is based
on low income federal funds. Eligibility for Medicare does not make a
person eligible for Medicaid. However, if the older adult receives Supple-
mental Security Income (SSI) from the federal government, they are eli-
gible for Medicaid assistance as well. While states are not mandated to
cover other low-income population groups, many cover institutionalized
elderly within a certain income level set by the state and disabled older
adults under the federal poverty line (FPL).
Many state Medicaid programs have also extended coverage for home-
and community-based services (HCBS), if these services are keeping the
older adult out of a covered nursing home stay. These services fall within a
newer Medicaid program known as Program of All-inclusive Care for the
Elderly (PACE). This program provides alternatives to nursing home care for
persons aged 55 or older who require a nursing facility level of care. Within
this program a coordinator plans medical, social service, rehabilitative, and
supportive services with the specific aim of preventing costly nursing home
admissions. The services within the PACE program are often received at
home, but they may also consist of collaborations with adult day care and
clinic providers. In addition to these groups, many state Medicaid plans also
have broad language that allows coverage to medically needy (MN) individ-
uals, although they do not fall into one of the traditionally covered groups.
In these cases, older adults may have income or assets that exceed the eligibil-
ity guidelines within the state, but cannot afford costly health care.
As stated earlier in this text, legislation enacted in 1996, known as
the Personal Responsibility and Work Opportunity Reconciliation Act or
(Public Law 104–193) “welfare reform” bill, made legal resident aliens
and other qualified aliens who entered the United States on or after that
period ineligible for Medicaid for 5 years. Whether or not older adult
aliens entering before 1996 or after the 5-year ban are eligible for Med-
icaid is decided by individual states. This means that many older adult
immigrants to the United States may not have any available form of pay-
ment for health care expenses.
While allowable medical expenses within Medicaid varies by state,
the federal government mandates that certain medical expenses are cov-
ered within all state Medicaid plans. Mandated covered expenses for older
adults include inpatient and outpatient hospital services, physician services,
nursing home services and home care services that are delivered to prevent
nursing home stays, and laboratory and X-ray services. Coverage of other
medical expenses, such as various diagnostic procedures, durable medical
equipment, medications, eyeglasses, and hearing aides, vary by state.
Cultural Focus
Legal resident aliens and other qualified aliens who entered the United
States in or after 1996 are ineligible for Medicaid for 5 years. Whether
or not older adult aliens entering before 1996 or after the 5-year ban are
eligible for Medicaid is decided by individual states. This means that many
older adult immigrants to the United States may not have any available
form of payment for health care expenses.
If an older adult is a Medicaid recipient, payment for health care

expenses is provided directly to the health care provider. States have a
great deal of flexibility in the amount of reimbursement for health care
costs and how health care is delivered. Some states pay individual provid-
ers for services, while others require Medicaid recipients to receive care
through health maintenance organizations (HMOs). Individual health
care providers who accept Medicaid patients must accept Medicaid pay-
ment as payment in full. In other words, regardless of the charge, the pro-
vider may not ask the Medicaid recipient to pay any part of the medical
bill. However, individual states may require some Medicaid recipients to
pay deductibles or co-payments for some health care services.
While Medicaid is used by all population groups in each state, the
highest expenditures are made on behalf of older adults. While children
average approximately $1,200 a year in Medicaid expenditure, older
adults, who make up only 9% of Medicaid recipients, average approxi-
mately $11,000 per person in annual Medicaid expenditures. Moreover,
Medicaid payment for long-term care services utilized by primarily older
adults was approximately $37.2 billion in 2001 (Centers for Medicare
and Medicaid Services, 2005).
Medicaid has more enhanced coverage and fewer limitations than
Medicare. Medicaid covers long-term care and some prescription medi-
cations, dental care, and eye care that Medicare does not cover. One of
the most utilized Medicaid benefits for older adults is the coverage of
long-term care in nursing facilities, which Medicare provides only for
rehabilitative days (Hogstel, 2001).
Private Pay, or Fee for Service

In private pay, or fee for service, older people pay out of pocket for any
health care services not covered by Medicare, Medicaid, long-term care,
private insurances, or veteran’s benefits. Some of the types of care not usu-
ally covered include: deductibles and co-pays for physicians, hospital vis-
its, and prescription medication; cosmetic and/or experimental surgery and
procedures; private duty nurses and home health aides; and nonmedical in-
home assistance, such as home makers, companions, and chore services.
Veteran’s Benefits
The Veteran’s Administration (VA) is a government entity that provides
health care for veterans (military personnel who fought during a war).
VA health care is provided through VA medical centers and facilities
located throughout the country. Eligibility for VA health care is deter-
mined through a network of VA health facilities and hospitals across the
United States. Once eligibility has been determined, qualified veterans

may receive health care for low, or no, cost.
Eligibility for VA health care coverage or the amount of coverage
the veteran is entitled to will depend on several factors. Most active
duty military personnel who served in the Army, Navy, Air Force,
Marines, or Coast Guard and were honorably discharged are eligi-
ble for VA health care coverage. In addition, military reservists and
National Guard members who served on active duty on order from the
federal government may also be eligible for some VA health services.
Eligibility for health care coverage is not limited to those who served
in combat.
The Veterans’ Health Care Eligibility Reform Act of 1996 was
developed to clarify eligibility for VA health care coverage and improve
health benefits for qualified beneficiaries. The legislative act resulted in
the development of the current Uniform Benefits package, which is the
standard enhanced health benefits plan generally available to all available
veterans.
Once eligibility has been approved, VA health coverage under
the Uniform Benefits package is comprehensive and provides for both
inpatient and outpatient coverage at VA medical centers and facilities
nationwide and abroad. Outpatient clinics provide physician services
and primary and preventive care. Diagnostic testing (including labora-
tory tests), minor surgery, and other needed benefits, such as prescription
medications, are covered for a small monetary fee for eligible patients
(Hogstel, 2001). In addition, the VA will pay for hearing aides and other
services after a small deductible has been met. Pharmaceutical coverage
is provided even if the prescriptions were written by an outside health
care provider. VA coverage improves for veterans with service-connected
health problems (Hogstel, 2001).
Long-Term Care Insurance

Long-term care insurance is a more recent concept designed to meet
the needs of the growing elderly population (Hogstel, 2001). Medicare
pays only for acute care needs of the older adults, and Medicaid cover-
age is available to only those with low income and virtually no assets
(such as a house). Alexander (2005) states that the possibility of older
adults requiring long-term care at some point in their lives is approxi-
mately 50%. Thus, middle-income members of the older population
requiring long-term care are not able to utilize Medicare or Medicaid
to pay for extended nursing home stays. With an average stay of 2 to
4 years and an average cost of $70,000 per year, older adults cannot
afford to pay out of pocket for nursing home stays. Consequently an
illness that results in a nursing home stay has the potential to bankrupt
most middle-income older adults.
Long-term care insurance was developed by private insurance
companies to meet the long-term and chronic needs of older adults. Long-
term care insurance was designed to pay for long-term health services
when multiple chronic health problems occur that require custodial care
not covered by Medicare or other insurance. There are many advantages
to owning a long-term care insurance policy. But, while insurance com-
panies that offer long-term care policies are usually very ethical, they are
essentially businesses with an interest in profit. In other words, while long-
term care insurance may legitimately and appropriately meet the needs of
older adults who purchase it, it is often very costly. The older the adult
is when the policy is purchased, the more expensive the policy. Monthly
premiums vary depending on age at the time of policy purchase, the antici-
pated length of coverage, waiting period, and the desired amount of daily
payments for health care expenses (Hogstel, 2001). Moreover, premiums
are often not fixed and may increase throughout the coverage period. In
some cases, the premium may rise so high that older adults are no longer
able to afford to pay. This may result in policy cancellation and loss of all
previous monthly premiums, just when the policy benefits are needed to
cover long-term nursing home, assisted-living, or home care services.
Long-term care insurance generally provides coverage for approved
care in nursing and assisted-living facilities, in addition to care in the
home by health care providers and community-based services, such as
care at adult day care centers. As the policies vary greatly, some services
within these facilities may not be covered. Alexander (2005) reports that
the coverage is needed the most when the older adult is least able to advo-
cate for coverage, often because of illness.
Long-term care insurance is a useful insurance alternative or addition
for middle-income older adults who do not qualify for Medicaid but have
insufficient resources for extensive long-term care stays (Hogstel, 2001).
Older individuals considering long-term care insurance should be encour-
aged to shop around for reputable plans that provide the anticipated policy
benefits and terms. Hogstel (2001) reports that the younger an individual
is when the plan is purchased, the lower the monthly premium.
The emergence of long-term care insurance is a new option for the
payment of health care expenses among the elderly. Because it has only
been available for the past 5 years or so, most of the current cohort of the
older adult population would be charged high premiums for coverage.
Thus, long-term care insurance is currently a rarely used method of pay-
ing for long-term health care needs among today’s older adults. However,
as baby boomers begin to consider their retirement years and plan for the
future, the ability to purchase long-term care insurance and utilize it for
payment of future health care expenses will increase. In the next decade,
society will likely see a vast change within the health care delivery system
and the reimbursement for health care as a result of the population of
baby boomers reaching the age of 65.
As discussed earlier in this chapter, health care costs have risen
sharply over the past several decades. When older adults have to pay
out of pocket for medical expenses, they often must use funds set aside
for food, rent, or other expenses of daily living. Consequently, paying
privately for health care presents a great barrier to achieving health out-
comes. Inability to pay out of pocket for expensive medications and treat-
ments plays a significant role in medical noncompliance or nonadherence.
As health care professionals, it is extremely important to be aware of the
ability of the older adult to access the recommended diagnostic test or
treatment before they are sent home from the hospital, health care office,
facility, or home care agency.
Many older adults are not able to access needed health care and
remain part of an underserved population.
PAYMENT OPTIONS FOR OLDER ADULTS WITHOUT

RESOURCES FOR HEALTH CARE
There are many reimbursement options for older adults in the United
States. However, they are not all-encompassing or available to all who
need them. If older adults did not pay into the Medicare system through-
out their lives, either because of their employment or immigrant sta-
tus, they are not eligible for Medicare unless they specifically pay for
it. Even those who receive Medicare are left with co-pays for physician,
clinic, and hospital visits, and they still have medications to pay for.
While Medicaid is a fairly comprehensive payment system option for
low-income older adults, it is not an option available to middle or higher
income older adults who may have some funds to support themselves
but not enough to finance their increasingly complex and costly health
care.
Regardless of the reason, there are many older adults who need
financial assistance to pay for health care. Often hospitals have programs
to help older adults finance their health care over a period of months, or
to excuse the older adult from paying, if they legitimately cannot afford
to do so. Physicians and other health care providers may offer the same
payment alternatives for services received at private physicians’ offices. In
addition, physicians in private practice may also have samples of medica-
tions to distribute to low-income older adults. Clinics often have sliding
scales to make health care within these facilities more affordable. There
are also various state-run programs that have resources for financing or
finding affordable health care for older adults.
As part of Title III of the Older American’s Act (OAA) of 1965,
increased focus was directed toward public and private health care
systems to provide improved access to services and advocacy for older
adults. Within this program are improved community services, such as
home-delivered meals, transportation, home health care, and home-
making assistance; adult day care; home repair; and legal assistance,
which allows many older adults to remain functionally independent and
community-dwelling. These programs are administered within local Area
Agencies on Aging (AAA), which are located within each state. AAAs pro-
vide older adults and health care providers with a tremendous resource
with which to access and afford health care. To locate the AAA within
each state, use the “links” tab located at http://www.n4a.org/. In addition
to this Web resource, the administration on aging offers a toll-free Elder-
care Locator telephone number, 1-800-677-1116, designed to help older
adults, families, and health care providers obtain necessary community
services throughout the United States. In addition to AAAs, senior service
offices within hospitals are good sources of information about hospital
and community-based resources.
SUMMARY
The last several decades have seen enormous changes in the health
care delivery system. As people continue to age, they tend to develop
more health problems, requiring greater use of this health care system
in turmoil. Medicare, the primary health insurance of older adults, has
undergone a particularly large number of revisions in an attempt to
lower the costs of this federally funded program. Medicaid and veteran’s
benefits are also available options for health care reimbursement. These
programs, too, have undergone revisions that affect the care of older
adults, and long-term care has assumed an important role in the health
care delivery system.
As the population continues to age, it is likely to require further
revisions in these systems. Nurses caring for older adults need to be
aware of these revisions and advocate for the best care for older adults.
However, nurses also have a duty to be respectful of the cost of this care
for both clients and the larger systems that fund the care. Finally, it is the
nurse’s role to help older adults find assistance to access health care that
is affordable so they can effectively manage health care problems.
REFERENCES
Alexander, R. (Ed). (2005). Avoiding fraud when buying long-term care insurance: A guide
for consumers and their families. Retrieved May 14, 2005 from http://consumerlaw
page.com/article/insure.shtml#intro.
Centers for Medicare and Medicaid Services. (2005). Medicaid: A brief overview. Retrieved
May 12, 2005 from http://www.cms.hhs.gov/publications/overview-medicare-medic
aid/default4.asp
Federal Interagency Forum on Age-Related Statistics. (2004). Older Americans 2004: Key
indicators of well being. Washington, DC: U.S. Government Printing Office.
Thomson Learning.
Kane, R. L. (2002). The future history of geriatrics: Geriatrics at the crossroads. Journal of
Gerontology: Medical Sciences, 57A, M803–M805.
Pew Research Center. (2006). Working after retirement: The gap between expectations
and reality. Retrieved July 12, 2007, from http://pewresearch.org/assets/social/pdf/
retirement.pdf
Pick a card—any card?: Helping patients understand the new Medicare-approved drug
discount cards. (2004). American Journal of Nursing, 104(7), 24–26.
Rosenkoetter, M. (2000). Retirement. In J. Fitzpatrick, T. Fulmer, M. Wallace, & E. Fla-
herty (Eds.), Geriatric nursing research digest (pp. 34–37). New York: Springer-
Vertag, Inc.
Stotts, N., & Dietrich, C. (2004). The challenge to come: The care of older adults. Ameri-
can Journal of Nursing, 104(8), 40–48.
C H A P T E R T H R E E
Normal Changes
of Aging
Learning Objectives
1. Identify normal physiological changes common in each aging
body system.
2. Discuss nursing interventions to compensate for normal aging
changes.
3. Identify the prevalence, risk factors, and treatment options asso-
ciated with constipation.
4. Identify the prevalence and risk factors associated with urinary
incontinence.
Mr. Alexander is a 70-year-old married man who comes to your clinic

requesting information on sexual dysfunction. On questioning him
further he tells you that his sexual functioning has declined over the past
10 years. He states that he can no longer maintain an erection, and gen-
erally he has a hard time even achieving one. He had spoken with his
doctor about Viagra, but was told that it interacted with “some heart
pill” that he is already taking. When you ask him how his relationship
with his wife has changed over the years he states that they are still very
happy together but that they both miss being intimate. He then states, “I
hate disappointing her, but I guess it’s just a part of getting old. I wish
there was something I could do.”
The story of Mr. Alexander is typical of today’s older adult. As older

adults continue to age, each body system undergoes changes. The changes
occur in response to exposure to environmental injury, illness, genetics,
stress, and many other factors. The changes are sometimes noticeable,
such as gray hair, wrinkled skin, and stooped posture. However, there
75
are also many unnoticeable changes within the aging body that are quite
undetectable to the naked eye. These changes may not become evident
until the older adult undergoes a physical examination with appropriate
diagnostic testing.
Normal changes of aging are sometimes considered to be inevi-
table and irreversible. However, there is a great deal of variability in
these age-related changes. Just because an individual is advancing in
years, it cannot be assumed that they will undergo specific changes. For
example, while many older adults have wrinkled skin and gray hair,
there are many others with unlined skin and blond, dark, or red hair;
some older adults have stooped posture, others have perfect posture.
Individual aging is influenced by many factors that are both preventable
and reversible.
Cultural backgrounds also play an important role in how a person
ages. For example, people with darker skin may possess more natural
protection against the sun and, thus, may wrinkle less than those with
lighter skin. It is generally agreed that biological aging changes begin
to appear commonly in the third decade of life, with subsequent linear
decline until death. Therefore, it is important for nurses to refrain from
making assumptions about normal aging.
Differentiating normal changes of aging from pathological aging
changes is an important part of health care for older adults. It is also
of critical importance for nurses to understand the normal physiologi-
cal changes associated with aging. In so doing, nurses will be able to
differentiate these physiological changes from abnormal or pathological
organ system changes. Consequently, nurses will be able to avoid mis-
interpreting age-related changes as those caused by disease, which can
lead to costly, uncomfortable, and time-consuming therapeutic attempts
to reverse normal aging. This error may then result in iatrogenesis or an
untoward event while receiving care. For example, consider an 89-year-
old woman newly admitted to an assisted-living facility. The admitting
nurse notices a red ring around the iris of her eye and refers her to an
ophthalmologist for follow-up care. She must pay for a van service to
bring her to the ophthalmologist and attends the appointment only to
have an adverse effect to the medication given to dilate her pupils for
examination. Instead of returning to the facility, she is admitted to the
hospital, where she falls out of bed and sustains a hip fracture requiring
6 weeks of rehabilitation. All of this could have been avoided if the nurse
had recognized the ring around the eye as arcus senilus, a normal change
of aging with no related visual effects.
Conversely, the incorrect assumption that changes induced by dis-
ease are age-related leads to therapeutic neglect of potentially or possibly
treatable conditions. Consider a 75-year-old man who has gradually been
Cultural backgrounds also play an important role in how a person ages.

For example, people with darker skin may possess more natural protection
against the sun and thus may wrinkle less than older adults with lighter
skin. It is generally agreed that biological aging changes begin to appear
commonly in the third decade of life, with subsequent linear decline until
death. Therefore, it is important for nurses to refrain from making assump-
tions about normal aging.
having greater problems with his memory over the past year. His wife
frequently notices that he loses track of things, is unable to find the right
words to express his thoughts, and forgets things that happened within
an hour of their occurrence. Some may assume that it is normal for older
people to experience forgetfulness as described here. However, these
symptoms are not normal changes of aging, but signs and symptoms of
early cognitive impairment. Failure to diagnose and treat this cognitive
problem will result in heightened progression of disease as well as risk for
other problems with health and functioning.
Health care may be delivered in a more efficient and effective man-
ner if health professionals can recognize and prioritize which problems
will benefit from intervention and which will not. Great variability
occurs within the aging process, therefore, nurses cannot assume that
older adults will exhibit specific changes of aging. While the two exam-
ples given previously may seem outrageous, the inability to differentiate
normal aging changes from pathological aging changes occurs every-
day and has similar complications for older adults’ health. This chapter
addresses the naturally occurring changes in each body system of older
adults. These changes are summarized in Table 3.1. The chapter begins
with changes in the cardiovascular system and the nursing interventions
used to compensate for these changes.
CARDIOVASCULAR SYSTEM
As part of the normal aging process, several anatomical and functional

changes occur within the geriatric cardiovascular system. One major
change is that the geriatric heart becomes larger and occupies a greater
amount of space within the chest. Unfortunately, this is often a symptom of
pathological cardiac diseases, such as cardiomyopathy. Consequently, an
individual whose heart size has increased may require a more comprehensive
TABLE 3.1 Normal Changes of Aging and Nursing Interventions
System Normal Aging Changes Nursing Interventions
Cardiovascular System • Heart becomes larger and occupies a • Can be cardiomyopathy, so refer for
greater amount of space within the chest. diagnostic tests.
• Reduction in the amount of functional muscle mass of • Inform patient that exercise can ulti-
heart. mately reduce the strain on the heart.
• Decreased amount of blood that is pumped throughout • Heart murmurs require further tests to
the circulatory system. determine its effect.
• More adventitious S4 heart sounds. • Fatigue, SOB, DOE, dizziness, chest
78
• Premature contractions and arrhythmias. pain, headache, sudden weight gain, or
• Blood flow is slower changes in cognitive function or cogni-
(wounds heal slower and impacts medication metabolism tion requires full assessment.
and distribution). • Know that the time of effectiveness may
• Low diastolic pressure. take longer when giving meds.
• Increased pulse pressure. • Inform patient that low diastolic pres-
sure is a risk for cerebrovascular ac-
cidents or strokes.
• Inform patient that exercise lowers
blood pressure.
Peripheral Vascular • Increase in the peripheral vascular resistance (blood has a • Inform patient that age, diet, genetics,
System hard time returning to the heart and lungs). and lack of exercise can transform non-
• Valves in the veins don’t function efficiently and form (nonpathological to pathological (atheroscle-
pathological) edema. rosis and arteriosclerosis), which can
result in CVD.
• Monitor older adults’ cholesterol levels
with lowering agents to prevent athero-
sclerosis and arteriosclerosis.
• Inform patient that exercise results in
lower cholesterol levels.
• Discuss the right medication, exercise
program, and diet for the patient as a
means to slow the progression of cardiac
changes.
Respiratory System • Decreased vital respiratory capacity. • Note that auscultating sounds is difficult
79
• Lungs lose elasticity. so it must be done on all lung fields in a
• Loss of water and calcium in bones causes the thoracic cage quiet environment.
to stiffen. • Inform that pollution and smoking
• Decreased amount of cilia lining system. worsens the cilia (try to help stop smok-
• Decreased cough reflex. ing by recommending behavioral man-
agement classes, support groups/nicotine
replacement therapies, antidepression
medications).
• Tell patients that they are at risk for
choking.
• Make sure patient’s respiratory function
is frequently assessed.
• Encourage regular exercise.
(continued)
TABLE 3.1 Normal Changes of Aging and Nursing Interventions (Continued)
Integumentary System • Skin becomes thinner and more fragile. • Promote the use of sun block and tell
• Skin is dry and loses elasticity (wrinkles). patient to avoid overexposure.
• Sweat glands lessen, which leads to less perspiration. • Avoid the use of soaps that dry skin and
• Subcutaneous fat and muscular layers begin to diminish; use a lotion after baths.
less padding, more easily bruised. • Protect high-risk areas such as elbows
• Dryness. and heels with padding.
• Skin tears. • Refer to a podiatrist.
• Fingernails and toenails become thick and brittle. • Help older adult maintain personal
• Hair becomes gray, fine, and thin. appearance.
• Facial hair on women.
• Decreased body hair on men and women.
Gastrointestinal • Inflamed gums. • Assess older adult’s ability to chew.
80
System • Periodontal disease. • Refer older adult for further oral evalua-
• Sensitive teeth. tion if necessary.
• Tooth loss. • Assist older adults in making changes
• Decreased peristalsis of esophagus. with their eating habits.
• Decreased gut motility, gastric acid production, and absorp- • Assess nutritional health frequently.
tion of nutrients. • Encourage older adult to drink water
• Difficulty evaluating wastes (constipation). (1.5 L).
• Involuntary leakage of liquid stool (fecal incontinence). • Add bulk and fiber to diet.
• Promote exercise.
• Enemas and laxative medications may
be given in severe situations.
• Diets high in fiber and bulk, adequate
fluids, and exercise.
• Bowel habit training (for cognitively
impaired).
• In severe cases, surgery may be appropriate.
Urinary System • Kidneys experience a loss of nephrons and glomeruli. • Assess urinary incontinence.
• Bladder tone and volume capacity decreases. • Kegel exercises.
• Incontinence (not a normal change, but occurs in response). • Voiding schedules (for cognitively
impaired).
Musculoskeletal • Decrease in total muscle and bone mass. • Encourage older adult to exercise
System • Muscle units that combine to form muscle groups diminish. regularly.
Sexual/Reproductive • Decrease in testosterone in men, and estrogen, progester- • Help older adult feel comfortable when
System one, and androgen in women. discussing sexuality.
Women: • Give vaginal lubricants to females.
• Follicular depletion in the ovaries. • Inform men to increase the time between
81
• Natural breast tissue is replaced by fatty tissue. erections.
• Labia shrinks. • Discuss use of oral erective agents.
• Decrease in vaginal lubrications and shortening and nar-
rowing of the vagina.
• Strength of orgasmic contraction diminishes, and orgasmic
phase is decreased.
Men:
• Increased length of time needed for erections and
ejaculation.
(continued)
TABLE 3.1 Normal Changes of Aging and Nursing Interventions (Continued)
Senses Eyes • Make sure older adult has a baseline eye

• Visual acuity declines. assessment early in older adulthood and
• Ability of pupil to constrict in response to stimuli decreases. follow up eye exams yearly.
• Peripheral vision declines. • Help older adult remove cerumen.
• Lens of the eye often becomes yellow. • Obtain a thorough history of taste and
• Arcus senilus. smell sensations and a physical examina-
82
Ears tion of the nose and mouth.
• Increased amount of hard cerumen. • Obtain a thorough diet history.
Taste and smell
• 30% of taste buds diminish.
Neurological System • Total brain weight decreases. • Help older adult maintain an active
• Shift in the proportion of gray matter to white matter. body and mind.
• Loss of neurons. • Encourage older adults to participate in
• Increase in the number of senile plaques. cognitive activities.
• Blood flow to the cerebrum decreases.
cardiovascular assessment in order to differentiate normal from patho-

logical cardiac changes.
A larger heart may lead students to equate size with function, how-
ever, this is not the case. Despite the increased size of the geriatric heart,
there is a total reduction in the amount of functional muscle mass within
the myocardium. In addition, the force of each heart contraction dimin-
ishes, which decreases the amount of blood that is pumped through the
circulatory system. Moreover, the valves that control the flow of blood
within the chambers of the heart and between the heart and lungs to the
circulatory system become stiffer with calcification, or calcium deposits.
This stiffness often prevents the full closure of these valves, resulting in
both nonpathological and pathological heart murmurs. The adventitious
S4 heart sound is often heard more commonly in older adults than in a
younger population as a result of these anatomical heart changes. Heart
murmurs among older adults often require further evaluation to deter-
mine the effect of the murmur on overall cardiovascular function.
The complex system of electrical impulses that controls the beat-
ing of the heart is also often affected by the normal anatomical changes
in this critical organ system. Consequently, premature contractions and
arrhythmias are auscultated more frequently among older adults than
in the younger population. These arrhythmias are often not pathologi-
cal in nature. An occasional missed heart beat or other disruption in
heart rhythm that is not accompanied by fatigue, shortness of breath
(SOB), dyspnea on exertion (DOE), altered circulation, or chest pain may
not be cause for major concern. However, when accompanied by these
symptoms, arrhythmias require immediate attention. When altered heart
rates are detected among older adults, full assessment for the presence
of underlying symptoms and a cardiovascular work-up are necessary to
differentiate normal from pathological aging changes.
As a result of the decreased force of contraction and often the inef-
fective closing of cardiovascular valves, blood flow through the body is
slower. This may have several consequences for older adults. First, slower
circulation often results in slower healing of wounds. For example, an
older adult who sustains a skin tear to her lower leg may have the wound
in various stages of healing for several weeks in comparison to a young,
healthy child whose wound would be healed within a week. Slower cir-
culation also impacts the length of time it takes for medications to take
effect as a result of altered medication metabolism and distribution. This
is important to keep in mind when administering medications to older
adults and evaluating their effectiveness in treating disease symptoms.
As older adults continue to experience changes in the cardiovascular
system, it is not uncommon for some to experience very low diastolic
blood pressure. This occurs as the heart muscle weakens causing the
pressure of the heart at rest to become greatly reduced. This may occur
even in the presence of systolic hypertension and is known as isolated sys-
tolic hypertension (Hill, Tannenbaum, & Salman, 2005). Consequently,
an increased pulse pressure (the distance between the diastolic and sys-
tolic blood pressure values) is frequently seen among older adults. Lower
diastolic blood pressure values have recently been implicated as a risk
factor for cerebrovascular accidents or strokes.
In the peripheral vascular system, older adults have an increase in the
peripheral vascular resistance, which means that the blood in the periph-
eral parts of the body (fingers and toes) has greater difficulty returning
to the heart and lungs to be reoxygenated and recirculated. The valves in
the veins of the lower extremities also become incompetent, resulting in
nonpathological accumulation of fluid in the lower extremities (depen-
dent edema). These changes are often worsened by nonmodifiable and
modifiable risk factors for disease. As a result of genetics, diet, and other
factors, older adults also tend to have a higher risk of developing both
atherosclerosis and arteriosclerosis in the cardiac and peripheral arteries,
respectively.
There are several changes in the normal lab values of older adults.
For example, hemoglobin (Hg) and hematocrit (Hct), and erythrocyte
sedimentation rate (ESR, Sed rate), which are essential measures of oxy-
gen carrying red blood cell production, volume, and function, are slightly
decreased among older adults. Leukocytes, or white blood cells, which
are essential for immune function, are also slightly decreased among
older adults. Table 3.2 provides a list of laboratory values for the older
adult with age-related changes described. Knowledge and awareness of
the normal ranges of specific blood values for older adults will enhance
effective assessment and management of disease.
While these normal changes of the aging cardiovascular system
may seem to position all older adults as sick and weak, this is not the
case. It is important to remember that there is great variability in the
aging process, and while some may experience all these aging changes,
others may experience none. Moreover, there are several interventions
that nurses may recommend to older adults to slow the onset of these
normal changes of aging, such as diet, exercise, and when necessary,
medication. There have been many attempts to halt and reverse the
aging process, however, Fisher and Morley (2002) report that “While
the concept of anti-aging therapies is intriguing, there is clearly lit-
tle evidence-based medicine to support most of the generally touted
approaches” (p. M638).
The role of regular exercise in preventing normal changes in the
cardiac system and preventing cardiac disease cannot be emphasized
enough. There is overwhelming evidence that regular exercise results in
lower cholesterol levels, which will reduce athero- and arteriosclerosis.

Moreover, exercise has been shown to lower blood pressure and enhance
weight loss, which will greatly reduce the strain on heart musculature.
Despite these clearly obvious benefits of exercise, the majority of older
adults do not exercise. Reasons for the lack of exercise among older
adults lie in habit. Cultural beliefs surrounding exercise are important in
motivating older adults to participate in exercise programs. Reijneveld,
Westhoff, and Hopman-Rock (2003) report that understanding cultur-
ally specific exercise choices, are critical to removing exercise barriers
among culturally diverse clients. Environmental barriers (no safe place
to exercise) and the presence of normal changes of aging (such as muscle
aches and pains) are also significant barriers to exercise among older
adults.
It is usually cautioned that older adults should take their slower
cardiovascular status into consideration when exercising or engaging
in heavy labor. This may mean starting new regimens slowly until it is
determined how the body will react physiologically. Frequent assess-
ments of cardiovascular status are also recommended to detect patholog-
ical changes early, when they are more amenable to treatment. Because
the cardiovascular system is one of the most vital organ systems in the
body, effective functioning is critical. It is essential that nurses assess this
system continually for signs and symptoms of failure. Dizziness, chest
pain, SOB, DOE, headache, sudden weight gain, or changes in function
or cognition should alert the nurse to conduct further assessments for
pathological cardiac function.
Nurses are in an ideal role to teach the interventions necessary to
help older adults to participate in exercise programs. Interventions should
begin by discussing the benefits of exercise. The nurse may help older
adults to choose exercise programs that they will enjoy, and encourage
them to do so. Choosing the right exercises and encouragement are key
factors in motivating older adults to exercise. The ideal exercise program
will combine strength training, flexibility, and balance. One of the most
popular forms of exercise among older adults is walking. Walking is an
exercise that transcends care settings, requires little equipment (except
good shoes), and is accessible 24 hours a day. Other exercises that are
found to be popular among older adults include both weight-bearing and
aquatic exercises. Weight-bearing and muscle-building exercises assist in
maintaining functional mobility, promoting independence, and prevent-
ing falls. In addition, weight-bearing exercises have been shown to be very
effective in reducing bone-wasting related to osteoporosis (Swanenburg,
de Bruin, Stauffacher, Mulder & Uebelhart, 2007). Aquatic exercises are
a pain-free method of promoting health and increasing functional ability,
especially for older adults with arthritis and osteoporosis.
The role of diet in reducing the effects of aging on cardiovascular

function is substantial. Lifelong eating habits, such as a diet high in fat
and cholesterol, are among many obstacles that prevent optimal nutri-
tion and contribute to pathological cardiovascular function. Diets high
in fat and cholesterol are among the leading cause of coronary artery dis-
ease. Nutritional assessment is one of the first steps toward helping older
adults to meet daily nutritional requirements with a diet rich in health
TABLE 3.2 Common Laboratory Tests Used to Assess Older Adults

Test
Why Used
Cholesterol; total cholesterol (TC), high density lipoprotein (HDL), low density
lipoprotein (LDL)
Normal Ranges
TC <200 mg/dl
HDL >60 mg/dl
LDL <100 mg/dl
Tests the amount of circulating cholesterol levels. Good indicator for risk of
cardiovascular disease, as well as to manage medications to prevent hyper-
lipidemia.
Complete Blood Count (CBC); hemoglobin (Hg), Hematocrit (Hct), and white
blood cells (WBC).
Normal Ranges
Males
Hg 10–17 g/dl
Hct 38–54%
Females
Hg 9–17 g/dl
Hct 35–49%
WBC 4,300–10,800 cells/mm3
Tests for red blood cell (hg, hct, ESR) function and white blood cell function
(leukocytes) to determine ability of red blood cells to carry oxygen and white
blood cell role in infection.
Drug assays (e.g., digoxin, dilantin, phenytoin, theophyllin, lithium).
See individual tests for reference ranges
A collection of tests used to measure the level of certain medications within the
body. Helpful in managing medication dosing.
Glucose and Hemoglobin A1C (HgA1C)
Normal Ranges
Glucose (fasting) 70–105 mg/dl
HgA1C < 8%
Used to evaluate blood sugar levels and effectiveness of glucose management
medications on glucose function among older adults.
Iron (Fe)
(continued)
TABLE 3.2 (Continued)

Normal Ranges
Serum Iron 35–165 ug/L
Plays a role in hemoglobin and red blood cell function. Low iron is diagnostic
for iron-deficiency anemia.
International Normalized Ratio (INR)
Normal Ranges
INR 2–3
Tests bodies clotting ability. Often used to evaluate response to warfarin
therapy.
Kidney Function Tests (BUN) and Creatinine
Normal Ranges
Males
BUN 8–35 mg/dl
Serum CR 0.4–1.9 mg/dl
Females
BUN 6–30 mg/dl
Serum CR 0.4–1.9 mg/dl
Commonly used to evaluate kidney function among older adults.
Liver function tests (LFTs)
Used to evaluate normal and pathological liver functioning
Prostate Specific Antigen (PSA)
Normal Ranges
PSA < 4 ug/L
Used to detect early signs of pathological prostate activity, such as benign pros-
tatic hypertrophy (BPH), or prostate cancer.
Thyroid Function Tests (T3, T4, TSH)
Normal Ranges
T3 75–220 ng.dl
T4 4.5–11.2 ug/dl
TSH 0.4–4.2 uU/ml
As thyroid problems are prevalent among older adults, these tests are frequently
used to determine thyroid function.
Vitamin Assays
Tests for function of vitamins within the body, such as vitamin X. Vitamins play
an essential role in all bodily system functions.
food choices. Teaching appropriate food choices is essential to changing

nutritional patterns and improving poor dietary patterns among older
adults. Taking small steps toward good nutrition, by slowly replacing
unhealthy food choices with healthier alternatives, is the most appropri-
ate nursing intervention to help achieve nutritional outcomes.
Cultural Focus
Cultural beliefs surrounding exercise are important in motivating older

adults to participate in exercise programs. Lewis, Szabo, Weiner, McCall,
and Piterman (1997) report that understanding culturally specific exercise
choices, such as Tai Chi for the Indo-Chinese, are critical to removing exer-
cise barriers among culturally diverse clients.
RESPIRATORY SYSTEM
In addition to the cardiac system, older adults experience changes in their

respiratory system as well. Changes experienced in the respiratory system
include an overall decreased vital respiratory capacity, which means less
air is inspired and expired. In addition, older adults’ lungs tend to lose
elasticity as they age, making the lungs less flexible and further impairing
the ability to effectively inhale and exhale. Loss of water and calcium in
the bones also causes the thoracic cage to stiffen adding an even greater
force against effective respiration.
There is often a decreased amount of cilia lining in older adults’
respiratory systems. These hair-like structures play an important role in
alerting the older adult to foreign items in the respiratory system, such as
food. The decrease in cilia is worsened by the presence of smoking and
other environmental pollutants, which flatten the cilia to the respiratory
passageway, rendering it ineffective. Moreover, older adults may have a
decreased cough reflex as part of the normal changes of the neurological
system. The combination of loss of cilia and decreased cough reflex place
the older adult at high risk for choking, aspiration of food products, and
the development of pneumonia and other infectious respiratory diseases.
Despite these seemingly important anatomical changes of aging,
older adults without respiratory illnesses are able to breathe effectively.
However, these changes in the respiratory system place the older adult
at a higher risk for the development of disease. Consequently, frequent
assessment of respiratory function and efficient treatment of disease is
critical to maintaining respiratory health. It is important to note that
because of the changes in the thoracic cage, assessing lung sounds in this
population may be challenging. Listening to all lung fields directly on the
skin, in a quiet environment, is often necessary to detect minor changes in
respiratory sounds that could indicate pathological processes. Frequent
assessments of respiratory function are also recommended to detect
pathological changes early, at a more treatable stage. Nurses should
assess respiratory status regularly and be alert for SOB, DOE, or changes
in function or cognition that could alert the nurse to a developing respira-
tory pathological process, such as infection or tumor development.
The respiratory system is a critical organ system. While changes in

the respiratory system will vary among the older population, smoking
cessation and exercise are two important interventions that will help to
maintain respiratory health.
The benefits of exercise are numerous. Among older adults, regular
exercise programs help to increase vital capacity, prevent normal and
pathological changes of aging, and reverse the effects of smoking. As
stated earlier, many older adults do not participate in exercise programs,
despite their obvious benefits. Nurses can play an essential role in help-
ing older adults choose the right exercise and encourage regular exercise
participation. As with cardiovascular status, it is usually cautioned that
older adults should progress slowly when beginning a physically demand-
ing program.
Cigarette smoking is one of the most critical negative predictors of
longevity. Smoking is well-known as a risk factor for the development
of multiple respiratory diseases including chronic obstructive pulmonary
diseases, such as bronchitis, asthma, emphysema, and bronchiectasis, as
well as cancer of the lung (U.S. Department of Health and Human Ser-
vices, 2004). Today’s older adults are among the first individuals who
have potentially smoked throughout their entire adult lives. The effects
of smoking are silent and often occur slowly over time. Moreover, symp-
toms of lung disease are not often experienced until extensive damage
has occurred. Despite the many years older adults may have smoked, it is
possible for older adults to experience the benefits of smoking cessation.
It is also important to note that older adults may be more motivated to
quit smoking than their younger counterparts, because they are likely to
experience some of the damage that smoking has caused.
Nurses are in an ideal position to assist older adults to quit smok-
ing to promote health or while recovering from an acute illness or man-
aging chronic illnesses. Interventions to stop smoking usually surround
behavioral management classes and support groups, which are available
to community-dwelling older adults. Nicotine-replacement therapy and
anti-depression medications are also helpful in assisting the older adult
to quit smoking.
INTEGUMENTARY SYSTEM
The skin of older adults generally becomes thinner and more fragile as
they age. The decreased amount of subcutaneous tissue allows for less
water, and the skin becomes dry and loses its elasticity. Consequently,
small lines and wrinkles appear on the skin. The appearance of lines and
wrinkles is closely associated with the amount of sun exposure sustained
throughout older adult’s lives, especially the early years. In fact, the skin
that has not been exposed to the sun (i.e., skin on the underside of the
arm) may be quite free of lines and wrinkles and appear very youthful.
Nurses caring for older adults know that people enjoy the sun. More-
over, some sun is healthy. The sun produces vitamin D within the body,
which is necessary for calcium metabolism. However, overexposure to
the harmful rays of the sun can accelerate the normal aging changes and
place the older adult at high risk for the development of pathological skin
problems, such as cancer. Nursing interventions to reduce the effects of
sun exposure on the skin and prevent against disease onset include the use
of sun protection. It is presently recommended that older adults should
be counseled to use sun block and avoid over exposure to the sun.
In addition to the wrinkling of the skin, the number of sweat glands
diminishes as people age, leading to less perspiration among older adults.
The subcutaneous fat and muscular layers of the skin also begin to dimin-
ish. These changes have several common and noticeable effects. First,
these changes result in dryness of the skin, which often is uncomfortable
and can lead to skin tears. These skin tears occur under seemingly little
trauma and may be very difficult to heal. In addition, the loss of subcu-
taneous tissue beneath the skin of older adults results in less padding and
a higher rate of bruising with minimal trauma. The dryness of the skin,
in combination with decreased perspiration, leads to the need to bathe
less frequently. Nurses caring for older adults may recommend that older
adults and caregivers avoid the use of soaps that further dry the skin and
replace moisture lost during bathing with a recommended moisturizer.
Moreover, great care must be taken to prevent the skin from skin tears.
The use of clothing and protection of high risk areas, such as elbows and
heels, with appropriate padding, may be helpful in preventing skin tears.
Preventing older adults from falls and traumas is a substantial issue for
nurses caring for the elderly, and this will be discussed in greater detail
in Chapter 5. Changes in subcutaneous tissue, fat, and muscle among
older adults result in less protection against temperature extremes. Con-
sequently, older adults exposed to extreme heat or cold are at risk for
developing hyperthermia and hypothermia, respectively. Proper environ-
mental control and adequate hydration are essential to prevent these dev-
astating consequences of normal aging changes.
Through the normal aging process, fingernails and toenails become
thick and brittle, and thus, nail care may become more difficult for the
aging adult to accomplish independently. Changes in vision and pain per-
ception may further complicate the task of nail care. In some facilities
and care agencies, nurses may assist older adults with nail care. However,
it is generally recommended that older adults enter the care of a podia-
trist when normal and pathological aging changes make independent nail
care difficult. Nurses may play an instrumental role in detecting the need
Medicare will cover skilled care if all these conditions are met:
1. You have Medicare Part A (Hospital Insurance) and have days left in your benefit period to use.
2. You have a qualifying hospital stay. This means an inpatient hospital stay of three consecutive days or more,
including the day you’re admitted to the hospital, but not including the day you leave the hospital. You must
enter the SNF within a short time (generally 30 days) of leaving the hospital and require skilled services
related to your hospital stay (see item 5). After you leave the SNF, if you reenter the same or another SNF
within 30 days, you don’t need another three-day qualifying hospital stay to get additional SNF benefits.
This is also true if you stop getting skilled care while in the SNF and then start getting skilled care again
within 30 days.
3. Your doctor has decided that you need daily skilled care. It must be given by, or under the direct supervision
of, skilled nursing or rehabilitation staff. If you are in the SNF for skilled rehabilitation services only, your
care is considered daily care even if these therapy services are offered just five or six days a week, as long as
you need and get the therapy services each day they are offered.
4. You get these skilled services in a SNF that is certified by Medicare.
59
5. You need these skilled services for a medical condition that
• was treated during a qualifying three-day hospital stay, or
• started while you were getting care in the SNF for a medical condition that was treated during a qualify-
ing three-day hospital stay. For example, if you are in the SNF because you had a stroke, and you develop
an infection that requires I.V. antibiotics and you meet the conditions listed in items 1-4, Medicare will
cover skilled care.
Smoking Cessation Medicare covers minimal regular doctor’s office visits, and
(Counseling to up to 8 face-to-face visits in a 12-month period if you are diagnosed with an illness caused or complicated by
stop smoking) tobacco use, or you take a medicine that is affected by tobacco.
Speech-Language See Physical Therapy/Occupational Therapy/Speech-Language Pathology.
Pathology
Substance-Related Medicare covers treatment for substance-related disorders in inpatient or outpatient settings. Certain limits
Disorders apply.
(continued)
for external assistance with nail care and make an appropriate referral.
This is essential in order to maintain hygiene and prevent infections.
Another change in the older adult’s integumentary system occurs in
the hair. This is one of the most obvious effects of aging and among the
most feared. The hair of older adults may become gray, fine, and thin,
but there is great variation among change in hair patterns as people age.
Some older adults may experience the loss of hair, or alopecia, which may
or may not be hereditary. As a result of hormone shifts, the appearance of
facial hair may be seen among women, and decreased body hair generally
occurs with both sexes.
Because many of the changes older adults experience in the integu-
mentary system affect their appearance, it is important to consider the
effect of these changes on the self-concept and self-esteem of older adults.
As in youth, it is important to remember that older adults also take great
care in their personal appearance, including personal hygiene, hair, and
clothing. It is the role of nurses and other health care professionals to
recognize the importance of personal appearance and to help older adults
maintain and enhance their personal appearance. As older adults con-
tinue to populate society, it is likely that the appreciation of the beauty of
this population will continue to grow.
GASTROINTESTINAL SYSTEM
Older adults experience a great deal of change within the important gas-
trointestinal system, which starts at the mouth and ends at the rectum.
At the start of the system, older adults commonly experience problems
chewing and swallowing food. This often results from the lack of avail-
ability of fluorinated water in the early years as well as inadequate dental
care. It was not until the year 1945 that Grand Rapids, Michigan, became
the first city in the United States to fluoridate its drinking water. Fluorina-
tion of drinking water, which continues to be supported by the American
Dental Association, is done to prevent tooth decay by reducing the effects
of harmful bacteria in the water. Because most of today’s cohort of older
adults was already beyond their developmental years by this time, they did
not benefit from the presence of fluorination in the water. Consequently,
inflamed gums or periodontal disease is common among older adults.
Moreover, sensitive teeth and tooth loss is seen regularly among older
adults. Tooth and gum problems often prevent older adults from being
able to chew (masticate) food. This may lead to a decrease of food choices
and self-denial of soft food related to its poor taste or appearance. Nurses
must consistently assess client’s ability to chew food and refer clients with
assessed problems in this area for further oral evaluation.
Decreased peristalsis of the esophagus slows the passage of food

through the next stage of the alimentary canal, which often results in
the need for older adults to chew food longer and eat more slowly. In
teaching older adults about the normal changes of aging, it is impor-
tant to introduce these changes and encourage older adults to make
changes in their daily eating habits. Midway through the gastrointesti-
nal system, older adults may experience decreased gut motility, gastric
acid production, and absorption of nutrients. While these changes may
not be independently pathological, they put older adults at high risk for
the development of nutritional deficiencies. Frequent assessment of nutri-
tional health, using necessary laboratory and physical assessment instru-
ments, is helpful for nurses to determine the effect of these normal aging
changes on nutritional status.
There are several changes in the normal lab values related to gastro-
intestinal function. Total albumin levels, which are essential indicators of
both liver function and malnutrition among older adults, lessen with aging,
in direct relation to reduced liver size and function. In addition, the enzyme
alkaline phosphatase (ALP), which is a measure of liver function, increases
with age. A decrease in plasma calcium necessary for adequate bone pro-
duction and maintenance also occurs as part of the aging process. Serum
potassium, which is essential in helping nutrients cross cell membranes,
and serum glucose both increase among older adults. The increase in serum
glucose will be discussed in greater depth in Chapter 6 because of its role
in positioning older adults at higher risk for Type 2 diabetes. Table 3.2
provides a list of laboratory values for the older adult with age-related
changes described. Knowledge and awareness of the normal ranges of spe-
cific blood values for older adults will enhance effective assessment and
management of disease.
On the other end of the gastrointestinal system, decreased peristalsis
of the large intestine slows the passage of food through the next stage of
the alimentary canal and out of the body. The increased time when the
digestive mass is in the bowel allows for greater time for water absorption
resulting in a higher incidence of constipation among the older popula-
tion. The two major bowel elimination problems that occur in the elderly
are constipation and fecal incontinence. These problems are caused in
part by normal changes of aging, but also result from the use of multiple
medications, the intake of foods low in dietary fiber, and the lack of
physical activity among older adults.
Constipation
Constipation, defined as the abnormally delayed or infrequent passage of
accumulated, often dry, feces in the lower intestines, is the most common
complaint among older adults (Beers & Jones, 2000). Many nurses who
care for older adults find that older adults are often preoccupied with the
risk for, or presence of, constipation, which results in frequent requests
for medication. Annells and Koch (2002) report that laxatives are the
most commonly sought after treatment for constipation, with approxi-
mately one-third of older adults requesting weekly laxatives to reduce
constipation. Constipation is a substantial problem for older adults and
has extensive effects on functional health. Moreover, untreated consti-
pation may result in life-threatening effects. Constipation also requires
excessive nursing resources for effective management (Lagman, 2006).
In addition to normal aging changes, lack of physical activity is a
major contributor to constipation. Environmental changes that result
in less privacy also contribute to constipation. Nursing interventions to
minimize the risk of constipation include encouraging adequate fluids.
For older adults who are not severely ill, daily fluid intake should be
between 30 and 35 ml fluid/kg (National Collaborating Center for Acute
Care, 2006). Maintaining a diet with sufficient bulk, such as green leafy
vegetables and grains, is also helpful in reducing constipation. Exercise
has a quick and favorable effect on constipation. Moreover, dietary mod-
ifications, such as the increase of fiber and fluid, can stimulate the colon
and resolve constipation. Stool softener medications, enemas, and laxa-
tive medications may be used when constipation is severe.
Bowel Incontinence
Bowel incontinence is defined as an involuntary unexpected leakage of
liquid stool. It is estimated that approximately 45% of nursing home resi-
dents suffer from this condition (University of North Carolina Center for
Functional Gastrointestinal and Motility Disorders, 2006). Fecal inconti-
nence results in part from normal aging changes to the bowel. However,
there are other causes of bowel incontinence as well, including: (1) his-
tory of urinary incontinence, (2) neurological disease, (3) poor mobility,
(4) severe cognitive decline, and (5) age greater than 70. The University
of North Carolina Center for Functional Gastrointestinal and Motility
Disorders(2006) reports that fecal incontinence is associated with hem-
orrhoids, diarrhea, constipation, childbirth injuries, diabetes, ulcerative
colitis, and dementia. As with constipation, diets high in fiber and bulk,
adequate fluids, and exercise are helpful in preventing and treating bowel
incontinence. In cognitive-impaired older adults, bowel habit training
may be helpful. This may be accomplished by first determining times
throughout the day when older adults are most often incontinent. The
information for this may be gathered through examination of the bowel
diary. Once the pattern of incontinent episodes is determined, the older
adult may be encouraged and assisted to the toilet a half hour before the
usual time of incontinence in order to prevent the incontinent episode
from occurring. In severe cases of fecal incontinence, resulting from tears
in the anal sphincter, surgery may be an appropriate treatment.
URINARY SYSTEM
Changes in the urinary system occur frequently as people age. The kid-
neys, which are responsible for concentrating urine and filtering meta-
bolic products for elimination, experience a total loss of nephrons and
glomeruli as people age. In the older adult, the bladder tone and volume
capacity may decrease as well. This results in a high incidence of urinary
incontinence (UI), or involuntary loss of urine among older adults. Stud-
ies have shown that between 10% and 58% of women and 6% to 28%
of men experience daily incontinence (Gray, 2003).
There are several changes in the normal lab values of older adults
within the genitourinary system. For example, the blood urea nitrogen
(BUN) values, which are commonly used to measure kidney function,
are increased as a result of decreased renal function. BUN values among
older adults are heavily influenced by dietary protein intake. Because lean
body mass declines with age, the total production of creatinine increases,
while creatinine clearance declines by almost 10% per decade after age
40. These are essential indicators of kidney function among older adults.
Normal changes in lab values are summarized in Table 3.2.
Urinary Incontinence
Urinary incontinence (UI) is not a normal change of aging, but it occurs
frequently among the older population in response to normal aging
changes. Because of the stigma associated with this embarrassing disor-
der, it is not readily diagnosed. Gray (2003) reports that UI occurs in up
to 11% of community-dwelling older adults. There are many types of UI,
but the two most frequent types of UI in the older population are stress
and urge incontinence. Stress incontinence results when the strength of the
urethral sphincter decreases and is unable to stop the flow of urine. This
most commonly occurs in response to weakened pelvic muscles that sup-
port the bladder. Older patients with stress incontinence frequently report
losses of small volumes of urine during laughing, sneezing, coughing, or
running/jumping. This type of UI occurs very commonly with aging. The
other common type of UI is urge incontinence, which results in the loss
of a large volume of urine. There are many causes of urge incontinence,
including neurological problems or infection. However, in many cases
of older people with UI, no known causes are identified. The risk for
developing UI increases with age, obesity, chronic bronchitis, asthma,
and childbearing. Many older adults experience a combination of both
types of incontinence, known as mixed.
Assessing UI is the first step in solving this embarrassing problem. It
is important to note that Bradway (2004) and other researchers report
that UI in women is a culturally bound experience. Narratives of women
with long-term UI revealed that it is an individual experience and inter-
preted and managed according to culture, individual and shared experi-
ences, and interactions with health care professionals, friends, and family
members. Consequently, many clients, including those from diverse cul-
tural backgrounds, may be reluctant to discuss incontinence. Nurses
must understand this and be sure to ask culturally appropriate assess-
ment questions.
After assessing the presence of UI, many interventions are available
to assist with these types of incontinence. The 2003 State of the Science
on Urinary Incontinence (Mason, Newman, & Palmer, 2003) reports that
practice related to urinary incontinence must change. “Use of absorbent
products is often the intervention applied to everyone. Individualized care
for UI isn’t provided” (p. 2). They further report that devices and medi-
cations should take a back seat to effective nursing interventions for UI,
including behavioral interventions, such as pelvic floor exercises and blad-
der training.
The easiest nursing intervention for cognitively intact older adults
with incontinence is to teach pelvic floor exercises, also known as Kegel
exercises. These exercises strengthen pelvic muscles to aid in the retention
of urine. Wyman (2003) found that pelvic floor muscle exercises com-
bined with lifestyle modification and bladder training exercises were very
effective in helping older adults with UI. While these exercises work well
to help older adults improve incontinence, they are challenging to learn.
Thus, nurses are instrumental in teaching older adults the correct pelvic
floor muscle exercise method. Older women may be taught to place a
finger in their vagina and squeeze around it. The correct technique occurs
when pressure is felt on the finger. Once the correct muscle is identified,
clients should be instructed to hold the squeeze for 3 to 4 seconds and
then relax for 3 to 4 seconds. It is recommended that the exercises be
performed 15 times, 2 or 3 times a day. Improvement in urinary inconti-
nence will be seen in 6 to 12 weeks. Nurses may suggest that clients do the
exercises to music first thing in the morning and last thing at night. Bio-
feedback, which provides clients with verification of the correct technique
while they are practicing the exercise, may be useful and is available at
many urology practices nationwide. More information on kegel exercises
may be found at http://www.biolifedynamics.com/kegel_exercises.html.
Cultural Focus
Researchers report that UI in women is a culturally bound experience.

Narratives of women with long-term UI revealed that it is an individual
experience and interpreted and managed according to culture, individual
and shared experiences, and interactions with health care professionals,
friends, and family members. Consequently, many clients, including those
from diverse cultural backgrounds may be reluctant to discuss inconti-
nence. Nurses must understand this and be sure to ask culturally appropri-
ate assessment questions.
Voiding schedules have also been shown to be effective in the treat-

ment of UI (Wyman, 2003), especially for older adults who are cognitively
impaired. Voiding schedules begin by determining times throughout the
day when older adults are most often incontinent. The information for
this may be gathered through examination of the bladder diary. Once
the pattern of incontinent episodes is extracted, the older adult may be
encouraged and assisted to void a half hour before the usual time of
incontinence in order to prevent the incontinent episode from occurring.
In addition, medications that act as anticholinergics or smooth muscle
relaxants assist in increasing bladder capacity to decrease the urge to
void.
Urinary incontinence is often a rationale for the insertion of an
indwelling catheter. This procedure, however, is a nearly guaranteed
method of acquiring a urinary tract infection. Indwelling urinary cath-
eters are contraindicated to treat UI in the older population. As discussed
earlier, although it is time-consuming, the nurse must initiate a record of
voiding times for 24 hours and then plan to offer the opportunities to
void about 30 minutes prior to usual voiding times. This bladder sched-
ule will prevent the negative consequences of UI and afford the older
adult dignity and respect.
MUSCULOSKELETAL SYSTEM
Multiple changes occur in the musculoskeletal status of older adults.

These changes often have a great impact on the health and functioning of
older adults. As people age, there is a decrease in total muscle and bone
mass. The decrease in bone mass occurs as bones lose calcium, causing
the bone structure to shrink and weaken. All of this places the older
adult at a higher risk for fractures. When the bone loss becomes more
severe, the older adult may be diagnosed with osteoporosis. Osteoporosis
is a pathological disease of the bone and will be discussed more com-

prehensively in Chapter 9. Changes in the normal lab values related to
musculoskeletal function include a decrease in plasma calcium necessary
for adequate bone production and maintenance. Moreover, total alkaline
phosphatase (ALP) may rise as a consequence of Paget’s disease or minor
bone trauma or fracture among clients with osteoporosis. Table 3.2
provides a list of laboratory values for the older adult with age-related
changes described. Knowledge and awareness of the normal ranges of
specific blood values for older adults will enhance effective assessment
and management of disease.
Individual muscle units that combine to form muscle groups also
diminish with age. It is important to note that both the decrease in bone
and muscle mass may be counteracted with exercise. Exercise is essential
to healthy aging, producing positive effects on older adults, including
the ability to maintain strength and flexibility throughout older adult-
hood. All older adults should be encouraged to find an exercise program
that they enjoy and participate in it regularly. As discussed earlier in
this chapter, walking and aquatic exercises are among two of the most
Title of Study: Changes in Postural Stability in Women Aged 20 to 80

Years
Authors: Low Choy, N., Brauer, S., Nitz, J.
Purpose: To identify the relationship between vision and postural stability
in order to introduce falls—prevention strategies.
Methods: Measurements of postural stability in 453 women aged 20 to 80
years using the Balance Master force-plate system, while performing the
modified Clinical Test for the Sensory Interaction and Balance, and the
Single-Limb Stance Test.
Findings: Aged 60- to 70-year-old women were more unsteady than
younger women in bilateral stance on a firm surface with eyes closed.
Initial instability was noted in 40-year-olds when single-limb stance was
tested with eyes closed. Further instability was evidenced in 50-year-olds
when a foam surface was introduced. A further decline in stability was
demonstrated for each subsequent decade when the eyes were closed in
single-limb stance.
Implications: Age, visual acuity, and support surface were significant vari-
ables influencing postural stability in women. The cause(s) of this insta-
bility and subsequent decline in stability requires further investigation
and research.
Journal of Gerontology, Medical Sciences 2003, Vol. 58A, No. 6, 525–530.
common exercises enjoyed by older adults. However, there are many

exercise programs to choose from. Tai chi, yoga, and pilates are among
the more recent forms of exercise that have gained in popularity among
older adults. Early research on these forms of exercise reveals great ben-
efits. For older adults, consistent involvement in exercise programs assists
greatly in reducing the normal changes of aging on the musculoskeletal
system. For an enhanced discussion of the role and benefits of exercise in
older adults, see Chapter 5.
SEXUALITY/REPRODUCTIVE SYSTEM
It is commonly believed that older adults no longer desire to participate

in sexual activities and lack sexual desires. This has led to a major neglect
in the consideration of normal changes in the sexuality and reproductive
systems. Moreover, this myth of aging has resulted in a failure to assess
the sexuality and reproductive system in older adults. Consequently, many
normal changes of aging sexual and reproductive systems are unknown
to older adults. In addition, many pathological diseases, such as gyneco-
logical cancers and impotence, are left undetected and untreated.
It is important to note that despite popular belief, sexuality continues
throughout the lifespan of older adults. The need to continue sexuality
and sexual function must be considered along with the other physiologi-
cal changes of aging. In both men and women, the reduced availability of
sex hormones in the older adult results in less rapid and less extreme vas-
cular responses to sexual arousal (Masters, 1986). The overall decrease in
testosterone in men and estrogen, progesterone, and androgen in women
results in changes in: (a) arousal, (b) orgasm, (c) postorgasm, and (d) the
extragenitals (Masters, 1986).
Aging women experience follicular depletion in the ovaries as a result
of a decrease in circulating hormones. This further leads to a decrease
in the secretion of estrogen and progesterone (Masters, 1986). Natural
breast tissue is replaced by fatty tissue, changing the external appear-
ance of the breast. The labia shrink and may hang in folds because of
lack of subcutaneous tissue. The vulva may appear to be dry and have
pale appearance without rugations, and the introitus atrophies. There
is a decrease in vaginal lubrications and a shortening and narrowing of
the vagina. The strength of the orgasmic contraction diminishes, and
the orgasmic phase is decreased. Normal changes of aging women may
result in an increased time to respond during sexual activity and dyspa-
reunia (painful intercourse). Older women may have an inhibited sexual
desire, orgasmic dysfunction, and vaginismus as a result of a decrease in
the amount of circulating hormones. Interventions to counteract these

changes may entail the use of vaginal lubricants to release friction during
intercourse and to decrease pain for the female. Moreover, because of
the change in response time, it may be necessary to increase the period of
time of foreplay prior to the sexual act to allow the body enough time to
physically respond to sexual feelings.
Specific changes of aging that occur among older men include an
increased length of time needed for erections and ejaculation (Ferrie,
2003). Erections become more dependent on direct penile stimulation.
Semen volume is decreased, and the refractory period between ejacula-
tions increases. Older men also find that pubic hair is thinner, and the
testicles may shrink in size. As with the aging female, the aging male may
need to increase the time for foreplay in order for the body to respond
physically to sexual feelings. In addition, a more rapid withdrawal fol-
lowing ejaculation may be needed to maintain the tension in condoms
and prevent leakage of sperm into the partner, which could cause the
spread of sexual transmitted disease (STD). Older men should also be
taught the need to increase the time between erections as a result of nor-
mal aging changes. For more information on the prevention of STDs
among older adults, see Chapter 5.
Impotence is more commonly seen among older men as a result
of increased illness, medication usage, and surgery within this popula-
tion. However, impotence is not a normal change of aging. In fact, in the
absence of this pathological problem, older men are usually free to con-
tinue functioning sexually throughout their lives. A collection of symp-
toms that are commonly known as andropause, or “male menopause,”
are currently being researched. This syndrome, developing in response
to the slow decline in testosterone as well as other factors, may result in
behavior changes and depression among older men (Ferrie, 2003).
A nurse’s reluctance to assess and plan care for older adults sur-
rounding sexuality has a substantial impact on older adult’s health and
functioning. Older adults experience many physiological changes in their
reproductive systems that impact their ability to function sexually. Because
the topic of sexuality is not widely discussed, older adults do not always
fully understand these changes. In fact, a study of 68 older adults living in
the community revealed that only 67% of the sample was able to answer
sexual knowledge questions correctly (Walker & Ephross, 1999). Despite,
older adults’ lack of knowledge regarding sexuality, teaching regarding nor-
mal and pathological aging changes is not provided, and interventions to
compensate for these changes are not planned. Consequently, older adults
may stop functioning sexually, because they think they are “abnormal” or
ill, and no one is available to counsel them otherwise.
Title of Study: Andropause: Knowledge and Perceptions Among the Gen-

eral Public and Health Care Professionals
Authors: Anderson, J., Faulkner, S., Cranor, C., Briley, J., Gevirtz, F., Rob-
erts, S.
Purpose: This study assesses the knowledge and perceptions of andropause,
the natural age-related decline in testosterone in men, among health
care providers and the general public.
Methods: Health care providers and members of the general public partici-
pated in brief surveys via a medical information telephone line. Trained
clinical interviewers administered the questionnaire and documented
the findings.
Findings: Of 443 general public participants, 377 (85%) agreed to partici-
pate in the survey. Of these, 77% had heard of andropause—male meno-
pause—and 63% had taken TRT (testosterone replacement therapy).
Out of 88 health care provider callers, 57 (65%) participated in the
survey. Of these participants, 65% were pharmacists, 80% had patients
with low testosterone symptoms, and 50% reported that patients rarely
or never spoke of low testosterone. Among HCPs and the general pub-
lic, respectively, 98% and 91% knew that low testosterone is treatable
with medication, and 60% and 57% knew that it results in osteoporo-
sis. Only 25% of HCPs and 14% of the general public knew that low
testosterone does not cause loss of urinary control.
Implications: Some health care providers, as well as members of the general
public, are knowledgeable about some aspects of low testosterone and
have misconceptions about others. Therefore, it is clear that education
is needed in this area.
Journal of Gerontology, Medical Sciences 2002, Vol. 57, No. 12, M793–M796.
In addition to normal aging changes, older adults experience other

barriers that prevent full sexual function. These include the loss of part-
ners in older adulthood and pathological illnesses, such as impotence or
diabetes, that affect sexual function. As nurses, it is critical to perceive
sexuality as equally important to other physiological systems when plan-
ning care.
CHANGES IN THE SENSES
Older adults experience changes in the five senses as a result of normal

aging. Overall visual acuity declines, and the ability to discriminate colors
becomes less acute. The ability of the pupil to constrict quickly in response
to stimuli decreases and peripheral vision declines. The lens of the eye often
becomes yellow, resulting in the development of cataracts in the older pop-
ulation. Because of the normal changes in the aging eye, the older adult is
at higher risk for diseases such as cataracts and glaucoma. Older adults
should have a baseline eye assessment early in older adulthood, with fol-
low-up eye appointments at least annually. A nonpathological anatomical
change seen frequently in older adults is known as arcus senilus, which is a
ring that appears around the older adult’s iris but has no impact on vision.
Consequently, no nursing interventions are necessary.
As a result of decreased body water, older adults tend to accumulate
an increased amount of hard cerumen in their ears, which may affect
hearing. The removal of the cerumen often requires assistance of a health
care professional, and this may increase hearing acuity. Hearing impair-
ments, while not a normal change of aging, occur frequently in the older
population as a result of environmental exposure to noise pollution, as
well as genetics. The prevalence of presbycusis, or high-pitched hearing
loss, also rises with age. The usual intervention for older adults who
become hearing impaired is consultation with a hearing professional.
Hearing aides, which are fitted to the ears of older adults and enhance
the sounds of the environment, may be an effective method to improve
hearing in the older population. Newer, more advanced methods of hear-
ing enhancement are currently being researched.
Older adults also experience an overall decline in both the senses of
taste and smell. This is due to an average decrease of approximately 30%
Critical Thinking Case study
Mrs. Pinkus is a pleasant, 90-year-old woman who resides in a skilled

nursing facility. She is alert and oriented but sometimes forgetful. She is
near-sighted and hard of hearing in her left ear. She enjoys dessert with
her dinner. She is continent of bowel and bladder and ambulates indepen-
dently. Her past medical history includes frequent episodes of pneumonia,
hypertension, and a right breast carcinoma.
1. What findings in Mrs. Pinkus’s profile would be considered normal
changes of aging?
2. Are there pathological changes present in Mrs. Pinkus’s profile? If
so, what are they?
3. What nursing interventions could be implemented to compensate for
normal changes of aging?
4. Do you feel the role of ageism may impact the nurse’s ability to dif-
ferentiate between normal and pathological changes of aging?
in the number of taste buds (Malazemoff, 2004). While this decline is a

normal aging change, a sudden decline in the ability to smell or taste may
be a symptom of disease. For example, Malazemoff (2004) reports that
the presence of gingivitis, periodontal disease, and other disorders com-
mon to older adults further reduces the ability to taste and smell food.
This change is often difficult for older adults who relied heavily upon the
smell of good food to maintain their nutritional level. It also explains why
older adults may not recognize odors often evident to others, such as that
of spoiled or burning food. The decline in taste and smell sensations may
lead to attempts to enhance the taste of food with increased salt and sugar.
However, depending on the presence of diseases, such as hypertension or
diabetes, these food supplements may be problematic. Malazemoff (2004)
recommends a thorough history of taste and smell sensations, as well as a
physical examination of the nose and mouth to differentiate normal from
pathological changes in aging. In addition, a thorough dietary assessment,
beginning with a 24-hour recall, is essential to identify the impact of the
change of taste and smell on the older adult’s diet.
NEUROLOGICAL CHANGES
Many people believe that as individuals age, cognitive impairment is

inevitable. While there are changes in the neurological system as people
age, these changes do not result in cognitive impairment. Chronic cogni-
tive impairment is a pathological change of aging resulting from demen-
tia. Dementia is a general term used to describe over 60 pathological
cognitive disorders that occur as a result of various disease processes,
heredity, lifestyle, and perhaps, environmental influences. It is defined by
the Alzheimer’s Association as a “loss of mental function in two or more
areas such as language, memory, visual and spatial abilities, or judgment
severe enough to interfere with daily life” (1999).
Some of the normal changes of aging that occur include a reduction
in total brain weight. There has been a documented shift in the proportion
of gray matter to white matter, and there is a total loss of neurons and an
increase in the number of senile plaques seen in the brain of older adults
upon autopsy. Older adults also experience a decrease in blood flow to the
cerebrum. The way these anatomical changes in the brain translate into
human behavior has great variability. Some older adults are often thought
of as “forgetful” and “slow.” Memory losses are also common to older
adulthood, but are often falsely labeled as dementia. However, dementia
is a pathological illness of the cognitive system and is definitely not a nor-
mal change of aging. Many older adults live well into their 10th decade as
intellectually keen as they were in their twenties and thirties.
Because of the great concern older adults have about becoming cog-
nitively impaired in older age, nurses are often called upon to provide
information on maintaining cognitive and intellectual capacity. The most
appropriate interventions to prevent the effects of normal aging on cog-
nitive functioning and reducing the risk for the development of demen-
tia are to maintain an active mind and body. Older adults should be
encouraged to participate in cognitive activities such as work, games, or
a course of study. Many colleges and universities allow older adults to
attend classes for low or no charge. In fact, 17% of older adults have a
bachelor’s degree or more. Keeping intellectually active is regarded as a
hallmark of successful aging.
SUMMARY
It is clear that as people age, each body system undergoes changes. The
changes are caused by many factors including exposure to environmental
injury, illness, genetics, stress, and many others. Most of these changes
occur over many years and are considered normal among older adults.
However, these changes often place the older adult at high risk for the
development of disease. It is extremely important to differentiate normal
from pathological changes in order to prevent improperly treating nor-
mal changes and failing to treat those that result from illness.
Teaching regarding the normal changes of aging should be the first
intervention made with all aging adults to help them understand what is
going on in their bodies. In addition, many interventions are available to
compensate for these changes as well as to prevent the development of
disease as a consequent of these interventions. Teaching and assurance by
the nurse that these changes are a normal part of aging allow older adults
to understand their bodies, to feel comfortable learning how to compen-
sate for these changes, and to discover how to prevent the development
of disease.
REFERENCES
Alzheimer’s Association. (1999). Alzheimer’s disease and related dementias fact sheet.
Retrieved from http://www.ncdhhs.gov/aging/ad/ADRD_FactSheet.pdf
Annells, M., & Koch, T. (2002). Older people seeking solutions to constipation: The laxa-
tivemire. Journal of Clinical Nursing, 11(5), 903.
Beers, M. H., & Jones, T. V. (Eds.). (2000). The Merck manual of geriatrics (3rd ed.).
Rahway, NJ: Merck Research Laboratories.
Bradway, C. K. W. (2004). Narratives of women with long-term urinary incontinence.
Unpublished doctoral dissertation, University of Pennsylvania, Philadelphia.
Ferrie, B. W. (2003, April 28). What is male menopause? Advance for Nurses, 5, 27–28.
Fisher, A., & Morley, J. E. (2002). Antiaging medicine: The good, the bad and the ugly. The
Journals of Gerontology, 57(10), M636–M639.
Gray, M. L. (2003, March). Gender, race and culture in research on urinary incontinence.
American Journal of Nursing, (Suppl.), 20–25.
Hill, M., Tannenbaum, S., & Salman, A. (2005). Hypertension. In J. Fitzpatrick & M. Wallace
(Eds.), Encyclopedia of nursing research (pp. 287–290). New York: Springer Publish-
ing Company.
Lagman, R. L. (2006). Constipation—Not a mundane symptom. Journal of Supportive
Oncology, 4(5) 223–224.
Lewis M, Szabo R, Weiner K, McCall L, Piterman L.(1997). Cultural barriers to exercise
amongst the ethnic elderly. Internet Journal of Health Promotion. Retrieved August
25th, 2007 from http://www.rhpeo.org/ijhp-articles/1997/4/.
Malazemoff, W. (2004). When the nose no longer knows—Smell and taste disorders in
elders. Nursing Spectrum, 8(8), 12–14.
Mason, D. J., Newman, D. K., & Palmer, M. H. (2003). Changing UI practice. American
Journal of Nursing, (Suppl.), 2–3.
Masters, W. H. (1986, August 15). Sex and aging—Expectations and reality. Hospital Prac-
tice, 175–198.
National Collaborative Centre for Acute Care. (2006). Nutrition support in adults. Clinical
guideline 32. London: National Center for Health & Clinical Excellence.
Reijneveld, S. A., Westhoff, M. H., & Hopman-Rock, M. (2003). Promotion of health and
physical activity improves the mental health of elderly immigrants: Results of a group
randomised controlled trial among Turkish immigrants in the Netherlands aged 45
and over. Journal of Epidemiology and Public Health, 57, 405–411.
Swanenburg, J., de Bruin, E. D., Stauffacher, M., Mulder, T., & Uebelhart, D. (2007).
Effects of exercise and nutrition on postural balance and risk of falling in elderly
people with decreased bone mineral density: Randomized controlled trial pilot study.
Clinical Rehabilitation, 21(6), 523–524.
University of North Carolina Center for Functional Gastrointestinal and Motility Disor-
ders. (2006). Understanding fecal incontinence. Retrieved July 13, 2007, from http://
www.med.unc.edu/ibs
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ing. Executive summary. Available at http://www.cdc.gov/tobacco/sgr/sgr_2004/pdf/
executivesummary.pdf.
Walker, B. L., & Ephross, P. H. (1999). Knowledge and attitudes toward sexuality of a
group of elderly. Journal of Gerontological Social Work, 31, 85–107.
Wyman, J. F. (2003, March). Treatment of urinary incontinence in men and older women.
American Journal of Nursing, (Suppl.), 26–35.
C H A P T E R F O U R
Assessing Older Adults
Learning Objectives
1. List techniques necessary for the systematic assessment of older
adults.
2. Discuss challenges and solutions to obtaining health histories and
physical examinations on older adults.
3. Identify alterations in older adult lab values.
4. Identify critical components of comprehensive geriatric assess-
ment.
5. State the two key components of assessing older adults.
Mr. Joseph is a 68-year-old man who has Down syndrome and is very
hard of hearing. He recently had a physical exam and routine blood work
done at the physician’s office you work at. He is currently 30 lbs over-
weight, and his total cholesterol is 280. His physician asks you to do
some teaching regarding lifestyle modifications that can be done to lose
weight and lower his cholesterol. However, when he comes in you have a
hard time communicating the information because he is so hard of hear-
ing. In addition, you are unsure of whether or not he understands the
material. He shakes his head when you ask if he has any questions, but
he looks very confused. By the end of the session he looks very frustrated
and upset and hurries to leave. You schedule a follow-up appointment in
a week to see how he’s doing and reinforce the material.
The story of Mr. Joseph happens frequently among older adults. Health
assessment of older adults is a process of collecting and analyzing data.
It is the first step in the nursing process. It is also essential in order to
formulate effective plans of care for older adults. The assessment of older
adults focuses on physiological findings, including normal changes of
aging, psychosocial data, functional abilities, and cognitive dimensions of
105
well-being. While nurses may assume that the assessment of older adults is
similar to that of a younger adult, older adult assessments must pay close
attention to the differentiation between normal and pathological changes,
as well as the impact of these changes on functional status. Moreover,
these assessments must consider potential subtle changes in function and
cognition that indicate early signs of disease in this population.
This chapter provides information on health assessment techniques
necessary for the assessment of older adults. Challenges to obtaining
health histories and physical examinations among older adults will be
discussed. Altered presentation of commonly occurring diseases among
the elderly will be identified, and the reader will be provided with mate-
rial on appropriate assessment of function and cognition.
SYSTEMATIC GERIATRIC ASSESSMENT
The nurses’ assessment of older adults requires the ability to actively lis-
ten as well as to use all other senses to gather data. This often draws upon
experience and expertise gained over time in working with the older pop-
ulation. An inexperienced nurse is often frustrated by the length of time
needed for the geriatric assessment, and the inability of some older adults
to keep focused on providing the necessary information. For example,
consider an 86-year-old woman with mild cognitive impairment (MCI)
who presents to a medical unit with a small bowel obstruction (SBO).
This assessment will probably take a long time, and it may be necessary
to consistently encourage the client to focus on answering the questions.
In an effort not to be rude, the nurse may allow the patient to continue
providing unessential information. Written forms and checklists can help
the nurse to keep the client more focused.
The physical assessment of the older adult demands that the health
care team include special considerations that are unique to the geriatric
population. Environmental adaptations are usually necessary to com-
pensate for the older adult’s physiological and psychological changes
of aging. Modifications to the physical environment start with a room
that is comfortably warm to the client and not exposing the client any
more than is necessary. Changes in subcutaneous tissue, fat, and muscle
among older adults provide less protection against temperature extremes,
consequently, older adults are more sensitive to temperature changes.
Amella (2004) states that the “key to providing appropriate treatment to
older adults is going beyond the usual history and physical parameters
to examine mental, functional, nutritional and social-support status”
(p. 43).
The room should be adequately bright but with indirect lighting to
compensate for diminished visual acuity. Fluorescent lighting and window
Assessing Older Adults 107
glare should be avoided. Straight-backed chairs with arms that are cush-
ioned for comfort should be utilized, making sure that the client’s height
allows for ease in rising from them. The examination table should be low
and well padded to protect from discomfort. The head of the examination
table should rise up, as some older adults may have difficulty lying flat for
any amount of time. There should be adequate space in the examination
room to accommodate mobility aides. The room should be free from dis-
traction and background noises. It is important to take into consideration
the energy level of the older adult and conduct the physical examination
at the individual’s own pace. Minimize skin exposure of the older adult to
prevent chilling. These factors may indicate the need to conduct the exami-
nation over more than one session. It is helpful to organize the examination
to reduce the changes in body positions and conserve the client’s energy.
Because the older adult may become disoriented in a different environ-
ment and/or have sensory impairments, various techniques need to be uti-
lized to assess each individual adequately. At the start of the examination,
it may be worthwhile for the examiner to spend some extra time establish-
ing a nonthreatening relationship. As a sign of respect, older adults should
be addressed by their last name and title. The first name should be used
only if invited to do so. The nurse must allow the older client enough time
to respond to questions. The nurse should speak facing the client and use
commonly accepted wording. Allowing hearing-impaired clients to see the
nurse’s entire face and body so that they may detect lip reading and body
language may be helpful. If the client wears hearing aids, make sure they
are on and working properly. For clients with visual deficits, nurses must
make sure that the clients have their glasses on and plan to use visual cues
as needed. Family members can provide important information, but the
examiner needs to focus on the client.
Older adult health assessment, which requires a substantial amount
of nursing time and resources, often conflicts with the hurried and
short-staffed health care environment in which older adults receive
care (Hogstel, 2001). Geriatric interdisciplinary teams (GITs)—made
up of physicians, nurses, physical therapists, occupational therapists,
recreational therapists, social workers, psychologists, and nursing assis-
tants—make assessment more efficient by assigning components of the
assessment to the most qualified member of the team. After completing
assigned components of the assessment, GIT members gather together
to plan care for the older adult, which is generally more comprehensive
and effective than when individual team members work alone (Fulmer
et al., 2005). Geriatric interdisciplinary team care has been effective
in managing the complex syndromes experienced by chronically ill
and frail older adults with multiple co-morbidities, because such care
requires skills that are not possessed by any one professional. Positive
outcomes of geriatric teams have been revealed in multiple studies,
Title of Study: Pain Perceptions of the Oldest Old: A Longitudinal Study

Authors: Zarit, S., Griffiths, P., Berg, S.
Purpose: To assess self-reported pain in the elderly and examine its changes
over time relative to other changes in health and functioning.
Methods: This was a population-based sampling of the oldest-old (86–92
years of age) in Sweden. Interviews were administered regarding their
pain, and other areas of health function.
Findings: At baseline, pain was prevalent in 34% and rose to 40% at follow-
up. Incidents of new pain cases were 16% during that time period. Pain
was significantly related to the following: sleep disturbances, medica-
tion usage, global subjective health, depressive symptoms, and mobility,
though the magnitude was relatively small.
Implications: There is an increase in the number of persons reporting pain
over a period of time after the age of 85. The relatively small associa-
tion of pain with other areas of functioning suggests adaptation among
the oldest-old.
including one by Li, Porter, Lam, and Jassal (2007). These researchers
found that a team approach to care delivery resulted in quicker hospital
discharge and improved functional status. The Institute of Medicine
(IOM) of the National Academy (2001), in attempts to reduce medical
errors and improve patient outcomes, challenges all health care profes-
sionals to recognize the need for effective interdisciplinary team care for
multiple patient populations.
As discussed in Chapter 1, the older adult population is becoming
increasingly culturally diverse. Consequently, during the assessment, close
attention must be paid to culturally appropriate behaviors. It is important
to determine how the older adult would like to be addressed and the lan-
guage that they are most comfortable speaking. If the older adult speaks a
language foreign to the nurse, the client should be questioned as to whether
or not an interpreter is desired or whether a family member would like to
communicate the client’s history. Attention should also be paid to the older
adult’s comfort with the amount of personal space, eye contact, and physi-
cal gestures of the health care provider. The relationship of the nurse to the
client requires recognition of and sensitivity to cultural differences, because
some cultural groups definitions of health and illness may differ from the
examiners. These same cultural groups may also have their own health
practices that are thought to promote health and cure illness within the
CѢљѡѢџюљ FќѐѢѠ
During the assessment, pay close attention to culturally appropriate behav-

iors. It is important to determine how the older adult would like to be
addressed and the language that they are most comfortable speaking. If
the older adult speaks a language foreign to the nurse, the client should be
questioned as to whether or not an interpreter is desired or whether a fam-
ily member would like to communicate the client’s history.
group. All nurses should make efforts to modify health care according to
the client’s cultural beliefs in order to provide culturally competent care.
It is important to remember that although older clients may be part
of a specific cultural group, they may have acculturated to a certain degree
during their time in the United States. Therefore, a cultural history is an
essential step in determining the basis of the client’s health care beliefs and
practices. Some health care facilities have begun to add cultural assessment
questions to client’s admission assessment. Sample questions to guide the
assessment may be found in Exhibit 1.4. It is important to remember that
all older adults should be treated with dignity and respect. Consequently,
always use a client’s formal title (Mr., Mrs., Dr.), or ask how they would
like to be addressed. If the older client speaks a language with which the
nurse is not familiar, determine if the older adult client would like an
interpreter or whether a family member would like to communicate the
individual’s needs. It is important to note that the fast pace in which the
American culture operates may be seen as a sign of disrespect to older
adults from different cultural backgrounds. A quick approach to patient
care, which is often essential in busy health care climates, often is perceived
as uncaring and hasty. Recognizing this allows for nurses to approach the
clients more slowly and with greater attention to caregiving and detail. The
amount of personal space, the comfort with eye contact, and the use of
physical gestures, such as hand-shaking, should also be assessed to deter-
mine the older adult’s comfort with these common social norms.
When conducting assessments on older adults, it is also necessary
to remember that some of the standardized assessment tools, such as the
Geriatric Depression Scale and the Mini Mental State Examination, are
available in different languages. Be cautious about interpreting a tool
that has not been formally translated, as the meanings of many words
change by cultural background. During the assessment, it is necessary
to determine the decision maker in the family and respect the client and
families wishes in sharing information. In some cultural backgrounds,
older adults are prevented from hearing about their diagnoses, and fam-
ily members are given this information. In addition, some diseases of
During the assessment, it is necessary to determine the decision maker in

the family and respect the client and family’s wishes in sharing informa-
tion. In some cultural backgrounds, older adults are prevented from hear-
ing about their diagnoses, and family members are given this information.
Thus, it is essential for nurses to assess client’s understanding of their role
in the plan of care and whether or not the plan is consistent with cultural
beliefs.
older adulthood, such as dementia and depression, are stigmatized in

many cultures. While some older adults will participate actively in setting
goals and objectives for care, as well as determining acceptable interven-
tions and outcomes, others will be more comfortable relinquishing this
task to family members and health care providers. Some cultures hold
health care providers in high esteem and, in attempts to be respectful,
may be unwilling to disagree with plans of care. Thus, it is essential for
nurses to assess clients’ understanding of their role in the plan of care and
whether or not the plan is consistent with cultural beliefs.
HEALTH HISTORY
The health assessment always begins with a health history. This is usu-
ally the first time that the older adult and nurse have an opportunity to
meet, and it marks the beginning of the therapeutic relationship. It is
important at this time to focus on gaining the trust of the client. Conse-
quently, a sufficient amount of time should be set aside for the health his-
tory so that the older adult does not feel rushed. Normal changes of aging
result in an overall slowing down of response time to questions, not to
mention that the older person being interviewed may have 80 or 90 years
of health history to relate to the nurse. Because of the time period that the
health history must cover, the older adult may have difficulty extracting
dates and details from memory, so it is important for the nurse to be
patient and understanding. Some older adults may find some information
to be too distressing to discuss, such as the birth of a still-born child, or
may fear the consequences of their health problems so they may withhold
certain medical information. Memories of painful tests or the fear of a
stressful diagnosis may also cause the older adult to minimize symptoms.
They may also fear being a burden on the health care system or on their
children and, thus, hide or minimize symptoms of disease for this reason.
A thorough health history, including past medical and surgical

history, cultural background, sources of social and financial support,
occupation, education, living arrangements, assessment of alcohol
and tobacco, and prescription and over-the-counter medication usage
(including herbal supplements) should be obtained. Nurses should
request that patients bring medication bottles to the assessment in order
to determine what medications the client is taking and whether or not
the older client’s prescriptions have been filled with a generic drug. As
noted earlier in this text, herbal medications, while rising in popular-
ity among all older cultural groups, may be the primary healing source
among some Asian, Hispanic, and other cultures. Awareness of the use
of CAM therapies allows nurses to assess for the interaction of these
therapies with traditional medications among all cultural groups. An
assessment of nutritional status, commonly obtained through the use of
a 24-hour recall, and a history of present illness should be obtained.
Special attention should be focused on the common problems of
aging. The assessment for subjective reports consistent with diseases such
as dementia, depression, musculoskeletal disorders, and sensory changes
should be part of every health history. For example, complaints of symp-
toms such as memory loss, forgetfulness, chronic fatigue, loss of appetite,
pain, and difficulties with hearing or vision are common among older
adults and should be included among all health histories. The health care
provider may use a form to gather this information orally, but must also
be observant of other symptoms of common aging problems, such as
depression, reading disabilities, or a dry cough.
Following the health history, the nurse must perform a review of sys-
tems (ROS) to determine any signs or symptoms of disease in each body
system. The ROS is a comprehensive collection of subjective symptoms,
including cardiovascular, respiratory, peripheral vascular, abdominal, integ-
umentary, genitourinary, neurological, and musculoskeletal systems. Ques-
tions regarding older adults’ health within each of these systems should be
posed. For example, within the abdominal system, the older adult may be
asked if there are any problems with nausea, vomiting, or diarrhea. Within
the neurological system, the client may be questioned regarding the incidence
As noted earlier in this text, herbal medications, while rising in popularity

among all older cultural groups, may be the primary healing source among
some Asian, Hispanic, and other cultures. Awareness of the use of CAM
therapies allows nurses to assess for the interaction of these therapies with
traditional medications among all cultural groups.
and prevalence of headaches. The health history and review of systems col-
lectively form the basis of the subjective portion of the health assessment.
REMINISCENCE AND LIFE REVIEW
The term reminiscence has been in use for many years as a manner in which
to help older adults experience memories of earlier times. It was originally
defined as thinking about or relating past experiences, especially those per-
sonally significant (McMahon & Rhudick, 1961). The concepts of reminis-
cence and life review are often used interchangeably but are similar in their
ability to help older adults recall memories from an earlier period of time
in order to experience emotions associated with these memories, or reach
resolution regarding past events. Haight (2005) suggests that one method of
reminiscence or life review that may be helpful during the health assessment
is the oral history or narrative therapy in which the client is asked to tell the
story about a particular problem or reason for seeking health care. In the
process of storytelling, new insights are gained by both the client and health
care provider, and the storytelling becomes therapeutic. Reminiscence may
also be accomplished by asking an older adult about their memories of
certain events, smells, or photographs. In order to stimulate reminiscence,
older adults may be asked to write about or tape record memories of past
events, develop a family tree, or write to old friends. Tornstam’s theory of
gerotranscendence, discussed in Chapter 1, suggests that reminiscence con-
tributes to the reconstruction of identity and the understanding of reality as
a process of reorganization and reconstruction.
PHYSICAL ASSESSMENT
A head-to-toe physical examination should follow the health history and

a complete review of systems. The physical assessment begins with the
evaluation of vital signs, including temperature, pulse, respiration, height,
and weight. Because of the potential for orthostatic hypertension, blood
pressure should be evaluated in three different positions: sitting, imme-
diate standing, and one-minute standing, especially if the older adult is
currently taking antihypertensive medications. Decreases in blood pres-
sure of more than 20 mm Hg, are indicative of orthostatic hypertension
and require further evaluation. Blood pressure readings should follow
the American Heart Association guidelines (see Chapter 6). Respirations
should fall within the normal range of 12 to 18 breaths per minute with
regular heart rates averaging between 60 and 100 beats per minutes. The
temperature response to infection among older adults varies greatly; some
older adults respond to infections with elevated temperatures and others

with aggressive infections show no febrile response. Gathering informa-
tion on clients’ weight and height is also essential to develop a baseline
for further comparison of nutritional and hydration levels, as well as
bone loss. Body mass indexes (BMI) less than 25 are considered ideal and
should be measured when possible.
Following the gathering of vital signs, a head-to-toe physical assess-
ment is necessary. The client’s skin should be evaluated for any unusual
findings, including cherry hemangiomas, liver spots, skin tags, keratoses,
and precancerous and cancerous lesions. The presence of herpes zoster
and decubitus ulcers, which occur commonly in older adulthood, should
be evaluated. Hair growth and nails should be assessed for uniformity,
with diminished hair growth and fungal infections of the nails requir-
ing further evaluation. Evaluation of the head and neck for the presence
of lesions or trauma should occur next, including the evaluation of the
sclera for whiteness and a notation of the arcus senilis, if present. Evalu-
ation for cataracts and macular degeneration should also be conducted,
as these conditions occur commonly in older adulthood. Visual acuity
declines as people age, so evaluation of vision and proper referral to an
ophthalmologist for follow-up of abnormal findings of the eye should
occur. Tympanic membrane and the light reflex in the ear should be
identified, and an evaluation of hearing should be conducted. The nose
should be palpated for tenderness and signs and symptoms of infection.
The mouth and teeth should also be evaluated for deviations from nor-
mal, and referrals should be made to a dentist for further management
of mouth and tooth disorders. The thyroid gland should be palpated for
enlargement and nodules.
The evaluation of the heart and lungs begins with the evaluation of
the carotid arteries and jugular beings in the neck. The carotid arteries
should be symmetrical, nonbounding, and absent of bruits and adven-
titious sounds. The jugular veins should not be distended. The heart
should be inspected and auscultated beginning at the apex. The first
two heart sounds should be auscultated and any adventitious sounds,
murmurs, rhythms, and pulsations should be noted. The lungs should
be inspected and palpated for tactile fremitus and equal expansion. The
lung fields should be percussed for areas of hyper-resonance or dullness.
Lung sounds should be evaluated in all fields and adventitious sounds
noted.
Inspection and palpation of the musculoskeletal system should begin
at the temporomandibular joint and proceed inferiorly to the feet. Each
joint, bone, and muscle group should be evaluated for abnormalities, ten-
derness, bilateral equality, strength, and range of motion. The abdomen
should be inspected for abnormal scars, pulsations, or distention, and
bowel sounds should be auscultated in all four quadrants. Older women

should also be examined for breast masses and gynecological abnormali-
ties, and older men should undergo an annual examination for prostate
enlargement or malignancies.
An important part of the physical exam is the evaluation of laboratory
tests. The proper use of these laboratory tests in evaluating older adults
requires both knowledge of the normal ranges for age and the nurses’
awareness of the clients’ health and medication history. These changes
were discussed in relation to specific bodily systems among older adults
in Chapter 3. Table 3.2 provides a list of laboratory values for the older
adult with age-related changes described. Among older adults, altered lab
values often put them at risk for the development of disease. For example,
an increase in glucose as part of the normal aging process likely plays a role
in the high incidence of Type 2 diabetes among older adults. Moreover, a
decrease in serum calcium plays a role in the higher risk of older adults
for osteoporosis. Consequently evaluation of appropriate laboratory tests
should be conducted as part of the health assessment among older adults.
In addition to lab values, it is important for nurses to understand the
normal physiological changes associated with aging and compare them
with abnormal change detected in organ systems. Misidentifying an age-
related change as disease-induced may lead to therapeutic attempts to
reverse normal aging. This may result in iatrogenic harm to the older adult.
For example, consider a 72-year-old man visiting a health care clinic. The
admitting nurse takes a routine fasting glucose level and finds it slightly
elevated. If the nurse did not understand that a slight increase in fasting
glucose commonly occurs with aging, this client would be sent for more
expensive testing and possibly costly and painful treatment for Type 2
diabetes. Conversely, incorrectly assuming it is an age-related change
may lead to therapeutic neglect of potentially or possibly treatable condi-
tions. For example, one of the common myths of aging is that all older
adults are cognitively impaired. While becoming cognitively impaired as
one ages is of large concern to the aging population and their families,
many older adults live well into their 10th decade with high cognitive
and intellectual functioning as they were in their twenties and thirties.
Memory losses are common in older adulthood, but the development of
dementia is not a normal change of aging. Instead, it is a pathological
disease process used to describe over 60 pathological cognitive disorders.
Refer to Chapter 3 for a detailed discussion of normal aging changes in
the elderly.
Altered presentation of illness is another challenge in the physical
assessment of older adults. Diseases may present with atypical clinical
signs and symptoms that can be confusing. Severe, acute illnesses will
often present with nonspecific or vague symptoms. Typical signs and
symptoms may be absent, such as a cough in an older adult with pneu-

monia. At other times, disease may present merely as failure to thrive,
changes in mental status, falls, anorexia, or self-neglect. All health care
providers need to be aware of these differences. For enhanced discussion
of the altered presentation of disease in the elderly, see Chapter 6.
CRITICAL COMPONENTS OF A COMPREHENSIVE

GERIATRIC ASSESSMENT
A comprehensive geriatric assessment is an interdisciplinary approach to

the evaluation of older adults’ physical, psychological, social, and spiri-
tual functioning. These types of assessments are generally conducted in
teams that include nurses, physicians, social workers, and therapists that
assess and plan care addressing the multiple needs of older adults. As
discussed earlier, when multiple disciplines collaborate in care planning,
this ensures the best communication and the most comprehensive and
effective plan for older adults.
A comprehensive geriatric assessment should always involve family
members and caregivers, as appropriate. Frequently, family members and
direct caregivers can contribute information that might be overlooked if
they are not included in the assessment process. Involving family mem-
bers in the planning of care for older adults not only gives the nurse the
opportunity to assess the status of their relationship with the older adult
client, but it also allows the nurse the opportunity to involve the caregiv-
ers in planning, education, and decision making. It is important to men-
tion the potential mistakes health care providers can make in regards to
family/caregiver involvement. One common mistake is to ignore the client
and focus primarily on the caregiver to answer all the questions, receive
information, and make decisions. Nurses may make ageist assumptions,
underestimate clients’ abilities, and not allow them to be active partic-
ipants in their own care. On the other hand, nurses may receive inac-
curate information if they do not involve the family or caregivers when
needed. Individuals with cognitive impairment may still be quite socially
skilled and may make the health care provider think they are cognitively
intact and able to give accurate information. Also, some older adults may
overestimate their abilities out of fear that the health care provider might
uncover certain information that could result in loss of independence or
institutionalization.
There are two critical components of geriatric assessment that must
be discussed here: function and cognition. When older adults experience
the onset of disease, changes in function and cognition are often the first
symptoms. A savvy clinician may detect these early symptoms, conduct
Title of Study: Congruence Between Disabled Elders and Their Primary

Caregivers
Authors: Horowitz, A., Goodman, C., Reinhardt, J.
Purpose: To study the congruence between perceived relationships among
the disabled elders and their caregivers from several perspectives.
Methods: 117 visually impaired elders and their caregivers were examined
through correlation analyses, kappa statistics, and paired t tests. 4 target
issues included: elders’ functional disability, elders’ adaptation to vision
impairment, caregivers’ overprotectiveness, and caregivers understand-
ing of the vision problem.
Findings: Elders did not rate caregivers as overprotective as much as care-
givers rated themselves. Caregivers assessed elders as more disabled
than the elders rated themselves. The two factors that correlated with
congruence across measures were the caregiver’s assessment of the
elder’s status and the quality of the relationship between the elder and
the caregiver.
Implications: The findings of this study emphasize the importance of
addressing congruence by target issue, rather than as a characteristic of
the caregiver relationship.
a thorough assessment, and diagnose disease at an early and often more

treatable stage. The presence of cognitive dysfunction should be assessed,
because acute decline in cognitive function often signals the onset of
physiological disease. Detection of changes in cognitive function may
help the older adult to receive earlier and, thus, more effective disease
treatment. In addition, detection of chronic cognitive dysfunction allows
for early planning to assure the safety, high functionality, and optimum
quality of life for the older adult.
Function
An older adult’s ability to independently complete activities of daily liv-
ing (ADLs) is a benchmark for health. If an older adult becomes incon-
tinent or unable to bathe themselves, this often requires a change in the
level of care. Moreover, an acute decline in functional status frequently
signals the onset of physiological disease among older adults. For exam-
ple, consider an older female who generally eats and bathes indepen-
dently. One morning she wakes up and requires assistance to get out of
bed and eat. This should signal the presence of functional decline and
begin the process of assessment to determine the cause of the functional

deficit. In this case, the presence of infection, delirium, or depression
may be the reason behind the sudden onset change in function. Conse-
quently, special attention must be paid to the functional assessment of
older adults.
Functional assessment is a systematic attempt to measure objec-
tive performance in ADLs, including bathing, dressing, toileting, eat-
ing, ambulating, and continence. Instrumental activities of daily living
(IADLs) are the more complex tasks people need for independent living.
The IADLs include being able to shop, cook, manage finances, climb
stairs, manage transportation, do housework and laundry, and manage
medications. Assessment of functional limitations in older adults is very
important for detecting disease and dysfunction, selecting appropriate
interventions, and evaluating the results of these interventions. With the
older adult, the ultimate goal is to maintain optimal function and be
as independent as possible. The geriatric interdisciplinary team works
toward promotion and maintenance of functional independence with the
goal of assisting the older adult to live independently as long as possible
and preventing hospitalization and institutionalization.
A functional geriatric assessment begins with a major review of
ADLs. The Katz Index is an excellent functional assessment tool that
has been used widely in many health care settings that care for older
adults (Wallace & Shelkey, 2007). IADL scales include the Lawton
IADL.
Cognition
A decline in cognitive function frequently signals the onset of physiologi-
cal disease among older adults. Nurses caring for older adults are often
in a position to evaluate cognitive status and screen for the development
of cognitive impairments, which will assist in differential diagnosis. For
example, consider an older nursing home resident who is usually cogni-
tively intact. This resident usually remembers nurses’ names, knows the
date, and is oriented to person, place, and time. One evening, during
the med pass, the client calls the nurse his mother. Further brief cog-
nitive assessment indicates that the client is disoriented. Among older
adults, this rapid change in cognitive status should signal the presence
of delirium and further assessment to determine the cause. In this case,
the presence of infection, medications, or sensory deprivation may be the
reason behind the sudden onset change in cognitive function. Changes in
cognitive status occur both in cognitively intact and cognitively impaired
older adults. For example, clients with Alzheimer’s disease may experi-
ence a decline in cognitive function in response to the pathological disease
processes listed previously.
Because altered cognitive status is one of the more commonly

occurring symptoms of disease among older adults, cognitive assess-
ment is an essential skill to be acquired by nurses caring for the older
population.
There are many instruments that can be used to accomplish this
purpose. One screening tool that has been used successfully to screen
for the development of changes in cognitive function symptomatic of
dementia is the Mini Mental Status Examination (MMSE; Folstein,
Folstein, & McHugh, 1975). Based on a 30-point scale, the MMSE
measures levels of awareness and orientation, appearance and behav-
ior, speech and communication, mood and affect, disturbances in
thinking, problems with perceptions, and abstract thinking and judg-
ment. The higher the older adult scores, the more intact the cognitive
status. When the scale is 23 or lower, the client has a problem with
cognition and needs further evaluation. The tool is easy to use after
a little practice and has been used for initial and subsequent evalua-
tion of older adults in a variety of settings. However, the instrument
has been criticized as being insensitive to culture, language, visual
impairments, and low literacy. The most effective way to perform the
assessment is to make the client comfortable and establish a rapport.
Eliminating noise and promoting attention and concentration will
allow clients to answer questions to the best of their ability. After the
examination, the score can be computed and used as a basis for care
planning.
SUMMARY
The assessment of older adults is the first necessary step in providing

care to this population. Geriatric assessment begins with a health his-
tory, followed by a review of systems and a comprehensive physical
examination. Knowledge of normal changes of aging and pathological
diseases greatly enhances the nurses’ ability to effectively assess older
adults. Particular attention to changes in function and cognition are
among the most important assessment parameters in the care of older
adults.
Older adults present challenges to health assessment. They greatly
benefit from having a health care provider who is able to evaluate their
ability to function independently, both physically and cognitively. The
comprehensive geriatric assessment provides an excellent means for fully
assessing all areas of older adult function. Such comprehensive assess-
ment can detect symptoms amenable to treatment resulting in the highest
possible quality of life for older adults.
Criticaљ Tѕinјinє Case StѢdѦ
Mr. Baxter is an 86-year-old man who presents to a comprehensive geri-

atric assessment center with early signs of dementia. He lives alone, takes
five daily medications, and until recently has been able to independently
complete his ADLs. However, last winter his furnace broke and his home
radiator was frozen for 5 days. His daughter came to visit and found him
living in the cold.
1. What dimensions does a comprehensive geriatric assessment gener-
ally involve?
2. What challenges do you anticipate in assessing Mr. Baxter?
3. What normal changes of aging may further complicate your assess-
ment of Mr. Baxter?
4. What are the most important components of assessment for Mr.
Baxter?
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domized clinical trial of outpatient geriatric evaluation and management. Journal of
the American Geriatrics Society, 49, 351–363.
Burns, R., Nichols, L., & Martindale-Adams, J. (2000). Interdisciplinary geriatric primary
care evaluation and management: Two-year outcomes. Journal of the American Geri-
atrics Society, 48, 8–13.
Folstein, M., Folstein, S., & McHugh, P. J. (1975). ‘Mini-mental state,’ a practical method
for grading the cognitive state of patients for clinicians. Journal of Psychiatric
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Fulmer, T., Hyer, K., Flaherty, E., Mezey, M., Whitelaw, N., Orry Jacobs, M. et al. (2005).
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clopedia of nursing research (pp. 510–511). New York: Springer Publishing Company.
Thomson Learning.
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Wallace, M., & Shelkey, M. (2007) Try this. Katz Index of Independence in activities of
daily living (ADL). Try this: Best practices in nursing care to older adults, a series from
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hartfordign.org/publications/trythis/issue02.pdf
C H A P T E R F I V E
Health Promotion
Learning Objectives
1. Differentiate between primary, secondary, and tertiary levels of
prevention among older adults.
2. Identify risk factors, harmful effects, and treatment for excessive
alcohol usage among older adults.
3. Identify the harmful risks and interventions to stop smoking for
older adults.
4. Discuss risk factors, assessments, and interventions for poor
nutrition among older adults.
5. List barriers and facilitators to exercise among older adults.
6. Identify the causes of sleep disturbance among older adults, and
provide nursing interventions to restore sleep quality.
7. Identify risk factors and interventions for fall prevention and
minimizing injury in older persons.
8. Plan the nursing care of older adults, utilizing nonrestraint
strategies.
9. Discuss appropriate immunizations for older adults.
10. Identify interventions for the early detection of cardiovascular
disease.
11. Identify interventions for early detection of diabetes.
12. State American Cancer Society guidelines for early detection of
cancer.
Mrs. Martin is an 82-year-old woman who was admitted to the hospital

after a recent fall. She claims that she tripped en route to the bathroom
and woke up on the floor in the morning. She lives alone, has no prior
history of falls, and states that her daughter calls her daily and visits on
121
weekends. You are the RN performing a follow-up home visit for a home
safety check.
Upon visiting the home you discover that although it is very neat
and clean, she has a number of throw rugs covering the hardwood floor
in her living room. In addition, the carpet in her bedroom is coming up
along the edges. Likewise, there currently is no clear path from her bed
to the bathroom. After your assessment you make a plan to discuss your
suggestions with Mrs. Martin.
The story of Mrs. Martin typifies that of older adults today. Older adults
have many health care needs. These needs have resulted from both nor-
mal and pathological changes of aging. Pathological changes of aging
may result from poor health practices acquired early in life and continued
into older adulthood. The Federal Interagency Forum on Aging-Related
Statistics (2004) reported that in the year 2001, the most leading causes
of death in the United States were heart disease, malignant neoplasms,
cerebrovascular diseases, chronic lower respiratory diseases, influenza,
pneumonia, and diabetes. These have an affect on all individuals at one
time or another, therefore, older adults may still benefit from health pro-
motion activities, even in their later years. In fact, health promotion is as
important in older adulthood as it is in childhood. Older adults are never
“too old” to improve their nutritional level, start exercising, get a better
night’s sleep, and improve their overall health and safety.
The U.S. Department of Health and Human Services developed
National Health-Promotion and Disease-Prevention Objectives (http://
www.health.gov/healthypeople) titled Healthy People 2010. These objec-
tives are achieved through varying levels of prevention. Primary preven-
tion involves measures to prevent an illness or disease from occurring,
for example, immunizations, proper nutrition, and regular fluoride
dental treatments. Secondary prevention refers to methods and proce-
dures to detect the presence of disease in the early stages so that effective
treatment and cure are more likely. Routine mammograms, hyperten-
sion screening, and prostate specific antigen (PSA) blood tests are a few
examples. Tertiary prevention is needed after the disease or condition has
been diagnosed and treated. This is an attempt to return the client to an
optimum level of health and wellness despite the disease or condition, for
example, physical, occupational, and speech pathology services follow-
ing a cerebrovascular accident.
Despite the need to promote health among older adults and the
clearly defined objectives, many barriers stand in the way of improved
health among this population. One of the greatest barriers surrounds
misconceptions about the benefits of health promotion for older adults.
Another barrier lies in the challenge of separating the normal changes
Health Promotion 123
of aging from pathological illness. For example, joints normally stiffen

as one ages, causing the older adult to use the joint less for fear that the
stiffness may worsen. In actuality, this joint may benefit from increased
activity, which would potentially reduce or reverse the normal change of
aging as opposed to exacerbate it. A final barrier to improving the health
promoting activities of older adults is their own motivation to change. In
fact, this is the most important factor in improving health. The best health
care in the world cannot make an individual do something they don’t
want to do.
Historically, older adults have not been targeted for educational pro-
grams regarding risk awareness or prevention, detection, and screening
activities. Only recently have third-party payers begun to pay for some
of the necessary screening activities. Older adults tend to have more dif-
ficulty attending cancer prevention, awareness, and screening activities
because of lack of funds or transportation. Sensory and cognitive deficits
may prevent them from understanding or utilizing the information that is
given. Fatalistic attitudes that cancer treatment for older adults is hope-
less also contribute to the problem.
Title of Study: Building a Model of Self-Care for Health Promotion in

Aging
Authors: Leenerts, M., Teel, C., Pendelton, M.
Purpose: To identify the essential factors in self-care related to health pro-
motion and well-being in aging. To organize these findings in a litera-
ture-based, integrated model with applicability in practice, research,
and education.
Methods: From the databases of Medline, CINAHL, and PsycINFO,
both theoretical and research articles from the past 10 years relating
to self-care and health promotion in community-dwelling elders were
accessed.
Findings: The topic of the elderly related to self-care and health promo-
tion is multifaceted and includes: internal and external environment,
self-care ability, education, and self-care activity. An education plan is
presented focusing on the promotion of self-care and health improve-
ment.
Implications: A model of self-care for health promotion for the elderly was
composed. Suggestions for its use in clinical practice were made, as well
as theory formation and hypothesis testing.
Journal of Nursing Scholarship, 34(4), 355–361.
PRIMARY PREVENTION
Ideal health promotion behaviors at the level of primary prevention,

include: smoking cessation and limited alcohol consumption, good nutri-
tion, exercise, adequate sleep, safe lifestyles, and updated immunizations.
Special attention to health promotion practices of diverse cultural groups
is necessary as some of these groups are at higher risk for diseases. A 2002
report released by the Institute of Medicine reports that health disparities
are evident in morbidity and mortality statistics. For example, African
American women are more likely to die from HIV and Hispanic Ameri-
can/Latinas are more likely to die from chronic Lyme disease. Moreover,
hypertension is among the top 10 causes of death in Asian American/
Pacific Islander and Native Hawaiian women. Despite the increased risk,
these populations tend to be less likely to receive regular blood pres-
sure and cholesterol evaluations. This chapter will discuss areas of health
promotion for older adults and provide recommendations for effective
interventions to promote health among the older adult population in the
primary secondary levels of prevention.
Alcohol Usage Among Older Adults

The Robert Wood Johnson Foundation (2001) estimates that the number
of older adults abusing alcohol will increase from 1.7 million to 4.4 mil-
lion by the year 2020. For women of all ages and men older than age 65,
more than seven drinks per week or more than three drinks per occa-
sion is considered a risk for problem drinking (The National institute on
Alcohol and Alcoholism). Alcohol dependence and alcoholism have the
potential for great consequences among older adults, including negative
effects on function, cognition, health, and overall quality of life. Nurses’
and health care professionals’ failure to understand the prevalence of
CѢltural Focus
Special attention to health promotion practices of diverse cultural groups

is necessary, as some of these groups are at higher risk for diseases reports
that health disparities are evident in morbidity and mortality statistics.
For example, African American women are more likely to die from HIV
and Hispanic American/Latinas are more likely to die from chronic Lyme
disease. Moreover, hypertension is among the 10 top causes of death in
Asian American/Pacific Islander and Native Hawaiian women. Despite
the increased risk, these populations tend to be less likely to receive regu-
lar blood pressure and cholesterol evaluations.
alcohol abuse is one of the greatest barriers surrounding interventions to

help older problem drinkers. This is partly due to the fact that symptoms
of alcohol use, including alteration in mental status and function, resem-
ble the symptoms of delirium, dementia, or depression, which occur fre-
quently among older adults. Moreover, older adults often are no longer
in the workforce where daily performance failures, common with alcohol
usage, can be more readily detected.
Alcoholism is a greater problem for older adults because older adults
are not able to physiologically detoxify and excrete alcohol as effectively
as younger people. Older adults with alcohol problems who receive treat-
ment are capable of achieving positive health outcomes (Blow, Walton,
Chermack, Mudd, & Brower, 2000). In fact, when older adults receive
effective treatment for their alcoholism, their prognosis is much better
than it is for their younger counterparts. When alcohol abuse is suspected
among older adults, it is necessary to refer them immediately to an appro-
priate program for effective treatment.
Smoking
It is impossible in one brief book to discuss all of the harmful effects of
cigarette smoking. Currently, there is evidence to support that cigarette
smoking causes heart disease, several kinds of cancer (lung, larynx, esoph-
agus, pharynx, mouth, and bladder), and chronic obstructive pulmonary
diseases, including bronchitis, asthma, emphysema, and bronchiectasis.
Cigarette smoking also contributes to cancer of the pancreas, kidney,
and cervix (U.S. Department of Health and Human Services, 2000). The
current cohort of older adults is one of the first groups to have poten-
tially smoked throughout their entire adult lives. The effects of smoking
are silent and often occur slowly over time. Older adults do not always
experience typical symptoms of disease until lung damage has occurred.
Research has shown that because smoking begins and propagates disease
development, it is one of the most critical negative predictors of longev-
ity. Because of the large number of medications older adults often take,
including over-the-counter (OTC) and herbal medications, the potential
for these drugs to interact with the nicotine in cigarettes is high. Nicotine–
drug interactions can cause many problems for the older adult.
Despite contrary belief, it is possible for older adults to experience
the benefits of smoking cessation even in old age. Moreover, it is impor-
tant to note that older adults may be more motivated to quit smoking
than their younger counterparts, because they are likely to experience
some of the damage that smoking has caused. Nurses are in an ideal
position to assist older adults to quit smoking to promote health or while
recovering from an acute illness or managing chronic illnesses.
Interventions to stop smoking usually surround behav-

ioral management classes, and support groups are available to
community-dwelling older adults. Nicotine-replacement therapy and
anti-depression medications are also helpful in assisting the older adult
to quit smoking.
Nutrition and Hydration

A large study was conducted among older adults aged 65 and older
(n = 1113) to determine whether older adult diets met the Recommended
Daily Allowance (RDA) and what factors contributed to dietary ade-
quacy. The results showed that diets were inadequate in 16.7% of the
older participants. Nutritional knowledge and the possession of positive
attitudes and beliefs contributed to good diets in the older population
(Howard, Gates, Ellersieck, & Dowdy, 1998). More recently, Odlund
(2003) found diets to be inadequate in community-dwelling older adults
and Ammerman, Lindquist, Lahr, and Hersey (2002) report that 4 of the
10 leading causes of death are related to poor diet.
Title of Study: Quality Assessment in Nursing Homes by Systematic Direct

Observation: Feeding Assistance
Authors: Simmons, S. Babineau, S., Garcia, E., Schnelle, J.
Purpose: To develop and test a standardized observational protocol for
routine use to evaluate feeding assistance quality.
Methods: Four feeding assistance quality indicators were defined and oper-
ationalized for 302 long-term residents in 10 skilled nursing homes. The
quality indicators included: (1) staff ability to adequately record intake,
(2) staff ability to adequately provide assistance to at-risk individuals
during mealtime, (3) staff ability to provide feeding assistance to resi-
dents identified by the Minimum Data Set as requiring assistance during
mealtime, and (4) staff ability to provide verbal prompt to residents
who receive physical assistance at mealtimes.
Findings: A significant difference exists between facilities for 3 of the 4
quality indicators. Staff “failed” the quality indicators as follows: QI 1:
42–91%; QI 2: 25–73%; QI 3: 11–82%; QI 4: 0–100%.
Implications: A standardized, observational protocol can accurately mea-
sure the quality of feeding assistance in nursing homes. This can be
replicated and shows significant differences exist between facilities.
Journal of Gerontology, Medical Sciences 2002, Vol. 57A, No. 10, M665–M671.
Risk Factors for Malnutrition

There are many factors that account for the high prevalence of nutri-
tional deficiencies in older adults. The normal changes of aging place
the older adult at a higher risk for nutritional deficiencies. In addition,
a decrease in the smell, vision, and taste senses and the high frequency
of dental problems makes it difficult for the older adult to maintain ade-
quate daily nutrition. Lifelong eating habits, such as a diet high in fat and
cholesterol, are other obstacles to maintaining optimal nutrition. Such a
diet is a leading cause of coronary artery disease. The diminishing senses
of taste and smell result in less desire to eat and may lead to malnutrition.
Diminishing taste is also accompanied by a decline in salivary flow, which
accompanies aging. The taste buds are sensitive to sweet, sour, salt, and
bitter. Although some taste sensations probably decline with age, the sen-
sitivity to sweet is apparently higher, which may account for the older
adult’s preference for sweeter foods.
Nutrition and hydration assessments are necessary to help older
adults meet daily nutritional requirements. By middle age, eating pat-
terns have become relatively fixed, and change may be difficult. Familiar
food patterns serve as a security blanket. Distinctive ethnic, racial, and
regional characteristics are still prevalent among older adults, and ethnic
or racial identity can be reaffirmed by suggesting the use of traditional
foods. To determine the cultural–religious influence on the client’s diet,
the caregiver should start with an in-depth history of the client’s dietary
habits. The client should be questioned closely on food likes and dis-
likes, ethnic preferences, and general nutritional knowledge. It is best to
encourage the good food habits of the client’s particular cultural group
and to make improvements gradually rather than impose too many
changes at once. When working with cultural and religious food pat-
terns—whether they be Chinese, Japanese, Mexican, American, Italian,
Indian, Jewish, or any other—the health care professional must have a
thorough understanding of the client’s cultural and religious preferences.
These could significantly impact their food intake and nutritional status.
There are many risk factors for malnutrition that must be assessed to
determine their impact on maintaining a healthy nutritional status. Lim-
ited income is a substantial concern among older adults and contributes
to the poor nutritional status in the population. Income usually decreases
sharply with age (see Chapter 1). Retirement, health problems that affect
one’s ability to work, and inflation are just a few reasons many older adults
live below the poverty line. This lack of income results in the tendency
to purchase lower cost foods, which may be less nutritious. Moreover,
many adults live in environments of care that are absent of adequate food
preparation and storage facilities, refrigeration space, and other elements
necessary to maintain a good level of nutrition. Lack of transportation

to purchase food and poor eating environments are other contributing
factors of malnutrition. One option for adults without transportation is
the Title III Meal Program. This program offers Meals-on-Wheels, which
serves healthy, home-delivered, hot meals to older adults. The cost of this
program varies depending on the older adult’s ability to pay.
In addition, because eating is often regarded as a social experience,
isolation from family members and friends often negatively impacts
nutrition by making the eating experience lonely. This is especially true
for long-term care environments where the older adult is often seated
away from others, but is left to eat in a loud, undesirable environment.
Malnutrition among older adults may be closely linked to loneliness,
boredom, anxiety, fear, bereavement, general unhappiness, isolation, and
depression.
Physiologically, older adults may experience malnutrition because of
some of the normal and pathological changes of aging. For example, loss
of teeth, which commonly occurs among older adults, greatly impacts
the eating experience. Moreover, the loss of teeth and replacement with
poorly fitting dentures may cause older adults to make poor food choices
simply because they’re easier to eat, such as ice cream, milk shakes, and
other foods high in carbohydrates. The lack of insurance reimbursement
for replacement dentures as the gum sizes change also contributes to this
problem. Moreover, the presence of chronic disease among older adults,
such as cardiovascular diseases and diabetes, further impact nutrition. In
these cases, the addition of dietary supplements may be helpful.
Failure to Thrive (FTT)

Failure to Thrive (FTT) is a syndrome used to describe a client who experi-
ences malnutrition in absence of an explanatory medical diagnosis. It was
first recognized as a syndrome in the late 1980s and is derived from work
with infants bonding with their mothers. In these studies, a lack of maternal
bonding seemed to be the cause of FTT in infants (Hogstel, 2001). FTT
in adults is thought to be similar in that it seems to result from a lack
Cultural Focus
Distinctive ethnic, racial, and regional characteristics are still prevalent

among older adults. Ethnic or racial identity can be reaffirmed by suggest-
ing the use of traditional foods. To determine the cultural–religious influ-
ence on the client’s diet, the caregiver should start with an in-depth history
of the client’s dietary habits.
of physical touching or affection and meaningful care. Earlier work on

touch indicates that when human beings lack touch, the experience is
equivalent to malnutrition and may possibly cause psychotic breakdown
(Colton, 1983). Because of the loss of partners and friends, as well as
translocation and institutionalization of older adults, touch depriva-
tion is highly likely to occur in this population. Gleason and Timmons
(2004)) underscore the importance of touch as a continued need that may
be fulfilled by health care professionals. However, the authors caution
professionals to assess the resident’s perception of touch in all cases.
FTT has often been found in conjunction with dehydration, impaired
cognition, dementia, impaired ambulation, and difficulty with at least
two activities of daily living. Neglect is a frequent cause of FTT and
is usually accompanied by family dysfunction and stress. Nurses play
an important role in the assessment of FTT and the timely implementa-
tion of interventions to prevent further malnutrition and promote client
health and safety.
Interventions to Promote Nutrition

After identifying nutritional concerns and risk factors, it is necessary to
plan care surrounding nutrition in the older adult. In light of the fact
that there was limited nutritional information available to current older
adults in their early and middle years, teaching is an essential interven-
tion. In 2003, the U.S. Preventive Services Task Force (USPSTF) con-
ducted a comprehensive review of dietary education programs. They
found sufficient support to recommend dietary counseling to produce
small to moderate changes in diet in primary care populations. They
also found that the need to increase dietary counseling increased greatly
in the presence of high cholesterol, obesity, diabetes, and hypertension.
When counseling was provided to disease populations, medium to large
changes in diet occurred. Consequently, once a dietary assessment has
been conducted, it is essential to provide teaching on what food in the
client’s diet is healthy and should remain and which should be replaced
with healthier alternatives.
One guideline that has been effective in this teaching is the Food
Guide Pyramid. These Dietary Guidelines for Americans recommend
3 to 5 servings of vegetables or vegetable juices, 2 to 4 servings of fruits
and fruit juices, and 6 to 11 servings of grain products daily. Moreover
they recommend a diet with less than 10% of calories from saturated fat
and less than 30% of calories from total fats with limited trans fats. Each
food group provides some but not all of the nutrients one needs. Foods
in one group cannot replace those in another, therefore, no one food
group is more important than another; they are all necessary for good
health. It is a convenient plan designed to help a person plan an adequate

diet, because it allows you to evaluate the daily intake of milk and milk
products, meat, fruits, vegetables, and bread, grains, and cereals. Many
older adults can name the food groups but are unable to recall the amount
of each food group that should be consumed per day.
It is essential to work with the older adults to help them identify
which foods provide maximum nutrition without empty calories. It is
also important to provide behavioral counseling to help patients set rea-
sonable weight and body fat goals and increase self-esteem and social
support to help to meet these goals.
Exercise
The role of regular exercise in promoting health and preventing disease
cannot be underscored enough. There is overwhelming evidence that
regular exercise results in improved sleep, reduced constipation, lower cho-
lesterol levels, lower blood pressure, improved digestion, weight loss, and
enhanced opportunities for socialization. A recent study by Melov, Tar-
nopolsky, Beckman, Felkey, and Hubbard (2007) found that six months
of resistance exercise training resulted in reverses signs of aging in human
skeletal tissue. Despite these seemingly wonderful results, a great deal of
research shows that the amount of exercise performed by older adults in
industrialized countries is reduced with age. This reduction occurs despite
the absence of both physiological and psychological restrictions against
exercise. However, normal changes of aging, diseases, and environmental
changes often result in barriers to effective exercise among older adults.
Nurses are in an ideal role to teach the interventions necessary to
help older adults to participate in exercise programs, beginning with the
benefits of exercise. Helping older adults choose exercise programs that
they will enjoy, as well as encouraging them to exercise with others, are
key factors in motivating them to exercise. The ideal exercise program
will combine strength training, flexibility, and balance. One of the most
popular forms of exercise among older adults is walking. Walking tran-
scends care settings, requires little equipment (except good shoes), and is
accessible 24 hours a day. Other exercises popular among older adults
include both weight-bearing and aquatic exercises. Weight-bearing and
muscle-building exercises assist in maintaining functional mobility, pro-
moting independence, and preventing falls. In addition, weight-bearing
exercises have been shown to be very effective in reducing bone-wasting
related to osteoporosis (Katz & Sherman, 1998). Aquatic exercises are a
pain-free method of promoting health and increasing functional ability,
especially for older adults with arthritis and osteoporosis. It is important
that older adults who have not been regularly exercising have a complete
health assessment prior to beginning a new exercise regime.
Sleep
Inability to fall asleep and sleep through the night are among the most
frequent complaints of older adults. Kryger, Monjan, Bliwise, and Ancoli-
Israel (2004) report that approximately 57% of older adults report one or
more sleep problems. Sleep is affected by both normal and pathological
changes of aging. Normal changes of aging include an increase in night-
time awakenings and overall sleep deficiency, shorter periods of deep sleep,
a decline in slow wave activity and longer time spent in stage 2 of the
sleep cycle. Pain and medication side-effects are among the pathological
contributors to poor sleep among older adults. Kryger et al. (2004) report
that inability to get a good night’s sleep results in: excessive daytime sleepi-
ness, attention and memory problems, depressed mood, falls, use of sleep-
ing medications, impaired health, and lower quality of life. A good night’s
sleep is essential to maintaining energy and function as well as motivation
to continue a high quality of life. The first step toward achieving good
sleep hygiene is to perform a comprehensive sleep assessment. Based on the
results of the assessment, the nurse may provide teaching about the effects
of normal changes of aging on sleep and reassure older adults that changes
in sleep are not necessarily problematic. With this information, anxiety
regarding “too little sleep” may be diminished. The following recommen-
dations may help the older adult to enhance their quality of sleep:
• Increase physical activity during the day.

• Increase pain medication or alternative pain methods to help older
adults suffering from painful conditions to get better rest at night.
• Examine the sleep environment. Adjustments in noise and lighting
may help older adults to sleep better.
• Assess the stress in the lives of older adults. Identification and
resolution of stressful life factors may help older adults to sleep
more peacefully.
• Some believe daytime napping can interfere with a good night’s
sleep. Therefore, older adults who choose to nap during the day
should acknowledge that it will likely reduce the total nighttime
sleep needed.
Fall Prevention
Falls among older adults in every care setting are a large national prob-
lem. Vu, Weintraub, and Rubenstein (2004)) report that falls occur at
a rate of 1.5 falls, per bed, per year. Many falls are benign and result
in no injury to the older adult. However, when an older adult falls, the
consequences may be devastating. They are likely to develop a fracture,
which begins them on a spiral of iatrogenesis, which may end in death.
In fact, the CDC (2006c) reports that 13,700 older adults died from falls
in 2003. While older men tend to die from falls, older women experience
more hospitalizations for fall-related hip fracture (http://www.cdc.gov/
epo/mmwr/preview/mmwrhtml/ss4808a3.htm).
Both normal and pathological aging changes, as well as unsafe
environments, contribute to the high rate of falls among older adults
and place them at higher risk for falls. Normal changes of aging sur-
round sensory alterations, such as visual and hearing decline, as well as
changes in urinary function. Pathological changes include neuromuscular
and cognitive disorders, osteoporosis, strokes, and sensory impairments.
Older adults who have fallen previously have a higher risk of experienc-
ing another fall.
The first line of fall prevention among older adults is to conduct a
comprehensive fall assessment. Once an older adult is determined to be at
Title of Study: Diabetes Mellitus as a Risk Factor for Hip Fracture in Mexi-
can American Older Adults
Authors: Ottenbacher, K., Ostir, G., Peek, M., Goodwin, J., Markides, K.
Purpose: To examine diabetes and other potential risk factors for hip
fracture in a sample of community-dwelling, older Mexican American
adults (> 65 years old).
Methods: 3050 older Mexican American subjects participated in a
longitudinal study. They were originally interviewed and tested to
establish a baseline and then reassessed in 2-, 5-, and 7-year inter-
vals. Incidence of hip fracture was noted for subjects over the 7-year
follow up.
Findings: At baseline, 690 individuals were identified with diabetes. 134
subjects experienced a hip fracture during follow-up. Cox proportional
hazard regression showed a greater hazard ratio for hip fracture for
diabetic subjects compared to those without diabetes (when adjusted
for age, body mass, smoking, and previous stroke). The hazard ratio for
Mexican Americans taking insulin was 2.84 when adjusted for covari-
ates.
Implications: In older Mexican Americans, it was found that an increased
risk for hip fracture exists for persons with diabetes. Because the Mexi-
can American population has a high incidence of Type 2 diabetes, fur-
ther study is needed for the risk factors for this ethnic group.
Journal of Gerontology, Medical Sciences 2002, Vol. 57A, No. 10, M648–
M653.
risk for falls, it is essential that a fall prevention program be implemented

to prevent this from occurring. Fall prevention interventions include a
thorough assessment of the environment in which the older adult lives.
Area rugs and furniture that may be fall hazards should be removed and
appropriate lighting and supports should be added to areas in which older
adults ambulate. Many homes and facilities have placed a patient’s mat-
tress on the floor to prevent injuries from falling out of bed. The use of
wall-to-wall carpeting also pads a patient’s fall, resulting in less injury on
impact. The use of an alarm for the bed or wheelchair to alert caregivers
of an older adult’s mobility may assist older adults who have had falls in
the past. Shelkey (2000) reports that specially trained dogs may also pre-
vent falls by alerting caregivers of the sudden mobility of an older adult.
Restraint Usage
In the need to prevent older adults from falling or harming themselves or
others, physical restraints were developed and once commonly used by
many nurses and health care providers in several environments of care. A
Title of Study: Changes in Postural Stability in Women Aged 20 to 80

Years
Authors: Low Choy, N., Brauer, S., Nitz, J.
Purpose: To identify the relationship between vision and postural stability
in order to introduce fall prevention strategies.
Methods: Measurements of postural stability in 453 women aged 20 to 80
years using the Balance Master force-plate system, while performing the
modified Clinical Test for the Sensory Interaction and Balance, and the
Single-Limb Stance Test.
Findings: Women 60 to 70 years old were more unsteady than younger
women in bilateral stance on a firm surface with eyes closed. Initial
instability was noted in 40-year-olds when single-limb stance was tested
with eyes closed. Further instability was evidenced in 50-year-olds
when a foam surface was introduced. A further decline in stability was
demonstrated for each subsequent decade when the eyes were closed in
single-limb stance.
Implications: Age, visual acuity, and support surface were significant vari-
ables influencing postural stability in women. The cause(s) of this insta-
bility and subsequent decline in stability requires further investigation
and research.
physical restraint is defined as a device or object attached to or adjacent

to a person’s body that cannot be removed easily and restricts freedom
of movement. Several types of restraints are available and range from
physical restraints, such as traditional side-rails on hospital beds, jackets,
belts, and wrist restraints, to chemical restraints, such as sedatives and
hypnotics. For a while in the 1980s, the fear of liability from falls was so
high and the use of restraint alternative so low, that restraint usage sky-
rocketed to the point where it was unusual to see an older adult without
a restraint in hospitals or long-term care facilities. The Omnibus Budget
Reconciliation Act (OBRA) of 1987 attempted to curtail restraint usage,
but few alternatives were available to keep clients from falling, and the
impact of the legislation was not as great as expected, but is improving.
Physical restraints greatly impact the physical, psychological, and
cognitive function of older adults. In fact, evidence surrounding the nega-
tive effects of restraint is so disturbing that the mandate for restraint-free
care can no longer be ignored. Older adults should only be restrained if
they are in immediate, physical danger or hurting themselves or others
and then for only a brief period of time. Restraint alternatives should
be implemented to keep residents safe from falls. Some of the alterna-
tives to restraints include placing an older adult’s mattress on the floor
so they are not injured while getting out of bed during the nighttime, as
well as the use of wander-guards and chair and bed alarms to alert the
caregivers when the client is attempting to get out of their bed or chair. As
mentioned previously, dogs may also been trained to summon a caregiver
when the client begins movement.
Adult Immunization
One of the greatest advances in primary prevention and public health has
been the use of immunizations to prevent disease. People age 65 and older
and persons of all ages with chronic diseases are at increased risk for com-
plications from viral infections. During epidemic outbreaks, more than
90% of deaths attributed to pneumonia and influenza occurred among
persons aged 65 and older. The few controlled studies of efficacy in per-
sons age 65 and older suggest that when there was a good antigenic match
between vaccine and virus, influenza vaccination prevented about 40% of
hospitalizations and deaths caused by respiratory illness. See Figure 5.1.
Influenza
Influenza is a major cause of morbidity and mortality in older adults. The
80 and older population experiences an estimated 200,000 hospitaliza-
tions and 36,000 deaths per year due to flu (CDC, 2006a). Despite the
increase in immunization rates and recent Medicare reimbursement for

the vaccine, influenza immunization rates among older adults in senior
housing is approximately only 30–60% while the number of older adults
receiving the vaccine has improved greatly. The CDC (2006a) reports
that influenza vaccination levels increased from 33% in 1989 to 66%
in 1999 among older adults, surpassing the Healthy People 2000 objec-
tive of 60%. The influenza vaccine, which is composed of inactivated
whole virus or virus subunits grown in chick embryo cells, can markedly
reduce the incidence of complications, hospitalizations, and death from
the disease (and should be given annually to all older adults, especially
those with chronic conditions such as pulmonary or cardiac problems
and those in long-term care facilities). Vaccination is contraindicated in
people who have experienced a reaction to the vaccine in the past and
caution should be exercised in administering the vaccine to older adults
who have allergies to eggs. A Healthy People 2010 goal (#14–29 a-b)
is to increase the number of older adults who are vaccinated annually
against influenza and ever vaccinated against pneumococcal disease (U.S.
Department of Health and Human Services, 2000).
Pneumonia
The effectiveness of pneumococcal vaccine in the general population
has not been determined with certainty. However, there is some evi-
dence, and the U.S. preventive task force has recommended that the
pneumococcal vaccine be used in immunocompetent individuals age 65
and older at otherwise high risk for pneumococcal disease. Estimates
indicate that pneumococcal infections resulted in death in approxi-
mately 7% of older adults hospitalized for the disease in 2004 (CDC,
2006b). Despite this high death rate, many older adults still remain
unvaccinated. The CDC recommends that all older adults should get the
pneumonia vaccination every 10 years. However, many barriers about
pneumococcal vaccination, such as the prevailing lack of importance
of the disease and vaccination and the myth that receiving the vaccina-
tion will result in the disease, prevent the older adults from receiving
immunization.
Tetanus and Diphtheria

In contrast to pneumonia vaccination, the effectiveness of tetanus and
diphtheria (TD) toxoids is established on the basis of clinical studies and
decades of experience. Currently, adults aged 50 and older account for
the majority of cases of tetanus, with persons age 70 and older having
a 26% case fatality rate. The TD vaccine series should be completed for
Recommended Adult Immunization Schedule, United States, 2003–2004
by Age Group by Medical Conditions
Age Group Pneumo- Measles,
Vaccine Tetanus-
coccal Mumps,
19–49 Years 50–64 Years 65 Years and Older Diphtheria Influenza 2 Hepatitis B*,5 Hepatitis A6 Varicella*,8
M e dical (polysacch- Rubella
( Td)*,1
Vaccine Conditions aride) 3,4 (MMR)*,7
Tetanus,
Diphtheria 1 dose booster every 10 years 1
( Td)* Pregnancy A
Influenza 1 dose annually 2 1 dose annually 2

Diabetes, heart disease,
chronic pulmonary disease,
chronic liver disease, B C D
including chronic alcoholism
Pneumococcal 1 dose 3,4 1 dose 3,4
(polysaccharide)
Congenital Immunodeficiency,
leukemia, lymphoma, generalized
malignancy, therapy with alkylating E F
Hepatitis B* 3 doses (0, 1-2, 4-6 months) 5 agents, antimetabolites, radiation or
large amounts of corticosteroids
Renal failure / end stage renal

Hepatitis A 2 doses (0, 6-12 months) 6 disease, recipients of
hemodialysis or clotting E G
factor concentrates
Measles, 1 dose if measles, mumps, or rubella
vaccination history is unreliable;
Mumps, Rubella 2 doses for persons with occupational
136
(MMR)* or other indications 7 Asplenia including elective
splenectomy and
terminal complement H E, I, J
component deficiencies
Varicella* 2 doses (0, 4-8 weeks) for persons who are susceptible 8
Meningococcal HIV infection E, K L

(polysaccharide) 1 dose 9
See Special Notes for Medical Conditions below—also see Footnotes for Recommended Adult Immunization Schedule, by Age Group and Medical Conditions, United States, 2003-2004 on back cover
See Footnotes for Recommended Adult Immunization Schedule, by Age Group and Medical Conditions, United States, 2003-2004 on back cover
For all persons Catch-up on For persons with medical / Contraindicated
For all persons Catch-up on For persons with medical / in this group childhood vaccinations exposure indications
in this group childhood vaccinations exposure indications
Special Notes for Medical Conditions
A. For women without chronic diseases/conditions, vaccinate if pregnancy will be at 2nd G. Hemodialysis patients: Use special formulation of vaccine (40 ug/mL) or two 1.0 mL
or 3rd trimester during influenza season. For women with chronic diseases/conditions, 20 ug doses given at one site. Vaccinate early in the course of renal disease. Assess
*Covered by the Vaccine Injury Compensation Program. For information on how to file a claim call 800-338-2382. Please also visit www.hrsa.gov/osp/vicp To file a claim for vaccine injury contact: vaccinate at any time during the pregnancy. antibody titers to hep B surface antigen (anti-HBs) levels annually. Administer
U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005, 202-219-9657. additional doses if anti-HBs levels decline to <10 milliinternational units (mlU)/ mL.
B. Although chronic liver disease and alcoholism are not indicator conditions for
This schedule indicates the recommended age groups for routine administration of currently licensed vaccines for persons 19 years of age and older. Licensed combination vaccines influenza vaccination, give 1 dose annually if the patient is age 50 years or older, has H.There are no data specifically on risk of severe or complicated influenza infections
may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers’ package inserts for other indications for influenza vaccine, or if the patient requests vaccination. among persons with asplenia. However, influenza is a risk factor for secondary
detailed recommendations. bacterial infections that may cause severe disease in asplenics.
C. Asthma is an indicator condition for influenza but not for pneumococcal vaccination.
Report all clinically significant post-vaccination reactions to the Vaccine Adverse Event Reporting System ( VAERS). Reporting forms and instructions on filing a VAERS report are available by calling D. For all persons with chronic liver disease. I. Administer meningococcal vaccine and consider Hib vaccine.
800-822-7967 or from the VAERS website at www.vaers.org. J. Elective splenectomy: vaccinate at least 2 weeks before surgery.
E. For persons < 65 years, revaccinate once after 5 years or more have elapsed since
For additional information about the vaccines listed above and contraindications for immunization, visit the National Immunization Program Website at www.cdc.gov/nip/ or call initial vaccination. K. Vaccinate as close to diagnosis as possible when CD4 cell counts are highest.
the National Immunization Hotline at 800-232-2522 (English) or 800-232-0233 (Spanish).
F. Persons with impaired humoral immunity but intact cellular immunity L. Withhold MMR or other measles containing vaccines from HIV-infected persons with
Approved by the Advisory Committee on Immunization Practices (ACIP), and accepted by the American College of Obstetricians and Gynecologists (ACOG) may be vaccinated. MMWR 1999; 48 (RR-06): 1-5. evidence of severe immunosuppression. MMWR 1998; 47 (RR-8):21-22;
and the American Academy of Family Physicians (AAFP) MMWR 2002; 51 (RR-02): 22-24.
FIGURE 5.1 Immunization guidelines recommended by the CDC.

all clients who have not received the primary series, and all adults should
receive periodic TD boosters. The optimal interval for booster doses is
not established, but the standard regimen suggests a booster about every
10 years. Figure 5.1 presents immunization guidelines recommended
by the CDC. Older adults often did not receive primary immunization
against diphtheria and tetanus in their childhood years. Lack of immu-
nization against these diseases leaves the older adult vulnerable to illness
and possible death from these two toxoids.
SECONDARY PREVENTION
Adopting and maintaining healthy behaviors is the key to a high qual-

ity of life. However, the secondary level of prevention is also essential in
detecting diseases at an early (often more treatable) stage. Strategies for
detecting disease at an early stage involve annual physical examinations;
laboratory blood tests for tumor markers, cholesterol, and other highly
treatable illnesses; and diagnostic imaging for the presence of internal dis-
ease. Essential areas in which secondary prevention is especially important
among the elderly include the early detection of cardiovascular disease.
Cardiovascular Disease
Cardiovascular disease (CVD) is a general term used for a wide vari-
ety of illnesses affecting this system. It affects approximately 50% of
older women and 70% to 80% of elderly men (Williams, Fleg, Ades,
Chaitman, et al. 2002). The CVDs most common among older adults
include hypertension, coronary heart disease, and stroke. Early detection
of CVDs will likely greatly impact treatment among older adults and has
the potential to decrease morbidity and mortality.
In addition to screening for risk factors for cardiovascular disease,
which include obesity, sedentary lifestyle, stress, alcohol, and smoking
discussed in the previous section, the most significant nursing interven-
tions necessary to detect cardiovascular disease are early and frequent
blood pressure and cholesterol screening. The JNC–VII criteria for blood
pressure are listed in Table 5.1. Frequent assessments should be con-
ducted to determine a client’s position within the provided ranges. When
a client’s blood pressure readings exceed the recommended limits, they
should be referred to their primary health care provider for blood pres-
sure management, including antihypertensive medications. The U.S. Pre-
ventive Services Task Force (USPSTF) recommends that older adults with
normal blood pressure readings participate in blood pressure screening
at least every 2 years.
TABLE 5.1 The JNC–VII Criteria for Blood Pressure

BP Classification SBP mmHG DBP mmHG
Normal <120 AND <80

Prehypertensive 120–139 OR 80–89
Stage I Hypertension 140–159 OR 90–99
Stage II Hypertension >160 OR >100
The American Heart Association guidelines for cholesterol levels are

listed in Table 5.2. Assessing cholesterol levels in clients within the normal
range is important in order to reduce morbidity and mortality among this
population. The USPSTF recommends that cholesterol levels be evaluated
every 5 years after age 45. When clients’ cholesterol levels exceed the
recommended limits, they should be re-evaluated more often and referred
to their primary health care provider for cholesterol management, including
treatment with cholesterol-lowering agents. Lipid-lowering medications,
known popularly as statins, are often effective in reducing further occlu-
sion of the cardiac vessels. Statin medications, such as atorvastatin (Lipi-
tor), fluvastatin (Lescol), lovastain (Mevacor), pravastain (Pravachol),
and simvastatin (Zocor), are usually prescribed and must be taken daily.
Nurses should instruct patients on proper administration of statins and also
assist in the evaluation of their effectiveness through periodic laboratory
evaluations. Primary prevention strategies are also recommended to reduce
the effects of high cholesterol on cardiovascular disease. It is important
to know that cultural backgrounds play an important role in cholesterol
levels among older adults. For example, Mexican American men generally
have higher cholesterol levels than any other ethnic group.
Diabetes
Type 2 Diabetes Mellitus (DM) is a chronic medical disease that occurs
commonly among older adults. It is estimated that 20% of the U.S. popu-
TABLE 5.2 American Heart Association Guidelines

for Cholesterol
Mg/dl Mg/DL Mg/dl
Desirable 200 >40 <100

Borderline High Risk 200–239 >40 100–159
High Risk >240 <40 >160
lation will develop Type 2 DM by the age of 75. The CDC reports that 17
million Americans have DM, and over 200,000 deaths occur each year
from diabetes-related complications. DM is often a silent killer as the CDC
estimates that 5.9 million Americans are currently unaware that they have
the disease. As people age, there is a normal increase in insulin resistance
and DM. As with cholesterol levels, cultural backgrounds effect the inci-
dence of diabetes among older adults, with the highest rates of DM occur-
ring in non-Hispanic Blacks. Identification of risk factors for Type 2 DM,
such as cultural influence, obesity, low levels of activity, and poor nutrition,
is the first step toward successful diagnosis and treatment of this disease.
Because Type 2 DM is manifested by an increase in blood glucose
levels, screening for this disease is most efficiently accomplished by test-
ing the blood for elevated glucose levels. Fasting glucose levels between
100 and 125 mg/dl are indicative of pre-diabetes and should be evaluated
often. Higher levels are indicative of diabetes and must be referred to the
primary health care provider for management. Management of DM often
involves the administration of hypoglycemic medications, as well as insu-
lin. Dietary management and weight loss are also recommended.
Cancer
Over half of cancer diagnoses in the United States occurs in those age
65 and older. The cancer incidence rate among people aged 65 to 69 is
approximately double that for those age 55 to 59. Age is also an important
predictor of cancer stage; those of advanced age often have their cancers
diagnosed at later stages than do younger persons. Therefore, the positive
outcomes of cancer treatment appear to diminish as age increases. For all
age groups, lung cancer is still the number one cause of cancer mortality.
For older men, the other major cancer killers, in order, are prostate, colon/
rectum, and pancreas. For older women, colon/rectum cancer is the high-
est killer, followed by cancers of the lung, breast, pancreas, and ovary.
Screening for cancer among older adults is the most effective manner
in which to detect the disease at the earliest possible stage. Consequently,
early detection leads to the most effective treatment. Table 5.3 provides
the American Cancer Society Recommendations on Screening for cancer.
A detailed description of the tests is provided at http://www.cancer.org.
It is important to note that many providers of care to older adults have
debated the usefulness and ethical nature of screening older adults for
cancer. Significant issues surround the cost effectiveness of these often
expensive and painful diagnostic tests versus benefit in increasing life
expectancy. Often cancer diagnosis among older adults results in treat-
ment that greatly decreases quality of life and does not result in improved
life expectancy.
TABLE 5.3 American Cancer Society Recommendations for the Early Detection of Cancer in Average-Risk
Asymptomatic People
Cancer Site Population Test or Procedure Frequency
Breast Women, age 20* Breast self- Beginning in their early 20s, women should be told about the benefits
examination (BSE) and limitations of breast self-examination (BSE). The importance of
prompt reporting of any new breast symptoms to health professionals
should be emphasized. Women who choose to do BSE should receive in-
struction and have their technique reviewed on the occasion of a periodic
health examination. It is acceptable for women to choose not to do BSE
or to do BSE irregularity.
Clinical breast ex- For women in their 20s and 30s, it is recommended that clinical breast
amination (CBE) examination (CBE) be part of a periodic health examination, preferably
140
at least every 3 years. Asymptomatic women aged 40 and over should
continue to receive a clinical breast examination as part of a periodic
health examination, preferably annually.
Mammography Begin annual mammography at age 40.*
Colonocial Men and Fecal occult blood Annual starting at age 50.
women. age 50* test (FOBT)†, or
Flexible sigmoidos- Every 5 years, starting at age 50.
copy, or
Fecal occult blood Annual FOBT and flexible sigmoidoscopy every 5 years, starting at
test (FOBT)† and age 50.
flexible sigmoidos-
copy,‡ or
Double contract DCBE every 5 years, starting at age 50.
barum (DCBE), or
Colonoscopy Colonoscopy every 10 years, starting at age 50.
Prostate Men, age 50* Digital rectal ex- The PSA test and the DRE should be offered annually, starting at age 50,
amination (DRE) for men who have life expectancy of at least 10 years.
and prostate-specific
antigen test (PSA)
Cervix Women, Pap test Cervical cancer screening should begin approximately 3 years after a
age 18* woman begins having vaginal intercourse, but no later than 21 years of
age. Screening should be done every year with conventional Pap tests
of every 2 years using liquid-based Pap tests. At or after age 30, women
who have had three normal test results in a row may get screened every
2 to 3 years. Women 70 years of age and older who have had three or
more normal Pap tests and no abnormal Pap tests in the last 10 years and
women who have had a total hysterectomy may choose to stop conical
cancer screening.
141
Endometrial Women, at At the time of menopause, women at average risk should be informed about risks and symptoms
menopause of endometrial cancer and strongly encouraged to report any unexpected bleeding or sporting to
their physicians.
Cancer- Men and On the occasion of a periodic health examination, the cancer-related checkup should include
related women, age 20* examination for cancer of the thyroid, testicies, ovaries, lymph nodes, oral cavity, and skin, as
check-up well as health counseling about tobacco, and exposure, diet and nutrition, risk factors, sexual
practices, and environmental and occupational exposures.
*
Beginning at age 40, annual clinical breast examination should be performed prior to mammography.
†
FOBT, as it is sometimes done in physicians’ offices with the single sicot sample collected on a fingertip during a digital rectal examination, is not
an adequate substitute for the recommended at-home procedure of collecting two samples from three consecutive specimens. Toilet bowl FOBT tests
are not recommended. In companion with guaiac-based tests for the detection of occult blood, immunochemical tests are more patient-friendly and are
likely to be equal or better in sensitivity and specificity. There is no justification for respecting FOBT in response to an initial positive finding.
‡
Flexible sigmoidoscopy together with FOBT is preferred over FOBT or flexible sigmoidoscopy alone.
§
Information should be provided to men about the benefits and limitations of testing so that an informed decision about testing can be made with
the clinician’s assistance.
Tertiary prevention and the treatment of acute and chronic diseases

to prevent further disease progression and improve function will be dis-
cussed in Chapters 9 and 10, respectively.
SUMMARY
This chapter underscores the need for primary prevention among older
adults to prevent and reduce the harmful effects of smoking and excessive
alcohol usage and to prevent the effects of poor nutrition and sleep pat-
terns, as well as sedentary lifestyles, on the health of older adults. Early
detection of fall risk and implementation of strategies to prevent falls, as
well as immunization against vaccine-preventable diseases, are additional
primary prevention strategies to help maintain the health and quality of
life of older adults. The early detection of disease is an essential second-
ary prevention strategy to decrease the morbidity and mortality of older
adults. Nurses who care for older adults can do much to promote their
health and well-being through education, research, and practice.
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C H A P T E R S I X
Pathological Disease
Processes in Older
Adults
Leaning Objectives
1. Identify clinical presentation of, and interventions for, commonly
occurring musculoskeletal disorders among adults.
2. Identify clinical presentation of, and interventions for, com-
monly occurring cardiovascular and respiratory disorders among
adults.
3. Identify clinical presentation of diabetes among older adults.
4. Identify clinical presentation of, and interventions for, commonly
occurring infectious diseases among older adults.
5. Identify clinical presentation of, and interventions for, cancer in
older adults.
6. Identify clinical presentation of, and interventions for, Parkin-
son’s disease in older adults.
Mr. Marse is a 75-year-old African American male who is extremely anx-

ious when he comes into the emergency department with complaints of
an intense crushing pain in his chest that has lasted for 30 minutes and
has been unrelieved by nitroglycerin. As you take Mr. Marse and his
wife to an examination area you notice that he is very short of breath,
and he tells you that he is feeling dizzy. His wife tells you that he has
been under a lot of stress recently and she is very worried about him. As
a result of Mr. Marse’s symptoms, you immediately call the doctor and
take Mr. Marse’s vital signs, which are as follows: BP 200/110, P 85, R 46,
T 100.1°F. He tells you that he does not think that he can stand the pain
much longer.
145
As is the case with Mr. Marse in the preceding case study, the older
population experiences a number of acute and chronic illnesses through-
out the later decades of life. These illnesses make up the majority of the 10
leading causes of death among the U.S. population (Table 6.1). Because of
the substantial amount of acute and chronic illnesses, the older population
needs experienced nursing care in order to prevent unnecessary morbidity
and mortality. Fulmer (2001) reports that older adults are hospitalized for
acute illnesses approximately three times as often as the rest of the popula-
tion, and their stays are double that of younger individuals.
Acute illnesses, by definition, develop quickly and last only a short
time. However, because of the interaction of normal changes of aging
and co-morbidity, some acute diseases become chronic in the older popu-
lation. While acute and chronic illnesses occur in all populations, the
risk factors, presentation, and duration of these conditions is different
in older adults than in their younger counterparts. Furthermore, older
adults with acute illnesses are more likely to develop life-threatening
complications, such as changes in mental status, dehydration, septice-
mia, pneumonia, falls, and other iatrogenic complications of disease and
disease treatment.
As the older adult population continues to increase in size and lifespan,
the number of chronic illnesses in this population will also increase. These
chronic conditions require effective disease management. It is estimated
that Currently 80% of older adults have at least one chronic illness and
50% have at least two chronic illnesses (Keller, Ostbye, & Goy, 2004).
It is important to understand the impact of acute and chronic dis-
ease on older adults. The presence of a chronic disease often requires daily
medications and frequent medical appointments for disease management.
Moreover, chronic diseases have the potential to decrease an older adult’s
ability to function independently. Almost 40% of community-dwelling
TABLE 6.1 Ten Leading Causes of Death in the United States

Heart Disease
Cancer
Stroke
Chronic Lower Respiratory Disease
Accidents
Diabetes
Pneumonia/Influenza
Alzheimer’s disease
Nephritis, nephrotic syndrome, and nephrosis
Septicemia
Source: http://www.cdc.gov/nchs/fastats/lcod.htm
Pathological Disease Processes in Older Adults 147
older adults experience some limitations related to chronic conditions. The

Federal Interagency Forum on Aging Related statistics (2004) reports that
13% of community dwelling men and 20% of women age 65–74 reported
they were unable to perform at least one ADL, with this number rising to
35% of men and 58% of women aged 85 and older. Currently the three
major chronic conditions in the older population are arthritis, hyperten-
sion, and hearing impairments. Osteoarthritis is the most common form of
arthritis and increases greatly with age (Hogstel, 2001).
This chapter will discuss each of the commonly occurring acute
and chronic conditions among older adults with the specific care con-
siderations for this population. The most commonly occurring muscu-
loskeletal disorders will be discussed first, followed by cardiovascular
and respiratory disease, diabetes, and infectious diseases, such as flu and
pneumonia. The chapter will conclude with a discussion of both cancer
and Parkinson’s disease in older adulthood.
MUSCULOSKELETAL DISORDERS
Osteoarthritis
Osteoarthritis (OA) is one of the most common chronic disorders seen
in older adults and is the number one cause of pain. It affects approxi-
mately 46.4 million Americans, with 8.8% of these reporting an arthritis-
related limitation (CDC, 2007a), and is believed to have a strong genetic
link. OA accounted for 71% of the pain in a nursing home pain study.
Older adults have suffered from osteoarthritis for thousands of years.
In fact, the Bible reports that King Asa, who reigned between 867 and
906 b.c., suffered from a disease of the legs thought to be osteoarthritis.
The prevalence of OA affecting the hip is reported to be 3–6% of White
older adults. However, studies of Asian, Black, and East Indian popula-
tions show a much lower incidence with a virtual absence of the disease
in Blacks and Hispanics.
Osteoarthritis affects approximately 20.7 million Americans: 15.4 mil-

lion women and 5.3 million men in the United States. Studies of Asian,
Black, Hispanic, and East Indian populations show a much lower inci-
dence of disease. Nurses must be knowledgeable about the cultural risk
of acquiring osteoarthritis and assess for this painful disease in all envi-
ronments of care.
OA can be a primary disorder, or a secondary disorder, resulting

from a previous anatomic abnormality, injury, or procedure, or from
occupational factors. Nursing assessment for OA includes the evaluation
of pain as the presenting symptom for most patients, and radiographic
examination of the joints can help aid in the diagnosis and staging of
OA. However, the progression of the disease as seen on X-rays does not
always coincide with the symptoms. In fact, older adults with minor
articular changes may experience profound pain. Treatment for OA is
aimed at relieving pain and preserving or restoring function. Pharma-
cological treatments frequently include nonsteroidal anti-inflammatory
drugs (NSAIDs) and acetaminophen, and narcotic pain relievers when
necessary.
Various nutraceuticals aimed at reducing pain and improving func-
tion are used frequently among older adults with OA. Herbal supplements
commonly used include vitamins C, D, and E, which have shown some evi-
dence of reducing OA symptoms. Ginger and glucosamine have also been
used extensively by older adults to reduce arthritis-related pain. Nurses
must exercise caution in the administration of nutraceuticals and provide
teaching regarding the possible danger of these herbal medications as little
is known about their interaction with prescription medications. Acupunc-
ture is becoming a more popular nonpharmacological OA management
strategy, and anecdotal evidence supports its use. However, there is insuf-
ficient literature to fully support the use of these alternative strategies inde-
pendently to reach treatment goals.
Joint replacement among older adults with osteoarthritis is gaining
in popularity. These surgical procedures are used primarily to replace hip
and knee joints that are dysfunctional because of the long-term effects
of osteoarthritis. While the rehabilitation may be long and intense, more
and more individuals in their eighties and nineties are having total joint
replacements with the hope that the surgery will bring about new mobil-
ity and greatly improve their quality of life.
Osteoporosis
Osteoporosis is another of the most common chronic diseases of older
adulthood. Physiologically, osteoporosis results from a demineralization
of the bone and is evidenced by a decrease in the mass and density of
the skeleton. A theory of the etiology of osteoporosis results from age-
related changes in the synthesis of vitamin C resulting in decreased cal-
cium absorption. The most common areas of bone loss are the vertebrae,
distal radius, and proximal femur.
Osteoporosis affects approximately 44 million women and men aged
50 and older in the United States. It is estimated that this number will
Title of Study: Testing an Intervention for Preventing Osteoporosis in Post-

menopausal Breast Cancer Survivors
Authors: Waltman, N., Twiss, J., Ott, C., Lindsey, Moore, T., Berg, K.
Purpose: To test a 12-month intervention for preventing or treating osteo-
porosis in postmenopausal women who had completed treatment for
breast cancer (except Tamoxifen) and for whom hormone replacement
therapy was contraindicated.
Methods: The intervention was multifaceted and consisted of: (1) home-
based strength and weight training exercises; (2) 5 or 10 mg alendronate
per day, 1500 mg calcium per day, 400 IU vitamin D per day; (3) educa-
tion on osteoporosis; and (4) strategies to promote adherence to interven-
tions. Outcomes were rated categorically: (1) adherence to interventions,
(2) dynamic balance, (3) muscle strength, and (4) bone mineral density
(BMD) of the hip, spine, and forearm.
Findings: 95% adhered to calcium and vitamin D, aldendronate therapy
was above 95%, and adherence to strength training exercises was above
85%. Over 1 year, the 21 participants showed significant improvements
in balance; muscle strength for hip flexion, hip extension, and knee
flexion; and BMD of the spine and hip. They also showed a signifi-
cant decrease in BMD of the forearm. 3 out of the 21 women who had
measurable bone loss at baseline had normal BMD after 12 months of
intervention.
Implications: Significant increases in BMD of the hip and spine were found
at 12 months, as well as a significant decrease in BMD of the forearm.
The multicomponent intervention only lasted 1 year, and the time nec-
essary for full bone modeling or remodeling is believed to be 4 to 6
months, respectively. BMD associated with exercise does not increase
until several remodeling cycles have been completed, so it was recom-
mended that this intervention be continued beyond 1 year. Data from
this study was used in the planning of a study that was to last for 2
years.
Journal of Nursing Scholarship, Fourth Quarter 2003.
grow to over 52 million by the year 2010 (National Osteoporosis Foun-

dation, 2003). In older adults with osteoporosis, the overall decline in
bone mass weakens the bone making it vulnerable to even slight trauma.
Normal changes of aging in the sensory system and in neuromuscular
coordination combine with medications and environmental factors to
place the older adult with osteoporosis at high risk for fall-related frac-
tures. Fractures of the humerus and femoral neck are common, as are hip
fractures in women over age 65. Fractures in older adults often position
these individuals in a spiral of iatrogenesis, with an increased risk of

impaired mobility, decubitus ulcers, pneumonia, and incontinence.
Older individuals who are at highest risk for osteoporosis include:
(a) small, thin women who have fair skin and light hair and eyes; (b) older
adults with a family history of osteoporosis; (c) postmenopausal women;
(d) women over age 65; and (e) men over age 80. In addition, older indi-
viduals who consume a diet low in calcium, smoke, use excess alcohol
or caffeine, or live a sedentary lifestyle are at higher risk for developing
the disease.
Older adults with osteoporosis may develop Kyphosis late in the
disease. Kyphosis is a convex curvature of the spine that causes loss of
height and chronic back pain as well as abdominal protuberance, gastro-
intestinal discomfort, and pulmonary insufficiency. Bone density screen-
ings can detect bone loss for those at risk for developing osteoporosis.
However, as there are often no symptoms of this disease, osteoporosis is
seldom diagnosed until a traumatic fracture is sustained. In the event a
fracture occurs, one common treatment procedure is kyphoplasty, which
involves the insertion of an inflatable bone around the fracture. This pro-
cedure has been effective at reducing the morbidity and mortality of this
disease.
Nursing interventions for the prevention of osteoporosis include
encouragement of diets high in calcium and a program of regular exer-
cise. Diets high in calcium (1500 mg/day) and weight-bearing exercise
are among key factors in preventing bone loss in normal individuals and
those at risk. New medications, administered weekly or monthly, have
been shown to prevent further bone loss in those diagnosed with osteopo-
rosis. Alendronate Sodium (Fosamax®), risedronate (Actonel®), or Raloxi-
fene (Evista®) have been shown to prevent further bone loss and develop
new bone mass. While clients taking the daily form of bone resorption
inhibitors do not have any special consideration, clients taking the weekly
form of the medication should be instructed to take the medication with
breakfast and stand or sit upright for 30 minutes after administration. The
use of calcitonin (Calcimar®, Miaclcin®, Ostreocalcin®) to treat postmeno-
pausal osteoporosis may be recommended. However, this medication must
be administered intranasally or intramuscularly once daily. Consequently,
once per week or month dosing is often preferred by clients.
In individuals with documented bone loss from osteoporosis,
nursing interventions surround fall prevention strategies. Fall preven-
tion interventions include a thorough assessment of the environment
in which the older adult lives. Area rugs and furniture that may be
fall hazards should be removed and appropriate lighting and supports
should be added to areas in which older adults ambulate. Many homes
and facilities have placed a patient’s mattress on the floor to prevent
injuries from falling out of bed. The use of wall-to-wall carpeting also
pads a patient’s fall, resulting in less injury on impact. The use of alarms
on beds or wheelchairs to alert caregivers of an older adult’s intent to
ambulate may assist to prevent falls among older adults who have fallen
in the past. Shelkey (2000) reports that specially trained dogs may be
helpful in alerting caregivers of the sudden mobility of an older adult
to prevent falls.
CARDIOVASCULAR AND RESPIRATORY DISORDERS
Hypertension
Hypertension (HTN), or abnormally high blood pressure, results from
many nonmodifiable and modifiable risk factors and lifestyle behaviors,
and is a serious risk factor for the development of many types of car-
diovascular and renal diseases. Thus, the prevention and treatment of
HTN in older adults is essential in order to maintain both health and
function among the older population. Hypertension is considered a silent
killer, because it has no signs and symptoms. While some older adults
experience headaches from elevated blood pressure, older adults with
this disorder may be unaware of it if they do not receive a blood pres-
sure reading. In fact, approximately one-third of people with HTN are
unaware they have it. The American Heart Association (2007) estimates
that of those with HTN, at least 50% are not on medication while about
25% more are on inadequate hypertensive therapy.
The JNC-VII criteria for blood pressure are listed in Table 5.1. The
guidelines define stage I hypertension as a blood pressure of 140/90 or
above measured on three separate readings. It is important for older adults
to undergo regular blood pressure screening and, if hypertensive, to fol-
low the directions of their physicians. Hypertension treatment guidelines
vary somewhat. Nevertheless, treatment of hypertension has been shown
to reduce morbidity and mortality in both genders and in all ages and
races (CDC, 2007b). Risk stratification is often used to make decisions
about treatment for hypertension. In clients with low CV risk factors,
even a blood pressure as high as 160/100 mm Hg may be treated with
lifestyle modifications alone. The combination of diabetes and smoking
together is more dangerous than either risk factor alone, related to the
possibility of microvascular complications occuring (ACP, 2007). In
contrast, in clients at high risk, such as those with diabetes, antihyperten-
sive drug therapy may be recommended, even when the blood pressure is
less than 140/90 mm Hg. The treatment target is a blood pressure of less
than 130/80 mm Hg (JNC-VII).
The current guidelines for staging and treating hypertension are

listed in Table 5.1. Nursing interventions for the treatment of hyperten-
sion generally begin with diet and lifestyle modification. Older adults with
diagnosed hypertension are generally encouraged to follow a low sodium
and low fat diet. Exercise is encouraged among older hypertensive clients
and has been shown to reduce blood pressure. Despite these clearly obvi-
ous benefits of exercise, the majority of older adults do not exercise, and
should be encouraged to choose culturally appropriate exercises that they
enjoy, such as walking, tai chi, or yoga. The stress management effects
of these therapies, as well as the cardiovascular benefits, are essential for
disease management.
Once-daily dosing of medications and a gradual approach toward
therapeutic leveling is essential. Drugs are increased very gradually until
optimal control is attained. In general, first-line therapy consists of thia-
zide diuretics, such as hydrochlorothizide (HCTZ) or Diuril; and beta
blockers, such as atenolol (Tenormin), labetolol (Normodyne), or pro-
pranolol (Inderal). Angiotensin-converting enzymes (ACE inhibitors),
such as benazepril (Lotensin) or captopril (Capoten); and calcium chan-
nel blockers, such as amlodipine (Norvasc) and diltiazem (Cardizen), are
used for first-line therapy only when the diuretics and beta blockers are
contraindicated. It is important to note that one of the major side-effects
of these medications is impotence. As a result of this side-effect, many
men stop taking the medication. It is important for nurses to assess for
this frequently occurring side-effect and determine its impact on medica-
tion compliance.
Congestive Heart Failure

Congestive heart failure (CHF) is a chronic medical condition that occurs
more commonly as people age. In the United States, approximately 4.8
million people have CHF, and each year 400,000 new cases are diagnosed.
Approximately 287,000 die each year from heart failure (CDC, 2006a).
Both the presentation and outcome of CHF are often influenced by the
presence of comorbidity, and about 80% of all clients with CHF are age
65 and older. CHF is a chronic illness that often presents as acute crisis.
The amount of hospitalizations for heart failure rose from approximately
400,000 in 1979 to over 1.1 million in 2004 (CDC, 2006a).
CHF is a multifaceted disease exacerbated by normal changes in
the heart that accompany aging. The individual structural (physical) and
functional (performance) changes that typify this disease are broad and
generally involve multiple body systems. CHF commonly occurs when
the pumping ability of the heart is impaired and it can no longer deliver
adequate blood circulation to supply the body’s metabolic requirements.
CHF may be used to refer to either left ventricular failure (LVF) or right
ventricular failure (RVF). Left ventricular failure is the cause of CHF in
older adults (Hogstel, 2001). Left ventricular failure may lead to right
ventricular failure causing fluid to accumulate in the lungs and heart,
virtually drowning the cardiac muscle. Approximately 287,000 people
died of CHF in 2006 (CDC, 2006a).
Many diseases result in CHF, but the CDC (2006a) reports that the
most common causes are coronary artery disease, hypertension, and dia-
betes, with 7 of every 10 people presenting with CHF having a previous
diagnosis of hypertension. CHF is an inclusive term for cardiac pathol-
ogies that obstruct circulation, causing excess fluid to build up in the
lungs and body tissues. Blood backed up into the lungs creates pulmo-
nary edema with accompanying dyspnea and fatigue. Fluid also becomes
obstructed in the venous system where the excess pressure causes it to
leak into body tissues. This fluid retention, in turn, creates edema, usually
seen in the lower extremities.
The typical presentation of CHF is the sudden development of short-
ness of breath (dyspnea) with exertion (DOE). Fatigue and weakness are
common. DOE often progresses to shortness of breath at rest, accompa-
nied by both orthopnea and paroxysmal nocturnal dyspnea (PND), or
dyspnea when lying down. In older adults, memory loss, confusion, dia-
phoresis, tachycardia, palpitations, anorexia, and insomnia may occur.
Pedal edema and fluid in the lungs are common findings. Normal and
pathological aging changes may often make the early assessment and
treatment of CHF difficult. For example, pedal edema or weight gain of
CHF may be confused with normal pedal edema that occurs with aging
or the side effects of steroid treatment for COPD. Altered cough reflex
may prevent early detection of pulmonary changes. Other symptoms
such as chest pain or tightness, fatigue, general weakness, a nonproduc-
tive cough, insomnia, and other may be commonly attributable to other
conditions of aging and orthopnea. For example, consider the case of an
89-year-old man with repeated incidents of anxiety attacks. Not until an
EKG and chest X-ray were done during, or subsequent to, these attacks
were cardiac and respiratory signs of CHF associated with these circum-
stances. The expected classic symptoms of CHF are not always exhibited
in the older adult.
Nurses play an important and comprehensive role when caring for
the older adults with CHF. The first role of nurses is to identify early
symptoms of CHF. Nurses who treat elderly patients will likely encoun-
ter this disease and should be aware of its signs and symptoms and how
they present in the older adult. Managing factors that will decrease hos-
pital readmissions is the next role of nurses. In so doing, disease progres-
sion will be minimized resulting in a maximum quality of life. Nurses
must educate clients about self-care and medication administration and

involve the clients in their own care. Treatment for CHF usually involves
a regimen of angiotensin-converting enzyme (ACE) inhibitors, digoxin,
and diuretics. ACE inhibitors, such as benazepril (Lotensin) or captopril
(Capoten), reduce mortality, relieve symptoms, and improve exercise tol-
erance, but they must be used cautiously in clients with an elevated serum
creatinine clearance or renal impairment. Digoxin is commonly used, but
it must be administered cautiously in clients on ACE inhibitors who are
in sinus rhythm. Diuretics, such as furosemide (Lasix), are often used
for CHF clients, and are most effective when sodium is restricted to less
than 2g/day to reduce diuretic doses. Potassium supplements should be
used, along with nonpotassium sparing diuretics. Anticoagulants, such
as warfarin (Coumadin), are used if there is concern about thrombi or
emboli. Vasodilators (nitrates) are often necessary (Hogstel, 2001). When
an older client with chronic CHF develops mild to moderate symptoms of
the disease, the administration of intravenous diuretics is usually started
in order to decrease cardiac workload. Without further symptoms, and
adequate urinary output, the older adults may be evaluated for several
hours in the emergency department, home, or outpatient facility and then
discharged. The persistence of symptoms or failure to reduce cardiac out-
put requires further treatment and hospitalization.
Nurses can be instrumental in the treatment of CHF by assisting older
adults with weight loss for obese clients, sodium restriction, alternating
periods of activity and rest with avoidance of activity levels that exacer-
bate symptoms, and appropriate drug therapy. Although intense physi-
cal exercise should be avoided, moderate exercise to tolerance should be
encouraged. Too much activity restriction can result in severe muscle and
cardiac deconditioning, which can cause the older adult to become a car-
diac cripple, that is, severely disabled and unable to tolerate normal levels
of activity because of severe deconditioning. Clients should alternate aero-
bic activity and rest and avoid excessive walking or swimming, because
these increase the cardiac workload.
Exacerbations and remissions are a common pattern with CHF.
Failure to intervene in a timely manner can lead to further decline, dis-
ability, and premature death. It has been demonstrated that long-term
care settings that implement a standardized interdisciplinary protocol for
treating CHF can improve resident care and apply preventative responses
that avoid hospitalizations (Martien & Freundl, 2004). It is important
to maintain older clients with CHF at the highest possible level of well-
ness to avoid the development of absolute failure, pulmonary edema, or
cardiogenic shock. The major causes of transition from chronic failure to
acute failure and/or pulmonary edema in the older adult are often infec-
tion, exacerbation of other co-morbidities, surgery, trauma, and other
severe stressors. Consequently, nurses must identify the role of these

issues, coordinate services to maintain health, and assist the client to pre-
vent precipitators of CHF to the extent possible.
Angina and Myocardial Infarction (MI)

Angina pectoris and myocardial infarctions (MI) are prevalent car-
diac disorders among older adults. It is estimated that angina occurs in
approximately 13.1% of older adults (CDC, 2007c). The Merck Manual
reports that MI occurs in approximately 35% of older adults, and 60%
of hospitalizations due to acute MI occur in persons 65 or older. A CDC
study of 356,112 adults nationwide reported that 12.9 had a history of
MI (CDC, 2007c).
A variety of factors can precipitate angina and MI among older
adults; the most common of which is coronary artery disease (CAD).
Other causes of MI include coronary thrombosis, coronary occlusion and
coronary spasm (AHA, 2007). Angina results from a lack of oxygen sup-
ply to the heart muscle due to a reduced blood flow around the heart’s
blood vessels. It is the most common symptom of myocardial ischemia
and is experienced commonly among older adults with coronary artery
disease (CAD). The American Heart Association (2007) defines a myo-
cardial infarction as “the damaging or death of an area of the heart mus-
cle (myocardium) resulting from a blocked blood supply to that area”
(AHA, 2007). It occurs when a part of the heart muscle dies because of
sudden, total interruption of blood flow to that area.
The classic clinical presentation of MI, regardless of gender, is pain.
The pain and dysrhythmias of MI are often more serious in older adults
than in younger clients as a result of both normal and pathological aging
changes. Moreover, older adults may not exhibit normal signs of MI,
which include: (a) crushing, radiating chest pain; (b) gray, or cyanotic
skin; (c) diaphoresis; (d) severe anxiety; (e) nausea and vomiting; and
(f) hiccough. In some cases, there may be no symptoms of MI (silent heart
attack). However, older adults may display several symptoms: (a) pain in
the back, shoulder, jaw, and/or abdomen; (b) a diminished level of con-
sciousness or acute confusion; (c) hypotension; (d) dizziness or syncope;
(e) transient ischemic attack (TIA); (f) CVA; (g) weakness; (h) fatigue;
(i) falls; (j) restlessness; or (k) incontinence. While research on clinical
presentation of MI among younger populations has revealed gender dif-
ferences in the clinical presentation of disease, a recent study by Rosen-
gren et al. (2004) revealed that there are no gender differences in clinical
presentation among older adults.
Nurses play an important and comprehensive role when caring for
older adults with MI. The first role of nurses is to identify early symptoms
of angina and MI. Both of these diseases may present as pain, so pain
complaints must be considered seriously and proper assessment imple-
mented. Nurse’s beliefs that pain is a natural and expected part of angina
or MI is among one of the most prevalent myths that prevent appropri-
ate treatment. Other barriers include older adult’s hesitancy to report
pain, because they also expect it, think nothing can be done for it, or
are afraid to bother their nurse. Objective pain is aided by the presence
of many standardized tools for assessing pain in older adults. The most
frequently used measure of pain evaluation is a numeric rating scale, in
which the client is asked to choose a position on a scale of 1 to 10,
with 1 being very little pain, and 10 being the worst pain imaginable.
However, some research suggests that the abstract nature of these scales
makes them difficult for some older adults, especially those with cogni-
tive impairments, to complete. Visual Analogue Scales (VAS) are straight
horizontal 100 mm lines with verbal pain descriptors on the left and
right sides. Older adults are asked to indicate a position on the scale that
represents their pain. These tests also are not perfect. The “Faces Scale”
depicts facial expressions on a scale of 0–6 with 0 = smile and 6 = crying
grimace, which is another alternative to objective pain assessment. Deter-
mining the right tool for each patient is a necessary step to utilizing these
objective measures effectively. These scales may be used for baseline and
subsequent pain assessments to evaluate effectiveness of treatment. For
older adults with cognitive impairments, awareness of known painful
conditions and evaluation of behavior is essential for effective assessment
and management of pain. The five-item Pain Assessment in Dementia
Scale has been demonstrated to be effective for assessing pain in this
population (Warden, Hurley, & Volicer, 2003).
After pain complaints are validated, further symptoms of angina and
MI should be evaluated in conjunction with the interdisciplinary team
using EKGs and cardiac enzyme evaluation. MIs are a medical emergency
and must be managed accordingly. Drug therapy for chronic angina usu-
ally involves the daily application of nitroglycerin patches (Nitrodisc®,
Nitro-Dur®) to enhance perfusion to the cardiac vessels. Clients with
chronic angina are usually encouraged to keep sublingual nitroglycerin
pills (Nitrostat®, Nitrolingual®) with them. Proper teaching regarding the
application of patches and the administration of sublingual nitroglycerin
is necessary. Clients should be taught to remove the patch and clean the
area before applying the next patch. Sublingual nitroglycerin must be
placed under the tongue and allowed to dissolve.
Lipid-lowering medications, known popularly as statins, are often
effective in reducing further occlusion of the cardiac vessels. Statin
medications, such as atorvastatin (Lipitor), fluvastatin (Lescol), lovas-
tain (Mevacor), pravastain (Pravachol), and simvastatin (Zocor), are
usually prescribed and must be taken daily. Nurses should instruct

patients on proper administration of statins and also assist in the evalu-
ation of their effectiveness through period cholesterol level evaluation.
The American Heart Association guidelines for cholesterol levels are
listed in Table 5.2. Assessing cholesterol levels in clients is important in
order to reduce morbidity and mortality among this population. Selec-
tive beta-blocker medications, such as acebutolol (Sectral) and atenonol
(Tenormin), may also be prescribed to prevent MI in patients with
angina. Like with CHF, nurses can be instrumental in the treatment of
angina and MI by assisting older adults with weight loss for obese cli-
ents, developing a program of physical activity levels, and encouraging
maintenance of a low cholesterol diet (see Chapter 5 for more details on
these health promotion activities).
Obstructive Airway Diseases

The group of obstructive airway diseases collectively rank as the fourth
leading cause of death in the United States, with an increasing mortality
rate, especially among older adults who continue to smoke. The three
major obstructive airway diseases found prevalently among older adults
include chronic bronchitis, asthma, and emphysema, which collectively
form the chronic obstructive pulmonary diseases (COPD). While the
three diseases have distinct pathological processes, they all result in dif-
ficulty breathing and, when untreated, may escalate to medical emer-
gencies. Chronic bronchitis is caused by the inflammation of respiratory
passages and results in edema and the development of sputum, which
tends to make breathing very difficult and, in some cases, impossible.
Asthma is manifested by the onset of bronchospasm, mucosal edema, and
large amounts of sputum production. Asthma is on the rise in the United
States with the incidence and death rates of the disease increasing among
all age groups, including older adults. Some older adults grow old with
the disease, and some experience new onset asthma in their later years.
Emphysema results from damage to the alveoli (the functional units in
the lungs), which results in a reduction in the lung tissue available for
aeration (alveolar-capillary diffusion interface).
While COPD may result from several factors, such as air pollution,
smoking continues to be the number one cause. Even though there is no
formula to calculate the number of cigarettes needed to produce COPD,
small airway changes may begin as early as at about a 20-pack-year-
history (packs per day times years smoked) (Hogstel, 2001). Persons
who have COPD tend to ignore their symptoms for a long time, which
means that clients may be admitted to the hospital, treated for other
problems, or go to surgery without a clear diagnosis of COPD, even
though it is present. As a result, they may develop unforeseen pulmonary

problems along with whatever treatment is being given. Consequently,
it is important for nurses to elicit a history of smoking or prolonged
exposure to second-hand smoke and history of COPD symptoms from
clients.
Nursing interventions for COPD vary by disease, but the goals of all
disease therapies are to maintain clear airways. Suggested nursing ther-
apy and management are similar across diseases. Teaching regarding the
use of oxygen is an important nursing role; ordering and demonstrating
the application of the nasal cannula, as well as instructions regarding
operating the tanks, is often needed. Clients using oxygen must be cau-
tioned not to increase the oxygen level beyond the prescribed dosage for
fear of medical complications and the possibility of becoming dependent
on higher levels of oxygen.
Treatment of both asthma and emphysema currently often entails the
administration of steroid medications. These medications may be inhaled
or administered orally. The side effects of these medications include skin
disorders and hormonal interference. Inhaled bronchodilators, such as
beta agonists or theophyllines, are also common treatments for obstruc-
tive pulmonary diseases. Teaching regarding the use of inhalers is often
necessary as these are the preferred method of drug administration. Cough
suppressants and antihistamines should be avoided among clients with
obstructive respiratory disorders as these medications impair coughing
ability and may cause fatal levels of sedation in respiratory compromised
clients. In clients where palliative measures are warranted, these medi-
cations may be appropriate to facilitate peaceful death. In these cases,
opioids have been supported as safe and effective in reducing terminal
dyspnea and respiratory distress.
Cerebral Vascular Accident (Stroke)

Cerebral vascular accidents, commonly known as stroke, are among the
leading cause of chronic disability in this nation. The risk of stroke occur-
ring increases sharply as people age, with approximately 700,000 strokes
occuring each year and 200,000 stroke deaths occurring among those
aged 65 and older. The symptoms of stroke include sudden onset weak-
ness or numbness in the face, leg, or arm on one side of the body; changes
in vision, including the loss of vision in one eye; difficulty speaking or
understanding language; or sudden onset, severe headache and dizziness.
Unexplained falls may also be symptomatic for stroke.
Risk factors for development of stroke are similar to those of other
cardiovascular diseases. Both modifiable and nonmodifable risk factors
account for the high rate of stroke among older adults. Smoking, obesity,
diabetes, and hypertension are among leading modifiable risk factors,

while advanced age and African American racial background are major
nonmodifiable risk factors for stroke development, the same as those for
other CV diseases.
Strokes are caused by three distinct pathological processes that stem
from risk factors for the disease. A hemorrhage results when a blood ves-
sel in the brain ruptures and part of the brain tissue dies. Emboli or clots
that form in one area of the body may also travel to the brain and cause
brain death. Finally, the carotid arteries, which carry oxygenated blood
to the brain, may become clogged preventing blood flow and resulting in
tissue death.
Often older adults with and without risk factors for the disease
experience “little strokes,” or warning strokes, called transient ischemic
attacks (TIAs). TIAs are manifested by lack of consciousness for a short
period of time lasting from 20 minutes to 24 hours and have the potential
to cause loss of blood flow to the brain. Consequently, reports of TIAs
should be accompanied by a full assessment and the identification of risk
factors and symptomatology for stroke. In addition, a plan of care to
prevent strokes from occurring must be implemented immediately.
Prevention of strokes generally involves the facilitation of adequate
blood flow to the brain. In clients with a history of emboli, anti-embolitic
therapy should be implemented and evaluated regularly for therapeutic
efficacy. In patients with occluded carotid arteries, carotid endarterec-
tomy procedures may be implemented (cleaning plaque from the carotid
artery) in order to enhance blood flow to the brain and reduce the chance
of an embolus breaking off from the plaque and moving to the cerebral
vasculature. Effective auscultation of the carotid arteries for bruits (the
sound of turbulent blood flow) during routine health assessments greatly
enhances the early detection of occlusions in the vasculature and facili-
tates stroke prevention.
Strokes may best be prevented by implementing nursing interven-
tions to reduce risk factors, such as obesity and hypertension. Diet and
nutritional management, exercise, and weight reduction are primary pre-
vention strategies that have been effective in reducing the risk of stroke.
Blood pressure management with these strategies, as well as prescription
Both the incidence and the mortality rates for strokes are higher for Blacks
than for Whites. Consequently, nurses must consistently assess risk factors
for strokes in these populations of older adults, including hypertension,
smoking, diabetes, and obesity.
medications, also reduces the risk of stroke substantially. Nursing inter-

ventions to prevent strokes in high-risk clients, or those with family histo-
ries or TIAs, include the administration of one aspirin per day, ticlopidine
(Ticlid), or warfarin (Coumadin) and management of hypertension.
When symptoms of a stroke are presented, a computed tomogra-
phy (CT) scan, or carotid or cerebral angiography, is usually conducted,
and the cause of the symptoms is identified. If the stroke is due to the
development of a clot (or thrombus), tissue plasminogen activator (tPA),
a clot-dissolving drug, may be administered immediately. The tPA may
potentially dissolve the clot that caused the stroke and quickly restore
blood flow to the brain (Hogstel, 2001). Nursing care for patients with
stroke focuses on stabilization of the client and rehabilitation to the high-
est possible functional level.
DIABETES MELLITUS
Diabetes mellitus (DM) is a chronic medical disease manifested by an

increase in blood glucose levels. The American College of Physicians
(2007) reports that 1 in every 14 Americans has diabetes, resulting in
over 200,000 deaths, 82,000 amputations, and 44,400 new cases of renal
disease each year. Due to greater screening and educational efforts at the
state and national levels, diagnosis rates for diabetes increased 49% from
1990 to 2000 and are expected to continue to rise (http://www.cdc.gov/
diabetes/pubs/glance.htm#growing).
DM is a prevalent disease among older adults, manifested by an
alteration in the production and use of insulin (Hogstel, 2001). In older
adults, elevated blood glucose levels symptomatic of DM result from
altered insulin availability. This is related to defects in the action and/or
production of insulin. When the glucose levels are elevated (hypergly-
cemia) glucose spills into the urine, hence the name diabetes mellitus,
which translates to sweet urine. There are two different types of diabetes
mellitus: Type 1 and Type 2. Type 1 is also known as juvenile onset DM,
or insulin dependent DM (IDDM). Type 2 DM generally appears during
older adulthood and is known as adult onset DM (AODM), or more
commonly, noninsulin dependent diabetes mellitus (NIDDM).
Diabetes and heart disease often go together with obesity and high
cholesterol to form what is commonly known as the cardiovascular
dysmetabolic syndrome. This syndrome involves a cluster of symptoms
including dyslipidemia, hypertension, hyperglycemia, hyperinsulinemia,
and endothelial dysfunction. Having diabetes raises the risk of cardio-
vascular complications because it can cause vascular changes. The insu-
lin sensitivity thought to result in DM may precede disease development
by several years and should be closely watched for by nurses caring for
obese patients.
Smoking greatly affects the symptoms of cardiovascular dysmetabolic
syndrome and is the greatest modifiable risk factor for preventing complica-
tions from diabetes. As reported in Chapter 5, smoking cessation even after
many years of heavy smoking may result in health benefits in the older pop-
ulation and should be encouraged by nurses working with older clients.
Nursing interventions for diabetes must begin with a thorough as-
sessment of functional ability, physical health, social support, financial
support, and older adult’s goals for treatment. The type of therapy should
be tailored to the individual client’s needs and issues. Overall goals aim
at reduction of cardiovascular risk factors, smoking cessation, exercise,
proper weight control, and control of hypertension. Diet and exercise are
two important therapeutic options. Exercise is helpful in increasing insu-
lin sensitivity (American College of Physicians, 2007), and many nursing
homes and care facilities offer exercise programs.
Therapeutic goals for older adults with NIDDM focus on blood glu-
cose control. This may be accomplished with low carbohydrate, diabetic
diets and weight loss and exercise, as well as management of the disease
with oral hypoglycemic medications and insulin when necessary. Com-
plications of NIDDM resulting from poor blood sugar control include
peripheral neuropathy, nephropathy, retinopathy, erectile dysfunction,
foot ulcers, and kidney failure. The use of angiotensin-converting enzyme
(ACE) is often recommended to minimize the damage to the kidneys from
poor blood sugar control.
NIDDM among older adults is closely linked to obesity and physical
inactivity in this population. Weight reduction is essential for managing
NIDDM in obese older adults, and it is of great importance for older
adults with NIDDM to develop healthy eating habits that will result
in control of glucose levels. Self-management of NIDDM in the elderly
includes a suitable diet, medication use, blood glucose monitoring, foot
examination, and exercise. Certain age-related barriers may prevent
older adults from following appropriate diets, adhering to medication
and blood sugar regimens, and beginning and maintaining an exercise
program. Examples of barriers to disease management include poor
vision (can result from diabetic retinopathy or cataracts), co-morbidities,
or decreased motor function. For more information on promoting exer-
cise, dietary assessments, and nutritional counseling, see Chapter 5.
While educating older adults with NIDDM, it is important to note
that medications may produce episodes of low blood sugar or hypoglyce-
mia. Consequently, older adults should be encouraged to carry lifesavers
or a sugary candy with them at all times to take in the event that they feel
weak or dizzy from hypoglycemia. It is also important to teach patients
how to monitor their daily blood sugar. The use of an alarm clock or
wristband, blood sugar tests, and other medications or activities may
help to increase adherence to blood sugar monitoring. Clinical manage-
ment of NIDDM involves awareness of symptoms in elderly patients,
establishment of healthy diet and exercise regimens, and maintenance
of hypoglycemic or insulin medications necessary to control blood sugar
and prevent complications.
INFECTIOUS DISEASES
Influenza
Influenza, commonly known as the flu, is a contagious viral disease that
frequently infects the population in the winter months. The Centers for
Disease Control (CDC, 2007d) report that between 10% and 20% of the
U.S. population are infected with the influenza virus each year. The flu
is often only a mild disease in healthy children and adults, manifesting
symptoms such as fever, sore throat, dry cough, headache, and aching
muscles. Older adults are more likely to develop life-threatening compli-
cations from the flu, such as changes in mental status, dehydration, pneu-
monia, extreme tiredness, and death. Each year, approximately 36,000
U.S. residents die from influenza, and 200,000 more are hospitalized
from the disease (CDC, 2006b).
The influenza virus is spread via droplets through the air when
someone infected with the virus coughs or sneezes. The viruses are spread
quickly from one person to another, particularly in places where there is
a large gathering of people. Carriers of the influenza virus may spread the
disease even before they begin experiencing symptoms.
Similar to pneumonia and other acute and chronic illnesses, older
adults may present with flu symptoms differently from their younger
counterparts. The classic symptoms of cough, congestion, nausea, and
vomiting may be absent or attributed to other disease processes. Older
adults with the flu may present with acute confusion or delirium. Con-
sequently, careful histories should be taken to differentiate symptoms
of the flu from other illnesses, such as chronic dementia, depression, or
psychosis. If the client has chronic confusion or dementia, the presence
of influenza may cause deterioration of the baseline cognitive and func-
tional status.
Evaluation of the symptoms of flu is essential when assessing older cli-
ents, especially during high-incidence seasons. Once an older adult devel-
ops the flu, nursing interventions include making sure that the client gets
plenty of rest as well as maintaining nutrition and hydration. Symptom-
atic treatment of the disease with fever reducers, such as acetaminophen
or ibuprofen, and cough suppressants is also often necessary. Because the

flu can quickly develop into pneumonia in the older population, vigilant
evaluation and treatment of the symptoms is imperative.
Vaccination remains the most commonly used method of prevent-
ing and reducing the impact of the flu. Vaccination is required each year,
because the flu viruses change constantly and unpredictably. Due to the
potential life-threatening complications of the flu, the U.S. Public Health
Service strongly encourages all older adults to get an annual flu vaccina-
tion, which is currently reimbursed by Medicare. However, as noted ear-
lier, all older adults do not have Medicare, especially those from various
cultural backgrounds that may have recently immigrated to the United
States. In these cases, some health departments, grocery stores, pharma-
cies, and senior centers offer free or low-cost vaccination clinics. Nurses
should encourage all older adults to get annual influenza vaccinations.
Contrary to popular opinion, receiving the flu vaccine does not cause the
flu. The most frequent side effect of vaccination is soreness and redness
around the vaccination site for 1–2 days. Reactions of low fever, mal-
aise, and muscle aches occur infrequently and most often affect persons
with no exposure to flu viruses, such as young children. Immediate reac-
tions, which are usually allergic reactions such as hives, swelling of lips
or tongue, and acute respiratory distress, only affect those who have a
hypersensitivity to a component of the vaccine component, usually egg
protein. Because the flu vaccine contains a small quantity of egg protein,
individuals with severe allergies to egg should consult with their physi-
cian before receiving the flu vaccine. The vaccine takes approximately
2–3 weeks to begin working.
Pneumonia
Although pneumonia is a grave health concern for all populations, it is
a substantial problem for older adults. Pneumonia results in the highest
number of infectious disease deaths in the United States with an esti-
mated 60,000 deaths each year (Institute for Clinical Systems Improve-
Medicare currently reimburses providers for annual influenza vaccinations.

However, not all older adults have Medicare, especially those from vari-
ous cultural backgrounds that may have recently immigrated to the United
States. In these cases, some health departments offer free or low-cost vac-
cination clinics. Nurses should encourage all older adults to get annual
influenza vaccinations.
ment [IGSI], 2003). The death rate from pneumonia is even higher
among older adults who have had recent surgery or been weaned from
mechanical ventilation, and it has a great impact on society because of
the high costs involved in treating this disease (Hogstel, 2001). Moreover,
the rates of pneumonia are projected to increase commensurate with the
rise in the geriatric population.
Normal changes of aging, such as lowered immune status, and
changes in respiratory function (Graf, 2006), including altered cough
reflex and diminished airway clearance, play an important role in the
increased risk of morbidity and mortality from pneumonia among older
adults. The presence of chronic diseases such as COPD, CHF, GERD,
impaired swallowing and tube feeding, and impaired mobility, as well as
alterations in levels of nutrition, also are risk factors for pneumonia and
resulting poor outcomes. Malnourished older adults, or those who have a
low albumin (Hogstel, 2001), are also at high risk for pneumonia.
The symptoms of infection change with age, resulting in both
delayed diagnosis and treatment of pneumonia among the elderly. These
factors contribute greatly to the increased mortality rate of the disease
among older adults. The delay occurs because pneumonia has a wide
variety of presentations. The traditional symptoms include cough, fever,
and dyspnea. Purulent sputum and pleuritic chest pain are often absent
or difficult to assess among older adults, but most experience confusion
or delirium, altered functional abilities, and/or decompensation of under-
lying illnesses. These symptoms are often present, along with the atypical
symptoms, but not in all cases. Amella (2004) reports that the fever and
chills associated with infectious diseases, such as pneumonia, are often
replaced with confusion and decreased functional status in older adults.
Amella (2004) further reports that an increased respiratory rate, with
decreased appetite and functioning, may be more sensitive for pneumonia
in this population than traditional symptoms. The presence of changes in
cognitive status among older adults as the presenting sign and symptom
of disease cannot be stressed significantly enough. Consequently, when
an older adult presents with acute confusion or delirium, or changes in
baseline cognitive function, a careful history and physical exam should be
undertaken in order to determine the causes of these cognitive changes. If
pneumonia is suspected, diagnostic testing, including a chest X-ray and
white blood count, should be initiated immediately.
Nursing assessment and management of pneumonia is based on
assessment of the disease as well as identification of the cause of infection.
Older adults with pneumonia may be treated at home or within an acute
or long-term care setting, as long as symptom management is adequate in
these environments. For older adults who require intravenous antibiotics
and frequent respiratory therapy, or for older adults with a history of poor
outcomes from pneumonia and other disease, hospitalization is necessary.
Mrs. Giovanetti was a 75-year-old woman who lived independently in her

own home with her husband. She volunteered 2 days a week at a local food
bank and remained an active member of the community. Three days into the
new year of 2002, she began to feel weak and tired. She shook it off as the
beginning of a cold and went to bed early. The next morning, she could not
get out of bed to perform her activities of daily living; she was confused as to
place and time and was short of breath. Her husband called an ambulance,
and she was admitted to the hospital with acute viral pneumonia.
1. What critical changes in function and cognition were present in
Mrs. Giovanetti as symptoms of her disease?
2. How common is the presence of pneumonia in the older adult
population?
3. What is the role of the pneumonia vaccine in preventing the presence
of this disease in the older populations?
4. What risk factors did Mrs. Giovanetti have for developing pneumonia?
5. What nursing interventions would you plan for Mrs. Giovanetti to
ensure a full recovery from the disease and prevention of iatrogenesis
during recovery?
Nursing interventions for the treatment of pneumonia include the admin-

istration of medications aimed at destroying the causative organism or virus.
In addition, high protein diets and increased fluid intake are necessary to
boost the immune system and provide adequate hydration to clear secretion.
Hydration should be approached with caution in clients with CHF. Antihis-
tamines and cough suppressants should be avoided among older adults unless
they are needed to help induce sleep at night, as both can prevent the cough
reflex necessary to clear pneumonia-related secretions (Hogstel, 2001).
Treatment of fever and discomfort with acetaminophen or NSAIDs is
indicated for pneumonia. Respiratory therapy, such as postural drainage and
percussion, may also be necessary. Clients should be evaluated frequently for
symptom progression. Complications that require follow-up and/or further
therapy include (a) dyspnea, (b) worsening cough, (c) the onset or worsen-
ing of chills, (d) fever occurring more than 48 hours after drug therapy is
begun, or (e) intolerance of the medications (Hogstel, 2001). The recovery
period for pneumonia may be extensive, lasting several months for some
older adults (Hogstel, 2001).
Sexually TransmiĴed Disease and Human Immunodeficiency

Virus/Acquired Immune Deficiency Syndrome
While health care providers are becoming increasingly knowledgeable
regarding the unique needs of older adults, the sexuality of this population
has continued to remain largely unrecognized. Consequently, nurses often

ignore the sexuality of older adults during assessments, assuming that
this aspect of human functioning is no longer applicable. The possibility
of older adults contracting STDs, such as chlamydia, gonorrhea, HIV,
or hepatitis, is not often considered. However, the original Janus Report
on Sexual Behavior found that weekly sexual activity for both men and
women continues past middle age (Janus & Janus, 1993). Moreover, a
recent study of 179 residents of subsidized independent-living facilities,
revealed that the majority had physical and sexual experiences in the past
year (Ginsberg, Pomerantz, & Kramer-Feeley, 2005).
Despite the prevalent myths, sexual activity among older adults occurs
frequently and is on the rise simply because there are so many more older,
healthier adults than ever before (Hogstel, 2001). Sexual activity in men
is heightened by the recent availability of erectile agents such as sildenafil
citrate (Viagra), vardenafil HCL (Levitra), and tadalifil (Cialis). Howover,
because older adults often are not educated regarding safe sex practices
and no longer fear pregnancy, condom usage is low, resulting in a great rise
in the number of STDs and new HIV cases diagnosed among older adults.
Nurses must include a sexual history in the health assessments of
all older adults. Sexual assessments are challenging for both the nurse,
who often has no education or experience concerning sexuality in older
adults, and the older adult, who may not be comfortable discussing sex-
uality with health care providers. Lack of experience and general dis-
comfort with sexuality among health care providers prevents geriatric
professionals from assessing and managing the sexuality needs of older
adults. In the case of most older adults, particularly those from certain
cultures, sexuality was not openly discussed. Some older adults may be
hesitant to verbalize their feelings for fear of being considered as lecher-
ous or depraved.
A model to guide sexual assessment and intervention of older adults
is available and has been well used among younger populations since the
1970s. The PLISSIT model (Annon, 1976) begins by first seeking permis-
sion (P) to discuss sexuality with the older adult. This permission may be
gained by asking general questions such as “I would like to begin to dis-
cuss your sexual health; what concerns would you like to share with me
about this area of function?” Questions to guide the sexual assessment
of older adults are available on many health care assessment forms. The
next step of the model affords an opportunity for the health care provider
to share limited information (LI) with the older adult. In response to the
increase in older adults with sexually transmitted diseases, it is essential
to provide them with safe sex information at this time. In the next part
of the model, specific suggestions (SS) are provided to older adults to
help them fulfill their sexuality. These suggestions may focus on the use
of CDC recommended safe sexual practices. The final part of the model
allows for intensive therapy (IT) to be provided to the older adult regard-
ing sexual issues that may arise during the assessment. This may include
the discovery of sexually transmitted diseases, which require treatment.
The assessment of an older adult’s sexuality should take place in a
quiet area that affords the client necessary privacy. The establishment of
a trusting relationship between health care provider and client is essen-
tial. The nurse must be respectful of the older adult’s sexual beliefs and
practices and prevent judgmental thoughts or comments. Appropriate
history questions regarding sexuality include (a) the number and his-
tory of partners, (b) sexual practices, (c) physical signs and symptoms of
sexual problems, (d) the level of satisfaction with current sexuality, and
(e) the use of protection and precautions. The nurse must provide educa-
tion on safe sex practices to all sexually active older adults, including the
use of condoms.
In the older adult population, STDs, such as syphilis, genital herpes,
and hepatitis, may remain from earlier years and be passed unknowingly
to partners.
Ten percent of all AIDS cases are among people aged 50 and older;
25% are over age 60 (http://www.hivoverfifty.org). However, it is impor-
tant to note that this number is most likely low due to misdiagnosis and
will continue to increase as the population of older adults increases. The
number of cases of other STDs and hepatitis are also likely to increase
commensurate with the increasing elderly population. Due to the normal
and pathological changes of aging, symptoms of HIV and AIDS may go
undetected. For example, common problems of aging such as fatigue, alter-
ation in function, or altered cognitive status (Hogstel, 2001), which could
be symptomatic for HIV, also occur as a result of normal aging changes.
The awareness of the possibility of STDs among older adults heightens the
awareness of these potential disorders and focuses attention on the need
for diagnosis. When sexual history questions lead the nurse to believe that
the older adult is sexually active, especially with more than one partner,
Cultural Focus
Many cultural biases present barriers to discussion about sexual practices

among older adults, which make assessment difficult. In some cultures,
sexuality is not discussed. Nurses must identify these barriers to assessment
and in a respectful manner assess older adult’s sexual practices. This will
provide nurses with the necessary information needed to implement inter-
ventions to prevent the transmission of sexually transmitted diseases.
diagnostic testing may include the presence of semen and vaginal cultures
to rule out infection. These tests should also be conducted if positive symp-
tomatology for STDs is present. However, STDs, such as chlamydia, gonor-
rhea, syphilis, and other diseases, often have few or no symptoms. Vaginal
or penile pain, itchiness or tenderness, and discharge may be symptomatic
of STD infections among older adults. Because HIV is often transmitted
simultaneously with other STDs, the nurse should encourage clients diag-
nosed with an STD to be tested for HIV. The ELISA test may be used to
diagnose the presence of the HIV virus. If this test is positive, the Western
blot test may be conducted to confirm HIV infection.
If STD, HIV, or hepatitis are diagnosed among older adults, appro-
priate drug therapy is initiated. Nurses should provide teaching and
medication administration as needed. In addition, the diagnosis of these
diseases provides an opportunity to teach older adults safe sex practices,
which is essential in order to prevent further, or repeat, infection.
CANCER
While the presence of cancer is seen in all populations, the incidence

and prevalence of cancer is disproportionate to the population. In
fact, approximately 75% of all malignancies in the United States occur
among older adults, which, at present, constitute only about 13% of
the population. Individuals aged 65 and older were found to account
for 56% of all cases of breast cancer and 80% of all prostate cancer in
2002. Clearly, advanced age is a risk factor for the development of can-
cer. But, older adults are also more likely to be diagnosed with cancer
at an advanced stage when the cancer is less amenable to treatment and
increased morbidity and mortality are more likely. Cancer diagnosis
and mortality are highly associated with factors such as race and socio-
economic status.
For both older men and women, lung cancer remains the highest
cause of mortality, followed by prostate cancer and colorectal cancer
for older men and breast cancer and colorectal cancer for older women.
Prostate cancer accounts for 43% of all new malignancies diagnosed in
the United States. Historically, older adults have not received such aggres-
sive therapy as the younger populations. Ageism and myths of aging pre-
vented older adults from being involved in clinical trials for new cancer
treatments, and health care providers often perceived this population to
be at high risk for adverse effects from cancer therapy. However, more
recently, older adults have begun to receive more aggressive treatments
for cancer and are tolerating these treatments well. While special consid-
eration for the normal and pathological changes of aging must be made,
older adults should be offered all treatments available to the younger

populations.
Approximately 218,890 men will be diagnosed with prostate can-
cer in 2007 (ACS, 2007). Of all men diagnosed with cancer each year,
approximately 27,000 will die. This rate is even higher for African
Americans (American Cancer Society, 2007). As stated previously, pros-
tate cancer deaths are second only to lung cancer deaths in the United
States (ACS, 2007). While 1 man in 6 will get prostate cancer during
his lifetime, only 1 man in 34 will die of this disease. Moreover, prostate
cancer is nearly 100% survivable if detected early (US Too!, 2004). The
availability of prostate specific antigen (PSA) testing for prostate cancer
has greatly increased the detection and treatment of early-stage prostate
tumors in older men. The American Cancer Society (2007) reports that
over 230,000 men will discover this year that they have prostate can-
cer with a median age of diagnosis of 71 years; more than one-third of
those newly diagnosed are older than 75. Treatment for prostate cancer
includes the options of internal or external radiation therapy, radical pros-
tatectomy, watchful waiting, and hormonal therapy for late stage disease.
Nurses play an instrumental role in providing teaching during and after
diagnosis with prostate cancer as well as referring clients to appropriate
educational and support services. Nurses will also be involved in admin-
istering treatments aimed at reducing the symptomatology surrounding
this disease as well as aiding treatment.
Among older women, over 200,000 new cases of breast cancer were
diagnosed in the United States in 2004. Like prostate cancer in men,
the risk of women developing breast cancer increases with age. Between
1986 and 2000, women aged 50 and older were the only group to expe-
rience an increased incidence of breast cancer. This is likely due to both
the increased numbers of older women during this time period as well
as the greater availability and attention toward breast cancer screening,
such as self-breast examination (SBE) and mammography. The progres-
sion in lumpectomy and mastectomy procedures, as well as new develop-
ments in radiation and chemotherapy treatments, has sharply increased
the survival rate for breast cancer for older women. The nursing role in
screening and administering treatments for breast cancer is essential in
promoting good outcomes for these older female clients.
Nurses play an instrumental role in both assessing for cancer
and cancer management. In terms of primary prevention, nurses must
educate, counsel, and encourage clients to engage in cancer preven-
tion activities, such as the use of sunscreen, smoking cessation, good
nutrition, and exercise. Secondary prevention strategies such, as self-
breast examination, mammograms, and prostate cancer and skin can-
cer screenings, should be recommended and followed-up to determine
compliance. Providing support and information during the diagnosis

process is essential in treatment decision making.
Pain management is another important role of nurses in managing
older adults with cancer. The most common pharmaceutical medications
used to treat pain in older adults consists of acetaminophen, nonsteroi-
dal and anti-inflammatory drugs (NSAIDs), and opioids. However, the
frequency of adverse drug reactions among older adults and analgesic
sensitivity in this population (Chapter 7) underscores the need for the old
cliché to “start low and go slow” (AGS, 1998). For example, NSAIDs
contribute to gastric ulceration and mask pain that leads to ulcer diag-
nosis. Older adults have also been found to respond to morphine as if
they were given a larger dose, suggesting the need to decrease morphine
dosages in this population. It is important to note that pain medication
for older adults should be given on a regular basis, not PRN, or as needed
(AGS, 1998). Collaborative pain medications, such as antidepressants,
anticonvulsants, and anxiolytics, may also be helpful in pharmacologi-
cally reducing pain among older adults. Nurses must also administer
radiation and chemotherapeutics and manage the difficult side effects of
these medications, which include nausea, vomiting, fatigue, and changes
to bodily image. Several medications are currently available to minimize
these symptoms, but they must be administered with caution among
older adults.
PARKINSON’S DISEASE
Parkinson’s disease (PD) is one of the most common neurodegenerative

disorders affecting the elderly population. It occurs in 1 of every 100
persons over the age of 60 (Lyons & Koller, 2001). Furthermore, it is
estimated that 3% of those persons over the age of 65 have PD, suggest-
Cultural Focus
While self-breast examinations are among the most effective methods for
detecting breast tumors, many older women avoid self-exams and mam-
mograms because of attitudes that one does not touch oneself or expose
one’s breasts to others. This may be a cultural belief or a holdover from
the teachings of prior generations. Nursing assessment of comfort levels
with self-breast examination and demonstration of appropriate techniques
are essential at enhancing compliance among older women of all cultural
groups.
ing that the occurrence of the disease increases with age (Noble, 2007).
It is estimated that, more than 1 million older adults in the United States
live with PD every day, which is more than many less frequent neurode-
generative diseases combined (Hogstel, 2001).
Parkinson’s disease affects men more than women and Whites more
than Blacks or Asian Americans. Nurses who understand the disease,
are aware of the signs and symptoms, know available treatment options,
assess individual functionality, and advocate for the client are best able
to implement plans of care for these clients (McMahon, 2004).
PD is a slow and degenerative nature that results from the death
of dopamine-producing neurons in the brain. By the time symptoms
are present, 70% to 80% of these neurons have already been destroyed
(Hogstel, 2001). Dopamine is the critical chemical responsible for body
movement and balance. It exists in balance with another chemical trans-
mitter, acetylcholine, which is not destroyed by the disease. When acetyl-
choline levels exceed dopamine levels, symptoms appear.
The causes of PD have not been determined. Recently, a genetic
component has been identified by research, and this is currently under
investigation. The roles of environmental toxins, poisons, viruses, and
medications have also been implicated in the development of PD, but
these are also still under investigation. Some medications, including
chlorpromazine and haloperidol, as well as reserpine, methyldopa, and
metacolpramide, have been linked to the development of PD symptoms.
There are no objective clinical markers for PD. The signs and symp-
toms of the disease usually bring the client into the health care setting,
where a thorough health assessment is conducted. The diagnosis of PD
is most often determined by the presence of three motor signs: tremor,
rigidity, and bradykinesia. Noble (2007) reports that patients present
with either “tremor dominant” PD or “motor disorder” characterized by
gait distruance, rigidity, and postural instability. Besides these common
signs, clients with the disease may exhibit additional symptoms such as
depression and autonomic dysfunction.
Identifying the signs and symptoms of Parkinson’s disease may be
accomplished during routine health assessment, but nurses must be aware
of the signs that characterize this disease, because they can be very dif-
ficult to assess. For example, postural changes that are typical in PD may
present as other musculoskeletal changes common with aging. Assess-
ment of the signs and symptoms is crucial for symptom management.
Signs and symptoms of the disease may be detected through a func-
tional assessment of older adults. For example, tremors make it difficult
to get dressed in the morning, rigidity makes it hard to get out of bed in
the morning, and bradykinesia may impair mobility. Overall, individual
function may be dramatically altered, and that should serve as a major
warning sign for nurses caring for older patients. The client’s response to
the medication levodopa may also aid in the diagnosis of PD.
There is no cure for PD. Therefore, symptom management is the pri-
mary focus of nursing care. It is imperative to make an early yet accurate
diagnosis so that an appropriate course of treatment may be determined.
Although the causes of PD are still unknown, a significant amount of infor-
mation regarding the disease is available. The goal should be to isolate the
signs and symptoms that typically characterize the disease and provide spe-
cific treatment options, both pharmacological and nonpharmacological. As
advocates for patients, nurses must understand and present to clients all of
the options available for treatment. It is important that nurses assess each
individual for characteristic signs and symptoms of the disease. The overall
goal of nursing care for PD clients is to provide support for individuals
with this life-threatening disease and their families and to meet physical,
psychological, social, and spiritual needs as the disease progresses.
Treatment of PD generally combines levodopa with carbidopa
(Sinemet®). These medications assist in boosting the level of dopamine
in the brain, thereby minimizing the symptoms of PD. As symptoms
progress, the ability to perform activities of daily living decreases and
the need for pharmacotherapy increases. Yet, the question remains as to
when to begin medical treatment. Some physicians recommend starting
medication as soon as the symptoms are diagnosed as PD; others may
recommend waiting until symptoms interfere with functional ability and
functional disability becomes apparent. Side effects of the medications
can include confusion, hallucinations, hypotension, nausea, and vom-
iting, so patients may choose to utilize nonpharmacological treatment
options or delay medical treatment, thus postponing potential discomfort
from the unwanted side effects.
If motor abilities are relatively intact, nonpharmacological treat-
ments may be extremely beneficial. Physical and occupational therapy
may help those with a shuffling gait, focusing on the client’s balance abili-
ties and providing assistive devices where applicable. Nutritional therapy
is also essential when caring for the Parkinson’s patient. Immobility is a
major contributor to constipation and, therefore, it is important to assess
the dietary needs of PD clients to prevent severe constipation. Exercise
is also extremely therapeutic for clients with PD by improving mobility,
flexibility, posture, balance, and overall function, as well as decreasing
the risk of falls related to the disease (Lyons & Koller, 2001).
SUMMARY
As the lifespan continues to increase, the incidence and prevalence of both

acute and chronic disease rises. The interaction of normal changes of aging
and co-morbidity often results in acute diseases developing into chronic

conditions among older adults. The risk factors, presentation, and dura-
tion of both acute and chronic illnesses is often different among older
adults than of their younger counterparts. Older adults are at a higher risk
for developing serious chronic illnesses than any other age group. More-
over, as the older adult population continues to rise, the number of chronic
illnesses among this population will also increase proportionally. The pres-
ence of chronic diseases among older adults presents the risk for functional
decline in the older population, which may greatly impact quality of life.
This chapter presented some commonly occurring acute and chronic
illnesses among older adults and the appropriate nursing care for these
specific conditions. In order to appropriately manage chronic illnesses
among older adults, attention must be paid to the special presentation
of disease in this population and the most effective geriatric health care
management of the disease. With quality nursing care, acute and chronic
illnesses can often be prevented or detected at an early stage, when treat-
ment is more successful. Ultimately, the risk for functional decline will be
minimized and quality of life maximized. Older adults may continue to
maintain a high functional ability despite many chronic illnesses. With the
help of knowledgeable and skilled health care providers and appropriate
disease management, functional independence becomes a very realistic
goal for older adults with chronic illness.
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C H A P T E R S E V E N
Medication Usage
Learning Objectives
1. Describe the demographics of medication usage in older adults.
2. Identify physiologic changes of aging and their effects on medica-
tion absorption, distribution, and clearance.
3. Discuss the prevalence of medication–medication, medication–
disease, and medication–nutrient interactions among older adults.
4. Identify special considerations for administration of medications
to older adults.
5. Discuss demographics and strategies for enhancing medication
adherence.
6. Describe the usage of herbal and illegal drugs among older
adults.
7. List medications that should be administered with caution in the
older adult population.
Mr. Turner is a 73-year-old man who has been admitted to the hospital
after being found unresponsive at home by his wife. His VS upon admis-
sion were T 97.5, P 75, R 16, BP 160/96, and a blood glucose of 640. He
has a history of Type 2 diabetes and HTN, but states that he is not on any
meds at this time. His wife states that he had been taking “some pills”
but that they were too expensive so he stopped taking them. When asked
if he checks his blood sugar at home, he states, “No, I never know how
to work that machine and I ran out of the stuff that goes with it.” His
physician plans to start him on oral hypoglycemics as well as an insulin
regimen and antihypertensives. A social worker comes to speak with him
and his wife about payment options, and you, as his nurse, plan to do
some diabetic teaching.
175
The story or Mr. Turner typifies today’s older adult. In the United States,
treatment of multiple acute and chronic illnesses often takes the form
of medication. For every symptom, ailment, or illness, there is usually a
long list of available treatments from which to choose. These treatments
include a number of prescriptions and over-the-counter medications. The
use of prescription, nonprescription, over-the-counter (OTC), and herbal
medications among older adults is substantial. The availability of multi-
ple and effective medications to treat the numerous diseases among older
adults undoubtedly plays an instrumental role in the increasing lifespan
of this population.
The availability and substantial usage of medications among the
elderly is both of benefit and concern among older adults and health care
providers. In fact, the use of excessive, and often inappropriate, medica-
tions among older adults remains one of the most prevalent problems
within the older population (Morley, 2003). In the United States, older
adults spend approximately $3 billion annually on prescription medica-
tions. Moreover, as adults continue to age, the number of prescription
medications rise. The Centers for Disease Control and the Merck Insti-
tute of Aging and Health (2004) report that the average older adult takes
five medications each day. Although older adults make up only 13% of
the population, they consume 34% of all prescription medications and
30% of all nonprescription medications.
In an effort to reduce the large amount of unnecessary medications
used by older adults in long-term care facilities, the Federal government
developed the Omnibus Budget Reconciliation Act (OBRA) in 1987 and
implemented it in 1990 (Standard of Practice—OBRA-90). While there
has been some success, use of both prescription and OTC medications
by older adults is disproportionate to census findings. Older adults cur-
rently represent only 10% of the population, but they use 25% of all
prescription medications. The Alliance for Aging Research (2002) reports
that the average older adult uses five prescription drugs and many over-
the-counter medications.
Medication usage among older adults is complicated by several issues.
Normal changes of aging often influence the manner in which medica-
tions are utilized by older adults. These changes affect how medications
are absorbed through the gastrointestinal tract, skin, or musculature;
distributed via the circulatory system; metabolized by the liver; and
cleared from the body through the kidneys. These four pharmacokinetic
mechanisms are also influenced by acute and chronic illnesses common in
older adulthood, which may further slow or impair the ability of organ
systems to absorb, distribute, metabolize, and excrete medications. These
changes are summarized in Table 7.1.
Medication Usage 177
TABLE 7.1 Pharmacokinetic Changes With Aging

Pharmacokinetics Changes Within Older Adults
Medication Absorption • Increase in gastric pH and a change in the

amount of fluid within the stomach.
• Decrease in time required for emptying stomach
contents.
• Takes stomach longer to move nutrients across
the membrane.
• Increased time needed for medications to become
effective.
• Increased time may also increase amount of
medication absorbed.
• Vitamins A and C may be more readily ab-
sorbed.
Medication Distribution • Reduced lean body mass.
• Increase in percentage of body fat.
• Total body intracellular and extracellular water
decreases by 15%.
• Alterations in plasma protein binding.
• Cardiac output declines by 1% every year.
• Blood flow to the liver declines from 0.3% to
1.5% a year.
Medication Metabolism • Reduced blood flow to the liver.
• Decrease in functional liver cells.
• The enzymes used to break down medicines are
reduced.
Medication Elimination • Reduction in the mass and a reduction in the
number and size of the nephrons.
• Reduced glomerular filtration rate.
• Decreased renal tubular secretion.
• Increased medication half-life.
PHARMACOKINETICS AND PHARMACODYNAMICS
Pharmacokinetics focuses on the drug absorption, distribution, protein

binding, hepatic metabolism (biotransformation), and renal excretion.
Specifically, pharmacokinetics is the study of how normal and pathologi-
cal aging changes affect how medications are received into the body, dis-
tributed throughout the body, changed to their active form, and excreted
when they complete their role. Among older adults, pharmacokinetics is
focused on how medications are absorbed through the gastrointestinal
track, skin, or musculature. The normal changes of aging that result in

a decrease in subcutaneous tissue and muscle mass are considered here.
Pharmacokinetics also focuses on how medications are distributed via
the circulatory system. Consequently, slow circulatory systems, common
among older adults, result in changes in the drug distribution aspect of
pharmacokinetics. How medications are metabolized by the liver and
cleared from the body through the kidneys are also components of phar-
macokinetic study. Pharmacokinetics has resulted in a number of clinical
interventions for older adults. For example, knowing that older adults
experience slower absorption of medications may result in the need for
a greater time period to achieve desired drug effect. It is important for
nurses caring for older adults to understand the impact of normal and
pathological age-related changes of aging in order to provide the plan of
care that will achieve optimal medication effectiveness.
Pharmacodynamics focuses on drug effects at the receptor level. This
refers to how medications work once they get to where they are supposed
to go. It has also been referred to as what a drug does to the body. Phar-
macodynamic changes are often caused by normal aging, but these pro-
cesses have been poorly studied and it is not well understood why some
drugs reveal enhanced effectiveness, while others do not.
Pharmacodynamic changes among older adults are challenging for
researchers, partly because specific organ responsiveness to medications
changes as people age. However, some specific pharmacodynamic changes
have been found among several drugs commonly prescribed for older
adults. For example, the California Drug Registry (2005) reports that
increased receptor responses have been documented for benzodiazepines
(commonly used for sleep enhancement), opiates (used for pain relief), and
warfarin (used for several conditions in which blot clots would commonly
form). Because of the change in pharmacodynamics, older adults receiving
these medications experience increased responses to these medications,
including increased sedation with benzodiazepines, increased analgesia
and respiratory suppression with the use of opiates, and increased antico-
agulant effects with the use of Warfarin. Other organ systems have also
been noted to result in changes in pharmacodynamics among older adults,
including the central nervous system, bowel, bladder, and cardiac system.
Changes in pharmacodynamics are of concern to nurses caring for older
adults because they may result in both the increased effects of medication
among older adults and a higher incidence of adverse drug reactions.
Medication Absorption
Several changes occur in the gastrointestinal system throughout life. These
include an increase in gastric pH and a change in the amount of fluid
within the stomach, as well as a decrease in the time required to empty

stomach contents and move active products and nutrients across mem-
branes. As part of the normal changes to the elderly circulatory system,
there is a decrease in the intestinal blood flow and altered intestinal motil-
ity. Some studies have reported an approximately 20% decrease in the
small intestine surface area. Currently, there is no research to support that
drug absorption decreases as a result of normal aging. However, the slow-
ing of many gastrointestinal symptoms leads health care professionals to
believe that an increased amount of time is necessary for medications to
become effective in older adults. It is important to note that increased time
for absorption may also increase the amount of medication absorbed. For
example, vitamins A and C may be more readily absorbed among older
adults because they remain in the small intestine longer.
In addition to these normal changes of aging, it is important to con-
sider the number of changes in nutritional levels and eating habits as well
as various disease states that may affect drug absorption. There is a sub-
stantial prevalence of nutritional deficiencies among older adults, partly
due to normal changes of aging. For example, decrease in smell, vision,
and taste and the high frequency of dental problems makes it difficult
for the older adult to maintain adequate daily nutrition. Furthermore,
lifelong eating habits, such as a diet high in fat and cholesterol, are other
obstacles to maintaining optimal nutrition. Such a diet is a leading cause
of coronary artery disease. Nutrition and hydration assessment are nec-
essary to help older adults minimize the effects of aging on drug absorp-
tion. Teachings regarding appropriate food choices, such as avoiding
spicy foods, which may be irritating to the stomach lining, are essential
to changing nutritional patterns and reducing the effects of nutrition on
drug absorption. Taking small steps toward good nutrition, by slowly
replacing unhealthy food choices with healthier alternatives, is the most
appropriate nursing intervention to help achieve nutritional outcomes.
Several diseases occur more commonly in the older population and
impact drug absorption. Achlorhydria, a disease that greatly reduces the
acidity of the stomach, may make it difficult to dissolve medications for
absorption. Other gastrointestinal disorders, such as gastroesophageal
reflux disease (GERD), or surgery to the stomach or small intestine, may
also alter drug absorption. Moreover, polypharmacy among the elderly
plays an impact on drug absorption, as multiple medications compete
for the same sites. For example, antacids, taken with some antibiotics or
cardiac medications may decrease the absorption of the later.
To illustrate the effects of normal changes of aging on absorption,
consider the case of a 75-year-old man in good health and residing in the
community. He walks 2 miles each day, continues to work, and takes a
daily multivitamin. He visits the primary care clinic for a routine physical
examination and complains of fatigue, headaches, flushing, and difficulty

sleeping. His history, health assessment, and physical exam do not reveal
any acute or chronic medical problems. It is recommended that he discon-
tinue the multivitamin, because his symptoms are consistent with vitamin
A toxicity. When his blood values return from the lab, this diagnosis is
confirmed. The patient discontinued the multivitamin, and the symptoms
were relieved.
Medication Distribution
There are several factors that affect drug distribution among older adults.
These include changes in fluid pH, plasma protein, and serum albumin
concentrations; reduced lean body mass; a relative decrease in total body
water; and an increase in the percentage of body fat, blood flow, and tis-
sue–protein concentration. These normal aging changes have the poten-
tial to alter the distribution of the medication compared to the blood
concentration. These anatomical and physiology aging changes have the
potential to greatly impact medication distribution among older adults.
Total body intracellular and extracellular water decreases by as much
as 15% among older adults. This reduces the distribution of water-soluble
medications and increases the distribution of fat-soluble medications.
For example, medications such as digoxin, lithium, aminoglycosides, and
cimetidine, which are water soluble, have the tendency to become ele-
vated among older adults. Consequently, administration of water-soluble
medications must be done with caution. Increased caution should be used
when administering any of these medications with diuretics, which fur-
ther reduce fluid volume in the body. Additionally, lean body mass is
reduced in older adults. The proportion of fat tissue increases with age
from 18% to 36% in men and from 36% to 48% in women between the
ages of 20 and 80 years. Consequently, fat-soluble medications, such as
barbiturates, phenothiazines, benzodiazepines, and phenytoin, have the
tendency to accumulate in the increased fat distribution of older adults
resulting in a prolonged half-life of these medications.
Alterations in plasma protein binding, which may occur as part of
the normal aging process, are of particular concern to nurses caring for
older adults (Hogstel, 2001). This change could potentially alter the dis-
tribution of a medication significantly, as well as change the half-life of
a medication and disrupt the steady flow of medication needed for dis-
ease management. As with drug absorption, this change is exacerbated
by other medications, which compete for the same binding sites. Plasma
protein binding can affect drug distribution, especially for drugs that are
highly protein bound. This change is particularly important for older
adults with multiple chronic illnesses that further reduce serum albumin
(Hogstel, 2001). When serum albumin is decreased, the number of avail-

able binding sites for medications is also decreased. This results in an
increased amount of active medication in the circulation and the poten-
tial for drug toxicity as free medication is potentially absorbed.
The cardiac output, which decreases by about 1% each year after the
age of 30, has further potential to alter medication distribution. Moreover,
blood flow to the liver, which decreases from 0.3% to 1.5% per year,
and blood flow to the kidneys must also be considered as metabolism
and elimination of such medications is dependent on their distribution to
these organs (Hogstel, 2001). With an altered blood flow, it is possible
that medications will have an increased half-life.
To illustrate the effects of normal changes of aging on distribution,
consider the case of a 95-year-old woman with a heel ulcer in need of
debridement. The client has multiple medical illnesses, including a long
history of heart failure (HF). The normal protocol is to administer pain
medication 30 minutes prior to the procedure. However, as the procedure
begins, the nurse realizes that the patient is experiencing pain. The nurse
requests that the surgeon stop the procedure and try again in another
30 minutes. Sixty minutes after the administration of medication, the
procedure begins again; this time the client remains pain free because the
medication was given increased time for distribution to the site of pain.
Hepatic Metabolism
Normal changes of aging that affect the biotransformation of medica-
tions vary greatly among older adults. Unlike medication absorption
and distribution, determining the function of the liver is difficult. Thus,
while medication metabolism is dependent on adequate liver function,
that function is difficult to determine. Consequently, in the absence of
diagnosed liver disease, it is often challenging to project how medications
will be metabolized among older adults.
Normal aging liver changes that affect medication metabolism
include reduced blood flow to the liver and a decrease in functional liver
cells, which have the potential to impact how effectively medications are
transformed. There are two phases of metabolism within the liver that
affect medication processes: phase I metabolism, which involves the use
of enzymes to break down medications, is reduced among older adults;
phase II metabolism, known as conjugation, is generally not affected by
the aging process (Hogstel, 2001).
While normal aging changes impact liver function and consequently
the metabolism of medication within this organ, pathological changes
of aging and the presence of chronic illness and treatments further
complicate the metabolism of medications in the liver. Specifically, the
use of multiple medications, alcohol, caffeine, smoking, poor nutrition,

and multiple disease processes have the potential to greatly affect liver
function and reduce the metabolism of medications.
To illustrate the effects of normal changes of aging on medication
metabolism, consider the case of an 83-year-old woman who recently lost
her husband. A grief therapist who works in the client’s community sug-
gests that she take one or two over-the-counter Benadryl capsules to help
her sleep during this difficult time. The client does as suggested. How-
ever, because this medication tends to be poorly metabolized by aging
livers, the medication accumulates and causes a delirium to begin in the
client over a period of several weeks. Consequently, the client must be
admitted to a skilled nursing facility for safety reasons, until the delirium
resolves.
Renal Elimination
Elimination of medications among older adults is one of the most well-
studied and easily predictable age-related changes in medication pharma-
cokinetics. Older adults experience a normal reduction in the number and
size of the nephrons, reduced glomerular filtration rate, and decreased
renal tubular secretion. Thus, it is generally understood that older adults
will eliminate medications more slowly than younger individuals, result-
ing in an increased medication half-life. However, it is important to note
that these changes vary greatly among older adults.
While it is tempting to measure the glomerular filtration rate by test-
ing creatinine clearance, there is often little change in serum creatinine
concentration, despite normal aging changes. Consequently, creatinine
clearance may not be the most reliable measure of renal function and
elimination of medications among older adults. A more sensitive measure
of medication elimination incorporates several variables, such as body
build or weight, age, and gender. This formula, known as the Cockcroft-
Gault formula, is used to calculate creatinine clearance (Cockcroft &
Gault, 1976). It may also be used to calculate the correct dosage of medi-
cation for older adult clients. For example, opiate medications are often
highly appropriate for older adults in pain, however, a reduction in the
dosage of opiates is recommended. The Cockcroft-Gault formula may
be useful in this case to calculate the necessary dosage to achieve pain
management without unnecessary sedation and cognitive effects. Conse-
quently, this formula may be helpful in calculating effect medication dos-
ages across environments of care. However, it is important to remember
that blood values for certain medications, such as digoxin, lithium, and
procainamide, are also available and provide a more accurate measure of
the medications levels within the body.
MEDICATION INTERACTIONS
Changes of aging and pharmacodynamics, as well as the presence of

disease and the numerous prescription and OTC drugs taken by older
adults (polypharmacy), makes this population at high risk for developing
adverse reactions to drugs. In fact, older adults are estimated to be at 2–3
times higher risk for adverse reactions to medications than their younger
counterparts. These adverse reactions result from drug-to-drug interac-
tions, drug and disease interactions, and drug–nutrient interactions. The
number of medications taken by older adults may independently predict
the incidence of adverse reactions.
As the number of medications taken by older adults increases, there
is a logical increase in the incidence of interactions between medications.
Medication interactions occur when two or more medications are com-
bined together, altering the strength and effectiveness of the medications.
Many medication interactions may be predicted when administered to
older adults based on previous knowledge of the drug. For example, the
administration of vitamin K with warfarin is a well-known drug–drug
interaction. In this case, the vitamin K increases the effect of warfarin,
causing a potentially fatal reduction in clotting ability.
Despite the fact that the average older adult has three chronic diseases
(Alliance for Aging Research, 2002), the number of older adults within
clinical trials for new medications remains shockingly low. Townsley, Selby,
and Siu (2005) report that older adults are significantly underrepresented
in cancer clinical trials. While older adults are among the largest users
of both prescription and OTC medications, the International Longevity
Center-USA reports that 40% of clinical trials between 1991 and 2000
explicitly excluded people over 75 from participating. Consequently, infor-
mation on the appropriate dosing, side effects, and medication interactions
is not available to guide usage of these medications among the elderly.
Falman, Lynn, Finch, Doberman, and Gabel (2007) recently reported
that the prescribing of inappropriate medications among older adults was
common practice. In their study of 4,602 Medicare beneficiary patients over
the age of 65, 44% were prescribed a medication that was known to be
inappropriate among the elderly, and 15% were prescribed two such medi-
cations. The Beers criteria, developed from the HCFA Guidelines for poten-
tially inappropriate medications in the elderly, presents medications known
to place older adults at risk for developing adverse reactions (Table 7.2).
Medication–Disease Interactions
Because the average older adult has three chronic diseases, it is very com-
mon that the medications used to treat one disease potentially could
affect management of another disease. This is especially true for patients

with hypertension, congestive heart failure, diabetes, and renal failure. In
patients with these diseases, the medication take for one can potentially
impact the medication taken for another. For example, the use of several
beta-blocker medications among older adults have reportedly contributed
to increased episodes of already-existing impotence among older men.
Another example may be the use of antihistamines, commonly prescribed
or available over the counter for cold and allergy symptoms. In patients
with benign prostatic hypertrophy (BPH), the medications may result in
urinary retention (Hogstel, 2001). These drug–disease interactions may
result in the need to discontinue a medication, or find an alternative that
does not impact other disease processes.
Medication–Nutrient Interactions
Medications often interact with nutrients among older adults and have
the potential to impact the nutritional status of the population in two
specific ways. First, many medications have the tendency to impact
appetite. For example, paroxetine, which is commonly prescribed for
depression among older adults, may result in a decreased appetite and
lead to weight loss and malnutrition. Conversely, several antipsychotic
medications prescribed for bipolar disease or schizophrenia in the elderly
may increase appetite resulting in the consumption of food poor in nutri-
ents and obesity (Hogstel, 2001).
The second major interaction between medications and nutrients
surrounds the impact of nutrients on the absorption, distribution,
metabolism, and elimination of nutrients. In other words, nutrients have
the potential to decrease absorption of medications, impair cardiac out-
put, and alter liver and kidney function, which are critical for medication
effectiveness. Moreover, older adults are at higher risk for medication–
nutrient interactions because of normal and pathological aging changes,
as well as higher rates of alcoholism and the use of restricted diets to treat
disease. For example, the absorption medication may be affected by the
intake of the medication with orange juice or milk.
Further difficulty in absorption may take place by the interaction of
the medication with food. For example, some antibiotics may be rendered
ineffective if combined with calcium or magnesium that was recently
ingested during a meal. The use of nutritional supplements among the
elderly, which contain many nutrients, may also potentially impact medi-
cation effectiveness. Administering medications via tube feedings results
in a similar risk of nutrient–medication interactions (Hogstel, 2001).
Moreover, certain nutrients may be excreted more quickly if they interact
with medications, for example, diuretics, such as thiazide.
To reduce the risk of medication–nutrient interactions, it is impor-

tant to pay close attention to the known interactions of medications.
Medications should be administered with water, as opposed to orange
juice, milk, or with nutritional supplements. Establishing an effective pat-
tern of medication administration and evaluating medication effective-
ness through assessments and care planning are the most appropriate
nursing interventions to reduce medication–nutrient interactions.
GENERIC MEDICATIONS
With an increased emphasis on cost-effective health care for older adults

over the past decade, the tendency to use generic medications is great.
The decreased cost of these medications makes them very attractive to
patients and third-party payers (such as Medicare). Generic medications
must meet legal standards for effectiveness, safety, purity, and strength
met by the original medication. Hogstel (2001) reports, “The total bio-
availability of a generic medication may not vary from that of the brand
drug by more or less than 20%” (p. 351); however, it is important to
note that 20% can make a substantial impact on medication effective-
ness, especially among medications with narrow therapeutic ranges. For
example, generic forms of warfarin, which requires a narrow range for
the effectiveness of clotting among older adults, may vary greatly from
one generic formula to another. It is also important to remember that
drugs within a given class may have differing side effects, which makes
substituting one medication for another challenging. Moreover, physi-
cians and nurse practitioners may not be aware that trade medications
have been substituted for generics. For example, a generic medication
may be chosen by a particular health plan that varies from the trade med-
ication. There are clearly situations in which generic substitution should
not be allowed. Consequently, it is the role of all health care providers to
advocate for the most effective medication necessary to meet the needs
of the client, and they should continually reassess the effectiveness of the
medication. Nurses must request that patients bring medication bottles
to the health care environment in order to determine if the older client’s
prescriptions have been filled with a generic drug or not.
INAPPROPRIATE MEDICATIONS
There are a number of medications that have been determined to be

inappropriate for older adults and should be used with extreme caution.
These are listed in Table 7.2.
TABLE 7.2 Beers Listing of Potentially Inappropriate Medications for the Elderly
amitriptyline (Elavil), disopyramide pentazocine (Talwin) Antihistamines such as: single and
chlordiazepoxide- (Norpace, Norpace CR) combination preparations containing
amitriptyline ticlopidine (Ticlid) chlorpheniramine (Chlor-Trimeton),
(Limbitrol), and doxepin (Sinequan) diphenhydramine (Benadryl), hy-
perphenazine-amitriptyline diphenhydramine droxyzine (Vistaril, Atarax), PERI-
(Triavil) meperidine (Demerol) (Benadryl) ACTIN® (cyproheptadine HCl),
promethazine (Phenergan),
barbiturates (all except meprobamate (Miltown, dipyridamole tripelennamine (PBZ),
phenobarbital) Equanil) (Persantine) and dexchlorpheniramine (Polarmine)
Long-acting benzodiazepines- ALDOMET® (methyldopa), ergot mesyloids (Hy- INDOCIN® (indomethacin),

chlordiazepoxide ALDORIL® dergine), cyclandelate INDOCIN SR® (indomethacin)
(Librium), chlordiazepoxide- (methyldopa/hydrochlorothiazide) (Cyclospasmol), (other
amitriptyline (Limbitrol), cerebral vasodilators) methocarbamol (Robaxin), cariso-
clidinium-chlordiazepoxide prodol (Soma),
186
(Librax), diazepam chlorzoxazone (Paraflex),
(Valium), and flurazepam metaxalone (Skelaxin),
(Dalmane) FLEXERIL® (cyclobenzaprine),
dantrolene (Dantirum), and orphen-
chlorpropamide (Diabinese) adrine (Norflex, Norgesic)
digoxin (Lanoxin) >0.125 phenylbutazone (Butazolidin)

mg/day
reserpine (Serpasil), resperpine com-
bination products
trimethobenzamide (Tigan)
Adapted from Beers, M. H. (1997). Explicit criteria for determining potentially inappropriate medication use by the elderly.
Archives of Internal Medicine, 157, 1531–1536.
Consideration of normal aging changes in the amount of subcu-

taneous, fat, and muscle tissue should be considered when administer-
ing parenteral medications to older adults. With the decreasing muscle
mass, it is possible that medications designed to reach the muscle may
be injected deeper. This may result in damage to underlying tissues,
as well as an alteration in expected response time to the medication.
Assessment of a client’s body composition and choice of needle size will
help minimize harmful effects of parenteral medication administration
to older adults. In addition, changes in vasculature may result in dif-
ficulty accessing peripheral intravenous sites for medication therapy.
Providers skilled in challenging intravenous access should be consulted
when alterations in vasculature prevent medication administration via
this route.
MEDICATION ADHERENCE
It is generally reported that about one-half of all patients take the medica-
tions exactly as prescribed upon leaving the physician’s office. The other
half take the medications incorrectly, or not at all. Of those who take
the medications incorrectly, one-third don’t take it at all, one-third take
some, and one-third do not even fill the prescription. Among the reasons
for nonadherence to medication regimes is that health care providers fail
to give clear instructions on use of the medication and when to take
each dose. Moreover, the American Chronic Pain Association recently
reported that 3 in 10 patients with chronic pain cannot fill their pre-
scriptions because they cannot afford them; others simply forget to take
it. Multiple prescriptions and complicated administration schedules, for
example, medications that change dosages, contribute to lack of adher-
ence (Hogstel, 2001). For example, many patients who wear daily nitro-
glycerin patches are not aware that one patch should be removed and the
area cleaned, before applying the next patch.
Cultural Focus
The cultural backgrounds of older adults should be considered when choos-

ing the route of medication administration. Some Vietnamese individuals
may view medications administered via injection as more effective than
those administered by mouth. Consequently, nurses caring for patients
with this health belief may suggest an injectable form of a medication, if
available.
Noncompliance rises along with the chronic illnesses commonly seen

among older adults. As the older adult is asked to commit more time and
resources to maintaining health, they are less likely to adhere closely to
the recommended regimen. It is also important to note that older adults
from various cultural backgrounds may not adhere to medication and
treatment regimes because such plans conflict with their cultural healing
beliefs. For example, a patient may be prescribed an oral medication to
reduce blood pressure, but she may not take the medication, because
her cultural background leads her to believe that oral medications are
destroyed in the stomach and, thus, not effective. Enhanced understand-
ing regarding older adults’ health beliefs will result in improved medica-
tion adherence.
In order to promote maximum adherence, it is essential that nurses
provide teaching regarding the recommended treatment regimen and
assess patients’ understanding, willingness, and capability to comply. In
so doing, it is estimated that up to 23% of nursing home admissions,
10% of hospital admissions, and many physician visits, diagnostic tests,
and unnecessary treatments could be avoided. Previous life experiences
and cultural backgrounds can be very important in teaching older clients.
Building on past experiences and integrating all aspects of life allows
older adults to integrate new information on a familiar foundation. To
aid in this teaching, many pharmacies provide information sheets with all
new prescriptions that include:
Mrs. Johnson is a 90-year-old woman admitted to a skilled nursing unit

for recovery from hip surgery. Medicare is paying for her 60-day antici-
pated stay. Her medications include: (a) Hydrochlorothiazide for hyper-
tension; (b) vitamins E and C, and Aricept™ for early signs of dementia;
(c) Zoloft for depression; (d) Darvocet™ PRN for arthritis-related pain;
and (e) Restoril™ PRN for sleep. She generally takes her medications with
orange juice each morning and PRN.
1. Which of Mrs. Johnson’s medications are safe for her to take, and
which should be administered with caution? Why?
2. What normal changes of aging may affect Mrs. Johnson’s drug
absorption, metabolism, distribution, and excretion?
3. What problems, if any, will Mrs. Johnson have in paying for her
medications at the skilled nursing facility?
4. Do you anticipate any drug–drug or drug–nutrient interactions for
Mrs. Johnson?
Title of Study: Congruence of Self-Reported Medications with Pharmacy

Prescription Records in Low-Income Older Adults
Authors: Caskie, G., Willis, S.
Purpose: To examine the congruence of self-reported medications with
computerized pharmacy records.
Methods: 294 members of a state pharmaceutical assistance program
who also participated in ACTIVE, a clinical trial on cognitive train-
ing in nondemented elderly persons, participated by providing phar-
macy records and self-reported medications. The average age of the
sample participants was 74.5 years (range + 65–91); 87.8% were
females.
Findings: It was found that 49% perfect agreement existed between self-
reports and pharmacy records for major drug classes to 81% for specific
cardiovascular and central nervous system drugs. Poorer health was
consistently related to poorer self-reports.
Implications: Self-reported medications are more likely congruent
with pharmacy records for medications prescribed for more seri-
ous conditions, for more specific classes of drugs, and for healthier
persons.
• Name(s) of the medicine

• Ordered dose
• Directions for use
• Possible side effects
• Other drugs that should not be taken concurrently
• What to do if adverse effects occur
Low health literacy is currently considered a silent epidemic within

the United States, affecting a substantial percentage of the population.
Among the most at-risk populations for low health literacy are older
adults who are also those most in need of health services. Healthy People
2010 defines health literacy as more than just an ability to read; it is
action-oriented, leading to an improved capacity to be a full participant
in one’s health care. Health literacy requires that older adults not only
be able to read information, but understand what they are reading, hear
instructions, calculate medications, and communicate questions. Low
health literacy often impacts the ability of older adults to fully understand
medication instructions and health interventions. It disrupts clients’ abil-

ity to effective prepare for diagnostic tests, make follow-up appointments,
and maintain health. Moreover, low health literacy is a significant factor
in noncompliance with health care treatments and medications. Kirsch,
Jungeblut, Jenkins, and Kolstad (2002) estimate that more than 90 mil-
lion Americans cannot understand basic health information. Nurses must
be aware of the large prevalence of health literacy among today’s cohort
of older adults and assess their clients’ ability to understand medication
instructions fully in order to enhance adherence and health outcomes.
Easily opened containers are preferred by older adults and may be
another intervention to increase adherence among older adults. Bold
labeling of medications is helpful for visually impaired clients, and a
review of medications should be conducted during each visit to a health
care provider to encourage medication compliance. Clients should be
encouraged to bring the actual medication container, as opposed to a
listing. In this way, generic medications can be assessed, and the amount
of medication remaining in the bottle can be measured against the pre-
scription filled date. This process should include both prescription and
over-the-counter medications.
Continual assessment of medication adherence and effectiveness is
very important. Nurses should always know which medications their cli-
ents are taking, what these medications are prescribed for, and what the
expected side effects and outcomes are. Changes in medication dosage
and prescribing should be made when medications are found to result in
adverse reactions, side effects, or are ineffective in meeting outcomes.
OVER-THE-COUNTER AND ILLEGALLY OBTAINED

NARCOTICS AND HERBAL MEDICATIONS
The use of over-the-counter (OTC) and illegally obtained narcotic drugs

and herbal medications among older adults is extremely prevalent and
underdetected. Older adults use OTC medications and illegal drugs to
treat pain, depression, gastric disturbances, anxiety, memory loss, and
other disorders when they are unable to obtain or pay for effective treat-
ment by health care providers. The use of these medications is often
not assessed by health care providers, as older adults are assumed to be
adherent to their prescription medication regime. However, the use of
unprescribed medications among older adults is very widespread. Typi-
cal OTC medications used by older adults include analgesics (aspirin,
Tylenol, Motrin), sleep aides (Tylenol PM, Benadryl), H2 agonists
(Pepcid), laxatives, and antihistamines. Each of these medications has the
potential to cause adverse reactions in the older adult population.
Cultural Focus
Older adults from various cultural backgrounds may be noncompliant

with medication and treatment regimes because they conflict with their cul-
tural healing beliefs. For example, a Hispanic client may be prescribed an
oral medication, such as Vasotec™ to reduce blood pressure, but may not
take the medication, because her cultural background leads her to believe
that oral medications are destroyed in the stomach and, thus, not effective.
Enhanced understanding regarding older adults’ health beliefs will result in
improved medication adherence.
A variety of medications is often used by older adults to reduce pain,

enhance mood, or provide sedation. The use of illegal, narcotic medica-
tions is not a new problem to the older population, but this prevalent
problem continues to be seldom recognized or evaluated by nurses and
other health care professionals. Illegal and narcotic drug use among older
adults results in great risk of harm to physical, psychological, and social
functioning, and the effects may become long-term.
Nurses may fail to detect narcotic drug use because the symptoms of
drug use, including alteration in mental status and function, mimic the
symptoms of delirium, depression, and dementia, which occur frequently
among older adults. Commonly used medications in these categories
include morphine, codeine, Demerol, and marijuana, as well as other
commonly used street drugs. While these medications may be prescribed
by a physician or nurse practitioner and administered with appropriate
evaluation of side effects and effectiveness, the use of these medications
places older adults at very high risk for adverse reactions. Possible
adverse reactions to OTC medications and illegally obtained narcotics
include oversedation and respiratory arrest, falls, delirium, metabolic dis-
turbances, and death.
The use of herbal medications to treat commonly occurring normal
and pathological changes of aging has grown considerably over the past
decade. The Gerontologocial Society of America (2004) reports that one-
third of older adults used alternative medicine in 2002. Researchers in
one California study also found that complementary and alternative
medicine (CAM) was used by 38–50% of ethnic minority elders (Astin,
Pelletier, Marie, & Haskell, 2000). Herbal medications may be preferred
over traditional medications among many cultural groups including
Chinese and other Asian cultures. Both the availability of these herbals,
often referred to as nutraceuticals, and the anecdotal evidence of their
effectiveness, have spawned the sudden growth in sales of these supple-
ments. Nutraceuticals are also less expensive than prescription drugs.
Title of Study: Factors Associated With Illegal Drug Use Among Older
Methadone Clients
Author: Rosen, D.
Purpose: To describe life stressors of exposure to illegal drug use and expo-
sure of illegal drug use to older methadone clients.
Methods: The administrative data of a subsample of clients in a metha-
done clinic was reviewed. This study focused on African American and
White clients who were over the age of 50. Respondents’ age, gen-
der, and race were socioeconomic control variables. Life stressors were
defined as those variables that indicate economic well-being and living
situations.
Findings: Exposure to methadone drug use within the client’s social net-
works and neighborhoods significantly increased the likelihood of ille-
gal drug use by the client.
Implications: Even though demographic trends show an increase in age of
the methadone population the user numbers are also increasing. There
is little research that shows their well-being and their needs.
The Gerontological Society of America (2004) reports that perceived effec-

tiveness and lower cost resulted in 13% of older adults turning to herbal
medications over prescription medication to treat medical problems.
Herbal supplements commonly used by older adults include vitamins
C, D, and E, which have shown some evidence of reducing symptoms of
osteoarthritis. Ginger and glucosamine have also been used extensively
by older adults to reduce arthritis-related pain. Ginkgo biloba is widely
used by older adults to enhance memory, and Saw Palmetto is used by
many older men to reduce symptoms of enlarged prostate glands and to
prevent prostate cancer. Ginseng is used by older adults to reduce stress,
and St. John’s wort is often used as an alternative or adjunct treatment
for depression. A summary of the most frequently used herbal medica-
tions and their indications is provided in Table 7.3.
While these herbal medications promise older adults relief from their
problems, they are not without danger. These medications may mask the
diagnosis and progression of disease among older adults. For example,
Saw Palmetto artificially reduces prostate specific antigen (PSA), the tumor
marker for prostate cancer—leading to false negative results for diagno-
sis or progression of prostate cancer. Moreover, herbal medications have
a high tendency to interact with other medications and conditions. For
example, ginger interacts with warfarin, a commonly used blood thinner
used by many older adults.
TABLE 7.3 Herbals and Herbal Components Under Study

by the NTP*
Aloe vera gel Widely used herb for centuries as a treatment for minor burns and
is increasingly being used in products for internal consumption.
Bitter Orange Bitter orange peel and its constituent synephrine are present in
dietary supplements used for weight. Synephrine and other bitter
orange biogenic amine constituents have adrenergic activity and
may result in cardiovascular or other adverse effects similar to
those induced by ephendra alkaloids.
Black cohosh Used to treat symptoms of pre-menstrual syndrome, dysmenor-
rhea and menopause.
Bladder- A source of iodide used in treatment of thyroid diseases and also
wrack found as a component of weight-loss preparations.
Blue-Green Claims to prevent cancer and heart disease and boost immunity.
algae Use has been promoted for use in children to treat Attention
Deficit Disorder
Comfrey Used externally as an anti-inflammatory agent in the treatment
of bruises, sprains, and other external wounds. Consumed in
teas and as fresh leaves for salads. Based in part on NTP studies
on the alkaloid components of comfrey, the FDA recommended
that manufacturers of dietary supplements containing this herb
remove them from the market.
Echinacea Used as an immunostimulant to treat colds, sore throat, and flu.
purpurea
extract
Ephedra Also known as Ma Huang. Traditionally used as a treatment
for symptoms of asthma and upper respiratory infections. Often
found in weight loss and “energy” preparations, which usually
also contain caffeine. The Food and Drug Administration (FDA)
has prohibited the sale of dietary supplements containing ephedra.
Ginkgo Ginkgo fruit and seeds have been used medicinally for thou-
biloba sands of years to promote improved blood flow, and short-term
extract memory and to treat headache, and depression.
Ginseng and Ginsenosides are thought to be the active ingredients in ginseng.
Ginsenosides Ginseng has been used as a laxative, tonic and diuretic.
Goldenseal Traditionally used to treat wounds, digestive problems and in-
root fections. Current uses include as a laxative, tonic, and diuretic.
Green tea Used for its antioxidative properties.
extract
Kava kava A widely used medicinal herb with psychoactive properties sold
extract as a calmative and antidepressant. A recent report of severe liver
toxicity has led to restrictions of its sale in Europe.
(continued)

Milk thistle Used to treat depression and several liver conditions including
extract cirrhosis and hepatitis and to increase breast milk production.
Pulegone A major terpenoid constituent of the herb pennyroyal. Has been
used as a carminative, insect repellent, emmenagogue, and abor-
tifacient. Has well-recognized acute toxicity to the liver, kidney
and central nervous system.
Senna Laxative with increased use due to the removal of a widely used
chemical-stimulant type laxative from the market.
Thujone Terpenoid is found in a variety of herbs including sage and tansy
and in high concentrations in wormwood. Suspected as the caus-
ative toxic agent associated with drinking absinthe, a liqueur
flavored with wormwood extract.
*Sales ranking from the American Herb Association, 18(3), 7.

From the National Toxicology Program Fact Sheet (2006). Retrieved August 2007
from http://ntp.niehs.nih.gov/files/HerbalFacts06.pdf
Safe usage of CAM by older adults requires health care providers to

specifically assess their use during every health care encounter. Astin et al.
report that 58% of those who use CAM did not mention their usage to
their primary health care provider. Health care providers must understand
the appeal of lower costs of these medications as opposed to the cost of pre-
scription medications. An evaluation of the nutraceuticals and prescription
medications used during the course of illness will provide the greatest safety
for older adults. The most important nursing intervention to prevent adverse
reactions from occurring with the use of OTC medications, alcohol, illegally
obtained narcotics, and nutraceuticals is to assess their use then educate the
client about the potentially dangerous effects of these medications.
SUMMARY
Older adults’ utilization of medications is very high and will continue

to rise throughout the twenty-first century. Medication usage in the
older adult population is complicated by both normal and pathologi-
cal changes in aging that affect drug absorption, metabolism, distribu-
tion, and excretion. Consideration must also be given to the interactions
of various medications, including prescription, OTC, herbal, and illegal
drugs, as well as alcohol and nutrients.
While much necessary attention has been focused on the excessive
usage of prescription medication, the increased use of herbal medications
Cultural Focus
The use of herbal medications to treat commonly occurring normal and

pathological changes of aging has grown considerably over the past decade.
In addition, herbal medications may be preferred over traditional medi-
cation among many cultural groups, including Chinese and other Asian
cultures. Both the availability of these herbals, often referred to as nutra-
ceuticals, and the anecdotal evidence of their effectiveness have spawned
the sudden growth in sales of these supplements. Safe usage of CAM by
older adults requires health care providers to specifically assess their use
during every health care encounter.
and illegal drugs by older adults will require additional attention and
research in the future to determine the effectiveness and risks with these
substances. Future study must also review ways to make necessary medi-
cations affordable for older adults.
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tive medicine use among elderly persons: One-year analysis of a Blue Shield Medicare
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ences, 55A(1) M4–M9.
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of aging and health in America. Retrieved July 13, 2007, from http://www.cdc.gov/
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A first look at the findings of the National Adult Literacy Survey (3rd ed.). Vol. 201.
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ment of older patients with cancer onto clinical trials. Journal of Clinical Oncology,
23, 3112–3124.
C H A P T E R E I G H T
Cognitive and
Psychological Issues
in Aging
Learning Objectives
1. Describe the prevalence of delirium, depression, and dementia in
older adults.
2. Discuss the symptoms of delirium, depression, and dementia.
3. Identify the importance and components of mental status assess-
ment.
4. Discuss treatment options for delirium, depression, and dementia.
5. Assess mood using a validated tool.
6. Contrast criteria for differentiating depression, delirium, and
dementia in older adults.
Mr. Katz is a 75-year-old White male who enters his primary care provid-
er’s office very confused. He states that he needs to see the doctor “right
now” and keeps repeating the request even though the nurse reassures
him that the doctor will be right with him. As you take Mr. Katz to the
exam room, he continues to be nervous and confused. His vital signs
are stable. His wife says he was barely able to get dressed and out of the
house this morning and has become increasingly able to do less for him-
self over the past several months.
One of the most prevalent myths of aging is all older adults will become
senile, or demented as a result of the aging process. Becoming demented
as one ages is of large concern to the aging population and their fami-
lies and is the focus of a great deal of study in the older population.
197
Many assume that as people age they will ultimately become cogni-
tively impaired. This image is perpetuated by the number of cognitively
impaired older adults requiring care in nursing homes, in adult day care,
or at home. However, this is not always the case. Many older adults live
well into their 10th decade as sharp as they were in their twenties and
thirties. While memory losses are common in older adulthood, the devel-
opment of dementia is not a normal change of aging. Dementia is a term
for a group of over 60 different pathological disease processes. These
cognitive impairments develop as a result of disease, heredity, lifestyle,
and perhaps environmental influences; they do not develop as normal
changes of aging. Dementia is a chronic loss of cognitive function that
progresses over a long period of time. Alzheimer’s disease (AD) is the
most common cause of dementia among older adults, making up about
50% of all dementia diagnoses, and there are approximately 4.5 mil-
lion U.S. residents with AD. Dementia is a devastating occurrence for
both older adults and loved ones, and much research is being conducted
on the prevention, diagnosis, early detection, and treatment of AD and
related dementias.
In older adults, three pathological cognitive and psychological con-
ditions occur frequently that lead to cognitive impairment. These condi-
tions are commonly known by those who care for older adults as the three
Ds: delirium, depression, and dementia. It is important to understand the
incidence, prevalence, causes, and treatment of these disorders in order
to give appropriate treatment. Delirium, depression, and dementia occur
from completely different disease processes, yet, they all tend to result in
similar symptoms of cognitive decline. It is important to recognize the
existence of these conditions in the older adult, screen for them appro-
priately, and refer the older adult for further evaluation and treatment
at the earliest possible point of care. Key features of each of the three
Ds are presented in Table 8.1. The following chapter reviews each of the
three Ds in terms of the epidemiology, diagnosis, and treatment. They are
presented in the order in which they may be assessed. In other words, if
an older adult is experiencing signs and symptoms of impaired judgment,
difficulty with language and calculation, disorientation or a change in
behavior, then the nurse may consider delirium, followed by depression,
then dementia.
Delirium
The typical scenario of delirium occurs as follows: an older adult is admit-
ted to the hospital for necessary or elective surgery. When she arrives, the
nurse asks her questions to complete the history, and she is able to quickly
recall dates and procedures, such as the onset of arthritis or cataracts. She
TABLE 8.1 Comparison of the Clinical Features of Delirium, Dementia, and Depression
Clinical Feature Delirium Dementia Depression
Onset Sudden/abrupt: depends on Insidious/slow and often Coincides with major life changes: often
cause; often at twilight of in unrecognized: depends on cause abrupt but can be gradual
darkness
Course Short, diurnal fluctuations in Long, no diurnal effects; symptoms Diurnal effects typically worse in the
symptoms; worse at night, in progressive yet relatively stable over morning; situational fluctuations, but less
darkness, and on awakening time; may see deceits with increased than with delirium
stress
Progression Abrupt Slow but uneven Variable: rapid or slow but even
Duration Hours to less than 1 month: Months to years At least 6 weeks can be several months to
seldom longer years
199
Consciousness Reduced Clear Clear
Alertness Fluctuates lethargic or hyper- Generally normal Normal
vigilant
Attention Impaired: fluctuates Generally normal Minimal impairment, but is distractible
Orientation Generally unpaired severity Generally normal Selective disorientation
varies
(continued)
TABLE 8.1 Comparison of the Clinical Features of Delirium, Dementia, and Depression (Continued)
Clinical Feature Delirium Dementia Depression
Memory Recent and immediate im- Recent and remote impaired Selective or “patchy” impairment; “is-
paired lands” of intact memory: evaluation often
difficult due to low motivation
Thinking Disorganized, distorted, frag- Difficulty with abstraction: Intact but with themes of hopelessness,
mented, incoherent speech, thoughts impoverished; judgment helplessness, or self-deprecation
either slow or accelerated impaired: words difficult to find
Perception Distorted: illusions, delu- Misperceptions usually Intact delusions and hallucinations absent
sions, and hallucinations: dif- absent except in seven cases
ficulty distinguishing between
reality and misperceptions
200
Psychomotor Variable hypokinetic, Normal; may have apraxia Variable; psychomotor retardation or
behavior hyperkinetic, and mixed agitations
Sleep/wake cycle Disturbed: cycle reversed Fragmented Disturbed, usually early morning awaken-
ing
Associated fea- Variable affective changes: Affect tends to be superficial, inap- Affect depressed dysphonic mood exag-
tures symptoms of autonomic hy- propriate and labile; attempts to gerated and details complaints; preoc-
perarousal: exaggeration of conceal deficits in intellect; person- cupied with personal thoughts; insight
personality type: associated ality changes, aphasia, agnosia may present; verbal elaboration; somatic com-
with acute physical illness be present; lacks insight plaints, poor hygiene, and neglect of self
Assessment Distracted from task: numer- Failings highlighted by family fre- Failings highlighted by individual,
ous errors quent “near miss” answers; strug- frequent “don’t knows”: little effort;
gles with test great effort to find an frequently gives up: indifferent toward test
appropriate reply; frequent requests does not care or attempt to find answer
for feedback on performance
201
Reprinted with permission from Springer Publishing Company. Forman, M., Fletcher, K., Mion, L., & Trygstad, L. (2003). Assessing cognitive
function. In M. Mezey, T. Fulmer, & I. Abraham (Eds.), & D. Zwicker (managing ed.), Geriatric nursing protocols for best practice (2nd ed.,
pp. 102–103). New York: Springer Publishing Company.
is prepared for surgery, uneventfully undergoes the procedure, and is sent

to the recovery room. Upon awakening from the anesthesia, she begins
calling out for a person who is not present. She randomly pulls at her
IV lines and pulls off her oxygen tube, alternating with periods of quiet
rest. Because she is an older adult, the health care providers assume she
is demented, give her sedative medications, and transfer her to a medical
unit. In fact, although this scenario occurs frequently, the myths that
surround the older adult’s development of cognitive impairment could
lead to inappropriate care for this woman. She is clearly experiencing
the sudden onset, short-termed cognitive impairment known as delirium,
but she may be diagnosed with dementia and sent to a nursing home for
custodial type care. Due to the myths of aging and lack of knowledge
about this cognitive disorder, delirium, like depression, is extremely under-
diagnosed among older adults. Inouye et al. (2001) originally reported that
nurses’ sensitivity for detecting delirium in hospitalized elderly patients
was low. McCarthy (2003) supported the need for strong environmental
management of delirium in order to enhance patient outcomes.
Delirium is defined as a transient state of global cognitive impairment
(American Psychiatric Association [APA], 1994) The diagnostic criteria
for delirium includes (a) reduced ability to maintain attention to exter-
nal stimuli and to shift appropriate attention to new external stimuli; (b)
disorganized thinking; and (c) at least two of the following: (d) reduced
level of consciousness; (e) perceptual disturbances; (f) disturbance of
the sleep–wake cycle; (g) increased or decreased psychomotor behavior;
(h) disorientation to person, place, or time; or (i) memory impairment.
These symptoms of delirium, commonly thought of as acute confusion,
usually develop over a short period of time (APA, 1994). Estimates of
the incidence and prevalence of delirium in acute care settings show
that approximately 16% of older adults experience this short-term
cognitive disorder. Jacobson (1997) expected to see an increase in the
amount of delirium reported as the population continues to age and the
prevalence of dementia increases. Edwards (2003) reports that delirium
is not a disease as much as a syndrome that may result from a variety
of causes.
The symptoms of delirium are best classified using a delirium
assessment tool, such as the Confusion Assessment Method (CAM). The
specific symptoms of delirium that separate it from dementia are the
acute onset and the fluctuating course of this disorder. In comparison,
dementia develops over a long period of time, with fairly stable cognitive
symptoms. For a diagnosis of delirium to be made, the older adult must
also have difficulty concentrating on tasks, or conversations and either
display disorganized thinking or altered level of consciousness. Delirium
may develop in both cognitively intact and impaired older adults.
Cognitive and Psychological Issues in Aging 203
The cause of delirium is not fully known but is believed to be mul-

tifactorial (Balas et al., 2007). The presence of previous brain pathology,
decreased ability to manage change, impaired sensory function, as well
as the presence of acute and chronic diseases and changes in pharmaco-
dynamic responses to medications, are all suggested causes. Cognitive
impairment, a burden of comorbidity, depression, and alcohol use, have
all been found to be independent predictors of delirium. Short and Winsted
(2007) also found that medications, and surgical procedudres predicted
delirium. Balas et al. (2007) report that older patients are at high risk for
the development of delirium during acute care hospitalization.
Delirium has vast implications for older adults, their families, and
the U.S. economy. Rizzo et al. (2001) report that delirium complicates
hospital stays for more than 2.3 million older persons each year, involv-
ing more than 17.5 million hospital days and accounting for more than
$4 billion of Medicare expenditures. The Harvard Health Letter (“Never
Been the Same Since,” 2007) reports that the presence of delirium has
multiple negative outcomes and may and place older adults at risk for
harm and permanent cognitive effects.
The most appropriate way to assess delirium is to understand its
frequent occurrence in all settings, especially acute and long-term care.
The use of a standardized delirium assessment tool, such as the Con-
fusion Assessment Method (CAM), is essential for effectively detecting
delirium.
Interventions to prevent delirium focus on best practices in care
of older adults. While research on the causes and interventions for
delirium is available, little has been done on work to prevent the onset
of delirium in hospitalized older adults. Inouye et al. (2007) studied
491 patients age 70 years or older who were admitted to acute care
units of large teaching hospitals. The researchers found that dementia,
vision impairment, functional impairment, high comorbidity, and the
use of physician restraints predicted delirium in the sample. Moreover,
the authors stated that four of these five risk factors are amenable to
clinical protocols that could be successfully implemented on the unit to
prevent the onset of delirum in hospitalized patients, were implemented
on the intervention units, and delirium was measured daily on all sub-
jects. The researchers suggest that prevention of delirium is the most
effective treatment strategy.
If delirium is assessed and determined to be the cause of cognitive
impairment, the first line of treatment is to identify and remove the cause
of the delirium. Delirium is a temporary and reversible condition, and
full recovery is possible. A change in one medication is often the rea-
son for the development of delirium, and a comprehensive analysis of
medication should be conducted. While medications themselves may not
Cultural Focus
Language barriers common to various cultural groups within the United

States may precipitate delirium, as well as sensory deficits and sensory
overload or underload. All of these factors should be considered in assess-
ing the older adult for delirium. Immediate detection and removal of the
cause of delirium will enhance the patient’s recovery. While the delirium is
resolving, it is important to keep the older adult safe.
be the cause of the delirium, the interaction of a medication with another

medication or with nutrients may trigger a delirium in an older adult.
Translocation syndrome, resulting from a change in surroundings from
a home to a nursing home or assisted-living facility, may also trigger the
onset of delirium. Language barriers common to various cultural groups
within the United States may precipitate delirium, as well as sensory defi-
cits and deprivation. The onset of acute or chronic medical conditions,
such as a urinary tract infection, or fracture, often precipitates a delirium
among older adults, as well. Waszynski (2007) also reports that alcohol-
ism and sensory impairment may cause delirium to begin among older
adults. These frequent causes should be examined in the older adult with
new onset cognitive impairment. If a new medication is added and an
interaction is suspected, remove the medication, if possible, to allow the
delirium to resolve. If a change in environment was the trigger, adding
familiar items to the new environment and having family around may
resolve the delirium. The older adult should also be assessed for the pres-
ence of infection or fractures and treated appropriately. If alcoholism is
determined to be the cause, the removal of alcohol and the detoxification
of the older adult will likely see the resolution of the delirium. Immediate
detection and removal of the cause of delirium will enhance the patient’s
recovery to the quickest extent.
While the delirium is resolving, it is important to keep the older adult
safe. This may include installing detection systems, such as chair and bed
alarms, to alert caregivers of wandering behavior. Shelkey (2000) reports
that specially trained dogs may be helpful in alerting caregivers of the
sudden mobility of an older adult with delirium or dementia. Implement-
ing fall prevention strategies, such as putting the mattress on the floor
and ensuring that the older adult is in the most familiar environment
possible, with appropriate translators, is essential. A calm, soft-spoken
approach to care is necessary, and the delirious older adult should not be
forced to participate in bathing or other behavior that frightens them. A
sponge bath with warm water and a lotion massage may be more sooth-
ing and comforting than a shower for a delirious older adult. This calm
Crіtical Thinking Case Study
Mrs. Ortega was admitted to the hospital for repair of her left hip after a
fall down her front porch steps. When admitted, she was alert and oriented
and had a pleasant affect. The surgery went as planned, and Mrs. Ortega
was transferred to the recovery room. Upon awakening from her anesthe-
sia, she was highly disoriented. She began yelling, attempting to remove
her IV, and trying to get out of bed. The nurses tried to calm her down, but
without success. She was finally administered a sedative medication and
transferred to a surgical unit.
1. Which of the three Ds does Mrs. Ortega most likely have? Why do
you think this?
2. If Mrs. Ortega’s pre-op status was not communicated to the surgical
unit nursing staff, which of the three Ds would Mrs. Ortega most
likely be assumed to have?
3. What risk factors did Mrs. Ortega have for developing this cognitive
impairment?
4. What interventions could be put into place for Mrs. Ortega in the
hospital and to make sure that this situation does not reoccur?
and understanding approach to care will speed the resolution of the delir-
ium and prevent injury. Frequently reassuring families of the temporary
nature of this illness is also necessary and essential for the emotional
stability of the family and the continued support for the older adult.
DEPRESSION
Older adults experience many losses, including health, home, job,

friends, family, spouse, and financial resources. These frequent losses are
blamed for the high incidence of depression among older adults. It is not
uncommon for a nurse or health care professional to state: “Of course
they’re depressed! I would be depressed too, if I went through what they
did.” In fact, one of the most prevalent myths of aging is that depression
is a normal response to the many losses older adults experience. Older
adults have the highest rates of depression within the U.S. population,
and this is often attributed to the frequent occurrence of loss within the
older population. While it is true that the situational life events men-
tioned previously play a role in the development or severity of depres-
sion, recent research on depression indicates that there is more to the
development of depression than the experience of loss. In fact, the nature
versus nurture controversy has uncovered the role of neurotransmitters
Title of Study: Delirium Among Newly Admitted Postacute Facility

Patients: Prevalence, Symptoms, and Severity
Authors: Kiely, D., Bergmann, M., Murphy K., Jones, R., Orav, E., Mar-
cantonio, E.
Purpose: To describe the prevalence of delirium, delirium symptoms, and
severity assessed at admission to postacute facilities.
Methods: Subjects from seven Boston area skilled nursing facilities
specializing in post acute care were assessed using the Mini Men-
tal Status Exam, Delirium Symptom Interview, Memorial Delirium
Assessment Scale, and Confusion Assessment Method (CAM) Diag-
nostic Algorithm. Delirium status was categorized: (1) full, (2) two
or more symptoms, (3) one symptom, and (4) no delirium. Descrip-
tive statistics were calculated, and chi-square analysis and analysis of
variance were used to examine delirium characteristics by delirium
group.
Findings: Among 2,158 subjects, approximately 16% had full CAM-
defined delirium at admission, 13% had two or more symptoms,
approximately 40% had one delirium symptom, and 32% had no
symptoms of delirium.
Implications: Results indicate that 16% of persons admitted to post acute
facilities have CAM-defined delirium, and more than two-thirds had at
least one delirium symptom. The detection and management of delirium
in post acute settings warrants the development and testing of strategies
to detect delirium.
in the development of depression among older adults. Because of the

many physiological changes in aging, this older adult population is more
susceptible to the effects of altered neurotransmission than in any other
age group. In fact, Healthy People 2010 (U.S. Department of Health and
Human Services, 2000) reports that older adults have the highest rate of
depression, and the rate is even higher among older adults with coexist-
ing medical conditions. Moreover, 12% of older persons hospitalized
for problems such as hip fracture or heart disease are diagnosed with
depression. Rates of depression for older people in nursing homes range
from 15% to 25%.
It is now generally agreed that chemical imbalances caused by the
decrease of certain neurotransmitters are the primary cause of depression
among older adults. Both depression and suicide occur more frequently
in older adults with a family history of the disease (Hogstel, 2001).

Moreover, the National Institute of Mental Health (2007) reports that
while more women have depression than men, non-Hispanic older white
men are the most likely to die by suicide with a rate of 49.8 suicides
per 100,000 older men. Hogstel (2001) reports a strong relationship
between depression/suicide and drug and alcohol abuse. While a chemi-
cal component is the most likely cause of depression, role changes in
aging, such as retirement, translocation, illness, and loss, may precipi-
tate depression in at-risk individuals. The National Institute of Mental
Health (2007) reports that 75% of older clients who successfully com-
mitted suicide had visited their health care provider within one month
of the suicide. This indicates the great need for nurses to effectively
assess for depression and suicidal ideation among older adults.
Changes in mood and thinking are the primary characteristics of
depression. The DSM-IV criteria for a diagnosis of major depression
disorder may be helpful in detecting depression. Just as there are differ-
ences among individuals, clients with depression differ in their emotional
states. These differences may be based on cultural, ethnic, religious,
or gender factors. For example, Aroian, Khatutsky, Tran, and Balsam
(2001) reported that providing support services for depression and lone-
liness was essential among elderly immigrants to the United States. Physi-
cal symptoms of sleep impairment and appetite changes could easily be
indicative of serious medical conditions, therefore, it is necessary to first
rule out any primary medical concerns.
A complete history, including family history, is essential to begin the
assessment of depression and should include questions about usual activi-
ties of daily living and any recent lifestyle changes. Use of the diagnostic
criteria for depression is one way to ask about symptoms. There are also
several depression scales, such as the Geriatric Depression Scale, which
are easy to administer and assist with assessment of the client’s condi-
tion. As stated earlier, depression often manifests itself as an alteration in
cognition among older adults. The National Institute of Mental Health
Cultural Focus
Just as there are differences among individuals, clients with depression dif-
fer in their emotional states. These differences may be based on cultural,
ethnic, religious, or gender factors. For example, Aroian, Khatutsky, Tran,
and Balsam (2001) reported that providing support services for depres-
sion and loneliness was essential among elderly immigrants to the United
States.
(2007) reports that in older adults with depression-related memory loss,

drug treatment for the disease resulted in improvement. This syndrome,
known as pseudodementia (Brown, 2005), may occur in both cognitively
intact and cognitively impaired older adults.
There are many treatment options for depression, including medi-
cation and psychotherapy as well as electric shock therapy. The most
frequently used form of treatment is medication. Not all older adults
are afforded the opportunity for therapy that may greatly improve
their levels of depression. Medication intervention in depression is
extremely helpful and may be used independently or in conjunction
with psychotherapy. There are several classes of antidepressants,
including selective serotonin reuptake inhibitors, tricyclic antidepres-
sants, monoamine oxidase inhibitors, and other atypical antidepres-
sants. It is important to note that antidepressant medications taken in
large amounts may result in death. In older individuals with depres-
sion, the risk of suicide is real; Hogstel (2001) reports the need to
dispense medications cautiously in older adults who exhibit suicidal
ideation to avoid overdosing.
Selective serotonin reuptake inhibitors (SSRIs) are a relatively
new class of medications, and they work by inhibiting the reuptake of
serotonin, thus increasing its concentration in the space between nerve
cells. Fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) are
examples of SSRIs. These antidepressant medications have an overall
lower side effect profile than their predecessor antidepressants, but they
are not perfect. The most common side effects of SSRIs are nausea,
diarrhea, dry mouth, tremors, and insomnia. Because of these effects,
SSRIs are usually taken in the morning right after breakfast, when cli-
ents are encouraged to be up and about, and the SSRIs help give them
an early morning boost. Caution should be excercised when adminis-
tering SSRIs to patients with Parkinson’s disease, and possibly other
tremulous disorders, because SSRIs may exacerbate their condition
to the point of inducing Parkinsonian crisis (Hogstel, 2001). Because
tremors are one of the more common side effects of SSRIs, it might be
wise to consider another class of antidepressant for these clients.
Tricyclic antidepressants (TCAs) are still used commonly to treat
depression among older adults, but they are increasingly replaced by
newer classifications of antidepressant medications. These medications,
including amitriptyline (Elavil), imipramine (Tofranil), and nortriptyline
(Pamelor), typically are poorly tolerated among the older population
because of the high side effect profile. They function by blocking the
reuptake of selected neurotransmitters, such as norepinephrine and sero-
tonin, which allows them to remain in the synaptic junction (the space
between the neurons) for a longer period of time. The most frequently
reported side effects of these medications include dry mouth, consti-

pation, tremors, blurred vision, postural hypotension, and sedation
(Hogstel, 2001). Administering the medications before bedtime often
decreases the client’s risk for falls.
Monoamine oxidase inhibitors (MAOIs) are rarely used because of
their high risk of medication interactions and side effects. Examples of
these include phenelzine (Nardil) and tranylcypromine (Parnate). They
function by preventing selected forms of monoamine oxidase, which
breaks down the chemicals norepinephrine, serotonin, and dopamine,
and like the TCAs, MAOIs remain in the neuroleptic synapse for a longer
period of time. Hogstel (2001) reports that common side effects include
orthostatic hypotension, tachycardia, edema, dizziness, and agitation. It
is essential that clients taking MAOIs adhere to a strict diet low in tyra-
mines (found in aged cheeses, for example) and avoid specific medications
(such as those containing ergotamine). Atypical antidepressants include
trazadone (Desyrel) and bupropion (Buspar). Similar to SSRIs and TCAs,
trazadone inhibits serotonin reuptake, and bupropion blocks the reuptake
of dopamine, norepinephrine, and serotonin. Hogstel (2001) reports that
side effects of these medications also may include dry mouth, dizziness,
and drowsiness, as well as some gastrointestinal problems, such as nausea
and vomiting, and an increase in the incidence of seizures. Stimulants such
as dextroamphetamine (Desedrine or Destrostat) and methylphenidate
(Concerta, Methylin, Methylin SR) may also be helpful in treating depres-
sion that is not responsive to newer generations of antidepressants.
Electroconvulsive therapy (ECT) is often poorly regarded among the
lay public because of negative media attention surrounding it. However,
despite its poor reputation, ECT is often an effective form of therapy
among older adults. ECT may replace the use of multiple antidepressant
medications and may benefit clients who have treatment-resistant depres-
sion. Prior to receiving ECT, older adults are administered an anesthetic
and a muscle relaxant. Side effects include some initial confusion and dis-
orientation, which typically resolves within a few days of treatment. The
ECT treatments are usually given every other day for 6–12 treatments,
with rapid resolution of depression exhibited.
Suicide
Untreated depression has the unfortunate capacity to end in suicide among
older adults. It is estimated that 15% of severely depressed people commit
suicide. The rate of suicide among older adults is disproportionate to the
population; while older adults currently account for only 12% of the pop-
ulation, they commit almost 20% of all suicides. Early reports on suicide
among older adults have revealed that while women make more suicide
attempts, men are three times more successful at completing suicide. More-
over, if there is a family history of suicide, risk increases (Yesavage, 1992).
Diagnosis of depression is the highest risk factor for suicide. In addi-
tion, the relocation of older adults from home to long-term care institu-
tions, living alone, and widowhood are also high risk factors for suicide
among older adults. Nurses must be aware of these risk factors and take
action when suicidal ideation is vocalized. Phrases such as, “I’m ready to
die; I wish the good Lord would just take me,” demonstrate feelings of
helplessness, hopelessness, and worthlessness consistent with depression.
Evidence has consistently revealed that approximately 80% of all people
who have committed suicide told someone about it first, often a primary
care provider. These types of statements require further evaluation with a
standardized geriatric depression scale.
DEMENTIA
Decline in the cognitive function of older adults is one of the most preva-
lent concerns and a major focus of study in the older population. While
normal changes of aging result in a decrease in brain weight and a shift in
the proportion of gray matter to white matter, the development of demen-
tia is not a normal change of aging. In fact, dementia, a general term used
to describe over 60 pathological cognitive disorders, occurs as a result of
disease, heredity, lifestyle, and, perhaps, environmental influences. It is
commonly believed that all older adults will develop dementia as they age,
but this is not the case. Memory losses are common to older adulthood,
but they are often falsely labeled as dementia. Dementia is a chronic loss of
cognitive function that progresses over a long period of time. The character-
istics of dementia differentiate it from delirium (see Table 8.1), which has a
sudden onset and acute duration. Dementia, as defined by the Alzheimer’s
Association (1999), is a “loss of mental function in two or more areas
such as language, memory, visual and spatial abilities, or judgment severe
enough to interfere with daily life” (p. 1). A commonly used scenario to
discriminate between common memory loss and dementia is: If you lose
your car keys, you simply experienced memory loss. If you find them and
don’t know what they are for—this may mean cognitive trouble.
Alzheimer’s Disease (AD)

While Alzheimer’s disease (AD) is not the only dementia affecting older
adults, it is certainly the most common, making up about 50% of all
dementia diagnoses. There are approximately 4.5 million U.S. residents
Title of Study: Memory Club: A Group Intervention for People With Early-
Stage Dementia and Their Care Partners
Authors: Zarit, S., Femia, E., Watson, J., Rice-Oeschger, L., Kakos, B.
Purpose: To investigate the immediate and long-term consequences of
dementia by examining afflicted individuals in the early stages of demen-
tia while they can still participate in decision making.
Methods: A 10-session group program, Memory Club, is comprised of
people with dementia and their care partners. Structured sessions of
dyads, as well as separate meetings with other people with dementia
and other care partners.
Findings: Participants evaluated this program very positively.
Implications: This study indicates that the person facing the long-term
effects of dementia, as well as those who care for the afflicted individu-
als, found it helpful to converse with other persons in their same situ-
ation.
with AD. Some other types of dementia are multi-infarct dementia,

Parkinson’s-related dementia, Huntington’s disease, Creutzfeldt-Jakob
disease, Pick’s disease, and Lewy Body dementia. Each dementia sub-
stantiates the classic definition given previously, including loss of mental
function, but there may be different cognitive symptoms depending on
the area/s of the brain affected by the disease.
Currently, the cause of AD is unknown. Research has supported
only two risk factors for the development of AD—advanced age and a
family history of the disease. Obviously, both of these risk factors are
nonmodifiable. Consequently, the most effective treatment for AD is not
risk factor modification, but early disease detection.
The Alzheimer’s Association (http://www.alzheimers.org) reports
that there are 10 early warning signs of AD, including (a) misplacing
items, (b) loss of initiative, (c) changes in personality, (d) poor judgment,
(e) changes in mood or behavior, (f) disorientation to time and place,
(g) memory loss that affects job skills, (h) difficulty performing familiar
tasks, (i) difficulty with finding the right words, and (j) problems with
abstract thinking. In the early or mild stage of AD, clients still have
many functional abilities, including the ability to perform certain tasks
until they are completed (Baum & Edwards, 2003), therefore, AD may
be difficult to detect by family and friends at this early stage, as older
adults with the disease are often able to interact appropriately in a social
environment.
Most often, the first sign of AD occurs when more difficult tasks
need to be completed, such as writing checks to pay bills, scheduling
appointments, or using the bus to get from one location to another. As the
moderate stage of AD develops, the older adult will experience difficulty
(a) finding the proper words to articulate thoughts or needs (aphasia);
(b) performing fine motor tasks, such as household tasks or ADLs
(apraxia); and (c) remembering (agnosia). Baum and Edwards (2003)
report that older adults may have a limited capacity to learn and prob-
lem solve at this stage of the disease. All of these changes may create
frustration for the older adult. While the older adult may have difficulty
recognizing some familiar faces at this stage of the disease, they may still
function well socially. As the disease progresses, the aphasia, apraxia,
and agnosia are enhanced; older adults in the final stage of AD often do
not speak at all, or it is garbled and incoherent. AD patients may become
very functionally limited, incontinent, and unable to ambulate. Finally,
there is often no memory left, and the patient’s level of consciousness
declines into a stuporous or comatose state (Baum & Edwards, 2003).
Effective evaluation of the cognitive function of older adults is the
benchmark of excellence in geriatric nursing care. Frequent evaluation
of cognitive status will allow the presence of delirium and dementia to
be detected at an early stage, which facilitates the most effective possible
treatment. If cognitive decline is detected, consistent reassessment of the
progression of the disease and development of a plan of care is necessary
for appropriate disease management. The use of a standardized cogni-
tive assessment instrument, such as the Mini Mental State Examination
(MMSE), is essential. If the older adult’s score on the MMSE is consistent
with low cognitive function, further diagnostic testing should occur to
rule out other causes of cognitive impairment, such as delirium or depres-
sion. Moreover, further cognitive evaluation will provide data to make a
more effective differential diagnosis.
Definitive diagnosis of all but multi-infarct dementia formerly was
limited to post-mortem brain autopsy. However, recent advances in
computed tomography (CT) scans, magnetic resonance imaging (MRI),
and, most importantly, positron emission tomography (PET) scans have
improved the ability to diagnose AD with more than 90% accuracy. In a
consensus report prepared by the Neuroimaging Group of the Alzheim-
er’s Association (Alzheimer’s Association, 2005), researchers found that
neuroimaging, such as MRI and CT, provided an accurate diagnosis of
AD. However, PET is another type of imaging technology that uses a
tracer called F-fluorodeoxyglucose (FDG), and in patients with AD, the
PET scan showed that their brain activity had a marked reduction in
FDG uptake. Thus, PET scanning may also be quite significant in evalu-
ating the progress of AD.
If older adults score low on screening instruments for cognitive
impairments, such as the MMSE, they should be referred for a com-
prehensive geriatric assessment to aid in the diagnosis of AD and to
rule out delirium and depression as possible causes of altered cogni-
tive function. Many major hospitals have such assessment centers, and
these can be a valuable resource for individuals and families coping
with decline in cognitive status. The Alzheimer’s Association is also a
valuable source of information about further diagnosis and treatment
for the disease.
Symptoms of dementia include difficulty communicating, forgetful-
ness, inattentiveness, disorganized thinking, altered level of consciousness,
perceptual disturbances, sleep–wake disorders, wandering psychomotor
disturbances, and disorientation. Working with older adults with cogni-
tive disorders is very challenging and often frustrating. The focus is on
maintaining function and independence as much as possible, while keep-
ing the older adult safe. Nurses who work with older adults are develop-
ing interventions to increase the quality of life for those who suffer from
dementia, including environmental manipulations, such as camouflaging
doors and installing door alarms, applying wander guards, and provid-
ing safe wandering areas. Restraints are not an appropriate alternative
for cognitively impaired older adults. Instead, placing mattresses directly
on the floor, using carpeting to decrease injury from falls, and using
commonly recalled signs and symbols to orient the older adult to the
environment are a few of the appropriate interventions. The Alzheimer’s
Association (2000) recommends the techniques in Table 8.2 for caring
for older adults with dementia.
One of the most important considerations in working with the
AD population is the need to plan for structure and consistency.
Maintaining a specific daily schedule may aid in reducing frustration
or uncertainty, because environmental changes or alteration in daily
routines may exacerbate dysfunction and worsen behavioral symptoms
(Souder & Beck, 2004). Once a patient progresses beyond the mild to
moderate stages of AD, increasing amounts of direct care and supervi-
sion are often needed. Translocation from one environment to another
may potentially upset the patient, so attempting to transition the patient
smoothly to this environment is important. One intervention is to main-
tain calm and comfort and to reassure his or her safety (Souder & Beck,
2004). Remember to speak directly to the older client with AD and lis-
ten respectfully, observing cues in facial expression, tone, and repetitive
phrases or behaviors to obtain insight into what the patient is feeling
(Souder& Beck, 2004).
TABLE 8.2 Tips for Assessing and Managing Troubling Behaviors

of Cognitively Impaired Older Adults
Assess Intervene Evaluate
Identify the troublesome Explore potential Did your intervention
behaviors: solutions: help?
• What was the • Are there unmet needs • Do you need to ex-
behavior? of the person with de- plore other potential
• What happened just mentia? Are they sick, causes and solutions
before or after the in pain, or sexually to the behavior?
behavior? Did some- unfulfilled?
thing trigger it? • Can you adapt the
• What was your environment instead
reaction? of the person?
• Can you change your
reaction or approach
to the behavior?
Adapted from the Alzheimer’s Association Steps for Understanding Challenging Be-
haviors (2000).
Maintaining function as long as possible is an important goal in

the care of AD clients. This may require cuing or modeling when the
client attempts to complete tasks such as ADLs (Souder & Beck, 2004).
Environmental factors may also contribute to the patient’s well being.
For example, placing a patient who needs a quiet environment in a room
close to a busy nursing station can overwhelm that patient and cause
problematic behaviors (Souder & Beck, 2004).
Several medications known as cholinesterase inhibitors have recently
been developed over the last decade to increase the levels of acetylcholine
in the brain. These medications include donepezil (Aricept), galantamine
(Reminyl), rivastigmine (Exelon), and tacrine (Cognex). These medica-
tions work to prevent further loss of cognitive function and to improve
cognitive status in older adults with dementia. They are most effective
when started in the early stages of the disease. Another medication that
has shown some promise in treating AD is Namenda®, or memantine. The
action of memintine differs from that of the cholinesterase inhibitors, but
it works well in combination with this classification of drugs and appears
to be well-tolerated. In addition, research to develop an AD vaccine is
ongoing. Preliminary studies suggest that the vaccine is effective at reduc-
ing cognitive decline. Unfortunately, early studies of the vaccine showed
the presence of brain inflammation among study participants, so further
research is necessary. However, a recent report by the Alzheimer’s Asso-
ciation (2005) indicates that an attenuate version of the vaccine currently
undergoing clinical trial shows signs of effectiveness in 20% of patients

enrolled in the study, and no adverse effects have been reported. Lithium
has also been suggested as a possible medication to suppress the develop-
ment of the beta-amyloid responsible for plaque formation among AD
patients. However, the cardiovascular and central nervous system side
effects of this medication make its use difficult.
Besides administering and evaluating the effect of medications, nurs-
ing interventions include physical and emotional support to the client
and the family. There are many cultural variations in the care decisions
made for older adults. Some cultural backgrounds lead to the belief that
older adults with cognitive disorders, such as AD, must be cared for at
home, by family. The traditional Western medicine model is more accept-
ing of institutionalization of older adults. The Profile of Older Ameri-
cans (Administration on Aging & U.S Department of Health and Human
Services, 2005) reports that 54.7% (10.7 million) of older noninstitu-
tionalized persons lived with their elderly spouses, and it is estimated
that family members provide approximately 80% of the care for older
adults.
The majority of care for patients with AD is often delegated to a
specific caregiver. In many cases, the caregiver is also an older adult, most
often a woman, with health problems of her own. The experience of
caregiving is very stressful and has been shown to result in the onset
of depression, grief, fatigue, decreased socialization, and health prob-
lems (Sullivan, 2007). Meeting the basic needs for nutrition, hygiene and
grooming, and continued functioning and mobility are essential. The
nurse, in conjunction with the caregiver, must also assess, document, and
report any changes in physical and mental status of the client immediately
so that interventions can be initiated to minimize short- and long-term
Cultural Focus
Some cultural backgrounds lead to the belief that older adults with cogni-
tive disorders, such as AD, must be cared for at home, by family. The tradi-
tional Western medicine model is more accepting of institutionalization of
older adults. The Profile of Older Americans (AARP, 2002) reports 54.7%
(13.7 million) of older noninstitutionalized persons lived with their elderly
spouses, and it is estimated that family members provide approximately
80% of the care for older adults. The nurse, in conjunction with family
caregivers, must also assess, document, and report any changes in physical
and mental status of the client immediately in order to implement interven-
tions to minimize short- and long-term disease effects. In addition, care for
the caregiver is often part of the nurse’s role.
disease effects. In addition, care for the caregiver is often part of the
nurse’s role. More information on caregiving can be found in Chapter 9.
SUMMARY
As the population of older adults continues to rise, an increase will be

seen in the number of cognitive and psychological disorders among this
population. Although the presence of delirium, depression, and dementia
are not normal changes of aging, they occur commonly in this popula-
tion and threaten a large number of older adults. The presence of cogni-
tive and psychological disorders among older adults markedly affects the
ability of this population to independently complete activities of daily
living. In addition, the presence of these illnesses is extremely costly, both
emotionally and financially, for clients and their families.
This chapter discusses three frequently occurring conditions among
older adults, commonly known as the three Ds: delirium, depression, and
dementia. The incidence, prevalence, causes, and treatment of these dis-
orders was reviewed. While delirium, depression, and dementia are the
result of completely different disease processes, they all produce symp-
toms of cognitive decline. It is challenging to determine which condition
is causing the problem, and it is of utmost importance to assess changes
in cognitive function and to refer the older adult for further evaluation
and treatment at the earliest possible point of care. This will ensure that
older adults receive the most effective management of cognitive and psy-
chological disease.
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Alzheimer’s Association. (1999). Alzheimer’s disease and related dementias fact sheet.
Retrieved on July 13, 2007, from http://www.alz.org/documents/national/FS-Related
Diseases.pdf
Alzheimer’s Association. (2000). Steps to understanding challenging behaviors. Retrieved
on July 13, 2007, from http://www.alz.org/national/documents/C-EDU-Stepsto
UnderstandingChallengingBehaviours.pdf
Alzheimer’s Association. (2005). Basics of Alzheimer’s disease. Retrieved on July 13, 2007,
from http://www.alz.org/documents/national/basics_of_alz_low.pdf
American Association of Retired Persons. (2005). Profile of Older Americans. Retrieved
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disorders (4th Edition). Washington, DC: Author.
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utilization among elderly immigrants from the former Soviet Union. Journal of Nurs-
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Richmond, T. S. (2007). Delirium in older surgical intensive care unit. Journal of
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Baum, C., & Edwards., D. F. (2003). What persons with Alzheimer’s disease can do: A
tool for communication about everyday activities. Alzheimer’s Care Quarterly, 4(2),
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Brown, W. A. (2005) Pseudodementia. The Pyschiatric Times, 22(13), 83.
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C H A P T E R N I N E
Ethical Issues of Aging

and Independence
Learning Objectives
1. Discuss ethical issues inherent in the aging process.
2. Define ethical principles used to guide ethical decision making.
3. Discuss problems and solutions associated with older adult
drivers.
4. Use an ethical framework to explore issues related to older
drivers.
5. Identify barriers and interventions to sexuality among older
adults.
6. Use an ethical framework to explore issues related to sexuality
among older adults.
7. Describe the incidence of problem and pathological gambling
and its impact on the health of older adults.
8. Use an ethical framework to explore issues related to gambling
among the elderly.
Mr. Larry is a 92-year-old healthy man. He lived in his own apartment

and is completely independent in ADLs and IADLs. On June 14, 2000, he
left his apartment complex at 8:09 a.m. to go to the store. While backing
out of his driveway, he failed to see a school bus passing on the intersect-
ing street and his car struck it on the passenger side. One child was killed
and six others were injured. Residents and city officials are outraged,
with many questioning why Mr. Larry was still driving.
Chronic illnesses that occur during the aging process frequently cause
nurses to encounter ethical issues in the care of this population. Chronically
219
ill older adults may experience cognitive disorders, suffer from pain and
discomfort, endure poor quality of life, or need to cope with end-of-life
issues. As nurses care for older adults, ethical dilemmas surrounding these
issues of older adulthood arise daily and are often in need of immediate
resolution. Moreover, these issues present great challenges to nurses and
other members of the health care team.
Ethics are defined in The American Heritage Dictionary of English
Language (2007) as “The study of the general nature of morals and
of specific moral choices.” The American Heritage Dictionary of the
English Language (2007) defines bioethics as “The study of the ethical
and moral implications of new biological discoveries and biomedical
advances, as in the fields of genetic engineering and drug research.”
Issues surrounding the ethical care of older adults are complex and
often require the integration of personal values and morals, as well as
other factors specific to the nurse, the client, and the situation. Each
person in the situation (client/resident, nurse, case manager, discharge
planner, social worker, physician, family, and lawyer) has a personal
perspective on effectively managing the situation based on their indi-
vidual values, life experiences, education, and other factors. Each per-
son also brings a set of morals and values used to identify right from
wrong.
This chapter will explore the ethical issues inherent in the aging
process. It begins with a discussion of ethical principles used to guide
ethical decision making. These ethical principles will be applied to three
E i -B P i
Title of Study: Our “Increasing Mobile Society”? The Curious Persistence

of a False Belief
Authors: Wolf, D., Longino, C.
Purpose: Overall mobility has actually declined since 1950, so the topic of
“increased mobile society” in the United States is examined.
Methods: Simple regression method analysis is used to estimate the size
and significance of mobility trends in the United States.
Findings: In all age groups, overall mobility has declined. The larg-
est decline is noted in the age group of 20–29 year olds, and the rate
of those 65 years and older is also large. Interstate mobility has also
declined or remained constant between adults aged 45 and 65 years.
Implications: Increased geographic mobility does not appear to be a con-
tributing factor in predicting declining care for the elderly relatives.
Ethical Issues of Aging and Independence 221
specific issues of independence among older adults, including driving,

sexuality, and gambling. At the conclusion of the chapter, students will
have an increased understanding of the ethical and legal issues that older
adults encounter and the resources used to assist with decision making
when these issues occur.
ETHICAL PRINCIPLES
While there are many complex and challenging decisions ahead for nurs-
ing students and nurses in the care of older adults, it is important to
know that nurses are not alone in making these decisions. Nurses are
members of health care teams composed of physicians, social workers,
therapists, clergy, and others who all bring unique perspectives to the care
of older adults. In many ethical situations, the team is called together to
discuss the situation and make decisions jointly. The nursing profession
is consistently guided by the American Nurses Association (ANA) code
for nurses. This document is a guideline for the goals, values, and ethical
decisions of nurses. It is considered nonnegotiable and supersedes the
policies of individual institutions in regard to nursing practice and ethical
decision making. The code for nurses provides a number of interpretive
statements specific to health care situations frequently encountered in
the care of older adults. For example, the ANA has a position statement
on polypharmacy among older adults and nurses’ participation in end-
of-life care. These statements can provide great support and resources
during difficult ethical encounters throughout nurses’ careers. The ANA
code for nurses and interpretive statements may be found at http://www.
nursingworld.org.
The ethical practice of nurses and other health care professionals
involves the application of ethical principles to each situation. Ethical
principles provide a framework for understanding the ethical issues that
frequently arise among the care of older adults. For example, consider
Mrs. Jones, a highly functioning 79-year-old widow recently admitted
to a nursing home with mild cognitive impairment (MCI). Mrs. Jones
began a friendship with Mr. Carl, who is cognitively intact and wheel-
chair bound. Mr. Carl is married to a woman who resides outside the
facility. The nursing staff has noticed more and more intimate touches
among the two residents and is concerned about whether Mrs. Jones
is competent to make the decision to participate in this increasingly
intimate relationship. The staff is also concerned about the moral and
ethical issues surrounding Mr. Carl’s relationship with a woman other
than his wife. The availability of ethical principles can be extremely
useful to guide nurses’ actions within the situation. Understanding and
effective use of ethical principles is essential to ethical decision making

and the resolution of ethical dilemmas. In bioethics, four principles
guide ethical deliberations: autonomy, beneficence, nonmaleficence,
and justice.
Autonomy
Autonomy conveys a respect for the person’s ability to govern self or
to freely choose one’s actions as long as these choices do not interfere
with the autonomy or rights of other persons. This principle has also
been called self-governance or self-determinism (Hogstel, 2001). World
Reference.com defines self-determinism as the determination of “one’s
own fate or course of action without compulsion.” Decisions involv-
ing autonomy or self-determination must consider the patient’s right to
choose for themselves, regardless of the consequences. Issues surround-
ing autonomy or self-determination are seen frequently in clinical areas,
when patients refuse medications, treatments, and surgical procedures
that are likely to improve their health. For example, clients of particular
cultural and religious backgrounds do not believe in blood transfusion
and, thus, will not consent to this procedure, even though it may be
necessary to save lives. Enhanced understanding regarding older adults’
health beliefs will result in improved capacity to make ethical health
care decisions.
In the case of Mrs. Jones, the right to autonomy is complicated by
the presence of mild cognitive impairment (MCI) and must be explored
further. The question remains: Is she competent to make the decision to
participate in an intimate relationship, or must another person be asked
to do this? In Mr. Carl’s case, the nursing staff must highly consider the
resident’s right to autonomy, even when the moral values and life experi-
ences of the nurses lead them to believe his relationship with Mrs. Jones
is wrong.
Ethical issues and dilemmas that surround this principle also in-
clude informed consent. Informed consent is defined by worlddictionary.
com as the “consent by a patient to a medical or surgical treatment or
to participate in an experiment after the patient understands the risks
C F
Clients from diverse cultural and religious backgrounds may have health
care beliefs that play a significant role in ethical decision making. Enhanced
understanding regarding older adults’ health beliefs will result in improved
capacity to make ethical health care decisions.
involved.” Informed consent must be obtained in order for a patient

to undergo a medical treatment and/or participate in research studies.
Informed consent is a required component of all health care proce-
dures and research studies and shows respect for persons by supporting
autonomous choice. From an ethical and caring perspective, informed
consent decreases anxiety about health care interventions and encour-
ages health care professionals, including nurses and researchers, to act
responsibly during clinical practice and research. Numerous violations
in informed consent have resulted in a great deal of mistrust of health
care professionals and researchers from the perspective of older adults.
The Tuskegee Syphilis studies conducted among African American men
in the 1930s and ’40s were one such example of the violation of multiple
rights of one particular ethnic group. In this case, men were enrolled in a
study, without their consent, and prevented from receiving penicillin for
the treatment of syphilis. Many men died from the disease, because even
though treatment was available, participants in this study were denied
access. As a result of these atrocious violations of autonomy and self-
determination, informed consent has become a standard component of
health care and research. Informed consent has the potential to increase
the willingness of patients and research participants to collaborate with
nurses based on a trusting relationship between the nurse and the recipient
of care.
In order to implement this principle safely in health care institu-
tions where research is conducted, institutional review boards (IRBs) are
established. The role of IRBs is to protect clients from unethical behavior
on the part of researchers and clinicians. In so doing, IRBS ensure that
research participants provide informed consent prior to participation
in research, that the participants’ results are confidential, and that no
manipulation or coercion occurs.
C F
The Tuskegee Syphilis studies conducted among African American men in

the 1930s and ’40s were one such example of the violation of multiple rights
of one particular ethnic group. In this case, men were enrolled in a study,
without their consent, and prevented from receiving penicillin for the treat-
ment of syphilis. Many men died from the disease, because even though
treatment was available, participants in this study were denied access. As
a result of these atrocious violations of autonomy and self-determination,
informed consent has become a standard component of health care and
research.
Beneficence
Beneficence is defined as “doing good or participating in behavior that
benefits a recipient of care.” This ethical principle forms the basis of
professional codes of practice for many health care disciplines. For
example, Mr. James, a 79-year-old man is admitted to a medical–sur-
gical unit for unexplained rectal bleeding. He has a history of two
previous suicide attempts over the past year, since his wife died. The
physician diagnoses a nontreatable malignancy. Out of concern that
this diagnostic information will result in another suicide attempt, the
health care team chooses to withhold this medical information from
Mr. James until they are certain that his depression is stabilized and
safety can be assured. In this case, the principle of beneficence assumed
prominence over the person’s right to self-govern. In the case of Mrs.
Jones and Mr. Carl earlier in the chapter, the actual and projected out-
comes of the intimate relationship would require assessment to deter-
mine what nursing actions are required regarding this relationship.
If an assessment of Mrs. Jones finds that she is incapable of under-
standing the consequences of her relationship with Mr. Carl, then she
must be prevented from being taken advantage of. However, if the
assessment leads nurses to believe that Mrs. Jones and Mr. Carl under-
stand the risks and consequences of their relationship, then the right
to autonomy prevails. The difference between the two cases is revealed
in each patient’s ability to act autonomously. Both Mrs. Jones and Mr.
James have questionable abilities to do this based on the presence of
MCI and the history of two suicide attempts, respectively. In these ethi-
cal dilemmas and all others, nurses and other health care professionals
must weigh the ability and right to act autonomously with the good
and the bad of each considered action and then render a decision based
on which action would be the most beneficial to the client and, thus,
meet the health care goals.
Nonmaleficence
Nonmaleficence focuses on the health care provider’s mandate to “above
all, do no harm.” This principle prevents nurses from aiding in physi-
cian-assisted suicide and/or causing pain or suffering to another person.
Nonmaleficence provides the legal and correctional framework. It places
value on all human life and freedom, the importance of each person’s
life and the need to honor the human dignity and choices of each person
(Hogstel, 2001). Discussions of active and passive euthanasia involve the
principle of nonmaleficence. Active euthanasia, committing a fatal act
on an ill person, is not morally acceptable in most societies. However,
passive euthanasia, letting a person die by omitting treatment (such as

food, medication, or surgery to maintain life) and allowing the disease or
injury to cause death, is practiced in this country and in other societies.
As stated earlier, the ANA code for nurses provides specific guide-
lines regarding nursing actions in a variety of ethical situations. These
actions supersede facility policy and are nonnegotiable. Among other
interpretive statements within the code, nurses are guided by the ANA
(1994) position statement on assisted suicide. This position statement
explicitly prohibits nursing involvement in active euthanasia or the inten-
tional ending of another’s life. However, there are examples of nurses
practicing passive euthanasia in certain situations. The recent case of a
younger woman in Florida who was brain damaged years earlier pro-
vides an interesting perspective on nurses’ involvement in ethical end-
of-life care issues. In this case, the client’s husband had petitioned courts
to remove his wife’s feeding tube. After multiple court battles, his peti-
tion was successful, and the tube was removed. While nurses may have
had differing ethical views on the decision, the ANA does not prohibit
involvement in removal of life-sustaining treatment in some cases. Nurses
in this case played an important role in providing compassion and care,
as well as keeping the client comfortable during her last few days.
As with all ethical dilemmas, the decision to omit treatment needed
to sustain life involves the analysis of ethical principles and the use of
excellent communication with all involved individuals, including the
client, health care providers, and family. In other situations, such as the
case of intimacy between older nursing home residents discussed ear-
lier, failure to assess Mrs. Jones’s ability to consent to participate in an
intimate relationship with Mr. Jones could be termed nonmaleficence.
While nurses are often uncomfortable and lack knowledge in assessing
and managing sexual issues among older adults, failure to do so in this
case has the potential to cause harm to both residents. Use of the nursing
process, as well as consultation with family and members of the health
care team, generally result in effective decisions.
Justice
“The principle of justice supports the fair allocation of resources to indi-
viduals or the provision of an equal share of available resources to each
person” (Hogstel, 2001, p. 540). This principle has specific application
to older adults who must consistently fight against ageism. As discussed
earlier in this text, ageism is defined as a negative attitude or bias toward
older adults, resulting in the belief that older people cannot, or should not,
participate in societal activities or be given equal opportunities afforded
to others (Holohan-Bell & Brummel-Smith, 1999). In the case of Mrs.
Jones and Mr. Carl, failure to recognize the sexual needs of older adults,
and manage these needs with similar priority to other physical needs, is a
violation of the ethical principle of justice. Ethical issues that arise from
the principle of justice and are influenced by ageism involve the distribu-
tion of health care resources at local and national levels, including micro
allocation and macro allocation, respectively. For example, approximately
60% of patients cared for today are older adults, yet only 34% of nurs-
ing schools require a course in geriatric nursing. Nurses caring for older
adults understand that ageism has great potential to impact the health
care of older adults and their access to services. Moreover, ageism has the
power to destroy the dignity and respect of older adults and impacts poli-
cies and care decisions for this population. Nurses must work consistently
to identify ageism and mitigate its ability to influence policies and care
decisions that will affect the quality of life of older adults. In so doing,
nurses play an instrumental role in preventing the consequences of aging
on older adults. This includes making sure that older adults are not dis-
criminated against in selection for medical procedures or resources.
Consistent with the principle of justice is the issue of whether or
not health care is a right for all persons, or a privilege for those who can
afford it. While the United States has discussed a national insurance pro-
gram, many other countries have implemented it in the spirit of justice.
DRIVING
As the percentage of older adults living in the United States continues to

increase, the number of older drivers will rise. In fact, if the current trend
in the number of older drivers continues, by 2026 this number could pos-
sibly exceed 2.5 times the 1996 levels. Moreover, conservative estimates
indicate that between 1990 and 2020, the total annual mileage driven by
older male drivers will increase by 465% and by older female drivers by
500% (Burkhardt, Berger, Creedon, & McGavock, 1998).
The risk for injuries, hospitalizations, and death from automobile
accidents is increased in the older adult population because of the many
normal and pathological changes in the neuromuscular and sensory sys-
tems. Consequently, the ability to respond to emergency driving situa-
tions may be slowed. Table 9.1 summarizes normal changes of aging that
affect driving ability. It is estimated that the number of elderly traffic
fatalities will more than triple by the year 2030, exceeding the number
of alcohol-related fatalities in 1995 by 35% (Burkhardt et al., 1998).
In addition, the increase in older drivers presents additional problems,
because cars, roads, and highways were not developed to accommodate
TABLE 9.1 Normal Changes of Aging That Aﬀect Driving Ability

System Normal Aging Changes
Senses Eyes
• Visual acuity declines.
• Ability of pupil to constrict in response to stimuli
decreases.
• Peripheral vision declines.
• Lens of the eye often becomes yellow.
Ears
• Increased prevalence of hearing disorders.
Neurological • Slower response time to stimuli.
• Shift in the proportion of gray matter to white matter.
• Loss of neurons.
• Increase in the number of senile plaques.
• Blood flow to the cerebrum decreases.
normal changes of aging among older drivers. This results in a large num-
ber of older adults unable to safely drive.
There are many ethical issues surrounding the decision about whether
older adults should continue to drive. These issues are summarized in
C i i T i i C S
Mr. Larry is a 75-year-old healthy man. He lives in his own apartment

and is completely independent in ADLs and IADLs. On June 14, 2000, he
left his apartment complex at 8:09 a.m. to go to the store. While backing
out of his driveway, he failed to see a school bus passing on the intersect-
ing street, and the passenger side of his car struck it broadside. One child
was killed and six others were injured. Mr. Larry is now charged with
manslaughter.
1. What normal or pathological changes of aging were involved in Mr.
Larry’s inability to see the school bus before colliding with it?
2. What do you think should be the resolution for this accident? Should
Mr. Larry face criminal charges, lose his license, or both?
3. What effect would the revocation of a license have on Mr. Larry’s
ability to function independently?
4. Do you feel that accidents like Mr. Larry’s underscore the need for
older adults to be retested in order to drive? Should older adults have
a mandatory license suspension?
5. What changes to vehicles and personal adaptations should be made
so that driving is safer for older adults and other drivers?
TABLE 9.2 To Drive or Not to Drive?
Ethical Principle Application to Issue of Independence
Autonomy (Self-Determination) The right to drive is complicated by normal changes in aging that effect senses and
The right to govern self or to freely response time. What impact these changes have on Mr. Larry’s ability to drive must be
choose one’s actions as long as these assessed. It is important to determine if these changes impacted the accident or whether
choices do not interfere with the the failure of Mr. Larry to see the school bus was independent of these normal aging
autonomy or rights of other persons. changes. In clients with acute and chronic illness, the impact of these diseases on driving
ability must also be assessed and weighed against the client’s right to autonomy.
Beneficence Putting Mr. Larry’s safety first requires a full assessment of his physical, psychologi-
Doing good or participating in behavior cal, and emotional health to determine if it is in his best interest to continue driving or
that benefits a recipient of care. whether he would be safer without a driver’s license. In this case, a driver’s refresher
course may be in the client’s best interest.
228
Nonmaleficence Failure to assess the impact of normal and pathological changes on Mr. Larry’s ability
Above all, do no harm. to drive puts both Mr. Larry and society at risk. With knowledge regarding the potential
impact of normal and pathological aging on driving among older adults, it is a nurse’s
duty to be sure to assess these changes and implement interventions to promote the
maximum safety for clients and society. Failure to do so in this case has the potential to
cause harm to both.
Justice The role of ageism in society often makes it easy to assume that older adults should not
The fair allocation of resources to drive. However, while normal changes of aging impact driving ability, there are many
individuals or the provision of an equal ways in which to compensate for these changes. Consequently, full regard for the rights
share of available resources to each of autonomy must be adhered to in order for justice to prevail in the case of Mr. Larry
person. and other older adult drivers.
Table 9.2. One ageist solution that has been suggested is to revoke their
license to drive at a certain age. In fact, this has been considered as a
viable solution to the problem. However, this will result in a great loss of
independence among this population, and considering the ethical prin-
ciples stated earlier, it is important to discuss ways in which older adults
may be assisted to maintain their safety and independence as long as
possible, while still protecting the safety of other drivers, passengers, and
pedestrians. Consider the case study in this chapter using the ethical prin-
ciples outlined earlier.
Nurses can play an essential role in helping older adults to maintain
safe driving practices and ensure the safety of the community by assessing
normal and pathological changes of aging in the older adult. The imple-
mentation of strategies to reduce the effects of normal aging and man-
age disease are also important components of safe driving. In addition,
nurses should recommend that patients learn to drive again, adapting to
their neuromuscular and sensory changes. Nurses working with older
adult drivers should encourage them to take driver refresher classes that
are run by the American Association of Retired Persons (AARP). Com-
pletion of the AARP driver refresher course often allows older adults to
save money on car insurance.
SEXUALITY IN OLDER ADULTS
One of the most prevalent myths of aging is that older adults are no lon-
ger interested in sex. Because sexuality is mainly considered a young per-
son’s activity, often associated with reproduction, society doesn’t usually
associate older adults with sex. In the youth-oriented society of today,
many consider sexuality among older adults to be distasteful and prefer
to assume sexuality among the older population doesn’t exist. However,
despite popular belief, sexuality continues to be important in the lives
of older adults. A survey of 1,126 older adults by Matthias, Lubben,
Atchison, and Schweitzer (1997) found that 30% had participated in
sexual activity over the past month. The need to continue sexuality and
sexual function should be as highly valued as other physiological needs.
Because much of society believes sexuality is not part of the aging pro-
cess, nurses and other health care providers rarely assess sexuality, and
few intervene to promote sexuality of the older population. Nurses may
avoid the discussion because they lack knowledge about sexuality in
older adults, or simply because they’re inexperienced and uncomfortable
with the issue.
The fulfillment of sexual needs may be just as satisfying for older
adults as it is for younger people. However, several normal and patho-
logical changes of aging complicate sexuality among older adults. Older

adults may experience performance anxiety and may not be familiar with
the risks of sexually transmitted diseases and appropriate prevention.
Negative self-concepts and role changes that frequently occur in response
to chronic illness may impact the experience of sexuality for older adults
and could result in fear of rejection or failure, as well as boredom or hos-
tility about sexual performance. The past sexual history of older adults
may also play a role in sexual health. Delays in sexual development or
a history of sexual abuse may continue to impact sexuality in the later
years. Despite difficult issues and the great need to assess older client’s
sexuality, many older adults are reluctant to discuss sexual issues with
health care providers.
Normal physiological changes of aging among women result in a
decrease in circulating estrogen, which results in a thinning of the vagi-
nal epithelium, the labia majora, and the subcutaneous tissue in the mons
pubis. The vaginal canal shortens and loses elasticity. Follicular depletion of
the ovaries as a result of a decrease in circulating estrogen leads to a further
decline in the secretion of estrogen and progesterone (Masters, 1986). In
response to these physiological changes, dyspareunia (painful intercourse),
orgasmic dysfunction, and vaginismus may result (Meston, 1997).
Viropause, andropause, or male menopause are new and contro-
versial terms to describe the physiological changes that affect the aging
male sex response. The syndrome, usually beginning between the ages
of 46 and 52 is characterized by a gradual decrease in the amount of
testosterone (Kessenich & Cichon, 2001). The loss of testosterone is not
pathological and does not result in sexual dysfunction. However, men
may experience fatigue, loss of muscle mass, depression, and a decline in
libido (Kessenich & Cichon, 2001).
In his work on the aging sexual response, Masters (1986) indi-
cated that the reduced availability of sexual hormones in both male and
female older adults result in declines in the speed and overall responses
to sexual arousal. The physiological changes in hormone secretion affect
four areas of sexual response: (1) arousal, (2) orgasm, (3) postorgasm,
and (4) extragenital changes (Masters, 1986). In men, these changes are
seen in the increased time needed to develop an erection and ejaculate.
Erections also may require direct penile stimulation (Araujo, Mohr, &
McKinlay, 2004). The volume of semen declines, and a longer period
of time is needed between ejaculations. For women, in addition to the
decline in vaginal lubrication and painful intercourse, the aging female
may also experience fewer orgasmic contractions or painful uterine
contractions during sexual activity (Harvard Medical School, 2003).
Infrequent rectal sphincter contractions and a postcoital need to urinate
may also be present (Harvard Medical School, 2003).
Title of Study: Andropause: Knowledge and Perceptions Among the Gen-

eral Public and Health Care Professionals
Authors: Anderson, J., Faulkner, S., Cranor, C., Briley, J., Gevirtz, F., Rob-
erts, S.
Purpose: This study assesses the knowledge and perceptions of andropause,
the natural age-related decline in testosterone in men, among health
care providers and the general public.
Methods: Health care providers and members of the general public partici-
pated in brief surveys via a medical information telephone line. Trained
clinical interviewers administered the questionnaire and documented
the findings.
Findings: Of 443 general public participants, 377 (85%) agreed to partici-
pate in the survey. Of these, 77% had heard of andropause—male meno-
pause—and 63% had taken TRT (testosterone replacement therapy).
Out of 88 health care provider callers, 57 (65%) participated in the
survey. Of these participants, 65% were pharmacists, 80% had patients
with low testosterone symptoms, and 50% reported that patients rarely
or never spoke of low testosterone. Among HCPs and the general pub-
lic, respectively, 98% and 91% knew that low testosterone is treatable
with medication, and 60% and 57% knew that it results in osteoporo-
sis. Only 25% of HCPs and 14% of the general public knew that low
testosterone does not cause loss of urinary control.
Implications: Some health care providers, as well as members of the general
public, are knowledgeable about some aspects of low testosterone and
have misconceptions about others. Therefore, it is clear that education
is needed in this area.
Journals of Gerontology Section A, Biological and Medical Sciences, 2002 Dec,
57(12), M793–M796.
The normal changes of aging may alter or delay the sexual response
of older adults, but sexual dysfunction is not a normal process of aging.
The frequent occurrence of chronic illnesses and the use of multiple medi-
cations among older adults, however, frequently interfere with the nor-
mal sexual function of older men and women. Morley and Tariq (2003)
report that medication usage, diseases such as diabetes and depression,
and surgery to structures involved in the sexual response (e.g., prostate,
breast) are all factors that result in sexual dysfunction among older
adults. In these cases, removal of the medication causing the dysfunction,
treatment of the chronic medical illness, and psychological therapy are
interventions that may contribute to the resolution of sexual problems
(Morley & Tariq, 2003). Medications, vacuum erection devices, and sur-
gery are options for resolving erectile impotence when other interven-
tions fail.
The assessment and management of sexual problems of older adults
is often complicated by ethical issues. As seen in the case of Mrs. Jones
and Mr. Carl earlier in this chapter, normal and pathological aging
changes, as well as the role of families, are important factors to consider
when addressing sexual issues in this population. Moreover, a nurse’s
lack of knowledge and experience and general reluctance to assess and
plan care related to sexuality issues has a substantial impact on the older
adult’s health and functioning. A summary of the ethical issues involved
in this case are presented in Table 9.3.
As discussed earlier, older adults experience many physiological
changes in their reproductive systems that impact their ability to func-
tion sexually, including changes in vaginal lubrication, response time,
and body image. Moreover, the presence of depression and diabetes, as
well as medications, such as beta blockers for hypertension, impact sex-
ual response. The loss of partners in older adulthood also significantly
impacts sexuality. However, because the topic of sexuality was not widely
discussed in previous decades, older adults do not always fully under-
stand these changes and their impact on sexuality. Despite older adults’
lack of knowledge about sexuality, education that addresses normal and
pathological aging changes, as well as the impact of role changes on sexu-
ality, and interventions to compensate for these changes, is rarely pro-
vided. Consequently, older adults may stop functioning sexually, because
they think they are abnormal or ill, and no one is available to counsel
them otherwise.
A sexual assessment is the first step to discussing sexuality of older
adults. The PLISSIT model (Annon, 1976) begins by first seeking permis-
sion (P) to discuss sexuality with the older adult. This permission may be
gained by asking general questions such as, “I would like to begin to dis-
cuss your sexual health; what concerns would you like to share with me
about this area of function?” Questions to guide the sexual assessment
of older adults are available on many health care assessment forms. The
next step of the model affords an opportunity for the health care pro-
vider to share limited information (LI) with the older adult. In response
to the increase in older adults with sexually transmitted diseases, it is
essential to provide them with safe sex information at this time. In the
next part of the model, specific suggestions (SS) are provided to older
adults to help them fulfill their sexuality. These suggestions may focus on
the use of CDC recommended safe sexual practices. The final part of the
model allows for intensive therapy (IT) to be provided to the older adult
regarding sexual issues that may arise during the assessment. This may
TABLE 9.3 Is This Sexual Relationship Safe?
Autonomy (Self-Determination) The right to autonomy is complicated by the presence of mild cognitive impairment (MCI)
The right to govern self or to freely and must be explored further. The question remains: Is Mrs. Jones competent to make
choose one’s actions as long as these the decision to participate in an intimate relationship, or must another person be asked to
choices do not interfere with the make the decision for her? In Mr. Carl’s case, the nursing staff must highly consider the
autonomy or rights of other persons. resident’s right to autonomy, even when the moral values and life experiences of the nurses
lead them to believe his relationship with Mrs. Jones is wrong.
Beneficence The actual and projected outcomes of the intimate relationship would require assessment
Doing good or participating in to determine what nursing actions are required regarding this relationship. If an assess-
behavior that benefits a recipient of ment of Mrs. Jones finds that she is incapable to understanding the consequences of her
care. relationship with Mr. Carl, then she must be prevented from being taken advantage of.
233
However, if the assessment leads nurses to believe that Mrs. Jones and Mr. Carl under-
stand the risks and consequences of their relationship, then the right to autonomy prevails
in this case.
Nonmaleficence Failure to assess Mrs. Jones’s ability to consent to participate in an intimate relationship
Above all, do no harm. with Mr. Carl could be termed nonmaleficence. While nurses are often uncomfortable and
lack knowledge in assessing and managing sexual issues among older adults, failure to
do so in this case has the potential to cause harm to both residents. Use of the nursing pro-
cess, as well as consultation with family and members of the health care team, generally
result in effective decisions.
Justice In the case of Mrs. Jones and Mr. Carl, failure to recognize the sexual needs of older
The fair allocation of resources to adults and manage these needs with similar priority as other physical needs is a violation
individuals or the provision of an of the ethical principle of justice.
equal share of available resources to
each person.
include the discovery of sexually transmitted diseases, which requires

treatment.
It is important to educate older adults about normal and patho-
logical aging changes in reference to sexuality. Interventions to promote
sexuality among older adults may focus on the use of touch to create
intimacy, as opposed to sexual intercourse. As older adults relocate to
more supportive environments, privacy may also be an issue to address
in order to help clients pursue sexuality in a dignified and respectful
manner. In promoting privacy, it is essential to consider client safety. It
may be the nurse’s role to order the necessary equipment, such as grab
bars and condoms, and demonstrate proper use to the older couple in
order to promote safety.
For older adults with dementia, it is essential to conduct highly
accurate assessments and document their ability to be involved in the
decision-making process. As seen in the earlier case study, if a client is
not capable of making competent decisions, then the nursing staff must
prevent them from being taken advantage of by a spouse, partner, or
other residents. Problematic sexual behaviors may occur in response to
unmet sexual needs in older adults with dementia. These may include
public masturbation or exposure, or making sexually inappropriate
comments or gestures to nurses or other clients. While these behaviors
are disturbing, they rarely go away when ignored. Further assessment
and planning of care can help the older adults to meet their sexual
needs in a dignified and respectful manner and will likely eliminate the
behavior.
GAMBLING
Pathological, problem, and at-risk gambling has increased significantly

over the past several decades. This is partially due to the widespread
growth of state-sanctioned gambling in the form of lottery tickets and
the growth of casinos. The incidence of gambling among older adults
has risen from 61% of the population in the 1960s to 80% in 1991.
Levens, Dyer, Zubritsky, Knott, and Oslin (2005) report that of 843
older adults studied, 69.6% of the sample had gambled at least once in
the last year, and 10.9% were identified as at-risk gamblers. Wiebe and
Cox (2005) showed that in their study of 1,000 older adults, 74.7%
gambled, with 1.6% gambling at problem levels. Older adults are at
greater risk for problem gambling because (a) they often have financial
problems that they hope gambling will resolve, and (b) the multiple
losses experienced by older adults is often soothed by the excitement
of casinos.
Gambling is often very problematic for the health of older adults

and may result in increased stress, alcohol use, and depression. In addi-
tion, gambling often results in a great loss of income, which could fur-
ther trigger medication noncompliance, malnutrition, and safety risks.
In order to prevent the possibly harmful effects of gambling among older
adults, nurses should assess for problem gambling during routine health
encounters. The Diagnostic and Statistical Manual of Mental Disorders
(DSM–IV) classifies pathological gambling as a psychological disor-
der and has established 10 criteria in classifying pathological gambling
behaviors (Table 9.4, NGISC, 1999).
Consider the case of Mr. Diamond, a 76-year-old man with a his-
tory of poorly controlled Type 2 diabetes and alcoholism. During his
most recent visit to the veteran’s administration primary care clinical, the
nurse noted that Mr. Diamond was tearful during his physical examina-
tion. Mr. Diamond’s fasting blood sugar was 641, and his HgA1C was
TABLE 9.4 DSM–IV “Diagnostic Criteria for 312.31 Pathological

Gambling”
Persistent and recurrent maladaptive gambling behavior as indicated by five
(or more) of the following:
(1) is preoccupied with gambling (e.g., preoccupied with reliving past
gambling experiences, handicapping or planning the next venture, or
thinking of ways to get money with which to gamble)
(2) needs to gamble with increasing amounts of money in order to achieve the
desired excitement
(3) has repeated unsuccessful efforts to control, cut back, or stop gambling
(4) is restless or irritable when attempting to cut down or stop gambling
(5) gambles as a way of escaping from problems or of relieving a dysphoric
mood (e.g., feelings of helplessness, guilt, anxiety, depression)
(6) after losing money gambling, often returns another day to get even (“chas-
ing” one’s losses)
(7) lies to family members, therapist, or others to conceal the extent of
involvement with gambling
(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to
finance gambling
(9) has jeopardized or lost a significant relationship, job, or educational or
career opportunity because of gambling
(10) relies on others to provide money to relieve a desperate financial situation
caused by gambling
TABLE 9.5 Ethical Decision-Making Framework
Autonomy (Self-Determination) Mr. Diamond clearly has the right to gamble. However, what variables in his life
The right to govern self or to freely interfere in this decision? Is he lonely, or financially compromised? Further assessment
choose one’s actions as long as these of these issues will help Mr. Diamond make a more informed decision regarding his
choices do not interfere with the autono- gambling behavior and its impact on disease management.
my or rights of other persons.
Beneficence It is important for the nurse to assess Mr. Diamond’s gambling behavior and its impact
Doing good or participating in behavior on his health. This is an appropriate nursing action that is in the best interest of the cli-
that benefits a recipient of care. ent. While assessment may be embarrassing for Mr. Diamond, it is essential to prevent
further risk to his health.
236
Nonmaleficence Failure to assess Mr. Diamond’s gambling behavior and its impact on his health would
Above all, do no harm. be termed nonmaleficence. While nurses often do not feel that gambling is a health care
issue, it has several health care consequences, such as stress and loss of financial resourc-
es, which could greatly impact health. Use of the nursing process, as well as consultation
with family and members of the health care team, generally result in effective assessment
and interventions.
Justice In light of the rising incidence of problem and pathological gambling in older adults,
The fair allocation of resources to assessment and management of gambling must take place at every health care encounter.
individuals or the provision of an
equal share of available resources to
each person.
elevated. The nurse made several recommendations to Mr. Diamond on

how to evaluate his blood sugar and take the medications. During the
teaching session, Mr. Diamond glanced at his watch and began to hurry
the appointment along. The nurse asked him what the rush was, and Mr.
Diamond responded that he had to catch the bus for the casino. The nurse
gained quick insight into an additional barrier to meeting Mr. Diamond’s
health care goals. Table 9.5 uses the ethical decision-making framework
to examine Mr. Diamond’s gambling.
Nursing interventions aimed at reducing pathological and prob-
lem gambling are focused on support for this addictive behavior and
reduction of the health-related consequences of gambling. In the case of
Mr. Diamond, referral to gamblers anonymous (http://www.Gamblers
anonymous.org), and assistance with purchasing diabetes supplies and
medications were obtained. Unwin, Davis, and DeLeeuw (2000) sug-
gest a six-step approach to helping problem and pathological gamblers
beginning with (1) screening for gambling using a standardized instru-
ment or the DSM–IV criteria, (2) immediate intervention if the client
is suicidal, (3) referral to Gamblers Anonymous, (4) enlisting the help
of family members to support treatment adherence and effectiveness,
(5) counseling, and (6) actively participating in the treatment plan with
subsequent assessment for relapses.
SUMMARY
In the care of older adults, many ethical, legal, and financial issues
will continue to arise. These issues range from who should receive ser-
vices to who should make the decisions and how health care bills will
be paid. These issues are complex and in great flux. Changes to laws
governing health care decisions influence how these decisions will be
made in the future. Moreover, the increasing older adult population is
retiring later thereby impacting the health care and financial status of
older adults.
There are several ethical principles that may be used to guide ethical
decision making. When health care team members use these principles as
the basis for discussion of ethical issues, they are better able to help cli-
ents make efficient and beneficial decisions. Furthermore, the use of legal
and medical resources to plan for the financial and health care future of
older adults is essential to ensuring maximum quality of life throughout
older adulthood.
REFERENCES
The American Heritage Dictionary of the English Language (4th ed). (2007). Ethics.
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American Nurses’ Association. (1994). Position statement on assisted suicide. Washington,
DC: Author.
Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral
treatment for sexual problems. Journal of Sex Education Therapy, 2(2), 1–15.
Araujo, A. B., Mohr, B. A., & McKinlay, J. B. (2004). Changes in sexual function in middle-
aged and older men: Longitudinal data from the Massachusetts male aging study.
Journal of the American Geriatrics Society, 52(9), 1502–1509.
Burkhardt, J. E., Berger, A. M., Creedon, M., & McGavock, A. T. (1998). Mobility and
independence: Changes and challenges for older drivers. Washington, DC: Depart-
ment of Health and Human Services (DHHS), under the auspices of the Joint DHHS/
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C H A P T E R T E N
Quality of Life Issues

Among Older Adults
Learning Objectives
1. Identify quality of life dimensions of older adulthood.
2. Describe the epidemic of elder mistreatment.
3. Describe the types, indicators of, and contributing factors to elder
mistreatment.
4. Discuss strategies for the assessing reporting, treatment, and pre-
vention of elder mistreatment.
5. Identify the incidence of pain and barriers to pain assessment in
older adults.
6. Assess pain using client self-report and/or a validated pain
instrument.
7. Identify strategies and considerations in treating pain in older
adults.
8. Identify benefits and challenges of grandparenting.
9. Describe spirituality as an important component of quality of
life.
Ms. Long, an 89-year-old White female, is admitted to your unit for

a fracture of the right wrist and a dislocated right shoulder, which
she claims to be the results of falling off a chair. She has a history of
hypertension and coronary artery disease. Her husband passed away
several years ago, and last year she began having trouble caring for
herself and keeping up with her medications. Her granddaughter, who
has been caring for her for the past 9 months, accompanies Ms. Long.
You are the nurse responsible for performing her initial health history
and assessment. During the history, the client timidly states that she
239
feels very lucky to have someone caring for her at home so she does
not have to go a nursing home. After this, she mentions that her grand-
daughter lost her job about 2 months ago but is still very busy and
spends most of her days away from the house. You ask the client about
her normal diet patterns, and she says that she typically has one meal
a day in the evening when her granddaughter comes home and just
snacks throughout the rest of the day. Upon examination, you realize
that she is 5’1” and weighs 85 lbs. In addition, you notice that there
appear to be several bruises at different stages of healing evident espe-
cially on her arms and legs. She also appears to have a stage II pressure
ulcer on her coccyx.
As individuals continue to age, a variety of special and unique quality-of-life

issues tend to occur. Some issues occur as the result of physical and cognitive
changes of aging, both normal and pathological. Others develop with chang-
ing older adult roles. Regardless of the cause for these changes, they have
the capacity to bring about great sadness and distress. Effective coping with
these issues is often a deciding factor in the quality of life of older adults.
QUALITY OF LIFE (QOL)
Quality of life (QOL) is a concept that was relatively unexplored prior to

the 1970s. Issues of cost-effectiveness and Medicare revisions stimulated
exploration into the substantial amounts of money being spent to keep
people alive for years on respirators and other life-sustaining equipment,
only to have such people die or return to a life considered to be “not worth
living.” The first such article to appear in the Journal of the American
Geriatric Society was a speech given by Senator Charles McMathias, Jr.
(1979). He spoke of improving the QOL for the elderly amidst the contro-
versy over the budget for health care and medical research. In 1983, ger-
ontologists Pearlman and Speer wrote “Quality of Life Considerations in
Geriatric Care,” a document that contained their opinion on the definition
of QOL for the elderly and the ramifications for decisions about euthana-
sia and terminating life support. They also explored related key concepts
in the definition of QOL. Since then, the research on QOL considerations
has expanded greatly. The discussion of QOL frequently surrounds the
treatment choices to be made with older adults. In these cases, the process
often compares “curing the disease” with the impact of that cure on QOL.
This is sometimes referred to as the risk-benefit ratio.
The concept of QOL is consistently characterized by two attributes,
multidimensionality and individuality. The multidimensional nature of
Quality of Life Issues Among Older Adults 241
Title of Study: Medical Staff’s Decision-Making Process in the Nursing

Home
Authors: Cohen-Mansfield, J., Lipson, S.
Purpose: To describe the medical decision-making process at the time of
status change events in a large suburban nursing home.
Methods: Questionnaires that described the medical decision-making pro-
cess for 70 residents of a large nonprofit nursing home facility were
completed by three female nurse practitioners and six male physi-
cians.
Findings: The most frequently cited treatment considered and chosen was
hospitalization, with family members involved in 39% of decisions and
nurses involved in 34%. Quality of life was the most important con-
sideration, and the effectiveness of treatment options and the specific
characteristics of the resident and the family’s wishes were other factors
involved in the decision-making process.
Implications: Multiple considerations are involved in the decision-making
process. They include: treatment options, the physician–patient rela-
tionship, family considerations, and quality of life.
Journal of Gerontology, Medical Sciences 2003, Vol. 58A, No. 3, 271—278.
the concept has been the focus of much scholarly work. Spitzer et al.
(1981) were among the first to explore the multidimensional nature of
QOL as activity, daily living, health, support, and outlook. Gurland
and Katz (1991) performed an extensive review of QOL literature in an
older adult population. Using content analysis, they developed a list of
15 domains in which QOL should be evaluated for older adults. These
domains include:
• mobility
• activities of daily living
• organizational skills
• orientational skills
• receptive communication
• expressive communication
• health and perceived health
• mood and symptoms
• social and interpersonal relations
• autonomy
• financial management
• environmental fit
• gratification, future image
• general well-being
• effective coordination
Other researchers have attempted to define the concept broadly by

identifying specific QOL domains. Ferrans (1990) reviewed the defini-
tions of QOL and found them to fall into five broad categories:
• normal life
• happiness
• satisfaction
• achievement of personal goals
• social utility
In an attempt to describe individual QOL values, many researchers

have evaluated the QOL specific to individuals from varied cultural back-
grounds, age groups, and diseases. For a definition of QOL to evolve, it
is necessary that the dimensions of life influenced by the individual and
disease group be identified. Current models of QOL tend to focus on four
specific areas of function and well-being: psychological, physiological,
spiritual, and social (Ferrell, Grant, Padilla, Vemuri, & Rhiner, 1991).
More recently, Bergland and Narum (2007) surveyed 282 elderly women
and found that quality of life was defined by continuity, empowerment,
and the quest for meaning.
In order to appropriately assess QOL for older adults receiving nurs-
ing care, it is important that this general model be used as a guideline.
Issues surrounding the QOL of older adults are vast, but this chapter will
explore four specific issues that have a great impact on the domains of
QOL. While the issues have the capacity to affect all domains, elder mis-
treatment impacts the psychological domain of health for older adults;
pain is the major physical issue; the spirituality of older adults will be the
focus of the spiritual domain; and grandparenting will guide the discus-
sion of the social domain.
In an attempt to describe individual QOL values, many researchers have

evaluated the QOL specific to individuals from varied cultural back-
grounds, age groups, and diseases. For a definition of QOL to evolve, it
is necessary that the dimensions of life influenced by the individual and
disease group be identified.
ELDER MISTREATMENT
It is estimated that approximately 1 million cases of elder mistreatment (EM)

occur each year. However, this number is likely a severe underestimation,
as elder abuse is frequently not reported for several reasons. Victims may
fear retaliation, feel shame, or have a desire or need to protect the abuser
(Cronin, 2007). Lack of mandatory universal reporting laws is another rea-
son. Table 10.1 lists mandatory reporting elder abuse laws by state. The
incidence of EM is likely to rise with the increasing older adult population.
Types of abuse include physical and psychological abuse and
neglect, sexual abuse, and financial abuse. Physical abuse may involve
intentionally causing pain or injuring older adults, while psychological
abuse involves threatening, insulting, or socially isolating the older adult
(Cronin, 2007). Physical and psychological neglect are often the most
challenging forms of elder mistreatment to assess because of the associ-
ated decline in physical and cognitive functioning common in these vic-
tims. Active physical neglect arises from the purposeful withholding of
necessities, whereas passive neglect results from the caregiver’s inability
to identify the older adult’s needs or to perform the tasks essential to
meet the older adult’s needs. The term neglect implies a failure to perform
an obligation and, therefore, raises questions regarding whether a family
does have an obligation to provide care for an older adult. It is important
to assess whether the caregiver is purposefully neglecting the older adult
victim or is simply not physically or cognitively capable of caring for this
person. Financial abuse may occur when the older adult’s funds, prop-
erty, or assets are used for wrongful purposes, and sexual abuse involves
the sexual assault or rape of an older adult.
Characteristics that may place older adults at risk for abuse include
(a) female gender, (b) advanced age, (c) functional dependence, (d) his-
tory of intergenerational conflict, (e) passive or stoic personality, (f) social
isolation, (g) physical and/or cognitive deficits, and (h) history of abuse.
Characteristics that increase risks for caregivers to abuse an older adult
include (a) substance abuse, (b) mental illness, (c) lack of knowledge or
experience with caregiving, (d) financial stressors, (e) history of abuse
as a child, (f) lack of outside interests and involvement, (g) extreme life
stressors, (h) aggressive and unsympathetic personality, and (i) unrealistic
expectations of the situation (Fillit & Picariello, 1998).
Effective assessment of elder mistreatment is the responsibility of
nurses and health care professionals in all settings. The greatest potential
for reducing and/or preventing older adult mistreatment is early identi-
fication and intervention. The nurse should be alert to signs and symp-
toms of possible elder mistreatment, which may include: (a) patterns of
unexplained injuries; (b) indication that the older adult is fearful of their
TABLE 10.1 American Bar Association Recommended Guidelines for State Courts Handling Cases Involving
Elder Abuse, 1995
Human Long-Term Financial
Health Services Law Care Facility Professionals Any
State Professional Professional Clergy Enforcement Employee and Staff Other Person
Alabama •
Alaska • • • • •
Arizona • • • •
Arkansas • • • •
California • • • •
Colorado
Connecticut • • • • •
Delaware • • •
District of • • • •
244
Columbia
Florida • • • • •
Georgia • • • • • •
Hawaii • • • • •
Idaho • • • • •
Illinois
Indiana • • • • •
Iowa
Kansas • • •
Kentucky
Louisiana •
Maine • • •
Maryland • • • •
Massachusetts • • • •
Michigan • • • •
Minnesota • • • • •
Mississippi • • • •
Missouri • • • • • • •
Montana • • • • •
Nebraska • • • • •
Nevada • • • • • •
New Hampshire •
New Jersey • • •
New Mexico •
New York
North Carolina •
North Dakota
Ohio • • • • • •
Oklahoma • •
Oregon • • • • •
Pennsylvania •
245
Rhode Island • • • • • •
South Carolina • • • • •
South Dakota
Tennessee •
Texas •
Utah •
Vermont • • • • •
Virginia • • • •
Washington • • • •
West Virginia • • •
Wisconsin
Wyoming •
Source: American Bar Association Recommended Guidelines for State Courts Handling Cases Involving Edler Abuse, 1995.
Retrieved June 28, 2005, from http://www.abanet.org/media/factbooks/eldt1.html
caregiver; (c) anger or indifference by the caregiver toward the individual;

(d) excessive concern by the caregiver regarding the individual’s assets;
(e) injuries or unexplained infections present in the client’s genital region;
(f) severe, unexplained dehydration or malnutrition, hypo- or hyperther-
mia related to environmental exposure; (g) poor hygiene of the client; or
(h) unexplained management of medication. It is important to note and
understand that victims may feel dependent upon the perpetrator and
fear reprisal if they report the mistreatment (Cronin, 2007). In addition
to the victims’ reluctance to report the mistreatment, barriers to detection
also are increased in that the signs and symptoms of abuse are commonly
occurring clinical conditions among older adults. For example, changes
in behavior may be a result of psychological abuse or an early sign of
disease change or onset. (Cronin, 2007).
While interviewing the older adult, the nurse must try to remain non-
judgmental and begin with nonthreatening questions. It is important to
interview the individual alone during this portion of the assessment and to
be alert for any inconsistencies between history and physical findings.
If elder abuse or neglect is suspected, the health care provider must
report it immediately to the local Adult Protective Services (Hogstel,
2001). However, these agencies are often understaffed and overburdened.
Consequently, the ability to quickly assess and protect older adults against
elder mistreatment is often compromised. However, an appropriate inves-
tigation must be conducted and intervention begun to ensure the older adult’s
safety. Statutes designed to safeguard older adults from elder mistreatment
have been passed in all 50 states. In these statutes, elder mistreatment is
Title of Study: A Comparison of Three Measures of Elder Abuse

Author: Meeks-Sjostrom, D.
Purpose: To present and compare three measurements for assessing elder
abuse.
Methods: Through a literature review, three measures for assessing elder
abuse were identified, reviewed, and evaluated according to their char-
acteristics and uses.
Findings: The three measures identified were: (1) The indicators of abuse
(IOA), a 22-item tool for identifying abuse, completed by a health care
professional following a home assessment; (2) The Elder Abuse and
Neglect Assessment (EAI).
Implications: The data from this study strengthened support for the use
of the measures to detect elder mistreatment in multiple environments
of care.
Journal of Nursing Scholarship, Vol. 36, No. 3, 247–250.
defined in terms of acts of commission (intentional infliction of harm),

or acts of omission (harm occurring through neglect) by a caregiver. The
definition of a caregiver may vary among states, but it generally includes a
relative or friend who is concerned and involved in some way with helping
manage one’s condition (Kassan, 2003).
PAIN
Pain is a major problem for older adults and those who care for them.
Flaherty (2007) reports that 25% to 50% of community-dwelling older
adults and 45% to 80% of nursing home residents experience untreated
pain. Marcus (2004) reports that there are many poor consequences of
pain. These include depression, decreased socialization, sleep distur-
bances, impaired functional ability, and increased health care utilization
and costs.
Despite the great prevalence and impact of pain on older adults,
there are many barriers that prevent success in this area. Some nurses
believe that pain is a natural and expected part of aging, and this remains
one of the most prevalent myths and a barrier to appropriate pain assess-
ment and management. Other barriers include older adults’ hesitancy to
report pain, because they may believe that it is an expected part of aging
and nothing can be done for it, or they simply may be afraid to bother
their nurse.
Both normal and pathological changes of aging affect the presenta-
tion of pain in older adults. However, mixed findings have been found
regarding whether or not the older adult’s perception of pain decreases
with age. Because objective biological markers of pain are not available,
nurses must rely on the patient’s self-report. There are many standard-
ized tools for assessing pain in older adults, but the most frequently used
measure of pain is a numeric rating scale where the client is asked to
rank their pain on a scale from 1 to 10, with 1 being very little pain, and
10 being the worst pain imaginable. However, some research suggests
that the abstract nature of these scales makes them difficult to use for
some older adults, especially those with cognitive impairments. Another
available tool is Visual Analogue Scales (VAS), which are straight hori-
zontal 100 mm lines with verbal pain descriptors on the left and on the
right sides. Older adults are asked to indicate a position on the scale
that represents their pain. These tests also are not perfect. The “Faces
Scale” depicts facial expressions on a scale from 0 to 6 with 0 for a smile,
indicating no pain, and 6 for a crying grimace, indicating lots of pain.
Determining the right tool for each patient is necessary to utilize these
objective measures effectively.
For older adults with cognitive impairments, clients may not be able
to verbalize pain appropriately. In these clients, yelling, wandering, and
repetitive or aggressive behavior may be signs of pain. In caring for the
cognitively impaired, the nurse needs to be aware of known painful con-
ditions. Evaluation of behavior for the signs and symptoms of pain is
essential for effective assessment and management (Horgas, 2007). The
five-item Pain Assessment in Advanced Dementia Scale (PAINAD) has
been effective for assessing pain in this population (Warden, Hurley, &
Volicer, 2003).
Once the presence of pain is identified, it is important to look
for the underlying cause of pain and determine whether it is acute or
chronic. When possible, the cause of pain should be targeted for inter-
ventions and then the use of both pharmacological and nonpharmaco-
logical pain management strategies implemented. The most common
pharmaceutical medications used to treat pain in older adults are acet-
aminophen, nonsteroidal and anti-inflammatory drugs (NSAIDs), and
opioids. However, the frequent adverse drug reactions and analgesic
sensitivity in this older adult population (see Chapter 6) underscore the
need for the old cliché to “start low and go slow” (American Geriatric
Society, 1998). For example, NSAIDs contribute to gastric ulceration
and mask pain. Older adults have also been found to respond to mor-
phine as if they were given a larger dose, suggesting the need to decrease
morphine dosages in this population. It is important to note that pain
medication for older adults should be given on a regular basis, not
PRN, or as needed (American Geriatric Society, 1998). Collaborative
pain medications, such as antidepressants, anticonvulsants, and anxio-
lytics, may also be helpful in pharmacologically reducing pain among
older adults.
In addition to pharmacological pain management strategies, non-
pharmacological pain interventions are receiving much attention for their
effectiveness in reducing pain among older adults. Exercise, educational
and cognitive therapy, massage, acupuncture, therapeutic touch, reiki,
and reflexology are all currently being investigated as potential adjuncts
to pain management. While the research is still forthcoming, early evi-
dence suggests that these interventions are effective in reducing pain in
multiple populations. The problem of pain in older adults is an ongoing
concern in need of further clinical investigation. Pain management at the
end of life will be discussed in Chapter 12.
GRANDPARENTING
The increase in lifespan has created a generation of grandparents that was

nonexistent in the past. Previous generations did not live a sufficient length
Cultural Focus
It is estimated that 25% of Black and Hispanic grandmothers live in house-

holds with grandchildren compared to less than one-tenth of White grand-
mothers (Szinovacz, 1998). Nurses must be aware of these trends and their
impact on the health of older adult grandparents.
of time for grandchildren to know their grandparents.While this is cer-

tainly a wonderful phenomenon, it is not universal. Due to the longer lifes-
pan of women, it has been revealed that grandchildren are more likely to
know their grandmothers than their grandfathers (Hogstel, 2001). More-
over, grandparenthood differs among cultures. For example, grandparent-
hood occurs at younger ages for Black and Hispanic women as compared
to White women.
In addition to the rising availability of grandparents, a substantial
increase has been seen in the number of grandparents raising grandchil-
dren. It is estimated that 25% of Black and Hispanic grandmothers live in
households with grandchildren compared to less than one-tenth of White
grandmothers (Szinovacz, 1998). Reasons for this increase in grandpar-
ents raising grandchildren often stem from child mistreatment and neglect
and may include: (a) impairment of the biological parents through sub-
stance abuse, (b) rise in rates of teen pregnancy, (c) presence of acquired
immunodeficiency syndrome (AIDS), (d) incarceration, (e) mental illness,
(f) emotional problems, and (g) premature parental death.
Grandparents who raise grandchildren are at higher risk for health
problems than older adults who do not serve in this caregiving role.
Moreover, grandparents raising grandchildren may also have financial
problems and other caregiving responsibilities (e.g., Spouse). Grandpar-
ents caring for grandchildren are more likely to have (a) higher rates
of chronic diseases, (b) female gender, (c) high rates of unemployment,
and (d) less than a 12th-grade education (Hogstel, 2001). In caring for
older adults, nurses must understand that grandparenting can be a stress-
ful role and those grandparents caring for grandchildren may experience
greater stress. Consequently, nursing interventions to maintain health,
prevent stress-related illness, and increase social support for the grand-
parent should be implemented with these older adult clients.
SPIRITUALITY
The presence of spirituality in the lives of older adults once was not
acknowledged. In fact, the original work of Rowe and Kahn (1997)
on successful aging neglected to include the component of spirituality.
However, more recently, spirituality has been identified as an integral

component of health and functioning. While the importance of spiritual-
ity is more readily acknowledged by society, expressions of spirituality
are increasingly diverse. Some cultures express their spirituality through
particularly religious practices, such as Buddhism or Taoism. Others have
spiritual practices that are apart from formal religion. Spirituality repre-
sents a search for meaning in life, and this becomes especially important
as older adults approach the end of life.
While the role of spirituality is strong through life for many adults,
its role at the end of life is magnified. Older adults are more likely to
explore the meaning of life and question the existence of an afterlife.
End-of-life care has recently been the subject of a great deal of research,
and the nursing role in promoting spiritual health at the end of life is
becoming better articulated. This role will be discussed more fully in
Chapter 12.
Spirituality is an inherent component of life for all people. It provides
a framework within which people conduct the search for meaning and pur-
pose in life. Koenig, McCullogh, and Larson (2001) define spirituality as
“the personal quest for understanding answers to ultimate questions about
life, about meaning, and about relationships that are sacred or transcen-
dent” (p. 18). Spirituality differs from religion, which specifically concerns
the spiritual beliefs and practices held by organized groups (e.g., Buddhist,
Catholic, Protestant, Jewish). Religion is defined by Koenig et al. as “an
organized system of beliefs, practices, rituals and symbols designed (a) to
facilitate closeness to the sacred or transcendent (God, higher power, or
ultimate truth/reality), and (b) to foster an understanding of one’s relation
and responsibility to others living together in a community” (p. 18). While
many people pursue spirituality through a specific religion, participation in
organized religion is not a prerequisite for spirituality. In fact, many older
adults do not affiliate with an organized religion, yet possess a deep sense
of spirituality.
Cultural Focus
While the importance of spirituality is more readily acknowledged by

society, expressions of spirituality are increasingly diverse. Some cultures
express their spirituality through particularly religious practices, such as
Buddhism or Taoism. Others have spiritual practices that are apart from
formal religion. Consequently, it is necessary to include spiritual assess-
ment with older adults in order to identify deficits in the older adult’s spiri-
tual needs. Then interventions may be implemented to help the older adult
improve spiritual connectedness.
It is of great importance that nurses understand that spirituality and

the practice of religion vary greatly among older adults. While the pro-
cess of aging often fosters a search for the meaning of life, not all older
adults search in the same way. The nurse is likely to practice a religion
different from the older adult, so it is important that the nurse does not
impose their personal beliefs and religious views on their patients. The
nurse must be open and understanding, allowing the older adult to pur-
sue spirituality in their own unique way.
The presence of spirituality has been associated with relief from
physical, mental, and addictive disorders and with enhanced quality of
life and survival. Understanding the role of spirituality in the health and
functioning of older adults underscores the need to plan care around
this important life component. Consequently, it is imperative that nurses
who care for older adults are well-prepared to assess and manage spiri-
tual needs. Older adults who engage in religious and spiritual practice
often cope better psychologically and have better physical health than
those who don’t (Koenig, 2007). Older adults residing in nursing homes
are potentially more at risk for poor mental and physical health due to
the many losses that go along with the aging process, loss of loved ones,
loss of home and independence, and loss of function, of which they have
little or no control.
It is necessary to include spiritual assessment when working with
older adults. In conducting spiritual assessments, the nurse may ask
about many topics: (1) the individual’s beliefs and practices; (2) what
spirituality means to the client; (3) whether the client is affiliated with
specific religions and is actively involved; (4) whether spirituality is
a source of support and strength; and (5) whether the client has any
special religious traditions, rituals, or practices they like to follow. Spir-
itual assessment scales are available, including Stoll’s Spiritual Assess-
ment Guide and O’Brien’s Spiritual Assessment Scale. These instruments
may be helpful to the nurse conducting spiritual assessments of older
adults.
Spiritual assessments may reveal deficits in the older adult’s spiri-
tual needs; interventions may need to be implemented to help the older
adult improve their spiritual connectedness. This process requires the
nurse to discuss with the client the role of spirituality and religion in the
lives of older adults. The nurse should encourage religious and spiritual
beliefs and practices in all environments of care, as allowed by institu-
tional policy. It is important for the nurse to be aware of the availability
of religious personnel within each facility and call upon these members
of the interdisciplinary team to help the older adult whenever necessary.
Spiritual counseling and praying with the patient are often great sources
of comfort to the patient and family.
Critical Tѕinјinє Case StudѦ
Mr. Hawkins is a 62-year-old man with severe peripheral vascular disease

secondary to NIDDM. He lives at home with his wife who provides his
daily care. Over the past 6 weeks, he has become more dependent in all
activities of daily living and has ceased his social activities. When his fam-
ily comes to visit, he responds to their concerns with grunts. He prefers
to watch television instead of spending time with his children and grand-
children. His appetite has been poor, and he is having difficulty sleeping
at night. On top of this, the circulation in his left foot has led to early
necrosis. Because he is not a good candidate for surgery, he was asked to
consider having an amputation.
1. How is Mr. Hawkins typical of older adults with chronic illness?
2. What risk factors may have contributed to Mr. Hawkins chronic
conditions?
3. What effect do Mr. Hawkins’s chronic conditions have on his ability
to independently complete his activities of daily living?
4. What other health problems do you expect Mr. Hawkins to be at
risk for, given his current conditions?
5. What nursing interventions could you put into place to increase
Mr. Hawkins’s health functioning and quality of life?
SUMMARY
As the population of older adults continues to rise, the number of special

problems that affect the quality of life unique to this population will
expand. Regardless of the trajectory of these quality of life issues among
older adults, nurses are in a key position to assess older adults for the
risk and existence of these commonly occurring issues and implement
strategies to reduce their negative consequences. In so doing, nurses can
promote a high quality of life for older adults in all care settings.
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American Medical Directors Association, 4(1), 9–15.
C H A P T E R E L E V E N
Environments of Care
Learning Objectives
1. Identify the most common environments of care for older adults.
2. Discuss the effects of caregiving on older adults caring for loved
ones.
3. Discuss strategies for reducing the risk of caregiving.
4. List positive and negative aspects to home care.
5. Identify supportive interventions in the community.
6. State the risks of acute care hospitalization for older adults.
7. Discuss aspects of skilled nursing facility admission and care.
8. Discuss risk factors and prevention strategies for urinary tract
infections and pressure ulcers in skilled nursing facilities.
9. Identify housing alternatives for older adults.
10. Discuss problems associated with homeless older adults.
You are the home care nurse assigned to see an 83-year-old male patient
who was recently discharged to his home from the hospital after a frac-
ture of the right tibia resulting from a fall. He has no other known health
problems. When you make your first visit to the client’s home, you notice
that there are several stairs that one must walk up prior to entering the
home. You notice that the only other way to enter the house is by walk-
ing up several stairs in the back onto the deck and going in the back
door. Concerned about the fact that this patient has a history of falls,
you make a notation of this in the client’s chart. When you enter the
client’s home, you assess his vital signs and then ask to listen to his lungs
and heart and to look at the right leg. You determine that all of these
assessments are within normal limits. As you ask the patient about his
pain, he grimaces but says that he is fine. However, you spend some time
explaining to him that it is okay to discuss pain with you, and he admits
255
to still being bothered by pain. He feels like his pain medicine is not really
helping, especially because the pain has been preventing him from eating
or sleeping properly. You decide to call the doctor to try to get a more
effective medication for pain. In addition, you work with the patient on
some deep breathing and guided imagery techniques. Before you leave,
you ask to take a quick look around the house to assess for safety. The
client agrees and states, “You should be very pleased; my wife picked up
all the rugs around the house and put one of those funny plastic mats
in the shower for me.” You cannot see any evidence of cords or other
barriers to affect mobility around the house and tell the client that all
seems to be in place. You do, however, advise the client to try to create
an alternative way of getting in and out of the house to help protect the
client from falling down the stairs. You also add that it may be wise for
him to stay inside for a little while until he is feeling more comfortable
with getting around.
As individuals age, the incidence of chronic and acute illnesses increases.

In many cases these illnesses result in a subsequent decline in functional
status. Functional decline accompanied by loss of spouse or significant
other and changes in economic status caused by either death of the fam-
ily provider or retirement often force older adults to make changes to
their environment in order to obtain functional or financial assistance.
Some changes that need to be made include adapting the home to a
lower level of functioning, having a friend or family member move in to
provide informal care, or leaving the current home for an assisted-care
environment.
While most older adults prefer to stay in their own homes as long as
possible, many others move to a variety of living environments within a
continuum of care, which extend from acute care facilities to long-term
care settings. Aging in place is a concept that refers to remaining in one
setting throughout the majority of older adulthood. Assisted-living facili-
ties, retirement homes, continuing-care retirement communities, and con-
gregate housing are alternatives to the older adult’s home that facilitate
aging in place to some extent. Regardless of where care is provided, it is
essential that cultural competence is achieved. The U.S. Department of
Health and Human Services, Office of Minority Health provides recom-
mended standards for cultural competence in health care settings (see
Cultural Focus).
Aging in place is important, because moving is emotionally chal-
lenging and there may be negative effects of relocating. Translocation
syndrome may occur when there is a change in the environment of older
adults. This may manifest as impaired physical health, depression, and
disruption of established behavior patterns and social relationships.
Recommended Standards for Cultural Competence
1. Promote and support the attitudes, behaviors, knowledge, and skills

necessary for staff to work respectfully and effectively with patients
and each other in a culturally diverse work environment.
2. Have a comprehensive management strategy to address culturally
and linguistically appropriate services, including strategic goals,
plans, policies, procedures, and designated staff responsible for
implementation.
3. Utilize formal mechanisms for community and consumer involve-
ment in the design and execution of service delivery, including
planning, policy making, operations, evaluation, training, and, as
appropriate, treatment planning.
4. Develop and implement a strategy to recruit, retain, and promote
qualified, diverse, and culturally competent administrative, clinical,
and support staff that are trained and qualified to address the needs
of the racial and ethnic communities being served.
5. Require and arrange for ongoing education and training for admin-
istrative, clinical, and support staff in culturally and linguistically
competent service delivery.
6. Provide all clients with limited English proficiency (LEP) access to
bilingual staff or interpretation services.
7. Provide oral and written notices, including translated signage at
key points of contact, to clients in their primary language informing
them of their right to receive no-cost interpreter services.
8. Translate and make available signage and commonly used written
patient educational material and other materials for members of the
predominant language groups in service areas.
9. Ensure that interpreters and bilingual staff can demonstrate
bilingual proficiency and receive training that includes the skills
and ethics of interpreting and knowledge in both languages of the
terms and concepts relevant to clinical or nonclinical encounters.
Family or friends are not considered adequate substitutes, because
they usually lack these abilities.
10. Ensure that the clients’ primary spoken language and self-identified
race/ethnicity are included in the health care organization’s manage-
ment information system as well as any patient records used by
provider staff.
11. Use a variety of methods to collect and utilize accurate demographic,
cultural, epidemiological, and clinical outcome data for racial and eth-
nic groups in the service area, and become informed about the ethnic/
cultural needs, resources, and assets of the surrounding community.
12. Undertake ongoing organizational self-assessments of cultural and
linguistic competence, and integrate measures of access, satisfac-
tion, quality, and outcomes for CLAS into other organizational

internal audits and performance improvement programs.
13. Develop structures and procedures to address cross-cultural ethical and
legal conflicts in health care delivery and complaints or grievances by
patients and staff about unfair, culturally insensitive, or discriminatory
treatment, or difficulty in accessing services, or denial of services.
14. Prepare an annual progress report documenting the organizations’
progress with implementing CLAS standards, including informa-
tion on programs, staffing, and resources.
©1999, HHS Office of Minority Health and Resources for Cross Cultural Health
Care
HOME CARE
It is estimated that approximately 95% of older adults live in the com-

munity by themselves or with others. The remaining 5% live in nursing
homes, assisted living, or continuing-care retirement homes. Of the 95%
that live independently, the majority live with spouses or by themselves
(Hogstel, 2001). The number of older adults living independently is
expected to increase with the improving health of the aging population.
Living in the same home environment through life has many advantages.
The older adult may remain among neighbors who share memories and
Title of Study: Views of Community-Dwelling, Old-Old People on Barriers

and Aids to Nutritional Health
Authors: Callen, B., Wells, T.
Purpose: An examination of both barriers and aids in the maintenance of
the health of old–old community-dwelling residents from their perspec-
tive.
Methods: Interviews were conducted on 68 community-dwelling residents
80 years or older. Two open-ended questions were used related to barri-
ers and aids to help nutritional health.
Findings: Despite reduced independence and increased physical limitations,
the interviewees were positive about their lives and made great attempts
to remain independent. Social connectiveness was noted as the main
factor in remaining independent.
Implications: Knowledge of positive practices and negative barriers is help-
ful to older persons in maintaining health promotion.
now watch out for each other; sometimes older adults are surrogate
parents or grandparents to new families who move into the neighbor-
hood. But, there are also problems with remaining at home for a life-
time. Many homes require costly and difficult repairs and maintenance
that older adults can no longer afford to manage. A decline in functional
status, vision, and hearing often make adaptation to a home and social-
ization difficulty. There is no medical care or assistance with ADLs and
IADLs built into the home, so the older adult either has to leave home
to obtain care, or hire outside providers. The latter may be costly and
expenses are not always covered by Medicare and private insurance.
Whether or not the older adult experiences a decline in health, an
interdisciplinary approach to home care is essential to facilitate aging in
place. Nursing, physical therapy, occupational therapy, speech-language
pathology, assistance with personal care, and social work are all available
to persons in the home setting. The interdisciplinary team works together
to assist the client in regaining strength and returning to the pre-illness
Title of Study: Measuring Patient-Level Clinical Outcomes of Home Health

Care
Authors: Keepnews, D., Capitman, J., Rosati, R.
Purpose: To examine the Outcomes Assessment and Information Set
(OASIS) data to analyze patient-level outcomes of home health
care.
Methods: Sixteen OASIS measures were compiled to construct an index.
The measures were activities of daily living (ADLs) and instrumental
activities of daily living (IADLs). Scores were taken at admission and at
the time of discharge. Predictors of functional status at discharge were
identified by regression analysis.
Findings: 78.1% of patients improved, 18.5% declined, and 2.8% showed
no change. 57.2% variance in functional status at discharge was shown.
The following were related negatively to functional outcomes of care:
age, visual impairment, having Medicaid as a payer, urinary inconti-
nence, cognitive impairment, and use of unplanned or emergency care.
Treatment received for care of open wounds or lesions and cardiovascu-
lar or orthopedic conditions were positively associated with functional
outcomes.
Implications: OASIS data is used to measure patient-level functional out-
comes of short-term home health services. More research is needed to
improve methods for determining patient outcomes and their predic-
tors.
Journal of Nursing Scholarship, First Quarter 2004.
level of functioning. The team collaborates with the client and family,
especially the caregiver.
Home care begins with an assessment on the initial visit, and this
sets the stage for all subsequent visits. The initial assessment includes the
assessment of the client’s (a) assets, (b) social support, (c) environment, and
(d) available community resources. The formal assessment of older adult
Medicare recipients is called the Outcome and ASessment Information Set
(OASIS). This is a group of data elements that forms the comprehensive
assessment for an adult home care patient and provides the basis for mea-
suring patient outcomes for purposes of outcome-based quality improve-
ment (OBQI). The OASIS includes sociodemographic, environmental,
support system, health status, and functional status attributes of the older
adult. The purpose of this assessment is to provide the home health nurse
with a picture of the client. Each home health agency uses its own assess-
ment form. Older adults often have multiple diagnoses, chronic illnesses,
and disabilities. Each part of the initial assessment is designed to aid the
home health nurse to form a holistic view of the client and to then develop
an appropriate plan of care that meets the client’s individual needs. Reim-
bursement from Medicare and insurance depend on the assessment of the
client and needs for skilled care as identified by the nurse.
Following the assessment, a plan of care is developed to help the cli-
ent meet their goals. It is important to note that Medicare reimbursement
for home care has become extremely limited over the past two decades.
Thus, the nurse must utilize every available resource in order to help the
client meet the goals in an efficient manner. Community resources are an
important part of home health, and the home health nurse should identify
community resources that may be useful (Hogstel, 2001). Community-
based services include such programs as employment resources, senior
center programs, senior housing, adult day care services, and alternative
community-based living facilities. Many of these programs are funded
through grants distributed through Area Agencies on Aging (AAA) or the
federal government, and all can enhance the well-being of older adults
and contribute to their ability to live independently, without financial dis-
tress and social isolation. Sometimes, the need for community resources
does not arise until later visits or client discharge. Consequently, it is
important to plan for resources from the start of visits to make sure the
client has all necessary services at discharge (Hogstel, 2001).
Caregiving at Home
When older adults continue to reside at home, cognitive, health, and
functional declines typically result in the need to have a caregiver live
in the home as well. Moreover, it is reported that the caregiver burden
is increasing. The Profile of Older Americans (AARP, 2007) reports that

53.6% (13.7 million) of older noninstitutionalized persons live with their
elderly spouses, and it is estimated that family members provide approxi-
mately 80% of the care for older adults.
The caregiver often provides the majority of care when the older
adult is recovering from an acute illness and continues until they can man-
age self-care activities. In some cases, however, the presence of chronic
physical disease, such as stroke or diabetes, or cognitive problems, such
as depression or dementia, require the caregiver to assist the dependent
older adult with all ADLs. In many cases, the caregiver is also an older
adult, most often a woman, with health problems of her own.
The experience of caregiving is very stressful and has been shown to
result in the onset of depression, grief, fatigue, decreased socialization, and
health problems of the caregiver (Sullivan, 2007). The Caregiver Strain
Index (Robinson, 1983) may be helpful in identifying stressors of caregiv-
ing that can lead to greater problems throughout the caregiving period.
The caregiver’s role and responsibilities may create stress that is situ-
ational, acute, or chronic in nature. Other variables associated with that
stress are sociocultural issues. For example, caregiving is a more accepted
part of the role in many cultural backgrounds, such as native Pacific
Islanders. Thus, this role may receive more support and lead to less stress.
In addition, family dynamics, attributes of the caregiver, and individual
characteristics of the older adult influence caregiver stress. Unfortunately,
approximately 50% of caregivers have been diagnosed with depression.
“Caregivers may be prone to depression, grief, fatigue, and changes in
social relationships. They may also experience physical health problems”
(Sullivan, 2007, p. 1). Nurses must evaluate caregivers for signs of vari-
ous diseases, including depression. Also, providing potential resources,
such as respite programs, may help preserve the family member’s mental
health, which may enable the family member to continue caring for the
loved one and delay nursing home placement.
It is important for home care nurses to assess clients at home for
signs and symptoms of neglect. As discussed in Chapter 10, active physi-
Other variables associated with that stress are sociocultural issues. For
example, caregiving is a more accepted part of the role in many cultural
backgrounds, such as native Pacific Islanders. Thus, this role may receive
more support and lead to less stress. In addition, family dynamics, attri-
butes of the caregiver, and individual characteristics of the older adult
influence caregiver stress.
cal neglect arises from the purposeful withholding of necessities, whereas

passive neglect results from the caregiver’s inability to identify the older
adult’s needs or to perform the tasks essential to meet the older adult’s
needs. The term neglect implies a failure to perform an obligation and,
therefore, raises questions regarding whether a family has an obligation
to provide care for an older adult. It is important to assess whether the
caregiver is purposefully neglecting the older adult victim or is simply
not physically or cognitively capable of caring for this person. Signs of
neglect include pressure ulcers, malnutrition, dehydration, and poor
hygiene. The nurse should also assess for signs and symptoms of physical
abuse including, bruising, swelling, and depression. The identification of
caregiver stress and early signs of abuse allow the nurse to intervene and
prevent harm to the client.
Home care nurses are in a position to assess caregiver stress and pro-
vide interventions to relieve stress as necessary. Respite care for the older
adult may be found for the older adult in a local skilled nursing facility so
that the caregiver may vacation and rest. Other supportive services, such
as home health aides, homemakers, chore services, or Meals on Wheels
may also be obtained. The caregivers must be supported and encouraged
to take care of themselves and pursue their own interests in activities.
In this manner, the caregiver will remain in better health and be more
actively engaged in society. This will ultimately assist the caregiver in the
transition to noncaregiving status once the care recipient dies.
ACUTE CARE
Any older adult with acute or chronic illness will spend some time in a
hospital or acute care facility. Fulmer (2001) reports that older adults gen-
erally spend twice the time in acute care facilities than their younger coun-
terparts do. While older adults were historically excluded from surgery and
other radical procedures because of a short projected lifespan, this is no
longer the case. Approximately 60% of hospital admissions, depending on
geographic area, are of older adults. However, despite the high prevalence
of older adults in acute care facilities, this environment of care is poorly
prepared to meet the commonly occurring problems of older adults. In
fact, the potential to acquire delirium, nosocomial infections, and decu-
bitus ulcers and to fall may make acute care settings very unsafe for older
adults.
Over the past few decades, several intervention models have been
introduced to make acute care facilities safer places for older adults. The
Geriatric Nurse Resource Project at Yale University Medical Center (Ful-
mer, 1991a; 1991b) and New York University Medical Center enrolls
interested nurses in geriatric care units into a program that provides
training on the commonly occurring problems of aging and education on

the best geriatric nursing practices. The nurse returns from the training
program to act as a resource in their unit for the best care of older adults.
This model has proven to be very effective at preventing many of the
common problems that result from hospitalization of older adults and
has served as a model for other hospitals to use.
The acute care environment offers an excellent opportunity to intro-
duce health-promotion strategies to older adults, because they have the
greatest need to adjust their lifestyle in order to return to a healthy status
(see Chapter 5). When recovering from illness, older adults may be more
amenable to learning information that they believe will prevent future
hospital admissions and restore their health. Moreover, the acute care
nurse is central in planning services for the older adult upon discharge.
Referrals to alternative housing and home care are needed to help the
older adult meet acute care goals in a shortened hospital stay environ-
ment. Supportive services at home will also assist in preventing hospital
readmission for recurring or unresolved illnesses.
A thorough assessment of the environment to which the older adult
is returning after acute care hospitalization helps to determine care
needs after discharge. This may be done as part of an interdisciplinary
care team in the acute care facility. While resolving the acute care illness,
nurses caring for older adults may assist in scheduling visiting nurses or
long-term care admissions. They can provide for follow-up care, trans-
portation, home health aide and homemaking services, adult day care,
or Meals on Wheels. These services will help older adults return to the
home care environment more readily prepared to recover from the illness.
In addition, helping older adults to locate health promotion programs,
such as those that will aid in smoking-cessation, stress-management,
weight-loss, or exercise, will allow them to enter these programs imme-
diately after discharge, while they are still motivated to do so.
SKILLED NURSING FACILITIES
Skilled nursing facilities (SNFs) provide 24-hour nursing care to older

adults who are unable to care for themselves. These facilities may be
private or public, and they may receive reimbursement from Medicare,
Medicaid, and private insurances, or the residents self-pay. Most SNFs
provide medication administration, wound care, daily assessment, meals,
and assistance with ADLs. Other available skilled services may be physi-
cal therapy, respiratory therapy, speech-language pathology services, and
occupational therapy (Hogstel, 2001). Residents may stay in SNFs for
short-term rehabilitation after surgery or medical illness, or they may
reside in them throughout their lives.
The typical SNF resident is a female widow in her seventies or eight-

ies who has two or more chronic health conditions requiring nursing care
and assistance. However, there are more and more resident centenarians
residing in nursing homes than ever before. Many residents of SNFs do
not have close family members or regular visitors.
Upon admission to a nursing facility, the resident’s private physician,
or the facility physician, must perform a history and physical examina-
tion within 48 hours. The documentation specific to SNFs is known as the
minimum data set (MDS). This is a core set of screening, clinical, and func-
tional status elements, including common definitions and coding categories
(See Figure 11.1). It forms the foundation of the comprehensive assess-
ment for all residents of long-term care facilities certified to participate
in Medicare or Medicaid and standardizes communication about resident
problems and conditions within facilities, between facilities, and between
facilities and outside agencies. This documentation must be completed on
admission to the facility and in specified intervals throughout the SNF stay.
Nursing facilities must provide information on the Resident Bill of Rights
upon admission so that the resident and family understand the resident’s
rights and responsibilities within the SNF. The admission process should
also involve a complete orientation and tour of the facility, as well as a
discussion of programs and requirements for the resident and family, if
possible. It is important that nurses provide an effective orientation and
transition to the facility in the first few days to decrease the risk of negative
health effects, which may be indicative of the translocation syndrome. The
translocation syndrome, discussed earlier, is very likely to happen during
admission to a nursing home or transfer to acute care from a nursing home
environment, so great attention to the older adult is essential to minimize
symptoms of translocation syndrome. Older adults must continually be
assessed for alterations in function and cognition and be supported to par-
ticipate in the environment at the highest possible level. Changes in function
and cognition and how the move affects the individual must be diagnosed
immediately and appropriate interventions implemented to ensure as safe
a transition as possible.
Two commonly occurring problems in long-term care facilities
include the frequent onset of urinary tract infections and pressure sores,
or decubitus ulcers.
Urinary Tract Infections

Urinary tract infections (UTIs) are the most common infection among
older adults and are caused by an accumulation of pathological bacteria
in the urine. However, it is important to note that bacteria in the urine
occurs commonly among older adults, especially women and those who
dwell in long-term care faculties. Bacteriuria, which is the presence of
Resident ______________________________________________________________ Numeric Identifier___________________________________________________________
MINIMUM DATA SET (MDS) — VERSION 2.0

FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
BACKGROUND (FACE SHEET) INFORMATION AT ADMISSION
SECTION AB. DEMOGRAPHIC INFORMATION SECTION AC. CUSTOMARY ROUTINE

1. DATE OF Date the stay began.Note — Does not include readmission if record was 1. CUSTOMARY (Check all that apply.If all information UNKNOWN, check last box only.)
ENTRY closed at time of temporary discharge to hospital, etc.In such cases, use prior ROUTINE
admission date CYCLE OF DAILY EVENTS
(In year prior
to DATE OF a.
ENTRY Stays up late at night (e.g., after 9 pm)
Month Day Year to this b.
2. ADMITTED 1. Private home/apt. with no home health services nursing Naps regularly during day (at least 1 hour)
FROM 2. Private home/apt. with home health services home, or year c.
last in Goes out 1+ days a week
(AT ENTRY) 3. Board and care/assisted living/group home
4. Nursing home community if d.
5. Acute care hospital now being Stays busy with hobbies, reading, or fixed daily routine
6. Psychiatric hospital, MR/DD facility admitted from e.
7. Rehabilitation hospital another Spends most of time alone or watching TV
8. Other nursing
home) Moves independently indoors (with appliances, if used) f.
3. LIVED 0. No
ALONE 1.Yes Use of tobacco products at least daily g.
(PRIOR TO
ENTRY) 2. In other facility NONE OF ABOVE h.
4. ZIP CODE OF
PRIOR EATING PATTERNS
PRIMARY
RESIDENCE Distinct food preferences i.
5. RESIDEN- (Check all settings resident lived in during 5 years prior to date of
TIAL entry given in item AB1 above) Eats between meals all or most days j.
HISTORY
5 YEARS Prior stay at this nursing home Use of alcoholic beverage(s) at least weekly k.
a.
PRIOR TO Stay in other nursing home
ENTRY NONE OF ABOVE l.
b.
Other residential facility—board and care home, assisted living, group ADL PATTERNS
home c.
In bedclothes much of day m.
MH/psychiatric setting d.
Wakens to toilet all or most nights n.
MR/DD setting e.
NONE OF ABOVE Has irregular bowel movement pattern o.
f.
6. LIFETIME Showers for bathing p.
OCCUPA-
TION(S) Bathing in PM q.
[Put "/"
between two NONE OF ABOVE r.
occupations]
INVOLVEMENT PATTERNS
7. EDUCATION 1. No schooling 5.Technical or trade school
(Highest 2. 8th grade/less 6. Some college Daily contact with relatives/close friends s.
Level 3. 9-11 grades 7.Bachelor's degree
Completed) 4. High school 8.Graduate degree Usually attends church, temple, synagogue (etc.) t.
8. LANGUAGE (Code for correct response)
a. Primary Language Finds strength in faith u.
0. English 1. Spanish 2.French 3. Other Daily animal companion/presence v.

b. If other, specify
Involved in group activities w.
9. MENTAL Does resident's RECORD indicate any history of mental retardation, NONE OF ABOVE x.
HEALTH mental illness, or developmental disability problem?
HISTORY 0. No 1.Yes UNKNOWN—Resident/family unable to provide information
y.
10. CONDITIONS (Check all conditions that are related to MR/DD status that were
RELATED TO manifested before age 22, and are likely to continue indefinitely)
MR/DD SECTION AD. FACE SHEET SIGNATURES
STATUS Not applicable—no MR/DD (Skip to AB11) a.
SIGNATURES OF PERSONS COMPLETING FACE SHEET:
MR/DD with organic condition
Down's syndrome b.
a. Signature of RN Assessment Coordinator Date
Autism c.
Epilepsy d. I certify that the accompanying information accurately reflects resident assessment or tracking
Other organic condition related to MR/DD information for this resident and that I collected or coordinated collection of this information on the
e. dates specified. To the best of my knowledge, this information was collected in accordance with
MR/DD with no organic condition f. applicable Medicare and Medicaid requirements. I understand that this information is used as a
basis for ensuring that residents receive appropriate and quality care, and as a basis for payment
11. DATE from federal funds. I further understand that payment of such federal funds and continued partici-
BACK- pation in the government-funded health care programs is conditioned on the accuracy and truthful-
GROUND ness of this information, and that I may be personally subject to or may subject my organization to
INFORMA- substantial criminal, civil, and/or administrative penalties for submitting false information. I also
TION Month Day Year
certify that I am authorized to submit this information by this facility on its behalf.
COMPLETED
Signature and Title Sections Date
b.
c.
d.
e.
f.
g.
= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
FIGURE 11.1 Box 11-2 sample minimum data set documentation.
265
Resident ______________________________________________________________ Numeric Identifier___________________________________________________________
MINIMUM DATA SET (MDS) — VERSION 2.0
FOR NURSING HOME RESIDENT ASSESSMENT AND CARE SCREENING
FULL ASSESSMENT FORM
(Status in last 7 days, unless other time frame indicated)
SECTION A. IDENTIFICATION AND BACKGROUND INFORMATION 3. MEMORY/ (Check all that resident was normally able to recall during
RECALL last 7 days)
1. RESIDENT
NAME ABILITY Current season a.
That he/she is in a nursing home d.
a. (First) b. (Middle Initial) c. (Last) d. (Jr/Sr) Location of own room b.
2. ROOM Staff names/faces c. NONE OF ABOVE are recalled e.
NUMBER 4. COGNITIVE (Made decisions regarding tasks of daily life)
SKILLS FOR
3. ASSESS- a. Last day of MDS observation period DAILY 0. INDEPENDENT—decisions consistent/reasonable
MENT DECISION- 1. MODIFIED INDEPENDENCE—some difficulty in new situations
REFERENCE MAKING only
DATE 2. MODERATELY IMPAIRED—decisions poor; cues/supervision
Month Day Year required
3. SEVERELY IMPAIRED—never/rarely made decisions
b. Original (0) or corrected copy of form (enter number of correction)
5. INDICATORS (Code for behavior in the last 7 days.) [Note: Accurate assessment
4a. DATE OF Date of reentry from most recent temporary discharge to a hospital in OF requires conversations with staff and family who have direct knowledge
REENTRY last 90 days (or since last assessment or admission if less than 90 days) DELIRIUM— of resident's behavior over this time].
PERIODIC
DISOR- 0. Behavior not present
DERED 1. Behavior present, not of recent onset
THINKING/ 2. Behavior present, over last 7 days appears different from resident's usual
Month Day Year AWARENESS functioning (e.g., new onset or worsening)
5. MARITAL 1. Never married 3.Widowed 5. Divorced a. EASILY DISTRACTED—(e.g., difficulty paying attention; gets
STATUS 2. Married 4.Separated sidetracked)
6. MEDICAL b.PERIODS OF ALTERED PERCEPTION OR AWARENESS OF
RECORD SURROUNDINGS—(e.g., moves lips or talks to someone not
NO. present; believes he/she is somewhere else; confuses night and
day)
7. CURRENT (Billing Office to indicate;check all that apply in last 30 days)
PAYMENT c. EPISODES OF DISORGANIZED SPEECH—(e.g., speech is
SOURCES Medicaid per diem VA per diem
a. f. incoherent, nonsensical, irrelevant, or rambling from subject to
FOR N.H. subject; loses train of thought)
STAY Medicare per diem Self or family pays for full per diem
b. g.
d.PERIODS OF RESTLESSNESS—(e.g., fidgeting or picking at skin,
Medicare ancillary Medicaid resident liability or Medicare clothing, napkins, etc; frequent position changes; repetitive physical
part A c. co-payment h. movements or calling out)
Medicare ancillary Private insurance per diem (including e. PERIODS OF LETHARGY—(e.g., sluggishness; staring into space;
d. co-payment) i.
part B difficult to arouse; little body movement)
CHAMPUS per diem e. Other per diem j.
f. MENTAL FUNCTION VARIES OVER THE COURSE OF THE
8. REASONS a. Primary reason for assessment DAY—(e.g., sometimes better, sometimes worse; behaviors
FOR 1. Admission assessment (required by day 14) sometimes present, sometimes not)
ASSESS- 2. Annual assessment
MENT 3. Significant change in status assessment 6. CHANGE IN Resident's cognitive status, skills, or abilities have changed as
4. Significant correction of prior full assessment COGNITIVE compared to status of 90 days ago (or since last assessment if less
[Note—If this 5. Quarterly review assessment STATUS than 90 days)
0. No change 1.Improved 2.Deteriorated
is a discharge 6. Discharged—return not anticipated
or reentry 7. Discharged—return anticipated
assessment, 8. Discharged prior to completing initial assessment SECTION C. COMMUNICATION/HEARING PATTERNS
only a limited 9. Reentry
subset of 10. Significant correction of prior quarterly assessment 1. HEARING (With hearing appliance, if used)
MDS items 0. NONE OF ABOVE 0. HEARS ADEQUATELY—normal talk, TV, phone
need be 1. MINIMAL DIFFICULTY when not in quiet setting
completed] b. Codes for assessments required for Medicare PPS or the State 2. HEARS IN SPECIAL SITUATIONS ONLY—speaker has to adjust
1. Medicare 5 day assessment tonal quality and speak distinctly
2. Medicare 30 day assessment 3. HIGHLY IMPAIRED/absence of useful hearing
3. Medicare 60 day assessment
4. Medicare 90 day assessment 2. COMMUNI- (Check all that apply during last 7 days)
5. Medicare readmission/return assessment CATION a.
Hearing aid, present and used
6. Other state required assessment DEVICES/ b.
7. Medicare 14 day assessment TECH- Hearing aid, present and not used regularly
8. Other Medicare required assessment NIQUES Other receptive comm. techniques used (e.g., lip reading) c.
9. RESPONSI- (Check all that apply) Durable power attorney/financial NONE OF ABOVE d.
d.
BILITY/ Legal guardian 3. MODES OF (Check all used by resident to make needs known)
LEGAL a. Family member responsible EXPRESSION
e. Signs/gestures/sounds
GUARDIAN Other legal oversight b. Speech a.
d.
Patient responsible for self f.
Durable power of Writing messages to Communication board e.
attorney/health care c. NONE OF ABOVE g. express or clarify needs b.
Other
10. ADVANCED (For those items with supporting documentation in the medical American sign language
f.
DIRECTIVES record, check all that apply) or Braille NONE OF ABOVE g.
c.
Living will Feeding restrictions
a. f. 4. MAKING (Expressing information content—however able)
Do not resuscitate b. Medication restrictions SELF 0. UNDERSTOOD
g. UNDER-
Do not hospitalize c. 1. USUALLY UNDERSTOOD—difficulty finding words or finishing
Other treatment restrictions STOOD thoughts
Organ donation d. h.
2. SOMETIMES UNDERSTOOD—ability is limited to making concrete
Autopsy request e. NONE OF ABOVE i. requests
3. RARELY/NEVER UNDERSTOOD
5. SPEECH (Code for speech in the last 7 days)
CLARITY 0. CLEAR SPEECH—distinct, intelligible words
SECTION B. COGNITIVE PATTERNS
1. UNCLEAR SPEECH—slurred, mumbled words
1. COMATOSE (Persistent vegetative state/no discernible consciousness) 2. NO SPEECH—absence of spoken words
0. No 1.Yes (If yes, skip to Section G) 6. ABILITY TO (Understanding verbal information content—however able)
2. MEMORY (Recall of what was learned or known) UNDER- 0. UNDERSTANDS
STAND 1. USUALLY UNDERSTANDS—may miss some part/intent of
a. Short-term memory OK—seems/appears to recall after 5 minutes OTHERS
0. Memory OK 1.Memory problem message
2. SOMETIMES UNDERSTANDS—responds adequately to simple,
b. Long-term memory OK—seems/appears to recall long past direct communication
0. Memory OK 1.Memory problem 3. RARELY/NEVER UNDERSTANDS
7. CHANGE IN Resident's ability to express, understand, or hear information has
COMMUNI- changed as compared to status of 90 days ago (or since last
CATION/ assessment if less than 90 days)
HEARING 0. No change 1.Improved 2.Deteriorated
= When box blank, must enter number or letter a. = When letter in box, check if condition applies MDS 2.0 September, 2000
FIGURE 11.1 Box 11-2 sample minimum data set documentation

(continued).
266
Resident ______________________________________________________________ Numeric Identifier _______________________________________________________
SECTION D. VISION PATTERNS
1. VISION (Ability to see in adequate light and with glasses if used)
5. CHANGE IN Resident's behavior status has changed as compared to status of 90
0. ADEQUATE—sees fine detail, including regular print in BEHAVIORAL days ago (or since last assessment if less than 90 days)
newspapers/books SYMPTOMS 0. No change 1.Improved 2.Deteriorated
1. IMPAIRED—sees large print, but not regular print in newspapers/
books
2. MODERATEL Y IMPAIRED—limited vision; not able to see
newspaper headlines, but can identify objects SECTION F. PSYCHOSOCIAL WELL-BEING
3. HIGHLY IMPAIRED—object identification in question, but eyes 1. SENSE OF At ease interacting with others a.
appear to follow objects INITIATIVE/ At ease doing planned or structured activities b.
4. SEVERELY IMPAIRED—no vision or sees only light, colors, or INVOLVE-
shapes; eyes do not appear to follow objects MENT At easek doing self-initiated
all that apply. If allactivities
information UNKNOWN, check last box only.c.
)
2. VISUAL Side vision problems—decreased peripheral vision (e.g., leaves food Establishes own goals d.
LIMITATIONS/ on one side of tray, difficulty traveling, bumps into people and objects, Pursues involvement in life of facility (e.g., makes/keeps friends;
DIFFICULTIES misjudges placement of chair when seating self) a.
involved in group activities; responds positively to new activities;
assists at religious services) e.
Experiences any of following: sees halos or rings around lights; sees
flashes of light; sees "curtains" over eyes b. Accepts invitations into most group activities f.
NONE OF ABOVE g.
NONE OF ABOVE c. 2. UNSETTLED Covert/open conflict with or repeated criticism of staff a.
3. VISUAL Glasses; contact lenses; magnifying glass RELATION- Unhappy with roommate b.
APPLIANCES 0. No 1.Yes SHIPS
Unhappy with residents other than roommate c.
Openly expresses conflict/anger with family/friends d.
SECTION E. MOOD AND BEHAVIOR PATTERNS Absence of personal contact with family/friends e.
1. INDICATORS (Code for indicators observed in last 30 days, irrespective of the
assumed cause) Recent loss of close family member/friend f.
OF
DEPRES- 0. Indicator not exhibited in last 30 days Does not adjust easily to change in routines g.
SION, 1. Indicator of this type exhibited up to five days a week NONE OF ABOVE h.
ANXIETY, 2. Indicator of this type exhibited daily or almost daily (6, 7 days a week)
3. PAST ROLES Strong identification with past roles and life status a.
SAD MOOD VERBAL EXPRESSIONS h. Repetitive health Expresses sadness/anger/empty feeling over lost roles/status
OF DISTRESS complaints—e.g., b.
persistently seeks medical Resident perceives that daily routine (customary routine, activities) is
a. Resident made negative attention, obsessive concern very different from prior pattern in the community c.
statements—e.g., "Nothing with body functions
matters;Would rather be NONE OF ABOVE d.
dead;What's the use; i. Repetitive anxious
Regrets having lived so complaints/concerns (non- SECTION G. PHYSICAL FUNCTIONING AND STRUCTURAL PROBLEMS
long; Let me die" health related) e.g.,
persistently seeks attention/ 1. (A) ADL SELF-PERFORMANCE—(Code for resident's PERFORMANCE OVER ALL
b. Repetitive questions—e.g., reassurance regarding SHIFTS during last 7 days—Not including setup)
"Where do I go;What do I schedules, meals, laundry,
do?" clothing, relationship issues 0. INDEPENDENT—No help or oversight —OR— Help/oversight provided only 1 or 2 times
during last 7 days
c. Repetitive verbalizations— SLEEP-CYCLE ISSUES
e.g., calling out for help, 1. SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during
("God help me") j. Unpleasant mood in morning last7 days —OR— Supervision (3 or more times) plus physical assistance provided only
k. Insomnia/change in usual 1 or 2 times during last 7 days
d. Persistent anger with self or sleep pattern
others—e.g., easily 2. LIMITED ASSISTANCE—Resident highly involved in activity; received physical help in
annoyed, anger at SAD, APATHETIC, ANXIOUS guided maneuvering of limbs or other nonweight bearing assistance 3 or more times —
placement in nursing home; APPEARANCE OR—More help provided only 1 or 2 times during last 7 days
anger at care received
l. Sad, pained, worried facial 3. EXTENSIVE ASSISTANCE—While resident performed part of activity, over last 7-day
e. Self deprecation—e.g., "I expressions—e.g., furrowed period, help of following type(s) provided 3 or more times:
am nothing; I am of no use brows — Weight-bearing support
to anyone" — Full staff performance during part (but not all) of last 7 days
m. Crying, tearfulness
f. Expressions of what 4. TOTAL DEPENDENCE—Full staff performance of activity during entire 7 days
appear to be unrealistic n. Repetitive physical
movements—e.g., pacing, 8. ACTIVITY DID NOT OCCUR during entire 7 days
fears—e.g., fear of being
abandoned, left alone, hand wringing, restlessness, (B) ADL SUPPORT PROVIDED—(Code for MOST SUPPORT PROVIDED
fidgeting, picking (A) (B)
being with others OVER ALL SHIFTS during last 7 days; code regardless of resident's self-
performance classification)
SELF-PERF
LOSS OF INTEREST
SUPPORT
g. Recurrent statements that
something terrible is about o. Withdrawal from activities of 0.No setup or physical help from staff
to happen—e.g., believes interest—e.g., no interest in 1.Setup help only
he or she is about to die, long standing activities or 2.One person physical assist 8. ADL activity itself did not
have a heart attack being with family/friends 3.Two+ persons physical assist occur during entire 7 days
p. Reduced social interaction a. BED How resident moves to and from lying position, turns side to side,
MOBILITY and positions body while in bed
2. MOOD One or more indicators of depressed, sad or anxious mood were
PERSIS- not easily altered by attempts to "cheer up", console, or reassure b. TRANSFER How resident moves between surfaces—to/from: bed, chair,
TENCE the resident over last 7 days wheelchair, standing position (EXCLUDE to/from bath/toilet)
0. No mood 1. Indicators present, 2. Indicators present,
indicators easily altered not easily altered c. WALK IN How resident walks between locations in his/her room
ROOM
3. CHANGE Resident's mood status has changed as compared to status of 90 WALK IN
days ago (or since last assessment if less than 90 days) d. How resident walks in corridor on unit
IN MOOD CORRIDOR
0. No change 1.Improved 2.Deteriorated
e. LOCOMO- How resident moves between locations in his/her room and
4. BEHAVIORAL (A) Behavioral symptom frequency in last 7 days TION adjacent corridor on same floor. If in wheelchair, self-sufficiency
SYMPTOMS 0. Behavior not exhibited in last 7 days ON UNIT once in chair
1. Behavior of this type occurred 1 to 3 days in last 7 days
2. Behavior of this type occurred 4 to 6 days, but less than daily f. LOCOMO- How resident moves to and returns from off unit locations (e.g.,
3. Behavior of this type occurred daily TION areas set aside for dining, activities, or treatments). If facility has
OFF UNITonly one floor, how resident moves to and from distant areas on
(B) Behavioral symptom alterability in last 7 days the floor. If in wheelchair, self-sufficiency once in chair
0. Behavior not present OR behavior was easily altered
1. Behavior was not easily altered (A) (B) g. DRESSING How resident puts on, fastens, and takes off all items of street
clothing, including donning/removing prosthesis
a. WANDERING (moved with no rational purpose, seemingly
oblivious to needs or safety) h. EATING How resident eats and drinks (regardless of skill). Includes intake of
nourishment by other means (e.g., tube feeding, total parenteral
b. VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS (others nutrition)
were threatened, screamed at, cursed at)
i. TOILET USE How resident uses the toilet room (or commode, bedpan, urinal);
c. PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS (others transfer on/off toilet, cleanses, changes pad, manages ostomy or
were hit, shoved, scratched, sexually abused) catheter, adjusts clothes
d. SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL j. PERSONAL How resident maintains personal hygiene, including combing hair,
SYMPTOMS (made disruptive sounds, noisiness, screaming, HYGIENE brushing teeth, shaving, applying makeup, washing/drying face,
self-abusive acts, sexual behavior or disrobing in public, hands, and perineum (EXCLUDE baths and showers)
smeared/threw food/feces, hoarding, rummaged through others'
belongings)
e. RESISTS CARE (resisted taking medications/ injections, ADL
assistance, or eating)
MDS 2.0 September, 2000
FIGURE 11.1 (continued).
267
Resident Numeric Identifier _______________________________________________________
2. BATHING How resident takes full-body bath/shower, sponge bath, and 3. APPLIANCES Any scheduled toileting plan a. Did not use toilet room/
transfers in/out of tub/shower (EXCLUDE washing of back and hair.) AND commode/urinal f.
Code for most dependent in self-performance and support.
(A) (B) PROGRAMS Bladder retraining program g.
(A) BATHING SELF-PERFORMANCE codes appear below b. Pads/briefs used
External (condom) catheter Enemas/irrigation h.
0. Independent—No help provided c.
1. Supervision—Oversight help only Indwelling catheter d. Ostomy present i.
2. Physical help limited to transfer only Intermittent catheter NONE OF ABOVE j.

e.
3. Physical help in part of bathing activity 4. CHANGE IN Resident's urinary continence has changed as compared to status of
4. Total dependence URINARY 90 days ago (or since last assessment if less than 90 days)
CONTI-
8. Activity itself did not occur during entire 7 days NENCE 0. No change 1.Improved 2.Deteriorated
(Bathing support codes are as defined in Item 1, code B above)
3. TEST FOR (Code for ability during test in the last 7 days) SECTION I. DISEASE DIAGNOSES
BALANCE 0. Maintained position as required in test Check only those diseases that have a relationship to current ADL status, cognitive status,
1. Unsteady, but able to rebalance self without physical support mood and behavior status, medical treatments, nursing monitoring, or risk of death. (Do not list
(see training 2. Partial physical support during test; inactive diagnoses)
manual) or stands (sits) but does not follow directions for test 1. DISEASES (If none apply, CHECK the NONE OF ABOVE box)
3. Not able to attempt test without physical help
ENDOCRINE/METABOLIC/ Hemiplegia/Hemiparesis v.
a. Balance while standing
NUTRITIONAL Multiple sclerosis w.
b. Balance while sitting—position, trunk control
Diabetes mellitus a. Paraplegia x.
4. FUNCTIONAL (Code for limitations during last 7 days that interfered with daily functions or
LIMITATION placed resident at risk of injury) Hyperthyroidism b. Parkinson's disease y.
IN RANGE OF (A) RANGE OF MOTION (B) VOLUNTARY MOVEMENT Hypothyroidism c. Quadriplegia z.
MOTION 0. No limitation 0. No loss
1. Limitation on one side 1. Partial loss HEART/CIRCULATION Seizure disorder aa.
(see training 2. Limitation on both sides 2. Full loss (A) (B) Transient ischemic attack (TIA) bb.
Arteriosclerotic heart disease
manual) a. Neck (ASHD) d. Traumatic brain injury cc.
b. Arm—Including shoulder or elbow Cardiac dysrhythmias e. PSYCHIATRIC/MOOD
c. Hand—Including wrist or fingers Congestive heart failure f. Anxiety disorder dd.
d. Leg—Including hip or knee Deep vein thrombosis g. Depression
e. Foot—Including ankle or toes ee.
Hypertension h. Manic depression (bipolar
f. Other limitation or loss Hypotension i. disease) ff.
5. MODES OF (Check all that apply during last 7 days) Peripheral vascular disease j. Schizophrenia gg.
LOCOMO- Cane/walker/crutch
TION a. Wheelchair primary mode of Other cardiovascular disease k. PULMONARY
d.
Wheeled self b.
locomotion MUSCULOSKELETAL Asthma hh.
Other person wheeled c. NONE OF ABOVE e. Arthritis l. Emphysema/COPD ii.
6. MODES OF (Check all that apply during last 7 days) Hip fracture m. SENSORY
TRANSFER Missing limb (e.g., amputation) n. Cataracts
Bedfast all or most of time Lifted mechanically jj.
a. d.
Osteoporosis o. Diabetic retinopathy kk.
Bed rails used for bed mobility Transfer aid (e.g., slide board,
or transfer b. trapeze, cane, walker, brace) e. Pathological bone fracture p. Glaucoma ll.
NEUROLOGICAL Macular degeneration mm.
Lifted manually c. NONE OF ABOVE f.
Alzheimer's disease q. OTHER
7. TASK Some or all of ADL activities were broken into subtasks during last 7
SEGMENTA- days so that resident could perform them Aphasia r. Allergies nn.
TION 0. No 1.Yes Cerebral palsy s. Anemia oo.
8. ADL Resident believes he/she is capable of increased independence in at Cerebrovascular accident Cancer pp.
FUNCTIONAL least some ADLs a. (stroke)
REHABILITA- t. Renal failure qq.
TION Direct care staff believe resident is capable of increased independence b. Dementia other than NONE OF ABOVE rr.
POTENTIAL in at least some ADLs Alzheimer's disease u.
Resident able to perform tasks/activity but is very slow c. 2. INFECTIONS (If none apply, CHECK the NONE OF ABOVE box)
Difference in ADL Self-Performance or ADL Support, comparing Antibiotic resistant infection Septicemia g.
mornings to evenings d.
(e.g., Methicillin resistant a. Sexually transmitted diseases h.
NONE OF ABOVE staph)
e. Tuberculosis i.
Clostridium difficile (c. diff.) b.
9. CHANGE IN Resident's ADL self-performance status has changed as compared Urinary tract infection in last 30
ADL to status of 90 days ago (or since last assessment if less than 90 Conjunctivitis c. days j.
FUNCTION days)
0. No change 1.Improved 2.Deteriorated HIV infection d. Viral hepatitis k.
Pneumonia e. Wound infection l.
SECTION H. CONTINENCE IN LAST 14 DAYS Respiratory infection f. NONE OF ABOVE m.
1. CONTINENCE SELF-CONTROL CATEGORIES 3. OTHER
(Code for resident's PERFORMANCE OVER ALL SHIFTS) a. •
CURRENT
OR MORE b.
0. CONTINENT—Complete control [includes use of indwelling urinary catheter or ostomy DETAILED •
device that does not leak urine or stool] DIAGNOSES c.
AND ICD-9
•
1. USUALLY CONTINENT—BLADDER, incontinent episodes once a week or less; CODES d.
•
BOWEL, less than weekly
e.
•
2. OCCASIONALLY INCONTINENT—BLADDER, 2 or more times a week but not daily;
BOWEL, once a week SECTION J. HEALTH CONDITIONS
3. FREQUENTLY INCONTINENT—BLADDER, tended to be incontinent daily, but some 1. PROBLEM (Check all problems present in last 7 days unless other time frame is
control present (e.g., on day shift); BOWEL, 2-3 times a week CONDITIONS indicated)
INDICATORS OF FLUID Dizziness/Vertigo f.
4. INCONTINENT—Had inadequate control BLADDER, multiple daily episodes; STATUS Edema g.
BOWEL, all (or almost all) of the time Fever
Weight gain or loss of 3 or h.
a. BOWEL Control of bowel movement, with appliance or bowel continence more pounds within a 7 day Hallucinations
CONTI- programs, if employed period a. i.
NENCE Internal bleeding
j.
b. BLADDER Control of urinary bladder function (if dribbles, volume insufficient to Inability to lie flat due to
shortness of breath Recurrent lung aspirations in
CONTI- soak through underpants), with appliances (e.g., foley) or continence b. last 90 days k.
NENCE programs, if employed Dehydrated; output exceeds Shortness of breath l.
2. BOWEL Bowel elimination pattern Diarrhea c. input c.
ELIMINATION regular—at least one a. Syncope (fainting) m.
PATTERN movement every three days Fecal impaction d.
Insufficient fluid; did NOT Unsteady gait
consume all/almost all liquids n.
Constipation NONE OF ABOVE provided during last 3 days d. Vomiting o.
b. e.
OTHER NONE OF ABOVE p.
MDS 2.0 September, 2000 Delusions e.

(continued).
268
Resident ______________________________________________________________ Numeric Identifier _______________________________________________________
SECTION M. SKIN CONDITION
2. PAIN (Code the highest level of pain present in the last 7 days)
at Stage
Number
1. ULCERS (Record the number of ulcers at each ulcer stage—regardless of
SYMPTOMS cause. If none present at a stage, record "0" (zero). Code all that apply
a. FREQUENCY with which b. INTENSITY of pain
resident complains or (Due to any during last 7 days. Code 9 = 9 or more.) [Requires full body exam.]
1. Mild pain cause)
shows evidence of pain
2. Moderate pain a. Stage 1. A persistent area of skin redness (without a break in the
0. No pain (skip to J4) skin) that does not disappear when pressure is relieved.
3. Times when pain is
1. Pain less than daily horrible or excruciating b. Stage 2. A partial thickness loss of skin layers that presents
2. Pain daily clinically as an abrasion, blister, or shallow crater.
3. PAIN SITE (If pain present, check all sites that apply in last 7 days) c. Stage 3. A full thickness
12 of skin is lost, exposing the subcutaneous
Back pain a. Incisional pain f. tissues - presents as a deep crater with or without
undermining adjacent tissue.
Bone pain b. Joint pain (other than hip) g.
Chest pain while doing usual d. Stage 4. A full thickness of skin and subcutaneous
12 tissue is lost,
Soft tissue pain (e.g., lesion, exposing muscle or bone.
activities c. muscle) h.
2. TYPE OF (For each type of ulcer, code for the highest stage in the last 7 days
Headache d. Stomach pain i. using scale in item M1—i.e., 0=none; stages 1, 2, 3, 4)
ULCER
Hip pain e. Other j.
a. Pressure ulcer—any lesion caused by pressure resulting in damage
4. ACCIDENTS (Check all that apply) of underlying tissue
Fell in past 30 days Hip fracture in last 180 days
a. c. b. Stasis ulcer—open lesion caused by poor circulation in the lower
Fell in past 31-180 days b. Other fracture in last 180 days d. extremities
NONE OF ABOVE e. 3. HISTORY OF Resident had an ulcer that was resolved or cured in LAST 90 DAYS
5. STABILITY Conditions/diseases make resident's cognitive, ADL, mood or behavior RESOLVED
OF patterns unstable—(fluctuating, precarious, or deteriorating) a. ULCERS 0. No 1.Yes
CONDITIONS 4. OTHER SKIN (Check all that apply during last 7 days)
Resident experiencing an acute episode or a flare-up of a recurrent or
b. PROBLEMS Abrasions, bruises
chronic problem a.
OR LESIONS
End-stage disease, 6 or fewer months to live c. PRESENT Burns (second or third degree) b.
NONE OF ABOVE d. Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions) c.
Rashes—e.g., intertrigo, eczema, drug rash, heat rash, herpes zoster d.
Skin desensitized to pain or pressure e.
SECTION K. ORAL/NUTRITIONAL STATUS Skin tears or cuts (other than surgery) f.
1. ORAL Chewing problem a.
Surgical wounds g.
PROBLEMS Swallowing problem b.
NONE OF ABOVE h.
Mouth pain c.
5. SKIN (Check all that apply during last 7 days)
NONE OF ABOVE d. TREAT- Pressure relieving device(s) for chair a.
2. HEIGHT Record (a.) height in inches and (b.) weight in pounds.Base weight on most MENTS
Pressure relieving device(s) for bed
AND recent measure in last 30 days; measure weight consistently in accord with b.
WEIGHT standard facility practice—e.g., in a.m.after voiding, before meal, with shoes Turning/repositioning program c.
off, and in nightclothes Nutrition or hydration intervention to manage skin problems d.
a. HT (in.) b. WT (lb.) Ulcer care e.
3. WEIGHT a.Weight loss—5 % or more in last 30 days; or 10 % or more in last Surgical wound care
180 days f.
CHANGE
0. No 1.Yes Application of dressings (with or without topical medications) other than
to feet g.
b.Weight gain—5 % or more in last 30 days; or 10 % or more in last
180 days Application of ointments/medications (other than to feet) h.
0. No 1.Yes Other preventative or protective skin care (other than to feet) i.
4. NUTRI- Complains about the taste of Leaves 25% or more of food NONE OF ABOVE j.
TIONAL many foods a. uneaten at most meals c. 6. FOOT (Check all that apply during last 7 days)
PROBLEMS PROBLEMS Resident has one or more foot problems—e.g., corns, callouses,
Regular or repetitive NONE OF ABOVE
complaints of hunger b. d.
AND CARE bunions, hammer toes, overlapping toes, pain, structural problems
a.
5. NUTRI- (Check all that apply in last 7 days) Infection of the foot—e.g., cellulitis, purulent drainage b.
TIONAL Parenteral/IV Dietary supplement between Open lesions on the foot
a. c.
APPROACH- meals
ES Feeding tube f. Nails/calluses trimmed during last 90 days
b. d.
Mechanically altered diet Plate guard, stabilized built-up Received preventative or protective foot care (e.g., used special shoes,
c. utensil, etc. inserts, pads, toe separators) e.
g.
Syringe (oral feeding) d. On a planned weight change Application of dressings (with or without topical medications) f.
Therapeutic diet program h. NONE OF ABOVE
e. g.
NONE OF ABOVE i.
6. PARENTERAL (Skip to Section L if neither 5a nor 5b is checked)
OR ENTERAL a. Code the proportion of total calories the resident received through SECTION N. ACTIVITY PURSUIT PATTERNS
INTAKE parenteral or tube feedings in the last 7 days 1. TIME (Check appropriate time periods over last 7 days)
0. None 3. 51% to 75% AWAKE Resident awake all or most of time (i.e., naps no more than one hour
1. 1% to 25% 4. 76% to 100% per time period) in the:
Evening c.
2. 26% to 50% Morning a.
Afternoon b. NONE OF ABOVE d.
b. Code the average fluid intake per day by IV or tube in last 7 days
0. None 3. 1001 to 1500 cc/day (If resident is comatose, skip to Section O)
1. 1 to 500 cc/day 4. 1501 to 2000 cc/day 2. (When awake and not receiving treatments or ADL care)
2. 501 to 1000 cc/day 5. 2001 or more cc/day AVERAGE
TIME
INVOLVED IN 0. Most—more than 2/3 of time 2. Little—less than 1/3 of time
ACTIVITIES 1. Some—from 1/3 to 2/3 of time 3. None
SECTION L. ORAL/DENTAL STATUS 3. PREFERRED (Check all settings in which activities are preferred)
1. ORAL Debris (soft, easily movable substances) present in mouth prior to ACTIVITY Own room a.
STATUS AND going to bed at night a. SETTINGS Day/activity room Outside facility d.
b.
DISEASE Has dentures or removable bridge
PREVENTION b. Inside NH/off unit c. NONE OF ABOVE e.
Some/all natural teeth lost—does not have or does not use dentures 4. GENERAL (Check all PREFERENCES whether or not activity is currently
(or partial plates) c. ACTIVITY available to resident) Trips/shopping g.
PREFER- Cards/other games a.
Broken, loose, or carious teeth d. ENCES Walking/wheeling outdoors
Crafts/arts h.
(adapted to b.
Inflamed gums (gingiva);swollen or bleeding gums; oral abcesses; Watching TV i.
ulcers or rashes e. resident's Exercise/sports c.
current Music d.
Gardening or plants j.
Daily cleaning of teeth/dentures or daily mouth care—by resident or f. abilities)
staff Reading/writing e.
Talking or conversing k.
NONE OF ABOVE g. Spiritual/religious Helping others l.
activities f. NONE OF ABOVE m.
FIGURE 11.1 (continued).
269
Resident Numeric Identifier _______________________________________________________
5. PREFERS Code for resident preferences in daily routines 4. DEVICES (Use the following codes for last 7 days:)
CHANGE IN 0. No change 1. Slight change 2. Major change AND 0. Not used
DAILY a. Type of activities in which resident is currently involved RESTRAINTS 1. Used less than daily
ROUTINE 2. Used daily
b. Extent of resident involvement in activities Bed rails
a. — Full bed rails on all open sides of bed
SECTION O. MEDICATIONS
b. — Other types of side rails used (e.g., half rail, one side)
1. NUMBER OF (Record the number of different medications used in the last 7 days;
MEDICA- enter "0" if none used) c.Trunk restraint
TIONS d. Limb restraint
2. NEW (Resident currently receiving medications that were initiated during the e. Chair prevents rising
MEDICA- last 90 days) 5. HOSPITAL Record number of times resident was admitted to hospital with an
TIONS 0. No 1.Yes STAY(S) overnight stay in last 90 days (or since last assessment if less than 90
3. INJECTIONS Record the number of DAYS injections of any type received during
( days). (Enter 0 if no hospital admissions)
the last 7 days; enter "0" if none used) 6. EMERGENCY Record number of times resident visited ER without an overnight stay
4. DAYS (Record the number of DAYS during last 7 days; enter "0" if not ROOM (ER) in last 90 days (or since last assessment if less than 90 days).
RECEIVED used.Note—enter "1" for long-acting meds used less than weekly) VISIT(S) (Enter 0 if no ER visits)
THE a. Antipsychotic 7. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
FOLLOWING d. Hypnotic
VISITS facility) how many days has the physician (or authorized assistant or
MEDICATION b. Antianxiety practitioner) examined the resident? (Enter 0 if none)
e. Diuretic
c. Antidepressant
8. PHYSICIAN In the LAST 14 DAYS (or since admission if less than 14 days in
ORDERS facility) how many days has the physician (or authorized assistant or
SECTION P. SPECIALTREATMENTS AND PROCEDURES practitioner) changed the resident's orders? Do not include order
renewals without change. (Enter 0 if none)
1. SPECIAL a. SPECIAL CARE—Check treatments or programs received during
TREAT- the last 14 days 9. ABNORMAL Has the resident had any abnormal lab values during the last 90 days
MENTS, LAB VALUES (or since admission)?
PROCE- TREATMENTS Ventilator or respirator
DURES, AND l. 0. No 1.Yes
PROGRAMS Chemotherapy a. PROGRAMS
Dialysis b. Alcohol/drug treatment SECTION Q. DISCHARGE POTENTIAL AND OVERALL STATUS
IV medication c.
program m.
1. DISCHARGE a. Resident expresses/indicates preference to return to the community
Intake/output d. Alzheimer's/dementia special POTENTIAL
care unit n. 0. No 1.Yes
Monitoring acute medical
condition e. Hospice care o. b. Resident has a support person who is positive towards discharge
Pediatric unit p.
Ostomy care f. 0. No 1.Yes
Respite care q.
Oxygen therapy g. c. Stay projected to be of a short duration— discharge projected within
Training in skills required to 90 days (do not include expected discharge due to death)
Radiation h. return to the community (e.g., 0. No 2.Within 31-90 days
Suctioning i. taking medications, house r. 1.Within 30 days 3. Discharge status uncertain
work, shopping, transportation,
Tracheostomy care j. ADLs) 2. OVERALL Resident's overall self sufficiency has changed significantly as
CHANGE IN compared to status of 90 days ago (or since last assessment if less
Transfusions k. NONE OF ABOVE s. CARE NEEDS than 90 days)
0. No change 1. Improved—receives fewer 2. Deteriorated—receives
b.THERAPIES - Record the number of days and total minutes each of the supports, needs less more support
following therapies was administered (for at least 15 minutes a day) in restrictive level of care
the last 7 calendar days (Enter 0 if none or less than 15 min. daily)
[Note—count only post admission therapies]
(A) = # of days administered for 15 minutes or more DAYS MIN
(B) = total # of minutes provided in last 7 days (A) (B)
SECTION R. ASSESSMENT INFORMATION
1. PARTICIPA- a. Resident: 0. No 1.Yes
a. Speech - language pathology and audiology services TION IN b. Family: 0. No 1.Yes 2. No family
b. Occupational therapy ASSESS-
MENT c. Significant other: 0. No 1.Yes 2. None
c. Physical therapy 2. SIGNATURE OF PERSON COORDINATINGTHE ASSESSMENT:
d. Respiratory therapy
e. Psychological therapy (by any licensed mental a. Signature of RN Assessment Coordinator (sign on above line)
health professional) b. Date RN Assessment Coordinator
2. INTERVEN- (Check all interventions or strategies used in last 7 days—no signed as complete
TION matter where received) Month Day Year
PROGRAMS Special behavior symptom evaluation program
FOR MOOD, a.
BEHAVIOR, Evaluation by a licensed mental health specialist in last 90 days
COGNITIVE b.
Group therapy
LOSS c.
Resident-specific deliberate changes in the environment to address
mood/behavior patterns—e.g., providing bureau in which to rummage d.
Reorientation—e.g., cueing e.
NONE OF ABOVE f.
3. NURSING Record the NUMBER OF DAYS each of the following rehabilitation or
REHABILITA- restorative techniques or practices was provided to the resident for
TION/ more than or equal to 15 minutes per day in the last 7 days
RESTOR- (Enter 0 if none or less than 15 min. daily.)
ATIVE CARE a. Range of motion (passive) f. Walking
b. Range of motion (active) g. Dressing or grooming
c. Splint or brace assistance
h. Eating or swallowing
TRAINING AND SKILL
PRACTICE IN: i. Amputation/prosthesis care
d. Bed mobility j. Communication
e. Transfer k. Other

(continued).
bacteria in the urine, is generally asymptomatic and does not appear to

cause renal damage or affect morbidity or mortality of older adults. It is
always present among clients with long-term indwelling catheters and
has a great economic impact among the older population.
Title of Study: The Minimum Data Set Depression Quality Indicator: Does
It Reflect Differences in Care Processes?
Authors: Simmons, S., Cadogan, M., Cabrera, G., Al-Samarrai, N., Jorge,
J., Levy-Storms, L., Osterweil, D., Schnelle, J.
Purpose: To determine whether those nursing homes that score differ-
ently on prevalence of depression (according to the minimum data set
[MDS] quality indicator), also provide different care for the depressed
client.
Methods: A cross-sectional study of 396 long-term residents in 14 skilled
nursing homes. Of those care facilities, 10 were in the lower quartile
and 4 in the upper quartile on the MDS depression quality indica-
tor. By the use of resident interviews, direct observation, and medical
records reviews, measurement of depressive symptoms were assessed.
The staff was assessed relating to their care process, by trained
researchers.
Findings: The prevalence noted by independent assessments was signifi-
cantly higher than prevalence based on the MDS quality indicator and
comparable between those homes reporting low versus high rates of
depression (46% and 41%, respectively).
Implications: The MDS quality indicator underestimates the prevalence of
depression, particularly in those homes reporting low or nonexistent
rates. Nursing homes need to enhance staff recognition of depressive
symptoms. Those nursing homes that report low prevalence of depres-
sion should not be accredited for providing better care.
When bacteriuria becomes pathological, the symptoms are gener-

ally incontinence, increased confusion, and falls among older adults
(Amella, 2004). Other common symptoms among older adults include
urinary frequency, dysuria, suprapubic discomfort, fever, and/or cos-
tovertebral tenderness. Diagnosis generally involves the collection of a
urine specimen for culture and sensitivity. Antibiotic treatment of should
only occur in the presence of symptoms, and a short course of antibiot-
ics is usually recommended. Treatment for longer periods of time may
be necessary among the older population, however, due to decreased
natural immune responses. As stated earlier in this text, indwelling
catheters should be avoided when possible due to the increased risk of
developing infections. If indwelling catheters are necessary, meticulous
catheter care is essential to prevent the development of UTIs and the
resulting complications.
Pressure (Decubitus) Ulcers

Decubitus ulcers occur commonly in long-term care settings. They are clas-
sified according to the severity of the wound, usually in four stages or types
(Table 11.1). Early stage pressure ulcers appear as a mild pink discolor-
ation of the skin in White individuals and a darkened area on those with
darker-pigmented skin. Early stage ulcers disappear a few hours after pres-
sure is relieved on the area. Later stage decubiti take the form of very deep
wounds extending through all layers of skin and underlying muscle. They
require extensive, time-consuming, and costly treatments and place the
older adult at high risk for septicemia should the wound become infected.
The most effective nursing intervention for pressure ulcers is preven-
tion. At an average cost of $1.3 billion a year, decubitus ulcers are a sub-
stantial drain on the health care system. They are also very preventable.
The Braden scale for pressure ulcer risk assessment is an effective tool
for assessing risk. Use of the assessment of risk factors contained in this
instrument enables nurses to identify and implement preventative mea-
sures to avoid the development of these wounds. Preventative measures
include the utilization of pressure relieving devices, such as mattresses,
pads and footwear, as well as regular and consistent skin assessment by
knowledgeable nursing professionals.
Nutrition is essential in preventing decubitus ulcers. A large study
conducted among older adults aged 65 and older (n = 1113) found that
diets were inadequate in 16.7% of the older participants. Normal changes
of aging place the older adult at a higher risk for nutritional deficiencies.
TABLE 11.1 National Pressure Ulcer Advisory Panel Pressure

Ulcer Classification
Stage I Intact skin with nonblanchable redness of a localized area,
usually over a bony prominence. Darkly pigmented skin may
not have visible blanching; its color may differ from that of the
surrounding area.
Stage II Partial-thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough. May also
present as an intact or open or ruptured serum-filled blister.
Stage III Full-thickness tissue loss. Subcutaneous fat may be visible, but
bone, tendon, or muscle are not exposed. Slough may be pres-
ent but does not obscure the depth of tissue loss. May include
undermining and tunneling.
Stage IV Full-thickness tissue loss with exposed bone, tendon, or muscle.
Slough or eschar may be present on some parts of the wound
bed. Often include undermining and tunneling.
Retrieved August 8, 2007, from http://www.npuap.org/pr2.htm

In addition, a decrease in the smell, vision, and taste senses and the high
frequency of dental problems makes it difficult for the older adult to main-
tain adequate daily nutrition. Lifelong eating habits, such as a diet high
in fat and cholesterol, are other obstacles to maintaining optimal nutri-
tion. The diminishing senses of taste and smell result in less desire to eat
and may lead to malnutrition. Diminishing taste is also accompanied by
a decline in salivary flow that accompanies aging. Chronic illness, depres-
sion, loneliness, isolation, limited funds to purchase food, and not know-
ing healthy food choices are also significant factors in malnutrition among
older adults. Once the nurse identifies the nutritional concerns and risk
factors, it is necessary to plan care surrounding nutrition in the older adult.
Eliminating risk factors for malnutrition and appropriate meal planning
are essential nursing interventions. Encouraging family to bring the older
adult food that they enjoy or coordinating home-delivered meals may be
helpful in promoting nutrition. Dietary supplements may also be essential
in providing needed nutrition among chronically ill older adults.
Once pressure ulcers have developed, daily care with recommended
products is implemented according to wound stage. Stage one ulcers are
usually massaged around the area of the wound and reassessed daily. Stage
two ulcers are generally treated with occlusive dressings and reevaluated
at regular intervals. Normal saline dressings are the treatment strategy
for stage three and four ulcerations. As nutrition is necessary for decu-
bitus ulcer prevention, it is also needed to heal a decubitus ulcer once it
forms. Nutritional management in conjunction with effective wound care
is integral to healing pressure ulcers.
ASSISTED LIVING
Assisted-living facilities (ALFs) developed in the 1980s to provide sup-

portive residential housing for the rapidly growing elderly population.
Prior to this time, women cared for their aging mothers, sisters, and moth-
ers-in-law at home. However, the rising number of women returning to
the workplace reduced the number of caregivers available for the informal
care of older adults. Most SNFs were not a desirable alternative because
of high cost and a focus on functional dependence, so lower cost ALFs,
with a greater emphasis on autonomy, became an appealing housing alter-
native to older adults with minor to moderate functional impairments.
“ALFs generally follow a nonmedical model, focusing on resident
autonomy, privacy, independence, dignity and respect, in a housing environ-
ment as homelike as possible” (Wink & Holcomb, 2002, p. 251). Because
there are no physicians and often no nurses in ALFs, the cost is usually lower
than a traditional SNF. The nonmedical model also precludes reimburse-
ment by Medicare, although Medicare reimbursement for these services
may be provided by an outside home care agency. The average monthly cost
of ALFs is $1,873 per person (National Center for Assisted Living, 1998).
Currently, the National Center for Assisted Living (1998) estimates
that there are more than 32,886 assisted-living residences in the United
States, providing housing to approximately 789,000 people. The average
annual income of ALF residents is $28,000, with financial resources of
approximately $192,000 (Marosy, 1997). The average age of residents in
ALFs in 2000 was 80 years with a range of 66 to 94 years. The services
offered at ALFs vary, but there is 24-hour supervision, three meals a day
plus snacks provided in a dining room setting, and a range of personal,
health care, and recreational services. These services may be included in
the monthly rate, or they may be offered at additional costs.
Advertisements for ALFs featuring attractive facilities and health
care have greatly influenced their successful occupancy in the past
decade. However, the health care and nursing services available at ALFs
vary widely throughout the country. Wallace (2003) reports that some
facilities have adequate 24-hour coverage, while others do not have reg-
istered nurses on site. Furthermore, the disparity in state regulations has
led to varied interpretations of what an ALF is and can do and the role
of nurses within these facilities. Older adults and their families should
research extensively the services within these facilities prior to selling
their homes and relocating.
CONTINUING CARE RETIREMENT COMMUNITIES
Continuing care retirement communities (CCRCs) are defined as “full

service communities offering long-term contracts that provide for a con-
tinuum of care, including retirement, assisted living and nursing services,
all on one campus” (New Life Styles,2005). CCRCs are a housing alterna-
tive for older adults that arose in the 1980s, and they continue to house a
small number of older adults today (Resnick, 2000). Their purpose is to
facilitate aging in place. CCRCs provide several levels of care, including
independent living, assisted living, and skilled nursing care. Theoretically,
the older adult may remain in the community by merely changing the
level of care received as changes occur in health, functional, or cognitive
status.
CCRCs are very expensive and require an entrance fee ranging
from $20,000 to $400,000, as well as a monthly payment ranging
from $200 to $2,500. Residence in a CCRC requires commitment to a
long-term contract that specifies the housing, services, and nursing care
provided. AARP (2007) reports that there are three types of CCRC
contracts:
• Extensive contracts include unlimited long-term nursing care at

minimal or no increase in monthly fee.
• Modified contracts include a specified amount of long-term care.
If chronic conditions require more care beyond that specified time,
the older adult is responsible for payments.
• Fee-for-service contracts require the older adult to pay the full
daily rates for long-term nursing care.
CCRCs originated from religious or social groups interested in car-

ing for members of their communities. More recently, private investors
have begun to purchase and operate these communities. Older adults
generally pay a large entrance fee or purchase a home within the commu-
nity and then pay a monthly fee. Skilled levels of care are reimbursable
under Medicare. However, independent and assisted livings are privately
paid. As with ALFs, periodic home care services may be reimbursable
under Medicare by home care nurses. Services provided depend on the
level of care and range from basic recreational services in independent
living to full care and meals in a skilled nursing environment.
A study of older adults relocating to CCRCs showed that they experi-
enced relocation stress that was consistent with the translocation syndrome.
Assistance by a wellness nurse was needed to help manage the consequences
of translocation within the first 6 months in the community (Resnick,
1989). Research exploring the health-promoting behaviors of CCRC resi-
dents found that it is essential for the older adults in these communities and
their care providers to focus on health promotion behaviors and activities in
order to keep costs down and quality of life high (Resnick, 2000).
HOMELESS OLDER ADULTS
While older adults often populate a variety of environments of care, it

is essential to acknowledge that homelessness is a significant problem
among this population. Little is known about the homeless older popula-
tion. The lack of knowledge stems from defining homelessness among
older adults. For example, is an older resident who was discharged from
assisted living because of changes in functional status and has no home
to return to considered homeless? In addition, because the older homeless
population rarely seeks health services, they are difficult to access. The
few available studies estimate that there are between 60,000–400,000
older homeless adults in the United States today, with an estimated dou-
bling of this number by the year 2030 (Burt, 1996).
The typical older homeless person is a male. Despite the lack of
health service use among older homeless adults, this population suffers
Cџіѡіѐюl Tѕіћјіћє CюѠђ SѡѢёѦ
Mrs. Hobson is an 89-year-old woman who has lived in her house for the
past 60 years. Her husband passed away 25 years ago, and she relies on her
two sons and daughter for groceries and transportation to health appoint-
ments. She is independent in all her activities of daily living. She lives in an
inner city area that has deteriorated greatly over her time there. Last night,
Mrs. Hobson’s home was burglarized. Mrs. Hobson startled the burglar,
and she was hit in the head with the crowbar used to break the window and
enter the house. She was treated in the emergency room and sent home.
1. What challenge does living on her own provide for Mrs. Hobson?
2. What other housing alternatives might Mrs. Hobson consider?
3. If Mrs. Hobson were to move to a more supportive environment,
what effects might she experience during this transition?
4. If Mrs. Hobson were to stay in her own home, what interventions
could be implemented to make her safer and enable her to function
at the highest possible degree of independence?
from substantial physical and mental illness, as well as alcohol and drug
abuse. This places older adults at high risk for increased morbidity and
mortality, including decreased bone density, increased risk of hip fracture
from falls, and increased motor vehicle accidents (Felson, Kiel, Ander-
son, & Kamel, 1988). It is important for nurses to consider the projected
increase in homelessness among older adults and focus research attention
at meeting the health needs of this challenging population.
SUMMARY
With the proportionate increase in the occurrence of chronic and acute

illnesses among older adults, the subsequent decline in functional status,
and the numerous losses sustained by older adults, changes in the living
environments are likely. Many older adults continue to live independently
at home or with a caregiver. Often changes in the environment are neces-
sary for financial reasons. In other cases, older adults may move to obtain
health care or a more functional supportive environment.
Moving from one environment to another is often stressful for
older adults. Translocation syndrome describes the symptoms older
adults may experience when they must change environments. Trans-
location can be very difficult and result in adverse physical and emo-
tional outcomes. There are many environments in which older adults
may receive health care and supportive care. These include acute care
facilities, nursing homes, assisted-living facilities, and continuing care
retirement communities. It is often the nurse’s role to assist the older

adult to find the environment where health and functional needs can be
met, and to relocate to the most stress-free environment possible.
REFERENCES

104, 40–52.
American Association of Retired Persons. (2007). Continuing care retirement communities.
Retrieved July 14, 2007, from http://www.aarp.org/families/housing_choices/other_
options/a2004-02-26-retirementcommunity.html
Burt, M. R. (1996). Homelessness: Definitions and counts. In J. Baumohl (Ed.), Homeless
in America (pp. 15–23). Phoenix, AZ: Oryx Press.
Felson, D. T., Kiel, D. P., Anderson, J. J., & Kamel, W. B. (1988). Alcohol consumption and
hip fractures: The Framingham study. American Journal of Epidemiology, 128(5),
1102–1110.
Fulmer, T. (1991a). The geriatric nurse specialist role: A new model. Nursing Management,
22(3), 91–93.
Fulmer, T. (1991b). Grow your own experts in hospital elder care. Geriatric Nursing,
March/April, 64–66.
Fulmer, T. (2001). Acute care. In J. J. Fitzpatrick, T. Fulmer, M. Wallace, & E. Flaherty
ing Company.
Thomson Learning.
Marosy, J. P. (1997). Assisted living: Opportunities for partnerships in caring. Caring,
16(10), 72–78.
National Center for Assisted Living. (2001). Facts and trends: The assisted living source-
book 2001. Retrieved July 14, 2007, from http://www.ahca.org/research/alsource-
book2001.pdf
New Life Styles. (2005). Types of Senior Housing and Care. Retrieved on August 25, 2007
http://www.newlifestyles.com/resources/articles/Selecting_a_Continuing.aspx
Resnick, B. (1989). Care for life. . . . Even if a life care community is Utopia, the move
can be a dramatic change. Here’s how to smooth the transition. Geriatric Nursing—
American Journal of Care for the Aging, 10(3), 130–132.
Resnick, B. (2000). Continuing care retirement communities. In J. J. Fitzpatrick, T. Fulmer,
M. Wallace, & E. Flaherty (Eds.), Geriatric nursing research digest (pp. 138–141).
New York: Springer Publishing Company.
Robinson, B. (1983). Validation of a caregiver strain index. Journal of Gerontology, 38,
344–348.
Sullivan, T. M. (2007). Caregiver strain index (CSI). In Try this: Best practices in nursing
care to older adults (issue 14). New York: The Hartford Institute for Geriatric Nurs-
ing, New York University, Division of Nursing.
Wallace, M. (2003). Is there a nurse in the house? The role of nurses in assisted living: Past,
present & future. Geriatric Nursing, 24(4), 218–221.
Wink, D, M., & Holcomb, L. O. (2002). Clinical practice. Assisted living facilities as a
site for NP practice. Journal of the American Academy of Nurse Practitioners, 14,
251–256.
C H A P T E R T W E LV E
End-of-Life Care
Learning Objectives
1. Identify the role of nurses in promoting the use of advance
directives among clients.
2. Discuss legal resources for end-of-life planning.
3. Describe assessment parameters important in palliative care.
4. Describe the nurse’s role in supporting a multidisciplinary team
approach to palliative and end-of-life care.
5. Identify the rationale for the team approach to care manage-
ment.
6. Identify physical, social, psychological, and spiritual needs and
nursing interventions at the end of life.
7. Provide care to enhance the grieving process of families.
8. Discuss challenges to widows and widowers.
9. Discuss the role of hospice in a “good death.”
Ms. Wallace is a 65-year-old woman with multiple sclerosis who is cur-

rently ventilator and feeding tube dependent. Her two sons are attempt-
ing to have her code status changed to DNR/DN. However, her daughter
is fighting to maintain her at full code status. Ms. Wallace had appointed
her husband as her health care proxy 5 years ago, but unfortunately he
passed away 6 months ago. The client now is incapable of communicat-
ing her wishes, although each family member states that they know what
she would want in this situation.
You are a nurse in her nursing home, and you have been taking care
of her regularly for the past month. You have established a relationship
with each member of her family and have spoken to each of them regard-
ing their feelings surrounding the situation. Several family meetings have
been held, but as of yet no compromise has been made. Her physician
comes to you to discuss how this issue may be resolved.
279
The story of Ms. Wallace is typical of today’s older adult. In this society,
there remains a marked difference between the way people want to die
and the way they actually do. If asked to envision perfect death, most
people would likely exclude the words “hospital,” “tubes,” “medica-
tion,” and “pain.” Yet, many older adults die in hospitals, with breath-
ing and feeding tubes, urinary catheters, and, unfortunately, much pain.
The goal of palliative care is to allow older adults to die in a manner that
they would consider a “good death.” The World Health Organization
(2005) defines palliative care as “the active total care of patients whose
disease is not responsive to curative treatment. Control of pain, other
symptoms, and psychological, social, and spiritual problems is para-
mount.” This definition clearly underscores the multidimensional nature
of end-of-life care with biological, psychological, social, and spiritual
components.
End-of-life care has recently undergone a great deal of research, and
the nursing role at the end of life is becoming better articulated. As one
approaches the end of life, they may explore the meaning of life and ques-
tion the possibility of an afterlife. There are many aspects to end-of-life
care, including communication, physical care, spiritual care, emotional
and psychological care, as well as working with the family in promoting
effective grieving.
ADVANCE DIRECTIVES
A major advancement in closing the gap between what a patient wants

and what actually happens at the end of life is the development of advance
directives. Norton and Talerico (2000) report that experienced health
care providers who are comfortable with end-of-life issues are more likely
to assess the readiness of older adults to make decisions about advance
directives. Older adults must be encouraged to complete advanced direc-
tives in order to have their wishes followed at the end of life. Nurses have
a unique opportunity to encourage the development of advance directives
in all environments of care.
In 1990, the Patient Self-Determination Act was created to require
every health care institution to develop policies and procedures for
advanced directives available to all who receive services in that facility.
Hogstel (2001) reports, “Failure to comply with the act may result in the
facility’s loss of Medicare and Medicaid payments” (p. 552). The act was
instrumental in helping older adults to consider advanced directives should
their decision-making capacity be altered while they are hospitalized.
Advanced directives are a mechanism in which individuals can make deci-
sions about their lives and health care prior to becoming ill. While it is not
End-of-Life Care 281
required that older adults make these decisions (and many do not), it is
required that hospitals provide clients with the option to do so. The use of
verbal statements, living wills, and durable powers of attorney are all con-
sidered legitimate advance directives for future health care treatment deci-
sions (Hogstel, 2001). An important Web site that may be helpful to older
adults and health care providers in developing these statements is Aging
With Dignity and may be accessed at http://www.agingwithdignity.org.
At the end of life, great care must be paid to the client’s nutrition and
hydration to maintain comfort, and the ethical issues related to main-
taining nutrition and hydration have received a lot of attention. In some
cases, nutrition and hydration through nasogastric or gastric tubes pro-
vides the only life-sustaining measure in the older adult’s life. Ethical
issues surrounding the decision to remove these life-sustaining issues are
prevalent. Families’ decisions about continuing, or removing these life-
sustaining treatments often conflict with health care providers. In these
cases, it is most appropriate to determine the client’s wishes. Moreover,
cultural values influence the decision to sustain or withhold nutrition and
hydration at the end of life. Caralis, Davis, Wright, and Marcial (1993)
found that Whites were more likely to withhold nutrition and hydration
Title of Study: Role Strain and Ease in Decision Making to Withdraw or

Withhold Life Support for Elderly Relatives
Authors: Hansen, L., Archbold, P., Stewart, B.
Purpose: To describe the strain and ease in decision making of family
care providers when the decision must be made whether to withdraw
or withhold life support for elderly relatives in various settings. To
describe role satisfaction derived from caregiving to their elderly
relatives.
Methods: Seventeen family caregivers were interviewed to gather descrip-
tions of their experiences when faced with decisions pertaining to life
support issues for their elderly relatives.
Findings: Role strain was related to issues before, during, and after deci-
sion making regarding life support. Role strain involved multifaceted,
complex, and dynamic issues related to caring for elderly relatives. Role
satisfaction did not coincide with the experienced role strain the family
caregivers experienced and described.
Implications: Research is needed in the areas of role strain, ease in decision
making, and role satisfaction related to family care providers experi-
ences with caring for their elderly relatives.
Cultural values influence the decision to sustain or withhold nutrition and

hydration at the end of life. Caralis, Davis, Wright, and Marcial (1993)
found that Whites were more likely to withhold nutrition and hydration at
the end of life than were other cultural groups.
at the end of life than were other cultural groups. This process is greatly
aided by the use of advance directives. In the absence of advance direc-
tives, ethical decision-making frameworks (Chapter 10) can be helpful in
guiding decision making regarding these issues.
Verbal statements regarding potential health care problems and pos-
sible treatment decisions may be made by older adults to health care
providers and trusted friends and family. These verbal comments indicate
a thoughtful approach to decisions that are consistent with ethical princi-
ples and with the older adult’s past decisions. They may be used to make
health care decisions when the older adult is no longer able to do so. If
these statements are spoken to health care providers, documenting them
in the patient record provides the best evidence of the patient’s wishes.
Another way in which older adults may make their desires for care
known in the event they are unable to make decision for themselves
is through living wills. Hogstel (2001, p. 553) defines living wills as
documents that provide a written statement about preferences for life-
sustaining treatment. Because the living will is a written form generally
filed with the older adult’s medical record, its usefulness is dependent
upon the health care providers to implement the older adult’s wishes
(Hogstel, 2001).
A durable power of attorney for health care or medical power of attor-
ney has power extended to making health care decisions in the event that
decision-making capacity of the older adult is impaired. Similar to a power
of attorney for financial decisions, the older adult designates a trusted per-
son to make health care decisions for them. The agent in this case may
receive diagnostic information, analyze potential treatment options, act as
an advocate for the client, and give consent to, or refusal of, care. This is a
legal advance directive that offers greater flexibility than a living will. The
document is not limited to life-sustaining measures but may apply to nurs-
ing home placement, surgery, or other forms of nonemergency treatment.
One of the great barriers to implementing a durable power of attorney
is finding someone to function as a substitute decision maker since older
adults may have outlived their significant others (Hogstel, 2001). In this
case, they may petition or hire a court-appointed power of attorney in
order to benefit from the flexibility offered by a durable power of attorney

for health care.
FINANCIAL PLANNING FOR END OF LIFE
There are many options that may be useful in planning for future financial
needs of older adulthood. Some of the options have limitations. For exam-
ple, a trust is limited to those who have significant financial assets. Trusts
allow the older adult to maintain maximum control of financial assets while
transferring the management of funds in a specified manner to an identified
party, such as a bank or financial planner. A trust designates beneficiaries,
individuals who will be in receipt of financial assets in the manner in which
the older adult specifies (Hogstel, 2001). Another financial option is a joint
tenancy, which is limited to those who have a trusted friend or family mem-
ber. By opening an account or purchasing a property with another person,
the older adult gives the trusted family member or friend unlimited access to
the property or account. While both of these options have limitations, they
are extremely helpful for many older adults who have or anticipate having
the need for assistance with financial affairs. A will is a written document
that gives instructions for the distribution of property, savings, and assets
upon the death of the older adult. These are important documents to help
the older adults determine the disposition of their assets upon death.
Regardless of the amount of financial assets, it is important for older adults
to consider designating power of attorney to a trusted relative or friend, in the
event that the older adult anticipates altered decision-making capacity. This situa-
tion may arise if the older adult were to experience a medical or surgical illness or
procedure and needed to make sure financial needs and obligations would be met
during that time. In this case, the power of attorney can manage the older adult’s
financial affairs, including filing taxes, paying bills, and banking during the older
adult’s recovery from a medical illness. When the older adult’s decision-making
capacity remains impaired, the designated individual manages the financial affairs
for the duration of the older adult’s life. This later case is known as a durable power
or attorney. Delegation of power of attorney can be very specific and provide lim-
ited instructions such as “pay bills for two months” or more general, providing the
agent with the power to manage all financial and personal matters.
DIMENSIONS OF END-OF-LIFE CARE
Nurses care for clients at the end of life in multiple care settings. There
are many aspects to end-of-life nursing care including communication,
physical care, spiritual care, emotional and psychological care, as well as
working with the family in promoting effective grieving. Physical dimen-

sions include management of common symptoms at the end of life, while
psychological dimensions include the completion of developmental tasks
as well as management of depression, anxiety, and agitation. Spiritual
aspects of care focus on the need to find meaning in life and death. Social
aspects of care revolve around completing roles that were essential to life.
The dying person’s bill of rights is found in Table 12.1.
Regardless of the aspect of nursing care delivery, culturally competent
care is essential when working with older adults. Sherman (2001) reports
that “Members of the palliative care team bring their own cultural perspec-
tives and life experiences. Hospice/Palliative care nurses must be culturally
TABLE 12.1 Dying Person’s Bill of Rights

• I have the right to be treated as a living human being until I die.
• I have the right to maintain a sense of hopefulness, however changing its
focus may be.
• I have the right to be cared for by those who can maintain a sense of hopeful-
ness, however challenging this might be.
• I have the right to express my feelings and emotions about my approaching
death, in my own way.
• I have the right to participate in decisions concerning my care.
• I have the right to expect continuing medical and nursing attention even
though “cure” goals must be changed to “comfort” goals.
• I have the right not to die alone.
• I have the right to be free from pain.
• I have the right to have my questions answered honestly.
• I have the right not to be deceived.
• I have the right to have help from and for my family accepting my death.
• I have the right to die in peace and dignity.
• I have the right to retain my individuality and not be judged for my decisions,
which may be contrary to the beliefs of others.
• I have the right to discuss and enlarge my religious and/or spiritual experi-
ences regardless of what they may mean to others.
• I have the right to expect that the sanctity of the human body will be
respected after death.
• I have the right to be cared for by caring, sensitive, knowledgeable people
who will attempt to understand my needs and will be able to gain some satis-
faction in helping me face my death.
Reprinted with permission from Sorrentino, S. A. (1999). Assisting with patient care.
St. Louis: Mosby, p. 843.
sensitive and responsive, providing care in a culturally competent manner”

(p. 23). The views of death differ among cultures as seen in Table 12.2.
Physical Dimension
The physical dimension of end-of-life care for older adults focuses on ensur-
ing that patients are pain-free while meeting other needs. This is not a time
for nurses to be influenced by myths that underlie the undertreatment of
pain in older adults (see Chapter 10). Clients must be assessed regularly for
the presence of pain. This can be accomplished with a standardized pain
assessment tool. Pharmacological and nonpharmacological interventions
must then be implemented on a regular schedule (not PRN) to ensure a
pain-free death. No older adult should ever die in pain. The physical dimen-
sion also focuses on the older adults’ declining functional ability. The ability
to perform ADLs should be assessed daily using a standardized functional
assessment tool (see Chapter 4). While the older adult should be encouraged
to maintain independence as long as possible, assistance may be needed
when the older adult is no longer able to complete ADLs independently.
Other physical symptoms common at the end of life include dyspnea, cough,
anorexia, constipation, diarrhea, nausea, vomiting, and fatigue. These phys-
TABLE 12.2 Cultural Views of Death

African Asian Latin
Native Americans Americans Americans Americans
Death is viewed in Prior bad memo- End-of-life care Reluctance to
a circular pattern ries of health care decisions may be make decisions
rather than linear. make older adults made by family on end-of-life is-
concerned about members who sues or complete
making end-of- consider it their advance directives,
life decisions. role, even if as well as endorse
the older adult the withholding
is competent or withdrawal of
to make deci- life prolonging
sions. This may treatment, use of
also involve the hospice services,
nondisclosure of support physician-
terminal illness assisted death, and
to protect the organ donation
older adult. Au- is common. The
topsy and organ well-being of the
donation are not family may be
acceptable, so as considered over
not to disturb the the well-being of
body. the client.
TABLE 12.3 Physical Symptoms at the End of Life

Physical Symptom Nursing Interventions
Dyspnea • Assess respiratory rate and effort as well as pattern of

dyspnea and triggering/relieving factors (i.e., activity).
• Respiratory rates >20 breaths/minute labored respi-
rations, use of accessory muscles and diminished or
adventitious lung sounds require follow-up and possible
intervention.
• Administer morphine solution by mouth, sublingual, or
via suppository Q2H, PRN. Diuretics (e.g., Lasix), bron-
chodilators, steroids, antibiotics, anticholinergics, and
sedatives should also be considered.
• Administer oxygen as appropriate to relieve symptoms,
especially in those who do not respond to morphine.
• Keep environment cool and position client for full chest
expansion.
Cough • Assess etiology of cough.
• If from excess fluids, treat accordingly with diuretics
(e.g., Lasix).
• Reduce smoking and make sure environmental air is
clear, cool, and humidified.
• Elevate head of bed.
• Ensure proper fluid administration.
• Administer cough suppressants/depressants, opiates,
bronchodilators, and local anesthetics.
Anorexia • Understand that lack of hunger is normal at the end of
life. Food and fluids at the end of life may create distress
and, thus, anorexia does not necessarily need to be
treated.
• Good mouth care, using a soft toothbrush or spongy
oral swab, is essential to prevent dryness, mouth sores,
dental problems, and infections.
• If the client can tolerate fluids, provide soups, tomato
juice, and sport drinks to prevent electrolyte imbalances.
Constipation • Recognize impact of morphine preparations on consti-
pation among older adults and administer prophylactic
treatment for constipation.
• Assess client’s self-report as well as physical symptoms of
constipation such as bowel distension, nausea, vomiting, or
rectal impaction.
• Recommended medications include stool softeners, such
as docusate sodium (Colace), and stimulant laxatives,
such as senna (Sennakot-S).
(continued)

Physical Symptom Nursing Interventions
• Bowel suppositories and enemas may also be used to
relieve constipation.
• Be alert for the progression of constipation to bowel ob-
struction. This may present as steady abdominal pain and
is a medical emergency.
Diarrhea • Assess presence and etiology of diarrhea and remove
cause, if possible.
• Ensure adequate fiber and bulk in diet and adequate
fluids.
• Determine times throughout the day when older adults
are most often incontinent through a bowel diary.
• Once the pattern of incontinent episodes is determined,
the older adult may be encouraged and assisted to the
toilet a half hour before diarrhea usually occurs.
• Consider the administration of diphenoxylate (Lomotil)
or loperamide (Imodium).
Nausea & • Assess client’s self report of nausea, along with aggra-
Vomiting vating/relieving factors. The use of diary may be helpful.
• Assess vomiting as well as aggravating/relieving factors.
It is important to note that retching and gagging may
occur even in unresponsive clients.
• Administer antiemetics around the clock (not prn).
Antiemetics that may be effective include prochlor-
perazine (Compazine) and metoclopramide (Reglan)
administered as a rectal suppository, intravenously, or
parenterally.
• Consider the combination preparation [ABHR] of loraz-
epam (Ativan), diphenhydramine (Benadryl), haloperi-
dol (Haldol), and metochlopramide (Reglan) if anti-
emetics alone are not effective at relieving symptoms.
Fatigue • Fatigue must be recognized as a major source of distress
among older adults at the end of life and has a great impact
on quality of life.
• Treatment of symptoms such as pain, nausea and vomit-
ing, and dyspnea significantly impact fatigue.
• Light exercise and activity, alternating with periods of
rest and relaxation, are effective at relieving fatigue.
• Music and guided imagery may also be helpful at
inducing rest and providing stimulation during fatigued
periods.
Adapted from Matzo, M. L., & Sherman, D. W. (Eds.). (2001). Palliative care nursing.
New York: Springer Publishing Company.
ical symptoms are summarized in Table 12.3 along with nursing interven-
tions to reduce symptoms and their impact on quality of life.
Psychological Dimension
In psychological terms, the older adult’s success in meeting the develop-
mental tasks of aging must be assessed. While end of life is often difficult,
this time also provides an opportunity to complete important develop-
mental tasks of aging. The psychological dimension focuses on how the
older adult feels about their self and their relationships with others. Are
there unresolved personal issues? Are there unfinished tasks that still need
to be completed so that the older adult feels that responsibilities have been
met? Discussing some of these issues with older adults who are approach-
ing the end of life will help to identify uncompleted tasks. While it may
appear to be too late, some older adults have completed academic degrees,
contacted estranged family members, and even have been married on their
death beds. The nurse may be the one to make the phone call or mediate
the discussion between two people who have not spoken in years. Nurses
can play an important role in helping older adults to complete these devel-
opmental tasks and experience a good rather than a bad death.
In addition to the developmental task of aging, the psychological expe-
rience of dying must be considered. End of life often involves the devel-
opment of depression, anxiety, confusion, agitation, and delirium. These
symptoms and suggested nursing interventions are described in Table 12.4.
Social Dimension
In the social dimension, it is important to identify the roles that older
adults have occupied and whether or not they have disengaged from
these roles. With the rising numbers of older adults caring for grandchil-
dren, the aging grandmother may be concerned about who will care for
her grandchildren when she passes away. Older adults may be employed
and worry about how their job responsibilities will be met upon their
death. They may also be caregivers to ill or cognitively impaired spouses
or siblings; the loved one’s future care is likely to be a concern.
Spiritual Dimension
The spiritual dimension allows the older adult to transcend from this life
into another existence. If the older adult has explored the meaning of their
life and has an expectation of an afterlife, death may be peaceful. How-
ever, older adults often continue to struggle with the meaning of life even
at the end. As discussed in Chapter 10, spiritual assessment and coun-
TABLE 12.4 Psychological Symptoms at the End of Life

Psychological
Symptom Nursing Interventions
Depression • Assess cause of depression—consider unrelieved pain and
anticipatory grieving.
• Openly discuss older adult’s fears and concerns regarding
end of life, in order to assist in the resolution of depression.
• Refer for counseling.
• Implement suicide precautions, if necessary.
• Consider administration of antidepressants, including
selective serotonin reuptake inhibitors (SSRIs), such as
fluoxetine (Prozac), paroxetine (Paxil), and sertraline
(Zoloft); tricyclic antidepressants, such as amitriptyline
(Elavil), imipramine (Tofranil) and, nortriptyline (Pamelor);
monoamine oxidase inhibitors (MAOIs), such as phenel-
zine (Nardil) and tranylcypromine (Parnate); and the other
atypical antidepressants, such as trazadone (Desyrel) and
bupropion (Buspar).
Anxiety & • Assess cause of anxiety/agitation—consider unrelieved
Agitation pain, urinary retention, constipation, or nausea as source
and treat appropriately.
• Openly discuss older adults’ fears and concerns regarding
end of life, in order to assist in the resolution of anxiety-
producing issues.
• Administer anxiolytics, such as lorazepam (Ativan),
diazepam (Valium), or clonazepam (Klonopin). However,
remember that these medications may result in delirium
among older adults.
• If anxiolytic medications fail to relieve anxiety, consider
the use of barbiturates, such as Phenobarbital, or neuro-
leptics, such as haloperidol (Haldol).
Delirium and • Assess delirium using standardized instrument, such as
Acute Confu- confusion assessment method (see Chapter 9).
sion • Delirium is a frequent occurrence at end of life as a result
of life-threatening conditions and treatment strategies.
• Immediate detection and removal of the cause of delirium
will enhance the patient’s recovery.
• While the delirium is resolving, it is important to keep the
older adult safe through the use of detection systems to
alert caregivers of wandering behavior and implementing
fall prevention strategies.
• A calm, soft-spoken approach to care is necessary, and the
delirious older adult should not be forced to participate in
caregiving activities that cause anxiety or agitation.
Mr. Casey, age 79, was admitted to the medical surgical unit for testing
because of vague abdominal discomfort. He was admitted during your
shift and was pleasant and respectful during the admission interview. He
stated that he was a devout Catholic and attended church every Sunday. He
also stated that he was sure the tests would show nothing, and he thought
his physician was overreacting by admitting him to the hospital. However,
over the course of several days, it was determined that Mr. Casey had end-
stage abdominal cancer. Because he lived alone, he and his only relative, a
sister, determined that he should remain in the hospital for the rest of his
short life. He was only expected to live for a few more weeks.
1. What questions might be appropriate to ask Mr. Casey to determine
the role of spirituality in his life and death?
2. What interventions might the nurse use to facilitate Mr. Casey’s spir-
ituality in the hospital environment?
3. Beyond spirituality, what other dimensions should be considered in
planning care for Mr. Casey? Provide examples of open-ended ques-
tions that could be asked to facilitate each dimension.
4. Beyond the patient and family, what other health care providers may
the nurses communicate with in order to facilitate the best possible
end-of-life care for Mr. Casey?
seling are integral to the promotion of peaceful death. The nurse must
explore spiritual concerns with the older adult in a respectful manner.
COMMUNICATION
Several steps are necessary to help older adults achieve “good deaths.”
One of the hallmarks of palliative care is communication between care-
givers, families, and patients. Nurses can be instrumental in bringing
together interdisciplinary teams to plan care for dying older adults and
assess effectiveness in meeting multidimensional palliative care needs.
This team approach provides clients comfort and the reassurance that
they will not be abandoned. Nurses are responsible for consistently eval-
uating the needs of dying patients and calling the team together if those
needs are not met. It is important that both the client and family are
encouraged to participate in care planning and evaluation.
Nurses communicate with the physician, who plays an important
role in effective symptom management. Consequently, regular pain
assessments and responses to treatment will be communicated to the
physician who can adjust medications to keep the client free of pain.
In addition, communication with physical and occupational therapists
ensures that physical function is maintained as long as possible and assis-

tance is obtained when needed.
After assessing psychological and social issues, nurses consult with
psychologists or counselors, who can help older adults complete develop-
mental tasks of aging, and with social workers, who help to resolve social
issues facing the older adult at the end of life. Nurses also work with pas-
toral care to assist the dying older adult to transcend life peacefully.
GRIEVING
Nurses’ work with older adults at the end of life does not end when the
older client passes away. Nurses are responsible for helping the family
through the grieving process. Grieving begins before the older adult dies
and proceeds differently for each family. Kubler-Ross (1964) describes
several stages of grieving that must be experienced for successful resolu-
tion of the loss. These stages include denial, anger, bargaining, accep-
tance, and grieving. Progression through these stages is unpredictable,
but necessary. Families who have lost an older relative never just “get
over it.”
A grief assessment helps to determine the type of grief, a family’s
reactions, the stages and tasks to be completed, and additional factors
influencing the grief process. Once the nurse gathers information on the
family’s grief, an active listening approach assists with resolution. Utiliz-
ing principles of therapeutic communication, nurses identify problems
with the grieving process and allow the family to talk through their situ-
ation, sharing experiences is appropriate so that the family knows they
are not alone. Nurses may identify support systems, such as bereavement
specialists and support groups, and they should encourage the family to
conduct activities and attend rituals surrounding the older adult’s death,
even when this may be difficult, because these ceremonies put closure to
the older adult’s life. It is important to note that grief work is never com-
pletely finished, but the pain becomes less over time.
WIDOWHOOD
It is well understood that the life expectancy of women is longer than that
of men. Moreover, societal trends have revealed that on average, women
marry older men. These two factors often combine to produce a substan-
tial number of older widows. The Federal Interagency Forum on Aging-
Related Statistics (2004) reports that women are three times more likely
to be widowed than men. There remains a paucity of research on the
experience of widowhood. The research literature that is available focuses
on the health effects of widowhood, with bleak outcomes. This literature
reveals that widows and widowers demonstrate health-related effects as a

result of their change in marital status (Dupre & Meadows, 2007). More-
over, it has been a common assumption for many years that widows are
susceptible to reduced health status, increased depression, and addictions
to both prescribed and easily available habit-forming substances.
Often, the combination of major caregiving duties that suddenly end
when the spouse passes and the grief associated with this loss increases
the risk of health problems and reduces functional status among older
adults. Nurses may effectively work with widows to assist in the griev-
ing process and provide support by consistently assessing for health risks,
implementing interventions to prevent health problems, and promoting
health and healing and effective communication. Support groups, spiritual
intervention, and enhancement of socialization may aide in the bereave-
ment process.
HOSPICE CARE
Hospice care at the end of life is an extremely valuable, yet underused, resource.
Approximately 620,000 clients had hospice services in the United States in
2000. Although hospices have provided end-of-life and palliative care for indi-
viduals in the United States for over 20 years, it is a highly underutilized service
(Hogstel, 2001). One-third of all hospice patients received hospice care for less
than 7 weeks, illustrating the lack of use of this beneficial service.The majority
of hospice patients were 65 years of age or older (Hoffman, 2005).
Title of Study: Nurses’ Attitudes and Practice Related to Hospice Care

Authors: Cramer, L., McCorkle, R., Cherlin, E., Johnson-Hurzeler, R.,
Bradley, E.
Purpose: To describe nurses’ characteristics, communications, and attitudes
related to hospice and terminally ill care.
Methods: A self-administered questionnaire was completed by nurses to
assess hospice-related training, knowledge, attitudes, demographics,
and personal experiences.
Findings: Characteristics associated with hospice care included: religious-
ness, having an immediate family member or close friend who had used
hospice care, and satisfaction with hospice caregivers. A greater self-
knowledge was related to discussion with hospice patients.
Implications: The perceived benefit of hospice care by the nurses was related
to the nurses’ discussion of hospice with terminally ill persons.
Journal of Nursing Scholarship,Vol. 35, No. 3, 249–255.
Approximately 3,200 hospice programs currently exist in the

United States, the District of Columbia, and Puerto Rico. Hospice
originated as a home care program established in Connecticut, which
became the first inpatient hospice facility in the United States when it
added inpatient beds to its facility. This original program grew into
the current U.S. model of hospice care (Hoffman, 2005). Hospice care
focuses on the value of life and revolves around the belief that dying is
a natural extension of the living process. Consequently, hospice clients
are empowered to live with dignity, alert and free of pain. The goal of
hospice care is to facilitate a “good death” for clients. Families and
loved ones are involved in giving care to the dying while maintaining
the highest possible quality of life. The environment aims to promote
physical, psychological, social, and spiritual aspects of life within the
context of differing cultural and spiritual values and beliefs. Nurses in
all settings are in pivotal positions to identify patient appropriateness
for hospice and to communicate with the client, family, and team about
this resource at the end of life.
SUMMARY
End-of-life care has recently become recognized as an important part

of the lives of older adults. The manner in which death is expressed
differs among people, but the search for the meaning of life often takes
place during older adulthood. Nurses play an important role in help-
ing older adults to manage multiple dimensions of end of life such as
physical and psychological symptoms, completion of roles and devel-
opmental tasks, and obtaining resources to determine the meaning of
life.
Client’s needs at the end of life are great and diverse. As nurses help
the older adult cope with end of life, they must also care for the many
needs of the older adults’ family. Excellent communication with members
of the health care team and the family is important. Equally important
is meeting the physical, spiritual, emotional, and psychological needs of
older adults to help them achieve a “good death.”
Cultural Focus
The experience of dying differs for each older adult and is bound by both
cultural and spiritual values and beliefs. In order to provide high quality
hospice care, nurses must understand the individual values of the dying
person and work toward meeting personal goals and needs.
REFERENCES
Caralis, P. V., Davis, B., Wright, K., & Marcial, E. (1993). The influence of ethnicity
and race on attitudes towards advance directives, life prolonging treatments, and
euthanasia. Journal of Clinical Ethics, 4, 155–165.
Dupre, M. E., & Meadows, S. O. (2007), Role strain and ease in decision making to with-
draw or withhold life support for elderly relatives. Journal of Family Issues, 28(5),
623–652.
Hogstel, M. O. (2001). Gerontology: Nursing Care of the older adult. Albany, NY: Delmar
Thomson Learning.
Kubler-Ross, E. (1964). On death and dying. New York: Macmillan.
Hoffman, R. L. (2005). The evolution of hospice in America: Nursing’s role in the move-
ment. Journal of Gerontological Nursing, 31(7), 26–35.
Norton, S. A., & Talerico, K. A. (2000). Facilitating end-of-life decision-making: Strategies
for communicating and assessing. Journal of Gerontological Nursing, 26(9), 6–13.
Sherman, D. W. (2001). Spirituality and culturally competent palliative care. In M. L.
Matzo & D. Sherman (Eds.), Palliative care nursing (pp. 3–47). New York: Springer
Publishing Company.
World Health Organization. (2005). Definition of palliative care. Retrieved June 6, 2005,
from http://www.who.int/cancer/palliative/definition/en/
C H A P T E R T H I R T E E N
Future Trends
and Needs
Learning Objectives
1. Project future demographics of older adulthood.
2. Discuss changes in the health care delivery system necessary to
respond to an increased population of older adults.
3. Identify anticipated developments in normal, pathological, physi-
cal, and cognitive aging changes over the next century.
4. State the role of health promotion in increasing the population
of older adults.
5. Discuss projected developments in geriatric assessment over the
next century.
6. Report on advances in the development of environments of care
for older adulthood.
7. Discuss future methods in which nurses may assist clients to have
a “good death.”
Mr. Hyer is a 65-year-old male with a diagnosis of AIDS. Recently, he

has developed pneumocystis carinii pneumonia (PCP), and his death is
now imminent. He is very weak and cannot perform care on his own. Mr.
Hyer and his partner decide that it would be best for him to go to a hos-
pice where they can help him to care for himself until his passing. They
get a referral from the doctor, and Mr. Hyer is admitted to the hospice
where you work. You have heard from the staff how strong Mr. Hyer is
and how well he is dealing with this aspect of his life. One evening, you
are with Mr. Hyer rubbing his back to help him get to sleep and he breaks
down. “I don’t want to die,” he states. He tells you that he is not ready
because he still has so much that he wants to do in his life. His niece is
295
expecting a baby in a couple months, and he wants to be a part of that.

He tells you how afraid of death he is and how he knows that everyone
thinks that he is so strong but that really he is just as sad and afraid as
everyone else, he just does not let anyone see that. “I am terrified to learn
what lies in store for me in the near future,” he explains. He says that
he realizes that there is nothing that can be done for him at this point,
but he just does not want to die. He also informs you how much he will
miss his family and friends and hopes that they know how much they are
loved and how much they mean to him. He also hopes that they realize
that he did not want to have to leave them and that they are able to go on
without him, especially his mother, sister, and partner.
The science of geriatric nursing has grown exponentially over the past
several decades, and it continues to expand today. Geriatric nurse sci-
entists have dedicated their research and careers to investigating how to
assess, prevent, and manage the common and pathological changes of
aging. As a result, the lifespan and quality of life for older adults have
become better. Throughout this book, the current available research on
the care of older adults has been presented. In this chapter, however, the
future of the science of geriatric nursing will be envisioned. This vision is
supported by the funding priorities of Table 13.1.
This chapter presents an exciting opportunity in which to visual-
ize how and what older adulthood will be in the future. The increasing
lifespan of older adults means that older adults will become the majority
of the population. This, in turn, will produce changing roles and envi-
ronments and necessary alterations in the health care delivery system. As
nurses increase their understanding of normal and pathological changes
of aging, nurse researchers and scientists will discover new ways to pre-
vent these changes through advanced assessment, health promotion,
medication, and various medical and surgical procedures. It is hoped that
the reader will savor these exciting advances in the care of older adults
and decide that they would like to participate in the care of this unprec-
edented number of older adults.
AMERICA CONTINUES TO GRAY
Believe it or not, by the year 2050, there will be more older adults than
children aged 0 to 14. Stop and think about that for a minute. Think of
the number of children running around on the beach during your sum-
mer vacation, or crying in the stores while you try to shop; and then
think to yourself that next to every child will be at least one older adult.
But don’t stop your vision yet! In your head, you likely have a picture of
a gray-haired, slightly sickly, and unfit elderly person or couple standing
TABLE 13.1 Research Priorities of the National Institute of Aging
PA Number Institute Date Open Date Closed Grant Type Sponsors
PA-05-117 NIA 06/03/2005 09/02/2008 T35 Ruth L. Kirschstein National

Research Service Award Short-
Term Institutional Research
Training Grants (T35)
PAR-05-061 NIA 03/02/2005 03/16/2008 R36 Aging Research Dissertation
Awards to Increase Diversity
PAR-05-055 NIA 02/18/2005 05/11/2007 T32 Jointly Sponsored Ruth L.
Kirschstein National Research
Service Award Institutional Pre-
doctoral Training Program in
297
the Neurosciences
PA-05-036 NIA 12/29/2004 11/02/2007 P01, R01, Retirement Economics
R03, R21
PAS-05-022 NIA 11/24/2004 11/02/2007 R21 R21 Grants for Alzheimer’s
Disease Drug Discovery
PAR-05-021 NIA 11/23/2004 11/02/2007 R01 Alzheimer’s Disease Pilot Clini-
cal Trials
PA-04-158 NIA 09/20/2004 11/01/2007 RO1, RO3, Ancillary Studies to the Ad Neu-
R21 roimaging Initiative
PA-04-123 NIA 07/07/2004 11/02/2007 R03 Sociobehavioral Data Analysis
and Archiving in Aging
PA-04-064 NIA 02/20/2004 04/01/2007 R41, R42, Technology and Aging: NIA
R43, R44 SBIR/STTR Program Initiative
(continued)
TABLE 13.1 Research Priorities of the National Institute of Aging (Continued)
PA Number Institute Date Open Date Closed Grant Type Sponsors
PA-04-026 NIA 11/21/2003 12/01/2006 R01 Acute Coronary Syndromes in

Old Age
PA-03-167 NIA 09/04/2003 11/02/2006 R21 Aging Musculoskeletal and Skin
Extracellular Matrix
PA-03-147 NIA 07/07/2003 07/30/2006 R01 Age-Related Changes in Tissue
Function: Underlying Biological
Mechanisms
PAS-03-128 NIA 05/23/2003 05/25/2006 R01 Genetics, Behavior, and Aging
PAS-03-122 NIA 05/13/2003 05/22/2006 R01, R21 Frailty in Old Age: Pathophysi-
298
ology and Interventions
PA-03-069 NIA 02/10/2003 03/01/2006 R01 The Biological Basis of
Hutchinson-Gilford Syndrome
(HGS): Relationship to Muta-
tions in the Lamin A/C Gene
(LMNA) and to Other Known
Laminopathies
PA-02-169 NIA 09/24/2002 09/25/2005 R01 Integrating Aging and Cancer
Research
PA-02-116 NIA 06/25/2002 07/15/2005 R01, R21 Age-Related Prostate Growth:
Biologic Mechanisms (R01 and
R21)
Retrieved June 28, 2005, from http://grants1.nih.gov/grants/guide/pa-files/index.html?sort=office&year=active

Future Trends and Needs 299
next to your envisioned child. This is typical of what is seen in the older
adult population today. However, the older adults who constitute the
large elderly population of 2050 may very well have a full head of blond,
red, or dark hair and be as physically fit as the 20-year-old athlete of
today.
In fact, it is now well understood that individuals currently aged
65 years can be expected to live an average of 18 more years than they
did 100 years ago, for a total of 83 years. Those aged 75 years can be
expected to live an average of 11 more years, for a total of 86 years.
The centenarians who are rare will be so commonplace that the White
House will likely abandon sending them birthday cards. People con-
tinue to live longer primarily because of the advances in health care.
Older adults are living improved lifestyles primarily due to advances
in medications to treat diseases, immunizations to prevent disease, new
diagnostic techniques to assist in the early detection and treatment of
disease, and new medical and surgical procedures to treat acute and
chronic diseases. As readers adjust the mental pictures of older adults
on the beach or in the store, prepare to visualize this large population
as both fit and healthy.
The cultural backgrounds of older adults are changing along with
the vast increase in the population. Scommegna (2007) reports that there
is an unprecedented shift in the cultural backgrounds of the U.S. popula-
tion; the White population of adults over 65 is expected to decrease from
approximately 87% to 75% of all older adults in the years 1990–2030.
In turn, the percentage of African American older adults is expected to
Cџiѡiѐюљ Tѕiћјiћє CюѠђ SѡѢёѦ
Imagine you are a nurse in the year 2050. You are employed at a 120-bed
acute-care teaching hospital in a major metropolitan area. Your specialty
area is oncology and your unit has 6 beds.
1. What changes do you anticipate in the health care delivery system
that make it possible for a major teaching hospital in a metropolitan
area to remain viable with only 120 beds?
2. What changes do you anticipate in care of cancer patients that make
it possible for an oncology unit to meet the needs of the environment
of interest with only 6 beds?
3. What changes in the presentation of disease, assessment, and man-
agement of disease do you anticipate among the elderly in the year
2050?
4. What technological advances are likely to enhance health care deliv-
ery in the year 2050?
The next decades will bring an unprecedented shift in the cultural back-
grounds of the U.S. population; and the White population of adults over 65
is expected to decrease from approximately 87% to 75% of all older adults
in the years 1990–2030. In turn, the percentage of African American older
adults is expected to rise from 8% to 9%; the percentage of Asian older
adults is expected to increase from 1.4% to 5%; and the percentage of
Hispanic older adults is expected to increase from 3.7% to 10.9%. These
statistics are important, because they predict a change in the manner in
which traditional Western medicine is accepted in this country.
rise from 8% to 9%; the percentage of Asian older adults is expected to

increase from 1.4% to 5%; and the percentage of Hispanic older adults is
expected to increase from 3.7% to 10.9%. These statistics are important,
because they predict a change in the manner in which traditional Western
medicine is accepted in this country.
With these improvements in health care and increased lifespan comes
the challenge to overcome ageism among society. Ageism is defined as a
negative attitude or bias toward older adults, or the belief that older people
cannot or should not participate in societal activities or be given equal
opportunities afforded to others. Today’s nurses are well-positioned to fight
ageism and dispel the many myths of aging. If the next generation can make
this change, older adults of the future will be free to age without bias and
restrictions on health care. Even though ageism will likely still exist among
some, most people will have the opportunity to enjoy encounters with older
adults more frequently and in better settings than is currently possible.
An additional research area that is likely to remain robust is the
focus on theories of aging. As introduced in Chapter 1, there are several
theoretical viewpoints that have been developed to describe why people
age. These theories are sociological, psychological, moral or spiritual,
and biological in nature. These theories provide insight into the common
problems of aging, and they provide the framework for advances in pre-
vention, assessment, and management of these problems. In time, greater
insights are likely to be gained.
CHANGES IN THE HEALTH CARE DELIVERY SYSTEM
Everyone in the United States who reads the newspaper or watches the
news on TV is aware of the problem of how to pay for health care for
the ever-increasing older population. In fact, the U.S. health care delivery
RђѠђюџѐѕ FќѐѢѠ
Title of Study: Stereotypes of the Elderly in U.S. Television Commercials

From the 1950s to the 1990s.
Authors: Miller, D. W., Leyell, T. S., Mazachek, J.
Purpose: To investigate the prevalence of negative stereotyping of older
adults within the U.S. advertising industry.
Methods: The authors viewed U.S. television commercials between the
years 1950 and 1990 in search of ageism trends.
Findings: Surprisingly, the researchers found little negative stereotyping
of older adults within the television commercials examined. The study
did not support that television advertising propagated negative ageism
stereotypes as originally hypothesized. In fact, trends toward positive
stereotyping of older adults were noted.
Implications: While the results did not reveal support for negative ste-
reotyping of older adults, the possibility was hypothesized. Nurses
should continue to be cautious of negative stereotyping in the media
and the implications of negative perceptions on the health care of
older adults.
International Journal of Aging & Human Development, August 2004, Vol. 58, No.
4, pp. 315–326.
system has undergone enormous changes over the past several decades in
attempts to find a way to pay for the health care of older adults. As dis-
cussed in Chapter 2, it is commonly understood that as people continue
to age, they tend to develop more health problems. These health prob-
lems require increased use of the health care system. With a larger num-
ber of older adults and greater use of the system, Medicare, the primary
health insurance of older adults, is in great danger of being unable to
fund needed health care services. While several attempts have been made
to curtail Medicare spending (see managed care discussion, Chapter 2),
these attempts have been unsuccessful, and the problem of how to pay
for the health care needs of older adults remains.
Currently, major discussion about the health care delivery system
centers on the payment for medications for older adults. While this is
one facet of the problem, future solutions to the cost-effective delivery of
health care to older adults must address the health care delivery system
itself. The attitude that everyone must make use of everything available
to restore and promote health has resulted in heavy medication and med-
ical system usage. In a society where so much is available, it is currently
unthinkable to withhold medications or services, even if the effective-
ness is questionable and can be problematic for older adults. This is an
ethical problem, the discussion of which will likely continue for decades
to come. Regardless of the ethical issues raised by the current health care
delivery system, revisions can be expected in the methods of reimburse-
ment, the amount of care delivered, and the role of the gatekeeper.
Two more cost-cutting strategies will be likely to generate research in
the coming decades. First, it is well-known that healthier older adults require
fewer health care services. Yet, the current health care delivery system does
not often support the use of preventative services for older adults. It is hoped
that, in the future, reimbursement will be provided for more wellness visits,
exercise, smoking cessation, and health promotion programs.
In addition, nursing medication errors account for millions of dol-
lars spent on health care every year. An Institute of Medicine (IOM)
expert panel identified four environmental factors that consistently con-
tribute to the quality of care delivered and the patient outcomes seen
(Kohn, Corrigan, & Donaldson, 2000) ): management, workforce, work
processes, and organizational culture factors. The IOM panel also pro-
posed recommendations to prevent these errors from occurring in the
future, including: (a) developing governing boards that focus on safety,
(b) introducing evidence-based management of organizational structures
and processes, (c) assuring high levels of leadership ability, (d) providing
sufficient staffing, (e) promoting ongoing learning and decision support
at the point of care, (f) encouraging interdisciplinary collaboration, (g)
creating work designs that promote safety, and (h) achieving an organiza-
tional culture that continuously addresses patient safety (pp. 16–17). The
next decades will likely see system changes in terms of quality assurance
programs instituted in all facilities to reduce these costly errors.
In addition to the need for sufficient funds to pay for affordable
and accessible care, more health care providers will be needed to care
for the older adult population. Health care providers, including, physi-
cians, nurses, therapists, and support personnel, must be educated on
the special needs of older adults, including the topics in this book. While
medical and nursing schools are beginning to offer courses in gerontol-
ogy within the curriculum, many programs still do not have a required
course in gerontology. Federal and private support has been increasingly
available to educate providers regarding gerontology. It is hoped that this
funding trend continues and the workforce to care for the rising older
population is prepared to accomplish this task.
ETHICAL, LEGAL, AND FINANCIAL ISSUES

FOR OLDER ADULTS
With all that is known about the increasing lifespan of older adults, advance
directives and financial planning have undoubtedly become household
words. Upon admission to any hospital, nursing home, or home care

agency, a discussion regarding advance directives is supposed to ensue. The
desired outcome is a decision about what the client would like done if cer-
tain changes in their health were to occur. However, the reality is that few
people are able to make that decision when it is needed. Many health care
professionals find themselves caring for older adults at the end of life, with-
out advance directives, health care proxies, and the other well-documented
legal methods designed to remove health care professionals from the deci-
sion-making process. Thus, ethical decision making on the part of nurses,
physicians, and other health care providers is part of everyday practice.
While ethical decision-making principles are not likely to change in
the future, it is anticipated that use of the legal system will enable older
adults to formulate advance directives. Because these legal mechanisms
for making health care decisions are fairly new, it is only logical to con-
clude that over time they will become easier to use and be used more
frequently with older adults entering the health care system. Closer rela-
tionships between attorneys and health care providers are likely to fol-
low. In addition, more attorneys may pursue this area of law in order to
assist older adults in making these difficult decisions prior to a crisis.
In addition to the need for legal documents to guide the health care
decision-making process, it is also necessary for older adults to plan
financially for their extended lives. Just as the Medicare system antici-
pated reimbursing the health care system for a much shorter period
of time for each older adult, so too, the Social Security system did not
anticipate paying older adults a monthly stipend until their eighth, ninth,
and tenth decades of life. Yet, that is exactly what they are doing and
will be doing increasingly in the future. Current discussion about the
future of the Social Security system concerns the privatization of funds,
which are paid into the system by members of the current workforce. In
other words, money paid into the Social Security system from currently
employed citizens would be invested in the stock market. The strength of
this would likely be a good return on the investments and a boost to the
economy. The downside of this plan lies in its risk of losing some, if not
all, Social Security funds.
Regardless of how the Social Security issue resolves, older adults
should consider doing some financial planning of their own. While it is
not always possible for lower wage workers to put away money from
their weekly paychecks, retirement funds are a good solution to financing
post-retirement years as a supplement to (or in place of) Social Security.
Many private companies have seen the need and opportunity for finan-
cial planning services for older adults and offer these services as needed.
Of course, all investments should be well researched prior to committing
any capital. Older adults may also consider postponing retirement so that
they have a shorter period of time without income.
NORMAL CHANGES OF AGING
Groups of health care professionals that gather each year at the Geronto-
logical Society of America (GSA) and American Geriatric Society (AGS)
can frequently be found debating the issue of whether normal changes of
aging are actually normal changes of aging. Perhaps they are so highly
influenced by the health and environment of older adults that they are
not normal at all, just common. If the latter is true, the improved health
and environment of older adults are likely to minimize the frequency of
these so-called normal changes of aging.
What this means is that the current picture of older adults may no
longer be accurate. With preventative exercise, diets, medications, and
restorative procedures, geriatric hearts and lungs may be as strong as
those of 20-year-olds. Cultural backgrounds also play an important role
in how a person ages. For example, people with darker skin possess more
natural protection against the sun and, thus, may wrinkle less than older
adults with lighter skin. It is generally agreed that biological aging changes
begin to appear commonly in the third decade of life, with subsequent
linear decline until death, but it is important in the future for nurses to
refrain from making assumptions about normal aging. The assistance of
talented hair stylists will make the hair of older adults blond, red, or bru-
nette; Botox, collagen injections, and highly skilled plastic surgeons will
leave older skin as smooth as a baby’s. Older adults will have 32 teeth
and will be eating nachos, dripping with spicy salsa. Oral erectile agents
such as Viagra™ and related products will continue to revolutionize the
sexuality of older adults. Gone will be the hearing aides and eyeglasses,
as the need for these are eliminated with hearing implants, laser Lasik™
treatments, and cataract removal.
Indeed these age-defying procedures are currently available and used
frequently enough to expect their continued popularity. Yet, there are
costs associated with these procedures, and availability does not mean
that they will be used or desired by all. The normal changes of aging may
Cultural backgrounds also play an important role in how a person ages.

For example, people with darker skin possess more natural protection
against the sun and, thus, may wrinkle less than older adults with lighter
skin. It is generally agreed that biological aging changes begin to appear
commonly in the third decade of life, with subsequent linear decline until
death. Therefore, it is important for nurses to refrain from making assump-
tions about normal aging.
be more difficult to predict in the future; however, the advances that have
produced greater variability in the aging process have also contributed to
the excitement of working with this population.
WELLNESS, HEALTH PROMOTION,

AND HEALTH EDUCATION
There are many modern scientific advances that may claim partial respon-
sibility for the increased longevity of older adults. However, the adoption
of healthier lifestyles undoubtedly plays a big part in improved health
and the longer life of older adults. Moreover, as originally discussed in
Chapter 5, older adults are never “too old” to improve their nutritional
level, start exercising, get a better night’s sleep, and improve their overall
safety. These health-promotion strategies, supported by Healthy People
2010, will continue during the twenty-first century to affect the lives of
all people beginning in childhood.
Barriers to healthy lifestyles for the young and old still remain, and
are a focus for further study by nurse researchers. Lack of motivation to
improve health will remain a barrier for years to come, and nurses must
continue to research the best ways to educate clients about the impor-
tance of good nutrition, exercise, smoking cessation, moderation in alco-
hol intake, and safety practices so that they can help individuals adopt
these behaviors.
Further research on health promotion will likely examine ways to
reduce additional barriers to healthy lifestyles. In the low-income popula-
tion, for example, lack of money for healthy food and transportation and
a lack of safe places to exercise will continue to be barriers to health. In
the current decades of post-welfare reform, sometimes simply being able
to find and afford food prevails over the need to eat a healthy diet. Also,
the need for two jobs precludes extra time at the gym or on a volleyball
team. Research that continues to uncover the benefits of health-promot-
ing practices will build the evidence for change to a healthier lifestyle,
but the means and methods to adopt these lifestyles also require further
investigation.
MEDICATION MANAGEMENT
There is no doubt that the pharmaceutical industry is prospering in the

current economy. For almost every disease that has been diagnosed over
the past 200 years, a medication has developed to prevent or treat that dis-
ease. While not all the medications are effective at curing the disease, they
may be effective at reducing the symptoms, prolonging life, or providing

the psychological support that something is being done. Based upon the
current growth in the pharmaceutical industry, it is expected that the
development of new medications will continue for years to come.
It is well known that the more medications older adults are tak-
ing, the higher the risk for adverse reactions. Medications to prevent and
manage disease and symptoms are needed, but more prudent use of medi-
cations in the older adult population is essential. Cautious medication
usage in older adults is needed, and so too is the need to contain medi-
cation costs, which may or may not be reimbursable under Medicare in
the future. Ethical considerations must be addressed when looking at the
short- and long-term outcomes of medication usage in older individuals.
Excessive and inappropriate prescription and OTC drug use will
likely be a major concern of professionals caring for older adults.
However, on the other end of the continuum, older adults are dispro-
portionately undermedicated in the areas of immunizations and pain
medication. With older adulthood comes declining immunity. Reimmu-
nization of vaccine-preventable diseases is necessary to both decrease
the risk of carrying the disease and of developing it. In addition, the
higher incidence of acute and chronic diseases in older adults puts them
at an increased risk for pain. Even though pain is very prevalent among
older adults, many barriers prevent effective pain reduction in this pop-
ulation. Besides finding ways to reduce excessive medication use in older
adults, there is also a need for improved immunization and pain man-
agement. Furthermore, the prevalence of illegal drug use among older
adults will continue to be an important area for research among geron-
tological investigators. The shift in cultural backgrounds in the United
States also predicts a change in the manner in which traditional Western
medicine is accepted in this country. Consequently, culturally competent
care is essential among nurses caring for older adults, and improved
understanding regarding complementary and alternative therapy will be
necessary.
Cultural Focus
The shift in cultural backgrounds in the United States also predicts a change
in the manner in which traditional Western medicine is accepted in this
country. Consequently, culturally competent care is essential among nurses
caring for older adults, and improved understanding regarding comple-
mentary and alternative therapy will be necessary.
GERIATRIC ASSESSMENT
Geriatric nurses have made incredible strides in the assessment of older

adults over the past decade. One needs to look at the large number of pub-
lications provided by nursing researchers to understand how far nurses
have come in attempts to more effectively assess the common problems
associated with aging.
While assessment instruments are widely available, more needs to be
done to effectively disseminate current assessment tools and develop new
ones. For example, the Mini Mental State Examination and the Geriat-
ric Depression Scale are in common use. However, the Pittsburgh Sleep
Quality Index and the Beers Criteria for inappropriate medications are
lesser known and underutilized. Further research into assessing older
adults should focus on how to best disseminate these assessment instru-
ments to nurses caring for older adults.
In addition, there are many common problems of aging for which no
assessment instrument is currently available, or for which the currently
available instrument is not as effective as it could be. Currently, no tools
exist to assess the risk for translocation syndrome, or to alert health care
providers to hazardous herbal medications. Although there are numerous
pain assessment scales, assessing pain in cognitively impaired older adults
remains problematic. Furthermore, many of the excellent tools available
lack reliability and validity studies to support their use in further research
and practice. In the twenty-first century, it is expected that these instru-
ments will be further developed, refined, and tested to enhance the quality
of geriatric nursing practice.
ADVANCES IN ACUTE ILLNESSES

AND CHRONIC DISEASE MANAGEMENT
The next five decades will bring about unprecedented advances in the
diagnosis, treatment, and cure of diseases that have plagued the popula-
tion for centuries. Drawing from the Human Genome Project, advances
have already begun in the genetic marking of diseases early in adulthood
or childhood. Identified diseases can be managed with medication or sur-
gical treatment to prevent onset. Genetic marking is commonly seen in
daughters or sisters of women who have breast cancer and now struggle
with the decision of whether to have a breast removed in the absence of
clinical disease. Genetic markings are also currently available for other
forms of cancer and heart disease and are used to help prevent the onset
of clinical disease later in life.
Acute heart diseases, such as congestive heart failure (CHF) angina

and myocardial infarction (MI), are likely to diminish in numbers as a
result of preventative health promotion strategies and medications. When
these acute conditions occur, they are likely to cause less morbidity and
mortality in the future than they have in the past, because more effective
treatments are available.
The coming decades will possibly see the emergence of vaccines to
prevent many of the common diseases associated with aging, such as
HIV and Alzheimer’s disease. With better utilization of currently avail-
able vaccines to prevent influenza, viral pneumonia, and common child-
hood diseases, the United States could theoretically find these vaccine-
preventable diseases eradicated. Of course, full eradication would
require 100% immunization of the population concurrent with the
absence of clinical disease. Even though this is theoretically possible, it is
not likely to happen in the near or distant future. Most would agree that
a high percentage of the population could benefit from the reduction of
communicable diseases. Thus, continued development and dissemina-
tion of vaccines are worthy goals.
Many other acute conditions are seen in older adults: urinary tract
infections (UTIs), sexually transmitted diseases (STDs), Lyme disease,
decubitus ulcers, osteoarthritis, osteoporosis, stroke, obstructive pul-
monary disease (COPD), Parkinson’s disease, diabetes, and so on. The
coming years are likely to see substantial improvements in early diag-
nosis, medications, and surgical interventions. While acute diseases
such as UTIs, STDs, and Lyme are curable, these diseases will likely
be detected earlier and cured faster, with fewer negative consequences
in older adults. The advances in the prevention of decubitus ulcers and
the improved overall health of older adults will likely contribute to a
marked reduction in the number of these painful and costly sores among
chronically ill older adults. New medications and surgical treatments
for arthritis and new methods of screening and preventing osteoporosis
and treating fractures will reduce the morbidity and mortality of these
chronic illnesses. With safer work conditions and a decline in the num-
ber of smokers in the United States, a decline will also be seen in the
number of older adults with COPD. A cure for Parkinson’s disease is
on the horizon. Improved prevention and management of diabetes is
actively being investigated.
Regardless of the trajectory of acute and chronic diseases in the
future, nursing will assume a leading role in reducing the consequences of
diseases in older adults. The life-threatening complications of acute and
chronic illnesses in older adults, such as changes in mental status, dehy-
dration, septicemia, and pneumonia, will be greatly reduced by advanced
research and improved clinical practice in geriatric nursing.
SPECIAL ISSUES OF AGING
Older adults experience a number of problems related to physical and

cognitive difficulties and the normal and pathological changes of aging.
These problems often impact both the independence of older adults and
their quality of life. One specific problem resulting from many of the path-
ological diseases is pain. Much research has focused on the experience of
pain among older adults during the past several decades, and improved
understanding of the pain experience, more effective assessment tools for
detecting pain in normal and cognitively impaired adults, and enhanced
pain management have resulted. Pain has become the fifth vital sign, and
ways in which to reduce pain will continue to be examined.
A recent news item highlighted the issue of driving among older adults.
An elderly man attempting to depress the brake in his car accidentally hit
the accelerator, crashed into an open-air market, and killed several adults
and children. As the population of older adults increases, so too does the
number of older drivers. Legislation is being proposed, and in some cases
has been adopted, to regulate the driving privileges of older adults so that
this type of accident does not happen again. Advocates for older adults
fear the impact of such legislation on the independence and quality of life
of this population. Modifications to highways, roads, and automobiles
can enhance the ability of older adults to drive safely. These are better
alternatives than regulating the driving privileges of older adults.
Other issues among older adults that will continue to be studied in
the future center around quality of life. More effective assessments in this
area will ease the difficulty associated with ethical treatment decisions
and end-of-life care. Issues of elder mistreatment will foster the develop-
ment of improved detection and increased availability of resources to
prevent this abuse. More emphasis will be placed on resources to support
older grandparents and enhance the quality of their lives as well.
PSYCHOLOGICAL AND COGNITIVE ISSUES

IN AGING
Advances in the prevention, assessment, treatment, and management

of the three Ds (depression, dementia, and delirium) have been steadily
forthcoming over the last half of the twentieth century. Undoubtedly,
they will continue to receive much attention and investigation as geron-
tological nursing progresses. Because many older adults live for decades
with unrecognized and untreated depression, enhanced assessment tools
administered in the form of a single question can now help identify older
adults at risk. This allows for earlier and more effective treatment. In
addition, the development of new SSRI antidepressant medications with

low side-effect profiles has led to more effective treatment of this prevalent
disorder. Future research will undoubtedly seek to discover more effective
assessment and medication management, as well as the development of
traditional and alternative therapies for depression management.
There are over 60 diseases in older adults that present with signs
and symptoms of dementia. The loss of mental function is a major fear
of those approaching older adulthood, as well as those caring for them.
How to prevent dementias will continue to be a topic of study, particu-
larly the prevention of Alzheimer’s disease, the most common dementia,
will receive a substantial amount of research.
Currently, the investigation of an Alzheimer’s vaccine is underway.
Stimulation of antibodies to beta-amyloid (the substance that makes
up most of the amyloid plaques consistent with Alzheimer’s disease) is
thought to prevent disease development. Further research is also inves-
tigating the role of lithium in blocking the development of neurologi-
cal plaques and tangles. Newer research suggests that the reduction of
estrogen use in older women is a possible cause of Alzheimer’s disease.
In addition to research on prevention, studies will explore ways to better
manage this disease with medication, improved nursing interventions,
and environments for optimal care.
Like dementia, delirium is receiving research attention. The sug-
gested causes of delirium are (a) a decreased ability to manage change,
(b) several environmental assaults, (c) impaired sensory function, (d)
acute and chronic disease, (e) medications, and (f) urinary catheteriza-
tion. With increased knowledge of the contributors to delirium, preven-
tion will become a benchmark of quality nursing care.
ENVIRONMENTS OF CARE
The future will undoubtedly find more older adults living at home and
fewer living in long-term care facilities. This shift in housing, fueled by
both the improved health of older adults and the poor reputation of
nursing homes, has already begun. The vacancy rate in nursing homes
approaches 50% in some states and is projected to rise. But, with the
increased number of older adults living at home, there is a greater
need for more community resources. Transportation, home-delivered
meals, assistance with ADLs, and social activities are among the many
needs of older adults living at home. It is likely that the future will see
an expansion of these services to allow older adults to live safely at
home.
Although the growth of assisted-living facilities and continuing-care

retirement communities will continue as an alternative to living at home,
these facilities will remain an alternative for wealthier older adults. The
improved health status of older adults will likely stabilize the number
of acute-care hospital admissions that have grown with the graying of
America. However, there is a need for acute-care nurses to develop a
better knowledge base and greater expertise for assessing and managing
hospitalized older adults in order to prevent the iatrogenesis common
during these hospital admissions.
SPIRITUALITY AND END-OF-LIFE CARE
Unquestionably, the role of nurses in end-of-life care has gained importance

during the past several decades. The end-of-life nursing care knowledge
base is stronger than it has ever been, but there is more to know. There is
growing evidence of the role of managing physical, psychological, social,
and spiritual needs at the end of life. This research will likely continue.
Nurses in all care settings must be aware of the necessary care for older
adults at the end of life in order to implement the best nursing practices.
Along the same lines, the need to assist older adults in having a peace-
ful “good death” has never been stronger. Recent attempts at promoting
end-of-life education in nursing have helped to bring this issue to the fore-
front, but many older adults continue to die daily in a less-than-desirable
manner. It is the goal of all gerontological nurses that older adults die on
their own terms. Consequently, additional research is needed. Integration
of end-of-life care into nursing curricula must be promoted. While hospice
is an excellent resource for end-of-life care, it is underutilized. Over the
next decades, it is hoped that nurses will gain greater knowledge and have
expanded resources to address the issues of end-of-life care.
CONCLUSION
The aging of America is extremely exciting! Gerontological research has

brought forth improvements in every area of older adult care. Moreover,
these advances have already succeeded in extending the lifespan, and
they will continue to produce unprecedented changes in the care of the
older adult population. From a vaccine to prevent cognitive impairment
to the development of a revised Medicare plan, the twenty-first century is
full of possibilities. Gerontological nurses will undoubtedly play a major
role in these innovations. However, the most gratifying result will be the
improved health and quality of life of the elderly.
REFERENCES
Kohn, L. T., Corrigan, J. M., & Donaldson M. S. (2000). To err is human: Building a safer
health system. Washington, DC: Institute of Medicine.
Scommegna, P. (2007). U.S. growing bigger, older and more diverse. Population Refer-
ence Bureau. Retrieved July 12, 2007, from http://www.prb.org/Articles/2004/US
Growing BiggerOlderandMoreDiverse.aspx
Web Resources
Hartford Institute of Geriatric Nursing: http://www.hartfordign.org

Alliance for Aging Research: http://www.agingresearch.org
Geronurseonline: http://www.geronurseonline.org/
American Association of Retired Persons: http://www.aarp.org/
National Institute of Aging: http://www.nia.nih.gov/
American Cancer Society: http://www.cancer.org/
Stanford Geriatric Education Center: http://sgec.stanford.edu/
Administration on Aging: http://www.aoa.gov/
313
Index
Page numbers ending in t (e.g. 101t) indicate a table on referenced page
Absorption, of medication, 178–180 cognitive functioning, 114

Abuse, of elders. See Elder mistreat- crankiness/disagreeability, 6
ment (EM) depression as normal, 7–8
Acculturation, defined, 13 influence from parents, 9
Achlorhydria, 179 lack of teachability, 6–7
Acquired immune deficiency syn- little benefit to society, 5
drome (AIDS), 165–168 loss of interest in sex, 8
age variations, 167 readiness to die, 9–10
and PCP, 295 senility inevitability, 7
Activities of daily living (ADLs), smelliness, 8–9
116–117 societal drain, 5–6
aging impact on, 4 protections against, 10
and home health care, 259, 262 Aging
as QOL domain, 242 aging in place, concept, 256
Acupuncture anti-aging therapies, 84
for osteoarthritis, 148 cognitive/psychological issues,
for pain management, 248 309–310
Acute care, 262–263 issues, 2–11
management advances, 307–308 government-funded health care,
Adherence, to medication prescrip- 3–4
tion, 187–189 legal, 302–304
Administration, of medication, medical concerns, 4
185–186 myths of aging, 4–10, 114
Adult Protective Services, 246 issues, ethical, 219–237, 302–304
Adults driving, 226–229
stages of adulthood, 3 gambling, 234–235, 237
without resources, health care principles, 221–226
financing, 71–72 sexuality, 229–234
Advance directives, 280–283 normal changes of, 75–103,
African American men, Tuskegee 304–305
Syphilis study, 223 cardiovascular system, 77,
Ageism 83–88
defined, 225–226, 300 gastrointestinal system, 91–94,
myths of, 6 178–179
315
316 INDEX
Aging (Continued) American Geriatrics Society (AGS),

hepatic metabolism, 181–182 22, 304
integumentary system, 89–91 American Heart Association
musculoskeletal system, 96–98 cholesterol guidelines, 138, 157
neurological changes, 102–103 hypertension information, 151
peripheral vascular system, 84 myocardial infarction definition,
respiratory system, 88–89 155
sensory changes, 100–102 American Journal of Nursing (“Pick a
sexuality/reproductive system, Card,” 2004), 4, 34
98–100, 230, 231 American Nurses Association (ANA),
urinary system, 94–96 20, 221
vs. pathological, 76, 78t–82t, American Nurses Credentialing
122 Center (ANCC), 20
normal vs. pathological, 76, 78t–82t, American Society of Aging (ASA), 22
122 Aminoglycosides, 180
pharmacokinetic changes, 177t Amitriptyline (Elavil), 208
special issues, 309 Andropause (male menopause), 98,
theories of 99, 230
biological, 22–24 Angina pectoris/myocardial infarction
moral/spiritual, 24–25 (MI), 155–157
Programmed Senescence theory, assessment
23 Faces Scale, 156
psychological, 24 Pain Assessment in Dementia
sociological, 25–26 Scale, 156
Aging with Dignity Web site, 281 Vision Analogue Scales, 156
Alcohol usage, 124–125, 204 medications, 156–157
Alkaline phosphatase (ALP), 92 precipitating factors, 155
Alliance for Aging Research, 3, 19, Angiotensin-converting enzymes
176 (ACE) inhibitors
Alternative medicine, 15, 18 for CHF, 154
Alzheimer’s Association, 211 for HTN, 152
Alzheimer’s disease (AD), 7, 117, 208, Annells, M., 93
210–216. See also Dementia Anti-aging therapies, 84
assessments, 212 Antidepressant medications, 33
causes/risk factors, 211 Antipsychotic medication, 184
diagnosis modalities, 212–213 Aquatic exercises, 130
early warning signs, 211–212 Area Agencies on Aging (AAA), 72,
interventions/management, 213 260
Amella, E., 164 Arrhythmias, of heart, 83. See also
American Association of Retired Dyspnea on exertion
Persons (AARP) (DOE); Shortness of breath
membership benefits, 10–11 (SOB)
sexuality study, 8 Arthritis, medication/supplements,
American Cancer Society, 139, 192
140t–141t Asian older adults, and CAM usage,
American Chronic Pain Association, 187 34, 36, 111
American Dental Association, 91 Aspiration of food, 88
Index 317
Assessments, 86t–87t, 105–118 Pain Assessment in Demential

of abuse, 243–244 Scale, 156
activities of daily living, 116–117 Visual Analogue Scales, 247
for Alzheimer’s disease, 212 of pneumonia, 164
of angina pectoris/myocardial of safety, 256
infarction of sexual history, 166, 167
Faces Scale, 156 for SOB/DOE, 88
Pain Assessment in Dementia systemization of, 106–110
Scale, 156 of urinary incontinence, 96
Vision Analogue Scales, 156 of vision, 101
Braden scale for decubitus ulcers, Assisted-living facilities (ALFs),
272 273–274
for cancer, 169–170 Assisted suicide, 225
of caregivers, 261 Asthma, 157, 158. See also Chronic
of cognitive disorders, 214t obstructive pulmonary dis-
components, 105–106 ease (COPD)
cancer, 139 Autonomy
cardiovascular disease, 137–138 and ALFs, 273
cognition, 117–118 and dementia, 234
cultural awareness, 109 and gambling, 234–237
diet/nutrition, 86–87, 113, and informed consent, 222–223
126–130 as QOL domain, 241
for falls, 132 right to, and MCI, 222, 224
function, 116–117 violations of, 224
health history, 110–112
laboratory tests, 114 Bacteriuria, 271
personal space awareness, 109 Barbiturates, 180
physical assessment, 112–115 Barriers, to health care
reminiscence/life review, 112 inability to pay, 30
team approach, 107, 108, 115 lack of primary care providers, 30
for delirium, 202, 203 lack of transportation, 37
for depression, 7–8, 207 Baum, C., 212
for elder abuse, 243–244 Beckman, K., 130
family members involvement, 115 Beers Criteria, for inappropriate medi-
Geriatric Depression Scale, 109 cations, 307
of health history, 110–112 Benadryl, 182
of home-bound elderly, 261 Beneficence, 224
instrumental activities of daily Benign prostatic hypertrophy (BPH),
living, 117 184
Katz Index, 117 Benzodiazepines, 178, 180
of medication compliance, 189 Bergland, A., 242
Mini Mental State Examination, Beta blockers, for HTN, 152
109, 118, 212, 307 Biases, of cultures, 15
for neglect, 261–262 Biological theories, of aging, 22–24
Outcome and Assessment Informa- Bipolar disorder, 184
tion Set, 260 Black older adults, 11, 147
of pain Bladder, loss of tone, 94
318 INDEX
Blood pressure. See also Hypertension congestive heart failure, 152–155

(HTN) hypertension, 151–152
AHA guidelines, 112 obstructive airway diseases,
diastolic, lowering of, 83–84 157–158
JNC-VII criteria, 138t, 151 Cardiovascular system, 77, 83–88
medications, 33 age-related changes, 181
and strokes, 84 arrhythmias, 83
Blood transfusions, and religious blood pressure changes, 83–84
background, 222 enlargement of heart, 77
Blood urea nitrogen (BUN) levels, 94 preventive measures, 137–138
Body mass indexes (BMI), 113 Care environments
Bottrel, M., 19 acute care, 262–263
Bowel (fecal) incontinence, 8–9, 92, assisted-living facilities, 273–274
93–94 continuing care retirement commu-
Braden scale, for decubitus ulcers, 272 nities, 274–275
Bradway, C.K.W., 95 future directions, 310–311
Breast cancer, 169 group homes, 256, 258
Bronchitis, chronic, 157 home care, 256–261
homeless adults, 275–276
Calcitonin, for osteoporosis, 150 SNFs, 256, 258, 263–264, 271–273
Calcium channel blockers, for HTN, 152 Caregivers, 115, 260–261
California Drug Registry, 178 assessment of, 261
Caloric restriction, 23–24 stress of, 261
CAM. See Complementary and Caregiver Strain Index, 261
alternative therapy (CAM) Carnes, B. A., 26
Campinha-Bacote, J., 14 Centenarians, 2, 299
Cancer, 168–170 Centers for Disease Control (CDC),
assessment for, 139 176
assessments/management, 169–170 Centers for Medicare and Medicaid
breast cancer, 169 Services, 66
and cigarette smoking, 125 Cerebrovascular accident (stroke),
early detection guidelines, 140t–141t 137, 158–160
lung cancer, 168 and diastolic blood pressure, 84
pain management, 170 interventions, 160
prostate cancer, 169 prevention, 159–160
Caralis, P. V., 281 risk factors, 158–159
Cardiomyopathy, 77 Changes, of aging
Cardiovascular disease (CVD) cardiovascular system, 77, 83–88,
assessment/preventive measures, 181
137–138 cultural group influences, 76–77
and cigarette smoking, 161 factors influencing, 75–76
and diabetes mellitus, 160–161 gastrointestinal system, 91–94,
Cardiovascular/respiratory disorders 178–179
angina/myocardial infarction, hepatic metabolism, 181–182
155–157 integumentary system, 89–91
cerebral vascular accident (stroke), musculoskeletal system, 96–98
158–160 neurological changes, 102–103
Index 319
normal vs. pathological, 76, 78t–82t, myths regarding, 114

122 and pain management, 248
peripheral vascular system, 84 reasons for decline, 117
respiratory system, 88–89 Communication
sensory changes, 100–102 at end of life, 290–291
sexual dysfunction, 75 expressive, QOL domain, 241
sexuality/reproductive system, receptive, QOL domain, 241
98–100 Complementary and alternative medi-
unnoticeable/undetectable, 76 cine (CAM), 15, 18
urinary system, 94–96 insurance noncoverage for, 34
CHF. See Congestive heart failure safe usage guidelines, 194
(CHF) usage by ethnic minorities, 34, 36,
Chlamydia, 166 111, 191
Choking, 88 Compliance issues, of older adults, 35–36
Cholesterol, 33, 138 Components, of assessment, 105–106
Chronic obstructive pulmonary disease critical components
(COPD) cognition, 117–118
bronchitis, chronic, 157 function, 116–117
emphysema, 157, 158 cultural awareness, 109
nursing interventions, 158 diet/nutrition, 116–117
and pneumonia, 164 health history, 110–112
and steroid treatment, 153 laboratory tests, 114
Cigarette smoking personal space awareness, 109
and COPD, 157 physical assessment, 112–115
and CVD in diabetics, 161 reminiscence/life review, 112
and longevity, 89 team approach, 107, 108, 115
OTC/herbal medication interac- Confusion Assessment Method
tions, 125 (CAM), for delirium, 202
related diseases, 125 Congestive heart failure (CHF),
and strokes, 159 152–155
Cimetidine, 180 chronic to acute causes, 154–155
Circulatory system, changes, 83 and dyspnea on exertion, 153
Cockcroft-Gault formula, for creatinine interventions, 153–154
clearance, 182 medications/treatments, 154
Codeine, 190 and pneumonia, 164, 165
Cognitive functioning/disorders. See precipitation factors, 153
also Alzheimer’s disease presentation, 153
(AD); Delirium; Dementia Conscious competence/incompetence
assessment/management, 93–94, stages, of cultural compe-
117–118, 214t tence, 14
Mini Mental State Examination, Constipation, 92–93
109, 118 Continuing care retirement communi-
and bowel incontinence, 93–94 ties (CCRCs), 274–275
changes in, 85 Coronary artery disease (CAD), 137,
impairment of, 102 155
mild cognitive impairment (MCI), Coronory thrombosis, 155
106, 221–222, 224 Creutzfeldt-Jakob disease, 211
320 INDEX
Cultural competence, 14–19 comparison with delirium/depres-

Cultural group considerations sion, 199t–202t
adaptation of care delivery, 108–109 cultural stigmatization of, 110
African American men/Tuskegee medication for, 214–215
Syphilis study, 223 and narcotic usage, 190
Asian older adults, and CAM pseudodementia, 208
usage, 34, 36, 111 scope of, 102
diagnosis conveyance adaptations, symptoms, 213
109–110 types, 211
dominant, health care practices of, vs. memory loss, 7
16t–17t Demerol, 190
and exercise choices, 85 Department of Health and Human
Hispanic older adults, 11, 34, 36, Services, U.S. (DHHS), 18
111, 147 Depression. See also Alzheimer’s
influence on aging, 76–77 disease (AD); Delirium;
nutrition considerations, 127 Dementia
stigmatization of dementia/depres- assessment/management of, 7–8,
sion, 110 207
viewpoints about death, 285 of caregivers, 261
views of death, 285 causes, 205–207
Cyanotic skin, 155 comparison with delirium/dementia,
199t–202t
Davis, B., 281 cultural stigmatization of, 110
Death. See also End-of-life issues DSM-IV criteria, 207
cultural views of, 285 and narcotic usage, 190
leading causes of, 146t and suicide, 209–210
Decubitus ulcers, 272–273 treatments
Defined diagnostic related groups electroconvulsive therapy, 209
(DRGs), 63 medications, 208–209
Delirium, 198, 202–205. See also Desquelles, A., 26
Dementia; Depression Diabetes mellitus, 160–162
causes (possible) and heart disease, 160–161
alcohol, 204 interventions, 161
medication, 203–204 management/management barriers,
translocation syndrome, 204 161–162
comparison with dementia/depres- and obesity, 161
sion, 199t–202t Type 1 (juvenile), 160
definition, 202 Type 2 (adult onset), 114, 138–139
interventions, 203 Diagnosis
resolutions procedures, 204–205 of Alzheimer’s disease, 212–213
symptoms, 202 cultural concerns for, 109–110
Dementia, 208–216. See also Alzheimer’s distressful memory issues, 110
disease (AD); Delirium; normal changes vs. pathological,
Depression 76–78t–82t, 122
assumptions/myths about, 197 Diastolic blood pressure, 83–84
and autonomy, 234 Diet/nutrition. See also Meal
case study, 29–30 programs
Index 321
assessments of, 86–87, 113, 126–130, Edwards, N., 202

179 Effective coordination, QOL domain,
and cardiovascular system, 86, 152 242
for constipation, 93 Ejaculation/erections, 99
cultural variation considerations, 127 Elavil (amitriptyline), 208
and declining income, 127–128 Elder mistreatment (EM), 243,
end of life issues, 281–282 246–247
Food Guide Pyramid, 129 abuse, types of, 243
for hypertension, 152 assessment for, 243–244
interaction with medications, interventions, 246–247
184–185 yearly statistics, 243
interventions for promotion, Electroconvulsive therapy (ECT), 209
129–130 Emotional concerns, of elders,
and primary prevention, 126–130 110–111
and teeth/gum problems, 91 Emphysema, 157, 158
vitamin supplements, 90, 183, Employment, in later years
191–192 advantages/disadvantages, 32–33
Digoxin, 180, 182 full-time vs. part-time, 32
Dimensions, of end-of-life care, End-of-life issues, 9–10, 15, 225. See
283–290 also Death; Dying Person’s
physical dimension, 285, 288 Bill of Rights; Patient
psychological dimension, 288 Self-Determination Act
social dimension, 288 advance directives, 280–283
spiritual dimension, 288, 290 assisted suicide, 225
Diuretics, for CHF, 154 communication, 290–291
Dizziness, 1, 85, 155 diet/nutrition concerns, 281–282
Doberman, D., 183 dimensions of care, 283–290
Domains, of QOL, 241–242 physical, 285, 286t–287t, 288
Driving issues, 226–229 psychological, 288, 289t
Durable medical equipment (DME) social, 288
providers, 63 spiritual, 288, 290
Durable power of attorney, 282 durable power of attorney, 282
Dyer, A., 234 financial planning, 283
Dying Person’s Bill of Rights, 284 grieving, 291
Dyspnea on exertion (DOE), 83, 85, hospice care, 292–293
88, 153 living wills, 282
Dysuria, 271 widowhood, 291–292
End state renal disease (ESRD), 38
Eating. See Diet/nutrition Environmental fit, QOL domain,
Education 242
for gerontological nursing, 37 Environmental modifications
of patients personal space awareness, 109
for diet/nutrition, 179 room considerations, 106–107
for medication adherence, Erectile agents, 166
187–189 Erickson, E. H., 24
for pain management, 248 Esophagus, decreased peristalsis, 92
for wellness, 305 Estrogen, decreases in, 98
322 INDEX
Ethical issues, of aging, 219–237, Fat-soluble medications, 180

302–303 Fecal incontinence. See Bowel (fecal)
ANA code for nurses, 221 incontinence
and decision making, 222 Federal Interagency Forum on Aging
ethics defined, 220 Related Statistics, 34, 122,
principles, 221–226 291
autonomy, 222–224 Federal poverty line (FPL), 66
beneficence, 224 Fee for service health care plans, 68
justice, 225–226 Felley, K., 130
nonmaleficence, 224–225 Financial management, QOL domain,
Ethnogerontology 241
defined, 13–14 Financial planning issues, 32, 283
and health care, 11–14 Financing of health care. See also
Euthanasia, 225 Medicaid program; Medi-
Exercise care program
benefits of, 130 for adults without resources, 71–72
and cardiac system/disease preven- defined diagnostic related groups
tion, 84–85 (DRGs), 63
choices for, 85, 130 health maintenance organizations
and constipation, 93 (HMOs), 62
cultural group variation, 85 long term care insurance, 69–71
Kegel, for UI, 95 Medicare Managed Care, 62
for lowering cholesterol levels, 85 Medigap plan, 62
for musculoskeletal health, 97 preferred provider organizations
for pain management, 248 (PPOs), 65
and respiratory system, 89 private pay/fee for service, 68
for Type II (adult onset) diabetes, prospective payment system (PPS), 62
161 veteran’s benefits, 68–69
Expressive communication, QOL Finch, M., 183
domain, 241 Fingernails/toenails, brittleness/care
of, 90–91
Faces scale, 156, 247 Fisher, A., 84
Fahlman, C., 183 Fluid intake, for constipation, 93
Failure-to-Thrive (FTT) syndrome, Fluoridation, of drinking water, 91
128–129 Fluoxetine (Prozac), 208
Falls Follicular depletion, of ovaries, 98
CDC statistics, 132 Food Guide Pyramid, 129–130
consequences of, 131–132 Fraud, in health care, 63–64
prevention of, 131–134 FTT syndrome. See Failure-to-Thrive
prevention strategies, 131–134, 150 (FTT) syndrome
restraint usage, 133–134 Fulmer, T., 19, 146, 262
risk assessment, 132–133 Function, assessments of, 116–117
Family members, assessment involve-
ment, 115 Gabel, J., 183
Fatigue Gambling issues, 234–237
of caregivers, 261 Gastroesophageal reflux disease
and congestive heart failure, 153 (GERD), 164, 179
Index 323
Gastrointestinal system, 91–94 Hair, changes in patterns, 91

and absorption of medication, Happiness, QOL category, 242
178–180 Harrington, C., 20
age-related changes, 178–179 Hayflick, L., 22–23
bowel incontinence, 93–94 Hayflick Limit, 22–23
constipation, 92–93 Head/neck assessment, 113
decreased esophageal peristalsis, Health and Human Services (HHS),
92 Dept. of, 122, 256
diseases of, 179 Health care delivery
fecal incontinence, 92 barriers to, 30, 37
Genital organs, changes challenges, 33–38
men, 99 inability to pay, 30
women, 98–99 lack of primary care providers,
GERD. See Gastroesophageal reflux 30
disease (GERD) lack of transportation, 37
Geriatric Depression Scale, 109, 207 changes in, 300–302
Geriatric Nurse Certification (through cultural differences for, 108–109
ANCC), 21 financing of
Geriatric Nurse Resource Project at for adults without resources,
Yale University Medical 71–72
Center, 262–263 Medicaid, 65–68
Gerontological nursing, 19–22, 37 Medicare/related plans, 38–39,
Gerontological Society of America 62–65
(GSA), 15, 18, 22, 191, private pay/fee for service, 68
304 veteran’s benefits, 68–69
Gerotranscendence theory, of team approach, 107, 108
Tornstam, 24, 25 Health care plans. See Health main-
Gilje, F., 20 tenance organizations
Ginger, for arthritis, 192 (HMOs); Medicaid system;
Gleeson, M., 129 Medicare Managed Care;
Gonorrhea, 166 Medicare system; Medigap
Government-funded health care, 3–4. private health insurance;
See also Medicaid system; Prospective payment system
Medicare Prescription Drug (PPS)
Improvement and Modern- Health history assessment, 110–112
ization Act (2003); Social CAM usage, 111
Security system (U.S.) common problems focus, 111
Grandparenting, and QOL, 248–249 medication history, 111
Gratification/future image, QOL review of symptoms (ROS), 111–112
domain, 242 Health insurance
Graying of America, 2, 296, 299–300 lack of, case study, 35
Grief long term care insurance, 69–71
of caregivers, 261 Medigap private plan, 62
end of life assessment, 291 noncoverage for CAM, 34
Group homes, 256, 258 termination by employer, 32
Guided imagery, 255–256 Health maintenance organizations
Gut motility, decreases of, 92 (HMOs), 62
324 INDEX
Health/perceived health, QOL and strokes, 159–160

domain, 241 treatment guidelines, 152
Healthy People 2010, 1–2, 122, 206 Hyperthermia/hypothermia, 90
Hearing impairments, 101 Hypotension, 155
Heart
assessment of, 113 Iatrogenesis, spiral of, 131–132, 150
symptoms of aging, 77, 83–88, 181 Imipramine (Tofranil), 208
Hepatic metabolism, 178, 181–182 Immunizations
Hepatitis, 166 influenza, 134–135, 163
Herbal medication, 125, 190–194 pneumonia, 135
NTP study, 192t–193t recommended schedule, 136
for osteoarthritis, 148 tetanus/diphtheria, 135, 137
Hierarchy of Needs, of Maslow, 24 Impotence, 99, 230, 232
Hip fractures, 149 Incontinence, urinary/bowel, 8–9
Hispanic older adults, 11 Individuality attribute, of QOL,
absence of osteoarthritis, 147 240–241
and use of CAM, 34, 36, 111 Influenza
Home and community-based services immunization for, 134–135
(HCBS), 67 life-threatening complications, 162
Home-bound elderly symptomatic treatment, 162–163
assessment of, 261 Informed consent, 222–223
benefits, 258 and IRBs, 223
problems, 258–259 Tuskegee Syphilis studies, 223
provider shortage for, 64 violations of, 224
statistics, 256 Institute of Medicine (IOM) of the
Home health care, 63, 260–262 National Academies, 108,
multidisciplinary approach, 259 302
and need for caregivers, 260–261 Institutional review boards (IRBs), 223
Homeless adults, 275–276 Instrumental activities of daily living
Hopman-Rock, M., 85 (IADL), 117, 259
Hormonal changes, 98 Integumentary system
Hospice care, 292–293 assessment of, 113
Hubbard, A., 130 hair pattern changes, 91
Human Genome Project, 307 hyperthermia/hypothermia, 90
Human immunodeficiency virus nail care, 90–91
(HIV), 165–168 sweat gland diminishment, 90
Humerus, fractures of, 149 wrinkles/sun exposure, 89–90
Huntington’s disease, 211 Interdisciplinary teams, members, 107
Hydration International Longevity Center-USA, 183
assessment, 127 Interventions
and FTT syndrome, 127 for Alzheimer’s disease, 213
and pneumonia, 165 for CHF, 153–154
Hydrochlorothiazide, for HTN, 152 for COPD, 158
Hypertension (HTN), 137, 151–152 for delirium, 203
medications, 152 for diabetes mellitus, 161
and quality of life, 239 for diet/nutrition promotion,
risk factors, 151 129–130
Index 325
for elder abuse, 246–247 Lithium, 180, 182

for elder mistreatment, 246–247 Liver. See Hepatic metabolism
for myocardial infarction, 156 Living wills, 282
for normal changes of aging, Longevity, and cigarette smoking,
78t–82t 89
for nutrition promotion, 129–130 Long-term care insurance, 69–71
for osteoporosis prevention, 150 Losses, enjoyment of eating, 1
for pneumonia, 165 Loving, G. L., 2
for smoking cessation, 126 Lung issues
for strokes, 160 loss of elasticity, 88
for urinary incontinence, 95 lung cancer, 168
IRBs. See Institutional review boards Lynn, J., 183
(IRBs)
Malazemoff, W., 102
Jacobsen, S. A., 202 Malnutrition. See also Meal programs
Janus Report on Sexual Behavior, 166 and Failure-to-Thrive syndrome,
Jassal, S. V., 108 128–129
Journal of the American Geriatric and pneumonia, 164
Society, 240 risk factors, 127–128
Jung, Carl, 25 Management
Justice, 225–226 of acute care, advances, 307–308
of Alzheimer’s disease, 213
Kahn, R. I., 9, 249 of chronic care, advances, 307–308
Kane, R. L., 37 of diabetes mellitus, 7–8, 207
Katz Index assessment, 117 financial, QOL domain, 248
Kegel exercises, for UI, 95 of medication
Kidneys blood pressure, 33
loss of glomeruli/nephrons, 94 NSAIDs, 170, 248
renal elimination, 182 of pain
Knott, K., 234 acupuncture, 248
Koch, T., 93 cancer, 169–170
Koenig, H. G., 250 cognitive disorders, 248
Kohlberg, XX, 24–25 massage, 248
Kovner, C. T., 20 of pneumonia, 164
Kubler-Ross, E., 291 MAOIs. See Monamine oxidase inhib-
Kyphosis, 150 itors (MAOIs)
Marcial, E., 281
Lacey, L., 20 Marijuana, 190
Larson, D. B., 250 Massage, for pain management, 248
Legal issues, of aging, 302–304 Masters, W. H., 230
Levens, S., 234 McCarthy, M. C., 202
Lewy Body dementia, 211 McCullough, M., 250
Li, M., 108 McMathias, Charles, Jr., 240
Lifespan, increases in, 2, 33 Meal programs
Life-sustaining treatments, removal Meals-on-Wheels program, 128,
of, 225 262
Lipid-lowering medications, 156 Title III Meal Program, 128
326 INDEX
Medicaid program, 13, 30 for CHF, 154

allowable expense diminishment, compliance assessment, 187–189
36 complications of usage, 176
home and community-based ser- as delirium trigger, 203–204
vices, 67 for dementia, 214–215
and Patient Self-Determination for depression
Act, 280 MAOIs, 209
Program of All-inclusive Care for SSRIs, 208
the Elderly, 67 TCAs, 208–209
reimbursement for SNFs, 263 distribution of, 180–181
and Supplemental Security Income excessive/inappropriate use of, 176
(SSI), 65–66 fat-soluble, 180
Medicare Managed Care, 62 geriatric medications, 185
Medicare Prescription Drug Improve- and hepatic metabolism, 181–182
ment and Modernization for hypertension, 152
Act (2003), 3, 34 inappropriate prescription writing,
Medicare program, 3, 30 183
allowable expense diminishment, interactions
36 with disease, 183–184
benefits limitation, 32 with nicotine, 125
change in hospital payments, 64 with nutrients, 184–185
coverage categories, 40t–61t lack of reimbursement for, 35
financing of, 38–39, 62–65 management of, 305–306
and OASIS, 260 narcotics, illegally obtained,
and Patient Self-Determination 190–194
Act, 280 for osteoarthritis, 148
reimbursement for SNFs, 263 for osteoporosis, 150
structure over-the-counter, 125, 190–194
Part A, 329 for pain management, 170, 248,
Part B, 39 255
traditional plan, 39, 62 for Parkinson’s disease, 171
types of providers, 39 polypharmacy, 179
usual customary and reasonable and renal elimination, 182
(UCR) fees, 39 side effects
Medications. See also Complementary for BPH, 184
and alternative therapy constipation, 92
(CAM); Herbal medication; of steroid treatment, 153
Omnibus Budget Medigap private health insurance, 62
Reconciliation Act (OBRA); Melov, S., 130
Pharmacokinetics/pharma- Memory issues. See also Alzheimer’s
codynamics disease (AD)
absorption of, 178–180 distressful memories, 110
adherence to, 187–189 memory loss
administration of, 185–186 activities for prevention, 103
for angina/myocardial infarction, and CHF, 153
156–157 vs. dementia, 7, 102
for asthma/emphysema, 158 Merck Institute of Aging and Health, 176
Index 327
Mezey, M., 19 Nails, care of, 90–91

Middle-old stage, of aging, 3 Narcotics, illegally obtained, 190–194
Mild cognitive impairment (MCI), Nardil (phenelzine), 209
106, 221–222 Narum, I., 242
and right to autonomy, 224 National Center for Assisted Living,
Mini Mental State Examination, 109, 274
118, 212, 307 National Council on Aging (NCOA),
Minimum data set (MDS), of SNFs, 10, 11
264, 265–270 National Gerontological Nursing
Mini-strokes. See Transient ischemic Organization (NGNO),
attack (TIA) 21–22
Mobility domain, of QOL, 242 National Health-Promotion and
Monamine oxidase inhibitors Disease-Prevention Objec-
(MAOIs), 209 tives (HHS), 122
Mood/symptoms, QOL domain, 241 National Institute of Aging, research
Moore, C., 20 priorities, 297t–298t
Moral development stages, of Kohl- National Toxicology Program (NTP),
berg, 24–25 192t–193t
Moral/spiritual theories, of aging, 24–25 Nature vs. nurture controversy,
Morley, J. E., 84, 231 205–206
Morphine, 190 Neglect abuse, 243, 261–262
Multidimensionality attribute, of Neurotransmitters, 205–206
QOL, 240–241 New York University Medical Center,
Multidisciplinary approach, to home 262–263
care, 259 Nicotine–drug interactions, 125
Multi-infarct dementia, 211 Nitroglycerin patches, 156
Musculoskeletal system, 96–98 Noninsulin dependent diabetes
assessment of, 113–114 mellitus (NIDDM). See Type
disorders 2 (adult onset) diabetes
osteoarthritis, 147–148 Nonmaleficence, 224–225
osteoporosis, 96–97, 114, Nonsteroidal anti-inflammatory drugs
148–151 (NSAIDs)
Myocardial infarction (MI). See for osteoarthritis, 148
Angina pectoris/myocardial for pain management, 170, 248
infarction (MI) Normal life, QOL category, 242
Myths about aging, 6 Norton, S. A., 294
cognitive functioning, 114, 197–198 Nortriptyline (Pamelor), 208
crankiness/disagreeability, 6 NTP. See National Toxicology
depression as normal, 7–8 Program (NTP)
influence from parents, 9 Nursing, gerontological. See Geronto-
lack of teachability, 6–7 logical nursing
little benefit to society, 5 Nutrition. See Diet/nutrition
loss of interest in sex, 8
readiness to die, 9–10 OASIS. See Outcome and Assessment
senility inevitability, 7 Information Set
smelliness, 8–9 Obesity, and diabetes mellitus, 161
societal drain, 5–6 O’Brien, M. E., 12–13
328 INDEX
Obstructive airway diseases, 157 cognitive therapy, 248

Older American’s Act (OAA) of 1965, guided imagery, 255–256
72 medication, 248, 255
Old-old stage, of aging, 3 nonmedical interventions, 248
Olshansky, S. J., 26 and quality of life, 247–248
Omnibus Budget Reconciliation Act Pain Assessment in Dementia Scale,
(OBRA), 134, 176 156, 248
Organization skills, QOL domain, 241 Parkinson’s disease (PD), 170–172
Orgasmic dysfunction, 98 and dementia, 211
Orientation skills, QOL domain, 241 medications for, 171
Orthopnea, and congestive heart failure, signs/symptoms, 171–172
153 treatment, 172
Orthostatic hypertension, 112 Paroxetine (Paxil), 208
Oslin, D. W., 234 Paroxysmal nocturnal dyspnea (PND),
Osteoarthritis (OA), 147–148 153
cultural variations, 147 Pascucci, M. A., 2
genetic link, 147 Pathological disease processes, 145–173
herbal supplements for, 148 cancer, 168–170
NSAIDs for, 148 cardiovascular/respiratory disorders
primary/secondary disorder, 148 angina/myocardial infarction,
Osteoporosis, 14, 96–97, 148–151. 155–157
See also Kyphosis cerebral vascular accident
etiology theory, 148 (stroke), 158–160
fall prevention strategies, 150–151 congestive heart failure, 152–155
interventions for prevention, 150 hypertension, 151–152
medications for, 150 obstructive airway diseases,
risk factors, 150 157–158
and spiral of iatrogenesis, 150 diabetes mellitus, 160–162
Outcome and Assessment Information infectious diseases
Set (OASIS), 260 influenza, 162–163
Ovaries, follicular depletion, 98 pneumonia, 163–165
Over-the-counter (OTC) medications, sexually transmitted diseases/
125, 190–194 HIV virus/AIDS, 165–168
musculoskeletal disorders
PACE. See Program of All-inclusive osteoarthritis, 147–148
Care for the Elderly (PACE) osteoporosis, 148–151
Paget’s disease, 97 Parkinson’s disease, 170–172
Pain. See also American Chronic Pain Patients
Association and autonomy/right to choose,
assessments 222–224
Faces scale, 156, 247 compliance/adherence problems,
Pain Assessment in Demential 35–36
Scale, 156 Patient Self-Determination Act,
Visual Analogue Scales, 247 280
chest pain, 85 Paxil (paroxetine), 208
management Payment issues. See Financing of
for cancer, 170, 248 health care
Index 329
PCP. See Pneumocystic carinii nutrition, 126–130

pneumonia (PCP) sleep, 131
Pearl, R., 23–24 smoking, 125–126
Pearlman, R. L., 240 secondary prevention
Personal goals achievement, QOL cancer, 139, 142
category, 242 cardiovascular disease, 137–138
Personal Responsibility and Work diabetes, 138–139
Opportunity Reconciliation Preventive Services Task Force, U.S.
Act (Public Law 104-193), 67 (USPSTF), 129
Pew Research center, retirement study, 32 Private pay health care plans, 68
Pharmacokinetics/pharmacodynamics, Procainamide, 182
177–182 Profile of Older Americans (AARP),
focus of, 177–178 215, 261
hepatic metabolism, 181–182 Progesterone, decreases in, 98
medication absorption, 178–180 Programmed Senescence theory, of
medication distribution, 180–181 aging, 23
renal elimination, 182 Program of All-inclusive Care for the
Phenelzine (Nardil), 209 Elderly (PACE), 67
Phenothiazines, 180 Promotion strategies
Phenytoin, 180 in acute care environment, 263
Physical assessment, 112–115 for diet/nutrition, 129–130
Physical care dimensions, at end of Prospective payment system (PPS),
life, 285, 286t–287t, 288 62, 64
Pick’s disease, 211 Prostate cancer, 169
Pittsburgh Sleep Quality Index, 307 Prozac (fluoxetine), 208
PLISSIT model, for sexual assessment, Pseudodementia, 208
232, 234 Psychological abuse, 243
Pneumocystic carinii pneumonia Psychological care dimensions, at end
(PCP), 295 of life, 288, 289t
Pneumonia, 88, 163–165 Psychological theories, of aging, 24
assessment/management, 164 Public Health Services, U.S. (USPHS), 20
death rate from, 164 Public Law 104-193. See Personal
immunization for, 135 Responsibility and Work
interventions, 165 Opportunity Reconciliation
risk factors, 164 Act (Public Law 104-193)
Polypharmacy, 179
Porter, E., 108 “QOL Considerations in Geriatric
Power of attorney, 282 Care” (Pearlman/Speer), 240
Preferred provider organizations Quality of life (QOL) issues, 239–252
(PPOs), 65 attributes, 240–241
Pressure (decubitus) ulcers, 272–273 categories, 242
Preventive measures defined, 240
primary prevention domains, 241–242
adult immunization, 134–137 elder mistreatment, 243, 246–247
alcohol usage, 124–125 grandparenting, 248–249
exercise, 130 pain, 247–248
fall prevention, 131–134 spirituality, 249–251
330 INDEX
Rauckhorst, L. H., 20 for decubitus ulcers, 273

Receptive communication, QOL for disease
domain, 241 cerebral vascular accident,
Reflexology, for pain management, 248 158–159
Reijneveld, S. A., 85 hypertension, 151
Reiki, for pain management, 248 malnutrition, 127–128
Reimbursement for medication issue, 35 modifiable/nonmodifiable, 84
Religious background, and blood osteoporosis, 150
transfusions, 222 pneumonia, 164
Reminiscence/life review assessment, 112 Robert Wood Johnson Foundation, 124
Renal elimination, 182. See also Rosenfeld, P., 19
Cockcroft-Gault formula, Rosengrena, A., 155
for creatinine clearance Rosenkoetter, M., 32
Reproductive system, 8, 98–100. See Rowe, J. W., 9, 249
also Sexuality/sexual issues Rubenstein, L. Z., 131
genital changes
men, 99, 230 Safety issues
women, 98–99, 230 for dementia, 29
hormonal changes, 98 Satisfaction, QOL category, 242
impotence, 99 Saw palmetto, 194
sexual dysfunction, 75 Schizophrenia, 184
Research priorities, of National Institute Scommegna, P., 11, 13
of Aging, 297t–298t Selby, R., 183
Resident Bill of Rights, 264 Selective serotonin reuptake inhibitors
Resistance exercise, benefits of, 130 (SSRIs), 208
Respiratory system, 88–89. See also Self-determination. See Autonomy
Lungs Self-governance. See Autonomy
assessment of, 113 Self-management
DOE issues, 83, 85, 88 of diabetes mellitus, 161
influence of exercise on, 89 Sensory changes, 100–102, 179
risks of choking/aspiration of food/ hearing impairments, 101
pneumonia, 88 smell/taste, 102, 127
and smoking cessation, 89 touch, 129
SOB issues, 83, 85, 88 visual acuity, 100–101
Respite care, 262 Sertraline (Zoloft), 208
Restraint usage, for fall prevention, Sexuality/sexual issues
133–134 andropause (male menopause), 99, 230
Retirement communities, 274–275 assessments, 167, 232, 234
Retirement issues, 31–33 complications, 230
Federal Interagency Forum on delayed sexual response, 231
Aging Related Statistics, 34 reproductive system
Gallup poll on, 5–6 hormonal changes, 98, 230
Pew Research center study, 32 impotence, 99, 230, 232
Review of symptoms (ROS) assessment, sexual dysfunction, 75
111–112 Sexually transmitted diseases (STDs),
Risk factors 99, 165–168
for abuse, 243 Shortness of breath (SOB), 83, 85
Index 331
Side effects, of medication Sun exposure

for BPH, 184 and Vitamin D, 90
constipation, 92 and wrinkles, 89–90
of steroid treatment, 153 Supplemental Social Security (SSI),
Siu, L. L., 183 65, 66
Skilled nursing facilities (SNFs), 256, Syncope, 155
258, 271–273
minimum data set (MDS) of, 264, Talerico, K. A., 294
265–270 Tariq, S. H., 231
problems in Tarnopolsku, M. A., 130
pressure (decubitus) ulcers, TCAs. See Tricyclic antidepressants
272–273 (TCAs)
urinary tract infection, 264, Team approach, to health care delivery,
270–271 107, 108
resident profile, 264 Technological advances, in health
short-term/long-term residence, care, 34
263–264 Teeth/gum problems, influence on
vs, ALFs, 273 nutrition, 91
Sleep issues Testosterone
deprivation consequences, 131 and andropause, 99, 230
Pittsburgh Sleep Quality Index, 307 decreases in, 98
Smoking. See Cigarette smoking Theories, of aging
SNFs. See Skilled nursing facilities biological, 22–24
(SNFs) moral/spiritual, 24–25
SOB. See Shortness of breath (SOB ) Programmed Senescence theory, 23
Social Security Act, 66 psychological, 24
Social Security system (U.S.), 4, 5, 13, sociological, 25–26
32, 303 Timmons, F., 129
Social utility, QOL category, 242 Title III Meal Program, 128
Sociological theories, of aging, 25–26 Title XIX, of Social Security Act, 66.
Speer, J. B., 240 See also Medicaid system;
Spiral of iatrogenesis, from falls, Medicare system
131–132, 150 Tornstam, L., 24, 25
Spirituality Townsley, C. A., 183
aging theories, 24–25 Transient ischemic attack (TIA), 155,
end-of-life care dimensions, 288, 290 159
quality of life issues, 249–251 Translocation syndrome, 204
SSRIs. See Selective serotonin reup- Tranylcypromine (Parnate), 209
take inhibitors (SSRIs) Treatments, in health care
Stages of development, of Erickson, 24 for cardiovascular disease
Statin medications, 138, 156 congestive heart failure, 154
Stress burden, for caregivers, 261 hypertension, 152
Stress incontinence, 94 importance of exercise, 84–85
Stroke. See Cerebral vascular accident continuous improvements in, 34
(stroke); Transient ischemic for COPD, 153
attack (TIA) for influenza, 162–163
Suicide, 209–210 for Parkinson’s disease, 172
332 INDEX
Tricyclic antidepressants (TCAs), 208 Vitamin supplements, 90, 183,

Tuskegee Syphilis studies, 223 191–192
Type 1 (juvenile) diabetes, 160 Vu, M., 131
Type 2 (adult onset) diabetes, 114, Vulva, dryness of, 98
138–139
Walking, benefits of, 130
Unconscious competence/incompe- Warfarin, interaction with Vitamin
tence stages, of cultural K, 183
competence, 14 Wayzynski, C., 204
University of North Carolina Center for Web sites
Functional Gastrointestinal Aging with Dignity, 281
and Motility Disorders, 93 fall-related hip fractures, 132
Urinary issues influenza facts, 162
bacteriuria/dysuria, 271 National Health-Promotion and
urinary incontinence (UI), 8–9, 94–96 Disease-Prevention Objectives,
(See also Stress incontinence) 122
bladder, loss of tone, 94 Weight-bearing exercise, 130
Kegel exercises, 95 Weight gain, sudden, 85
kidneys, loss of glomeruli/neph- Weintraub, N., 131
rons, 94 Welfare reform. See Personal Respon-
voiding schedule, 96 sibility and Work Oppor-
urinary tract infection (UTI), in tunity Reconciliation Act
SNFs, 264, 270–271 (Public Law 104-193)
Usual customary and reasonable Well-being, QOL domain, 242
(UCR) fees, 39 Western biomedical model, of U.S.,
11–12
Vaccination. See Immunizations Westhoff, M. H., 85
Vaginismus, 98–99 Widowhood, 291–292
Veteran’s Administration (VA) health Wright, K., 281
care programs, 68–69 Wrinkles, and sun exposure, 89–90
Veteran’s Health Care Eligibility Wyman, J. F., 95
Reform Act of 1966, 69
Visual Analogue Scales, 247 Young-old stage, of aging, 3
Visual changes
assessment for, 101, 113 Zoloft (sertraline), 208
visual acuity, 100–101 Zubritsky, C., 234

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Essentials of

Meredith Wallace PhD, APRN-BC

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Springer Publishing Company, LLC

Acquisitions Editor: Allan Graubard

Library of Congress Cataloging-in-Publication Data

Printed in the United States of America by Bang Printing.

ONE The Graying of America 1

TWO The Health Care Delivery System 29

THREE Normal Changes of Aging 75

FOUR Assessing Older Adults 105

FIVE Health Promotion 121

SIX Pathological Disease Processes in Older Adults 145

SEVEN Medication Usage 175

EIGHT Cognitive and Psychological Issues in Aging 197

NINE Ethical Issues of Aging and Independence 219

TEN Quality of Life Issues Among Older Adults 239

ELEVEN Environments of Care 255

TWELVE End-of-Life Care 279

Psychological Dimension 288

THIRTEEN Future Trends and Needs 295

The current standards of living, nutrition, prevention and treatment of

a refreshing contribution to the currently existing literature that is more

Layfield, K. D. (2004). Impact of intergenerational service learning on students’ stereotypes

Mrs. Molina, an 85-year-old White female, comes to the walk-in clinic

The story of Mrs. Molina is typical of commonly occurring health care

aged 65 years can be expected to live an average of 18 more years than

The great advances in science, which have created a generation of older

Government-Funded Health Care

AGEISM—FACTS AND MYTHS OF AGING

such as retirement, relocation, loss of spouse, financial constraints, and

36 million members, which represents over 50% of older adults. The

ETHNOGERIATRICS AND HEALTH CARE

Scommegna (2007) predicts an unprecedented shift in the cultural back-

of medical problems with little respect for the impact of treatment on

Title of Study: Developing a Multisite Project in Geriatric and/or Geronto-

Scommegna (2007) reports that there is an unprecedented shift in the cul-

status on individual and population aging in the three broad areas of

• What are your own cultural backgrounds, attitudes, and beliefs?

• Which of these behaviors are different from those of others around

These questions may be used individually or administered to a col-

Sample Cultural History Questions

Source: Standford Geriatric Education Center Ethnogeriatric Core Curriculum

in 2002. The use of CAM will be discussed in greater detail in Chapter 7.

and complementary therapies is practiced, and great respect toward the

adults requiring care has resulted in a critical shortage of nurses prepared

Title of Study: Gerontological Nursing Content in Baccalaureate Nursing

was developed in 1984 to support the growth of knowledge related to

of “programmed cell death” or “apoptosis.” The manner and timeline

and is obtained when a person develops an understanding of themselves

Critical Thinking Case Study

Olshansky, Carnes, and Desquelles (2001) report that

There are no lifestyle changes, surgical procedures, vitamins, antioxi-

This statement summarizes the great advances in aging that have

without issues that need to be addressed. The presence of multiple medi-

The Health Care

Mr. Jackson is an 80-year-old man with moderate to severe dementia. He

The story of Mr. Jackson is typical of today’s older adult. It is logical to

While older adults are generally considered to be retired, many older