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ADVANCED PRACTICE
NURSING
in the Care of Older Adults
SECOND EDITION
ADVANCED PRACTICE
NURSING
in the Care of Older Adults
SECOND EDITION

Laurie Kennedy-Malone, PhD, GNP-BC, FAANP, FGSA

Professor of Nursing, School of Nursing
University of North Carolina at Greensboro
Greensboro, North Carolina

Lori Martin-Plank, PhD, FNP-BC, NP-C, GNP-BC, FAANP

Clinical Associate Professor, College of Nursing
University of Arizona
Tucson, Arizona

Evelyn Groenke Duffy, DNP, AGPCNP-BC, FAANP

Associate Professor
Director of the Adult-Gerontology Primary Care Nurse Practitioner Program
Associate Director of the University Center on Aging and Health
Frances Payne Bolton School of Nursing
Case Western Reserve University
Cleveland, Ohio
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com

Copyright © 2019 by F. A. Davis Company

Copyright © 2019 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part
of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: Susan R. Rhyner

Manager of Project and eProject Management: Catherine H. Carroll
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As new scientific information becomes available through basic and clinical research, recommended treatments
and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this
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editors, and publisher are not responsible for errors or omissions or for consequences from application of the
book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described
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Library of Congress Cataloging-in-Publication Data

Names: Kennedy-Malone, Laurie, 1957- author. | Plank, Lori Martin, author. | Duffy, Evelyn Groenke, author.
Title: Advanced practice nursing in the care of older adults [electronic resource] / Laurie Kennedy-Malone,
Lori Martin-Plank, Evelyn Groenke Duffy.
Description: 2nd edition. | Philadelphia : F.A. Davis Company, [2019] | Includes bibliographical references
and index.
Identifiers: LCCN 2018038367 (print) | LCCN 2018039007 (ebook) | ISBN 9780803694798 |
ISBN 9780803666610 (pbk.)
Subjects: | MESH: Geriatric Nursing—methods | Advanced Practice Nursing | Palliative Care |
Geriatric Assessment
Classification: LCC RC954 (ebook) | LCC RC954 (print) | NLM WY 152 | DDC 618.97/0231—dc23
LC record available at https://lccn.loc.gov/2018038367

Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients,
is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional
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0/19 0 + $.25.
I dedicate this book to my husband Chris and my son Brendan for their unwavering support
during the writing of this book. To my parents, Nancy and Edward Kennedy, you continue to be
models of successful aging that motivate me to continue to be passionate about advanced practice
gerontological nursing. To graduates that I have worked with over the years, your continued
dedication and expertise in working with older adults is appreciated and admired; thanks to
those who also served as contributors to this edition.
—L.K.-M.

To my husband Rick and daughter Erin, thank you both for your patience and encouragement
throughout the writing of this book. To my patients, who are also my teachers, thank you for
entrusting your health to me; it has been my honor and privilege to serve you and to learn
from you.
—L.M.-P.

To my husband Mark who supported me as I worked on this book in New Zealand, England,
Italy, Ireland, Colorado—on every vacation we have taken. To my children Patrick, Colin, and
Caitlin and my fabulous GNP daughter-in-law Kristen—you bless me every day. To my Aunt
Karleen Groenke Sime who inspired me to become a nurse. To my father John and my in-laws
Shirley and Art, who continue to live vital lives in their late 80s. Finally, to all my patients who
challenge me to be the best provider I can be and my students who motivate me to constantly
be better.
—E. G. D.
 Preface

With the continued rapid growth of the older adult popu- tests with accompanying results are used to form a differen-
lation, there remains an increased demand for health-care tial diagnosis.
providers to deliver age-specific care and direct disease man- Unit III, “Treating Disorders,” provides 11 chapters of
agement. Advanced Practice Nursing in the Care of Older Adults concise, updated information pertaining to disease manage-
will serve as a guide for advanced practice nurses who are ment of illnesses common in older adults, presented by body
privileged to provide care to older adults. Designed as a text for systems. Each chapter opens with an assessment section that
students, as well as a reliable source of evidence-based prac- provides the reader with a focused review of systems and the
tice for advanced practice nurses, this book contains informa- physical examinations needed to obtain pertinent informa-
tion on healthy aging, comprehensive geriatric assessment, tion for diagnosis and treatment of the older adult. Signal
and common symptoms and illnesses that present in older symptoms indicating atypical presentation of illness are
adults. Given the complexity of prescribing for older adults highlighted at the beginning of each condition. The discus-
taking multiple medications, a new chapter on polyphar- sion of each problem and disorder follows a consistent mono-
macy is included. The book concludes with a chapter on care graph format:
delivery for patients with chronic illnesses who face end-of-
■ Signal symptoms
life care.
■ Description
Throughout the book, case studies are included to provide
■ Etiology
further practice and review. An important feature of this
■ Occurrence
book is the use of the Strength of Recommendation Taxon-
■ Age
omy (SORT) [Ebell, M. H., Siwek, J., Weiss, B. D., Woolf, S. H.,
■ Ethnicity
Susman, J., Ewigman, B., & Bowman, M. (2004). Strength
■ Gender
of recommendation taxonomy (SORT): A patient-centered
■ Contributing factors
approach to grading evidence in medical literature American
■ Signs and symptoms
Family Physician, 69(3), 548–556], which provides a direct
■ Diagnostic tests
reference to evidence-based practice recommendations for
■ Differential diagnosis
clinicians to consider in the care of older adults.
■ Treatment
In Unit I, “The Healthy Older Adult,” the first chapter,
■ Follow-up
“Changes with Aging,” addresses the normal changes of
■ Sequelae
aging, expected laboratory values in older adults, presen-
■ Prevention/prophylaxis
tation of illness, atypical disease presentation, bimodal
■ Referral
conditions, and the impact of chronic illness on functional
■ Education
capacity. In the second chapter, “Health Promotion,” updated
information pertaining to health promotion and disease pre- Unit IV, “Complex Illness,” addresses complex manage-
vention strategies for older adults from Healthy People 2020 ment of patients requiring chronic illness management, pal-
and the U.S. Preventive Services Task Force (USPSTF) is pro- liative care, and supportive care at end of life, and includes a
vided, including an immunization schedule and information new chapter on polypharmacy. The text concludes with two
on the Welcome to Medicare Visit. Also covered is an over- appendices—“Physiological Influences of the Aging Process”
view of physical activity, sexual behavior, dental health, and and “Laboratory Values in the Older Adult”—both of which
substance use, as well as a section pertaining to the older are ready references for the busy practitioner.
traveler. Recommendations for exercise and safe physical In addition to the content of the book, a Bonus Chapter,
activity are provided in this unit. Nutritional Support in the Older Adult, selected Refer-
Unit II, “Assessment,” opens with a detailed chapter on ences, and other online resources to aid the user in practice
comprehensive geriatric assessment. Information on phys- and review of the key concepts are available at DavisPlus.
ical, functional, and psychological health is delineated, and Case studies are provided to support critical thinking and
information on quality of life measures is included. Next is are available for users to complete on their own or for edu-
the fifth chapter, “Symptoms and Syndromes,” which pro- cators to incorporate into their course requirements. To
vides the clinician with a concise description of more than 20 enhance the delivery of competency-based education, the
symptoms prevalent in older adults. A rapid reference detail- case studies were mapped to the Adult-Gerontology Primary
ing common contributing factors and associated symptoms Care Nurse Practitioner Competencies (2016).
and clinical signs that should be worked up for each present- For the faculty, there are PowerPoint presentations
ing condition is included. Recommendations for diagnostic and a well-developed test bank located on DavisPlus. The

vii
viii Preface

Active Classroom Instructors’ Guide is an online faculty practice guidelines on prevention and management of condi-
resource that maps the resources available with the text and tions common in older adults.
includes lecture notes and additional case studies.
This book is written by and for advanced practice nurses REFERENCE
involved in the care of older adults across multiple settings of National Organization of Nurse Practitioner Faculties. (2016). Adult-
care. While intended as a guide for the management of care Gerontology Acute Care and Primary Care Nurse Practitioner com-
for older adults, clinicians are encouraged to deliver individ- petencies. Retrieved from http://c.ymcdn.com/sites/www.nonpf.org/
ualized, patient-centered care considering the latest clinical resource/resmgr/competencies/NP_Adult_Geri_competencies_4.pdf.
 Contributors

Sue A. Anderson, PhD, RN, FNP-BC Lisa Byrd, PhD, FNP, GNP, FAANP
Associate Professor, Family Nurse Practitioner Practice Administrator
Program Coordinator Florida Health Care Plans
Saint Mary’s College Nurse Practitioner, Assistant Professor
Notre Dame, Indiana University of South Alabama
Epistaxis; Rhinitis; Asthma Lake Mary, Florida
Bowel Incontinence; Diarrhea; Fatigue; Urinary Incontinence;
Louann Bailey, CRNP Wandering
Nurse Practitioner
Inpatient Medical Services Carol Calianno, RN, MSN, CWOCN, CRNP
Akron, Ohio Nurse Practitioner – Dermatology and Wound Ostomy
Chest Pain Continence Specialist
Philadelphia VA Medical Center
Tracy Ballard, MSN, GNP-BC Philadelphia, Pennsylvania
Nurse Practitioner Skin Cancer
Optum
Greensboro, North Carolina Christina Coletta-Hansen, MSN, ANP-BC, ACHPN
Gastroenteritis Palliative Care Nurse Practitioner
Einstein Medical Center Montgomery
Judith A. Berg, PhD, RN, WHNP-BC, FAANP, FNAP, Norristown, Pennsylvania
FAAN Palliative and End of Life Care
Clinical Professor
The University of Arizona College of Nursing Kristin R. Curcio, DNP, AGPCNP-BC, AOCNP
San Diego, California Nurse Practitioner
Atrophic Vaginitis; Breast Cancer Cone Health Cancer Center at Wesley Long
Greensboro, North Carolina
Sharon Biby, MSN, APRN, ANVP-BC, AGPCNP-BC Lung Cancer; Bladder Cancer; Liver Cancer; Brain Tumor;
Nurse Practitioner, Advanced-Practice Stroke Nurse Pancreatic Cancer
Cone Health
Greensboro, North Carolina Nancy Dirubbo, DNP, FNP-BC, FAANP, Certificate
Stroke in Travel Health
Director
Anna Wentz Boone, PhD, ANP-BC Travel Health of New Hamsphire, PLLC
Adult Nurse Practitioner Laconia, New Hampshire
Rockingham Gastroenterology, Cone Health Medical Travel and Leisure
Group
Reidsville, North Carolina Brenda L. Douglass, DNP, APRN, FNP-BC, CDE,
C. Difficile; Cholecystitis; Peptic Ulcer Disease; Gastritis CTTS
DNP Program Director, Assistant Clinical Professor,
Angela Brown, DNP, FNP-BC, ANP-BC, CDE Family Nurse Practitioner
Clinical Assistant Professor, Family Nurse Practitioner Drexel University
University of Arizona Philadelphia, Pennsylvania
Tucson, Arizona Chronic Obstructive Pulmonary Disease
Cellulitis; Hearing Loss

ix
x Contributors

Janet DuBois, DNP, APRN, FNP-BC, FAANP, FNAP Debra A. Friedrich, DNP, FNP-BC, CLS, BC-ADM,
Associate Professor FNLA, FAANP
Loyola University New Orleans Diplomate, Accreditation Council for Clinical
New Orleans, Louisiana Lipidology
Pneumonia; Upper Respiratory Tract Infection Assistant Professor
University of South Florida College of Nursing
Kristen Tomblin Duffy, CRNP Tampa, Florida
Nurse Practitioner Hyperlipidemia
Lehigh Valley Health Network
Allentown, Pennsylvania Cynthia Gerstenlauer, ANP-BC, GCNS-BC, CDE,
Dysphagia; Hematuria CCD
Nurse Practitioner
Renee E. Edkins, DNP, ANP-C, Fellow, American Troy Internal Medicine
Society of Lasers in Medicine & Surgery Troy, Michigan
Director Laser Surgery Program, UNC Division of Osteoporosis
Plastic & Reconstructive Surgery, Medical Laser
Safety Officer Larry Ryan Gibson, MSN, AGNP-C
University of North Carolina, Department of Surgery Nurse Practitioner
Chapel Hill, North Carolina Alliance Urology Specialists
Burns Greensboro, North Carolina
Cystitis
Vaunette P. Fay, PhD, RNC, FNP, GNP
Director, Continuing Education; Lead Nurse Planner; Eric Gill, DNP, AGNP-C
Professor of Nursing Nurse Practitioner
The University of Texas Health Science Center at Rockingham Gastroenterology Cone Health Medical
Houston, Cizik School of Nursing Group
Houston, Texas Reidsville, North Carolina
Dehydration; Pruritus Cirrohsis; Esophagitis; Gastroesophageal Reflux Disease; Irritable
Bowel Syndrome; Acute Pancreatitis; Chronic Pancreatitis
Carrie Fernald, DNP, AGPCNP-BC
Nurse Practitioner Mary Jane Griffith, RN, MSN, GNP-BC, ACHPN
PACE of Triad Nurse Practitioner
Greensboro, North Carolina LTC Health Solutions
Joint Pain; Osteoarthritis Columbia, South Carolina
Palliative and End of Life Care
Diana Filipek-Oberg, RN, BSN, MSN, AGACNP-BC
Surgery APN Mary Guhwe, DNP, FNP-BC, SCRN
Cooper University Hospital Nurse Practitioner
Camden, New Jersey Duke University Hospital
Clinical Adjunct Faculty Durham, North Carolina
Drexel University Dizziness
Philadelphia, Pennsylvania
Chapter 7 Case Study; Assessment of the Respiratory System; Candace Currie Harrington, PhD, DNP, APRN,
Chapter 8 Case Study AGPCNP-BC, CDP
Clinical Professor
Nancy A. Fisher, RN, MSN, GNP-BC East Carolina University
Nurse Practitioner, Rheumatology Greenville, North Carolina
Cleveland Department of Veterans Affairs Heart Failure
Cleveland, Ohio
Gout; Rheumatoid Arthritis Melodee Harris, PhD, APRN, GNP-BC, AGPCNP-BC
Assistant Professor
University of Arkansas for Medical Sciences College of
Nursing
Little Rock, Arkansas
Delirium; Dementia
 Contributors xi

Theresa C. Hollander, CRNP Donna Behler McArthur, PhD, FNP-BC, FAANP,

Nurse Practitioner FNAP
Jefferson Health Adjunct Clinical Professor
Abington, Pennsylvania Vanderbilt University School of Nursing
Ischemic Heart Disease University of Arizona College of Nursing &
Department of Neurology, College of Medicine
Shelly Jesberger, MSN Tuscon, Arizona
Nurse Practitioner Headache; Seizure Disorders
Veterans Health Administration
Cleveland, Ohio Sincere McMillan, ANP-BC
Hemoptysis Nurse Practitioner
Memorial Sloan Kettering Cancer Center
Carol G. Kelley, PhD, AGPCNP-BC New York, New York
Associate Professor Colorectal Cancer
Frances Payne Bolton School of Nursing, Case
Western Reserve University Laurie Lovejoy McNichol, MSN, RN, CNS, GNP,
Cleveland, Ohio CWOCN, CWON-AP, FAAN
Falls Clinical Nurse Specialist, WOC Nurse
Cone Health
Nanette LaVoie-Vaughan, ANP-C, DNP Greensboro, North Carolina
Nurse Practitioner Pressure Injuries
Geriatric Neuropsychiatry Services
Raleigh, North Carolina Jennifer Mondillo, MSN, MBA, CRNP
Agitation; Constipation; Failure to Thrive Clinical Instructor
Villanova University
Sheree L. Loftus, PhD, MSN, APRN-BC Villanova, Pennsylvania
Nurse Scientist Assessment of the Cardiovascular System
Mount Sinai Union Square
New York, New York LaTroy Navaroli, DNP, FNP-BC, CWS
Investigator Nurse Practitioner Would Specialist
CHEAR Center Navaroli Medical
Bronx, New York Warren, Pennsylvania
Parkinson’s Disease; Restless Legs Syndrome Oral Nutritional Supplementation

William J. Lorman, JD, PhD, MSN, PMHNP-BC, D. Che Navey, A-GNP, MSN, RN
CARN-AP Neurohospitalist, Advanced Practice Clinician
Vice President & Chief Clinical Officer Novant Health Presbyterian Medical Center
Livengrin Foundation Charlotte, North Carolina
Bensalem, Pennsylvania Tremor
Alcohol Abuse; Prescription Drug Abuse
Olivia Faith Ogburn, AGPCNP
Denise Lucas, PhD, FNP-BC, CRNP, FAANP Nurse Practitioner
Chair, Advance Practice Programs Gastroenterology Oncology Clinic
Duquesne University Wake Forest Baptist Medical Center
Pittsburgh, Pennsylvania Winston Salem, North Carolina
Benign Prostatic Hyperplasia; Drug-Induced Impotence; Prostate Gastric Cancer
Cancer; Prostatitis
Loretta Phillips, RN, NP-C, APRN, BC
Rhonda W. Lucas, MSN, AGNPC Nurse Practitioner
House Calls Provider Capital Nephrology Associates
Optum Raleigh, North Carolina
United Healthcare Acute Kidney Injury; Chronic Kidney Disease
Reidsville, North Carolina
Herpes Zoster
xii Contributors

Sabrina Pickens, PhD, RN, ANP-BC, GNP-BC Susan D. Ruppert, PhD, RN, FNP-C, ANP-BC, FNAP,
Assistant Professor – Tenure Track, Faculty FCCM, FAANP, FAAN
University of Texas Health Science Center at Houston Professor, Associate Dean of Graduate Studies
Cizik School of Nursing Cizik School of Nursing at The University of Texas
Houston, Texas Health Science Center at Houston
Elder Abuse Houston, Texas
Anemia of Chronic Disease; Anemia; Iron Deficiency
Allen V. Prettyman, PhD, FNP-BC, FAANP
Associate Professor – College of Nursing Valerie K. Sabol, PhD, ACNP-BC, GNP-BC, ANEF,
University of Arizona FAANP
Tucson, Arizona Professor and Division Chair, Healthcare in Adult
Pulmonary Tuberculosis Populations
Duke University School of Nursing
Catherine R. Ratliff, PhD, GNP-BC, CWOCN, CFN Adult Acute Care & Gerontology Nurse Practitioner
Nurse Practitioner/Clinical Associate Professor, School Department of Medicine, Division of Endocrinology,
of Nursing Metabolism and Nutrition
University of Virginia Health System Duke University Medical Center
Charlottesville, Virgina Durham, North Carolina
Peripheral Vascular Disorders Obesity

Barbara Reall, MBA, MSN, CRNP Susan Kate Sandstrom, MSN, APRN-BC, ADCN
Senior Clinical Services Manager Nurse Practitioner
Optum University Hospitals, Seidman Cancer Center
Horsham, Pennsylvania Cleveland, Ohio
Hypertension Oral Cancer

Luann Richardson, PhD, DNP Jennifer Serafin, RN, BSN, MS, GNP-BC
Associate Professor Nurse Practitioner
Robert Morris University Kaiser Permanente
Moon Township, Pennsylvania South San Francisco, California
Anxiety; Bipolar Disorder Endometrial Cancer; Ovarian Cancer

Lauren Robbins, DNP, APRN, GNP-BC Terri Setzer, NP-C

Nurse Practitioner Nurse Practitioner
Atlanta VA Healthcare System Reidsville Clinic for GI Diseases, Cone Health Medical
Decatur, Georgia Group
Bowel Obstruction Reidsville, North Carolina
Nonalcoholic Fatty Liver Disease
Mary Ellen E. Roberts, DNP, APN-c, FNAP, FAANP,
FAAN Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAAN,
Director – Doctor of Nursing Practice Program FAANP
Seton Hall University Clinical Associate Professor, Retired
South Orange, New Jersey PMHNP Specialty Coordinator
Cardiac Arrhythmias; Myocardial Infarction University of Arizona, College of Nursing
Tucson, Arizona
Barbara Rogers, CRNP, MN, AOCN, ANP-BC Depression
Nurse Practitioner
Fox Chase Cancer Center Tracey Sherrod, MSN, ANP-C, GNP BC
Philadelphia, Pennsylvania Adult and Gerontological Nurse Practitioner
Leukemias Vidant Healthplex
Wilson, North Carolina
Nephrolithiasis
 Contributors xiii

Carroll M. Spinks, GNP-BC Jennifer L. Warren, MSN, NP-C

Nurse Practitioner Nurse Practitioner
Triad HealthCare Network Anticoagulation Clinic
Greensboro, North Carolina Wake Forest Baptist Health
Corns and Calluses High Point, North Carolina
Pulmonary Embolism
David V. Strider, DNP, MSB, APRN, CCRN, ACNP-BC
Nurse Practitioner, Clinical Assistant Professor of Tomika Williams, PhD, AGPCNP-C
Nursing Assistant Professor of Nursing
University of Virginia School of Nursing East Carolina University
Charlottesville, Virginia Greenville, North Carolina
Peripheral Vascular Disorders Malnutrition

Ladsine Taylor, MSN, GNP-BC Colleen Wojciechowski, MSN, GNP-BC

Gerontology Nurse Practitioner Nurse Practitioner, Retired
Bill Hefner VA Medical Center Community Living Veteran Administration Durham Health Care System
Center Cary, North Carolina
Salisbury, North Carolina Cough
Peripheral Neuropathy
M. Catherine Wollman, DNP, GNP-BC, CRNP
Barbara A. Todd, DNP, CRNP, FAANP, FAAN Consultant
Director, Graduate Nurse Education Demonstration Ponte Vedra, Florida
Hospital University of Pennsylvania Chronic Illness and the APRN
Philadelphia, Pennsylvania
Valvular Heart Disease

Renee Walters, PhD, RN, CCRN, FNP-BC

Clinical Operations Manager, Clinical Associate
Professor
Boise State University
Boise, Idaho
Restrictive Lung Disease; Immune Thrombocytopenic Purpura
 Reviewers

Wendy Biddle, CFNP Valerie Flattes, APRN, MS, ANP-BC

Program Director MSN-FP program Assistant Professor
South University University of Utah
Savannah, Georgia Salt Lake City, Utah

Joan Blum, MSN, APRN Stacy Harris, DNP, APRN

Assistant Professor Graduate Program Coordinator, Assistant Professor
Clarkson College University of Central Arkansas
Omaha, Nebraska Conway, Arkansas

Sharon Chalmers, PhD, CNE, APRN, FNP-BC Ann McDonald, DNP, MSN
Professor of Nursing Assistant Professor
University of North Georgia Western Carolina University
Dahlonega, Georgia Cullowhee, North Carolina

Claudia M. Chaperon, PhD, RN, APRN, BC Clarice Wasmuth, MSN, NP

Associate Professor Professor
College of Nursing Georgia State University
University of Nebraska Medical Center Atlanta, Georgia
Omaha, Nebraska

xv
 Acknowledgments

The second edition of this book would not be a reality if crew for carrying us over the finish line, without which we
not for the kind assistance and guidance of some wonderful would not have completed the charge. To Ashleigh Lucas,
people whom we would like to thank. To Susan R. Rhyner, Amy Daniels, and Tyesha Harvey who assisted in informa-
our Senior Acquisitions Editor, who believed in the timeli- tion retrieval, thanks for your timely research. We are most
ness of updating this edition given the impact that the APRN appreciative to our dedicated contributors who believe in the
consensus model for advanced practice registered nurses has importance of creating a reference specific to the care of older
on nursing education and practice with the required inclu- adults written by advanced practice registered nurses. We
sion of gerontology and geriatrics for all advanced practice also would like to acknowledge those who have contributed
nurses taking care of older adults. To Christine M. Abshire, to our previous books. We especially want to thank Kathleen
our Senior Content Project Manager, who kept us on track Ryan Fletcher for being a part of the journey over the past
and provided us order. To Teresa Wilson for your quick turn- 20 years; your expertise and dedication to advanced practice
around editing and to Sharon Y. Lee, Daniel Domzalski, and gerontological nursing will not be forgotten.

xvii
 Contents in Brief

Unit I 12 Musculoskeletal Disorders 305

The Healthy Older Adult 1 13 Central and Peripheral Nervous System

Disorders 328
1 Changes With Aging 2
14 Endocrine, Metabolic, and Nutritional
2 Health Promotion 6 Disorders 361
3 Exercise in Older Adults 19 15 Hematological and Immune System
Disorders 407
Unit II 16 Psychosocial Disorders 428
Assessment 25
4 Comprehensive Geriatric Unit IV
Assessment 26 Complex Illness 469
5 Symptoms and Syndromes 34 17 Polypharmacy 470
18 Chronic Illness and the APRN 474
Unit III
19 Palliative Care and End-of-Life
Treating Disorders 95 Care 485
6 Skin and Lymphatic Disorders 96
appendix A Physiological Influences of the
7 Head, Neck, and Face Disorders 127
Aging Process 499
8 Chest Disorders 152
appendix B Laboratory Values in the Older
9 Peripheral Vascular Disorders 215 Adult 505
10 Abdominal Disorders 225
11 Urological and Gynecological
Disorders 280 Index 507

xix
 Psychological Health 31
Unit I
Socioenvironmental Supports 32
The Healthy Older Adult 1 Quality of Life Measures 32
CHAPTER 1 Changes With Aging 2 Summary 32

Fundamental Considerations 2 CHAPTER 5 Symptoms and

Physiological Changes With Aging 2 Syndromes 34
Laboratory Values in Older Adults 3 Assessment 34
Presenting Features of Illness/Disease in the Older Bowel Incontinence 34
Adult 3 Chest Pain 38
Chronic Illness and Functional Capacity 5 Constipation 41
Summary 5 Cough 43
CHAPTER 2 Health Promotion 6 Dehydration 46
Diarrhea 47
Primary, Secondary, and Tertiary Prevention 7
Dizziness 51
Healthy Lifestyle Counseling 7
Dysphagia 53
Screening and Prevention 9
Falls 55
Immunizations 12
Fatigue 57
Travel and Leisure 12
Headache 59
Summary 17
Hematuria 63
Case Study 17
Hemoptysis 65
CHAPTER 3 Exercise in Older Adults 19 Involuntary Weight Loss 67
Available Resources 19 Joint Pain 72
Barriers and Facilitators to Exercise for Older Peripheral Edema 74
Adults 20 Pruritus 77
Plan for Incorporating Exercise into Patient Syncope 78
Encounter 20 Tremor 81
Key Guidelines for Safe Physical Activity (Physical Urinary Incontinence 83
Activity Guidelines Advisory Committee,
Wandering 88
2008) 21
Case Study 90
Summary 22
Case Study 23
Unit III
Treating Disorders 95
Unit II
CHAPTER 6 Skin and Lymphatic
Assessment 25
Disorders 96
CHAPTER 4 Comprehensive Geriatric Assessment 96
Assessment 26 Burns 97
Physical Health 26 Cellulitis 103
Functional Health 30 Corns and Calluses 104

xxi
xxii Contents

Herpes Zoster 106 Peripheral Vascular Disease 219

Pressure Injuries 109 Venous Disease (Chronic Venous Insufficiency) 221
Psoriasis 113 Case Study 223
Skin Cancer 117
CHAPTER 10 Abdominal Disorders 225
Superficial Fungal Infections 120
Case Study 125 Assessment 225
Acute Kidney Injury 226
CHAPTER 7 Head, Neck, and Face Bladder Cancer 230
Disorders 127 Bowel Obstruction 231
Assessment 127 Cholecystitis 233
Cataract 128 Chronic Kidney Disease 235
Epistaxis 130 Cirrhosis of the Liver 239
Glaucoma, Acute and Chronic 132 Clostridium difficile 242
Glaucoma, Acute (Primary Angle-Closure) 132 Colorectal Cancer 245
Glaucoma, Chronic (Primary Open-Angle) 133 Diverticulitis 249
Hearing Loss 136 Esophagitis 251
Hordeolum and Chalazion 138 Gastric Cancer 253
Age-Related Macular Degeneration 139 Gastritis 256
Oral Cancer 141 Gastroenteritis 258
Retinopathy 144 Gastroesophageal Reflux Disease 260
Rhinitis 146 Hernia 263
Case Study 150 Irritable Bowel Syndrome 265
Liver Cancer 268
CHAPTER 8 Chest Disorders 152
Nephrolithiasis 270
Assessment of the Cardiovascular System 152
Nonalcoholic Fatty Liver Disease 272
Assessment of Risk Factors for Coronary Artery
Peptic Ulcer Disease 274
Disease 152
Case Study 276
Clinical Examination Features 153
Assessment of the Respiratory System 154 CHAPTER 11 Urological and Gynecological
Asthma 155 Disorders 280
Cardiac Arrhythmias 160 Assessment 280
Chronic Obstructive Pulmonary Disease 164 Atrophic Vaginitis 282
Heart Failure 170 Breast Cancer 284
Hypertension 175 Cystitis 289
Ischemic Heart Disease 179 Endometrial Cancer 292
Lung Cancer 185 Ovarian Cancer 293
Myocardial Infarction 187 Benign Prostatic Hyperplasia (Benign Prostatic
Pneumonia 191 Hypertrophy) 295
Pulmonary Embolism 196 Drug-Induced Erectile Dysfunction 297
Pulmonary Tuberculosis 199 Prostate Cancer 299
Restrictive Lung Disease 203 Prostatitis 301
Upper Respiratory Tract Infection 205 Case Study 303
Valvular Heart Disease 207
CHAPTER 12 Musculoskeletal
Case Study 211
Disorders 305
CHAPTER 9 Peripheral Vascular Assessment 305
Disorders 215 Bursitis, Tendinitis, Soft Tissue
Assessment 215 Syndromes 307
Abdominal Aortic Aneurysm 216 Fractures 310
Chronic Lymphedema 218 Gout 312
 Contents xxiii

Osteoarthritis 315 Anxiety 434

Polymyalgia Rheumatica 319 Bipolar Disorder 436
Rheumatoid Arthritis 322 Delirium 439
Case Study 325 Dementia 443
Depression 451
CHAPTER 13 Central and Peripheral Nervous
Elder Abuse 456
System Disorders 328
Grief and Bereavement 459
Assessment 328 Insomnia 461
Brain Tumor 331 Prescription Drug Misuse (Hazardous or Risky
Parkinson’s Disease 333 Users) 463
Peripheral Neuropathy 336 Case Study 466
Restless Legs Syndrome 344
Seizure Disorders 346 Unit IV
Stroke 352
Case Study 359
Complex Illness 469
CHAPTER 17 Polypharmacy 470
CHAPTER 14 Endocrine, Metabolic, and
Pharmacokinetic/Pharmacodynamic Changes 470
Nutritional Disorders 361
Tools to Assist Providers to Avoid PIMs and
Assessment 361 Polypharmacy 472
Acute Pancreatitis 362 Preventing Polypharmacy, Addressing
Chronic Pancreatitis 366 Polypharmacy 472
Diabetes Mellitus, Types 1 and 2 369
Failure to Thrive 377 CHAPTER 18 Chronic Illness and the
Hyperlipidemia 379 APRN 474
Hyperthyroidism 384 Definitions of Chronic Disease and Chronic
Hypothyroidism 387 Illness 474
Malnutrition 389 Demographics of Chronic Illness 474
Obesity 392 Multiple Chronic Conditions 475
Osteoporosis 396 Economic Burden of Chronic Disease 477
Pancreatic Cancer 402 Minorities and Chronic Disease 478
Case Study 404 Function and Frailty 478
Evidence-Based Practice and Chronic Disease 479
CHAPTER 15 Hematological and Immune Chronic Care Model of Quality Improvement 479
System Disorders 407 Legislation and Chronic Disease 480
Assessment 407 Transitions of Care 480
Anemia of Chronic Disease 408 Provider Reimbursement for Chronic Illness
Anemia, Iron Deficiency 410 Care 482
Immune Thrombocytopenic Purpura (Idiopathic The Role of APRNs in Chronic Disease 482
Thrombocytopenic Purpura) 413 Case Study 483
Leukemias 414
CHAPTER 19 Palliative Care and End-of-Life
Acute Lymphoblastic Leukemia 414
Acute Myeloid Leukemia 416
Care 485
Chronic Lymphocytic Leukemia 419 Overview of Palliative Care 485
Chronic Myeloid Leukemia 423 Symptom Management 486
Case Study 426 Delirium 486
Dyspnea 488
CHAPTER 16 Psychosocial Disorders 428 Pain 490
Assessment 428 The Dying Patient 493
Agitation 429 Grief and Bereavement 496
Alcohol Misuse (Hazardous or Risky Drinkers) 431 Case Study 497
xxiv Contents

appendix A Physiological Influences of the

Aging Process 499
appendix B Laboratory Values in the Older Index 507
Adult 505
 unit I
The Healthy
Older Adult
CHAPTER

1
Changes With Aging
Laurie Kennedy-Malone

FUNDAMENTAL A.) Although Appendix A uses a single-system approach, the

CONSIDERATIONS clinician must be aware that all the systems interact and,
in doing so, can increase the older person’s vulnerability to
illness/disease. For example, the risk of respiratory infection
The aged population continues to be incredibly diverse; it in the geriatric population is considerable, and the physiolog-
includes some individuals who are nearly twice as old as ical influences may include limited chest wall expansion, cilia
others and is reflective of growing cultural diversity as well. atrophy, and alterations in the immune system. During the
Knowing what is expected in aging, what diseases are prev- clinical decision-making process, the clinician knowledgeable
alent in aging, and what constitutes successful aging is an about physiological changes with aging will be less likely to
immense challenge even for the most skillful advanced clini- undertreat a treatable condition. For example, the astute cli-
cian. When assessing the aged individual, the advanced prac- nician will use the diagnostic process to differentiate the more
tice nurse should be familiar with the range of normal and benign seborrheic keratosis from the more serious melanoma
expected changes associated with aging so that older persons in the aged individual. While educating the older patient, the
falling outside this range may be identified and interventions informed professional will be less likely to attribute a finding
taken appropriately and expeditiously. to the aging process alone. When clinicians associate findings
In the past, wellness was considered the mere absence of to aging alone, the older person may conclude that there is
disease, but with more information from longitudinal studies no point in changing behavior because the process is inevita-
of aging, we are learning a great deal about the charac- ble. Additionally, the clinician may take a fatalistic approach
teristics of successful physiological and psychosocial agers and undertreat common conditions such as heart failure and
(O’Brien et al., 2009). A profile of what constitutes suc- diabetes.
cessful aging is beginning to emerge, and the illness–health The major impact of these physiological changes can be
continuum continues to expand to include adults living into highlighted with four primary points. First, there is a reduced
old age. This chapter focuses on familiarizing the advanced physiological reserve of most body systems, particularly
practice nurse with fundamental underpinnings that serve cardiac, respiratory, and renal. Second, there are reduced
to guide the approach to assessment and management of homeostatic mechanisms that fail to adjust regulatory
the older adult. In addition to appreciating the physiological systems such as temperature control and fluid and electro-
changes that come with aging, the advanced practice nurse lyte balance. Third, there are the changes in the sympathetic
needs to understand how aging changes influence reference response, which contribute to orthostasis and falls, as well
laboratory values. Recognizing that presenting features of as lack of hypoglycemic response. Fourth, there is impaired
disease/illness may be different and having a greater aware- immunological function: infection risk is greater and auto-
ness of the impact of chronic illness on functional capacity immune diseases are more prevalent. The clinician is advised
and quality of life provide the advanced practice nurse with not to be complacent in that some processes previously con-
a perspective in approaching the older adult that is different sidered normal, age-related changes are now being refuted.
from that of younger adults. Historically, normal aging studies were conducted using a
cross-sectional study method. Today, results are becoming
PHYSIOLOGICAL CHANGES increasingly available from longitudinal studies of aged pop-
ulations, some of which began in the 1930s (Besdine, 2016;
WITH AGING O’Brien et al., 2009).
This more reliable methodology provides some challenges
The physiological changes associated with the usual aging to previously held conclusions. The clinician is encouraged
process have been detailed by system, and the impact of these to stay informed regarding the research in expected and
changes has been described. (These can be found in Appendix successful aging so that this information may be carefully

2
 Chapter 1 ■ Changes With Aging 3

considered, interpreted, and translated quickly into the clin- creatinine clearance provides an index of renal function for
ical setting. use in choosing doses of renally eliminated or nephrotoxic
drugs (such as digoxin, H2 blockers, lithium, and water-
soluble antibiotics). The Modification of Diet in Renal Disease
LABORATORY VALUES (MDRD) and Cockcroft-Gault equations both provide useful
estimates of the GFR (Boparai & Korc-Grodzicki, 2011). The
IN OLDER ADULTS performance of these two formulas was compared in an older
adult population, and the Cockcroft-Gault formula was found
Healthy individuals of all ages often have asymmetrical dis- to be inferior to the MDRD equation; however, the MDRD
tribution of test results. Normality in a statistical sense may equation is not as practical and is more complex to use (Fliser,
be extrapolated incorrectly to normality in terms of health. 2008). The use of serum drug concentration measurements
In addition, the standards previously available to the health- (where these are available) or timed urine specimens is rec-
care worker with which to compare normal laboratory values ommended until more acceptable methods of calculating
have been based on randomly collected samples of younger renal function in this population become available.
healthy adults. Many factors can influence laboratory value Finally, when considering which laboratory tests to order,
interpretation in the older adult, including the physiolog- it is worth remembering the doctrine primum non nocere, to
ical changes with aging, the prevalence of chronic disease, do no harm. Excessive blood sampling may lower the hema-
changes in nutritional and fluid intake, lifestyle (including tocrit; repeated fasting tests may provoke nutritional com-
activity), and the medications taken (Dharmarajan & Pitchu- promise; and extensive use of tests often requires drugs that
moni, 2012). may cause adverse reactions. Any risks involved in laboratory
Clinicians may find that reference ranges, therefore, may testing must be considered with respect to the patient’s clin-
be preferable. Reference ranges or intervals, such as age, sex, ical condition and weighed against the test’s expected ben-
or race, can be defined demographically. For example, the ref- efits. The clinician should plan in advance the use for each
erence range for older adults might be the intervals within test result value obtained, especially for less specific or less
which 95% of persons over age 70 fall. These may be further sensitive tests such as sedimentation rate and serum alkaline
defined physiologically (e.g., fasting or activity status) or phar- phosphatase levels. “Ordering a test requires assessing the
macologically (e.g., medication, tobacco or alcohol use). Even likelihood that a patient has specific conditions prior to the
this more precise method does not ensure a healthy sampled order, along with the accuracy of test and as to how it will
population as the standard, and using the reference range change management” (Dharmarajan & Pitchumoni, 2012,
method may not differentiate normal aging from disease. p. 267). Once laboratory tests are available for review, test
The reference values presented for the older adult cohort (see results should be discussed with the patients, with abnormal
Appendix B) are not necessarily desirable ones. Longitudinal test results interpreted for the aging individual and addressed
chemical studies support the concept of biochemical indi- with the patient and/or caregivers. In addition to under-
viduality; that is, each individual’s variation is often much standing the fundamental changes that accompany aging
smaller than that of the larger group. Biochemical individ- and their influence on interpreting laboratory values and
uality is of particular importance in detecting asymptomatic medication management, the advanced practice nurse needs
abnormalities in older adults. Significant homeostatic dis- to understand the presenting features of illness/disease in
turbances in the same individual may be detected through older adults (Dharmarajan & Pitchumoni, 2012).
serial laboratory tests, even though all individual test results
may lie within normal limits of the reference interval for the
entire group. PRESENTING FEATURES
The clinician must determine whether a value obtained OF ILLNESS/DISEASE IN
reflects a normal aging change, a disease, or the potential
for disease. Although abnormal laboratory findings are often
THE OLDER ADULT
attributed to old age, rarely are they true aging changes. Mis-
interpretation of an abnormal laboratory value as an aging The manifestations of illness and disease in the older adult
change can lead to underdiagnoses and undertreatment in can be very different, even if the underlying pathological
some situations (e.g., anemia or urinary tract infection) and process is the same as in younger individuals. The advanced
overdiagnosis and overtreatment in others (e.g., hypergly- practice nurse should be aware of what can influence the
cemia or asymptomatic bacteriuria). At times, the result of presentation. Underreporting of symptoms by older adults
a laboratory value may be within the appropriate reference may occur if they attribute the new sign or symptom to age
range, yet indicate pathology for the older adult (Dharmara- itself (Amella, 2004). By erroneously associating aging with
jan & Pitchumoni, 2012). The serum creatinine level may be disease, disuse, and disability, older adults perceive this change
within the normal range, yet indicate renal impairment in as inevitable and either fail to present to the health-care pro-
a patient with inadequate protein stores, and different mea- vider or, if they do, fail to challenge the assumption that this
sures might need to be considered. One value of significance represents normal aging. At times an acute symptom such as
to the practitioner with prescriptive privileges is the calcula- pain or dyspnea is superimposed on a chronic symptom, and
tion of creatinine clearance in the estimation of renal func- the older adult may not recognize that it represents a new
tion, for instance when dosing enoxaparin (Shaikh & Regal, or exacerbated pathology (Bell et al., 2016). The advanced
2017). practice nurse is well advised to never attribute something to
Reduced renal function, particularly the glomerular fil- normal aging without doing a careful and methodical search
tration rate (GFR), affects the clearance of many drugs, and for a treatable condition.
4 Chapter 1 ■ Changes With Aging

Certain diseases are more common in the older adult and

TABLE 1-1
an understanding of the epidemiology is critical in the inter- Presentation of Illness in Older Adults
pretation. Certain neoplasms and malignancies such as basal ILLNESS ATYPICAL PRESENTATIONS
cell carcinoma, chronic lymphocytic leukemia, and prostate
cancer have a high prevalence beginning in older adulthood. Acute abdomen Absence of symptoms or vague symptoms
Neurological conditions such as Parkinson’s disease, demen- Acute confusion
tias, stroke, and complex partial seizures are more common Mild discomfort and constipation
Some tachypnea and possibly vague respiratory
to have initial onset in older age. Polymyalgia rheumatica
symptoms
along with giant cell arteritis almost exclusively begins in Appendicitis pain may begin in right lower
patients over the age of 50 (Besdine, 2016). quadrant and become diffuse
Complicating the care of older adults is when patients
develop geriatric syndromes that often involve multiple body Depression Anorexia, vague abdominal complaints, new
onset of constipation, insomnia, hyperactivity,
systems and have more than one underlying cause (Bell et
lack of sadness
al., 2016). For patients presenting with one or more of new
geriatric giants: frailty, anorexia of aging, sarcopenia, and Hyperthyroidism Hyperthyroidism presenting as “apathetic
cognitive impairment, the risk escalates for falls, delirium, thyrotoxicosis,” i.e., fatigue and weakness; weight
injuries, and depression, subsequently placing these patients loss may result instead of weight gain; patients
report palpitations, tachycardia, new onset of
at dangers for iatrogenic events that could lead to hospital-
atrial fibrillation, and heart failure may occur
ization, institutionalization, and subsequently, death (Morley, with undiagnosed hyperthyroidism
2017).
Hypothyroidism Hypothyroidism often presents with confusion
Altered Presentation of Illness and agitation; new onset of anorexia, weight
loss, and arthralgias may occur
Advanced practice nurses managing the care of older adults
are challenged to recognize altered, atypical, vague, or even Malignancy New or worsening back pain secondary to
nonspecific signs and symptoms of common conditions in metastases from slow growing breast masses
Silent masses of the bowel
older adults (Auerhahn & Kennedy-Malone, 2010). It is well
documented that disease progress may be different for the Myocardial Absence of chest pain
older adult, especially the frail older adult (Bell et al., 2016). infarction (MI) Vague symptoms of fatigue, nausea, and a
The failure to develop an elevated temperature or fever with decrease in functional and cognitive status;
an underlying infectious process differs greatly from pre- classic presentations: dyspnea, epigastric
discomfort, weakness, vomiting; history of
sentation of illness in a younger patient. The patient with
previous cardiac failure
depression may not present with a dysphoric mood but rather Higher prevalence in females versus males
agitation and psychotic features. The older adult may present Non-Q-wave MI
with cardiac manifestations of undiagnosed thyroid disease
(Amella, 2004). Additional illustrative examples include Overall infectious Absence of fever or low-grade fever
diseases process Malaise
jaundice, which is suggestive of viral hepatitis in younger
Sepsis without usual leukocytosis and fever
individuals but may represent gallbladder disease or a malig- Falls, anorexia, new onset of confusion and/or
nancy in the older adult, and delusions or hallucinations, alteration in change in mental status, decrease in
which are suggestive of bipolar disorder in younger individ- usual functional status
uals but may represent dementia or medication side effects in
Peptic ulcer Absence of abdominal pain, dyspepsia, early
the older adult (Williams, 2008).
disease satiety
Because the symptoms or signs of illness or disease may be Painless, bloodless
vague and nonspecific, even a modest change in functional New onset of confusion, unexplained
level or behavior should alert the clinician to carefully explore tachycardia, and/or hypotension
the potential for a treatable condition. Family members or
Pneumonia Absence of fever; mild coughing without
caregivers may report that a patient may no longer be coop-
copious sputum, especially in dehydrated
erating or participating in individual care. Unusual changes patients; tachycardia and tachypnea; anorexia and
such as these become red flags to the beginning of an atypi- malaise are common; alteration in cognition.
cal presentation of illness. In many cases the progression of
the condition is insidious, often presenting as a change in Pulmonary edema Lack of paroxysmal nocturnal dyspnea or
coughing; insidious onset with changes in
cognition or an alteration in functional status. Other signif-
function, food or fluid intake, or confusion
icant changes in patients with altered presentation of illness
often include new onset of falls, weakness, fatigue, anorexia, Tuberculosis (TB) Atypical signs of TB in older adults include
and unexplained tachypnea (Auerhahn & Kennedy-Malone, hepatosplenomegaly, abnormalities in liver
2010). Table 1-1 depicts common conditions that often have function tests, and anemia
altered presentation of illness in older adults. Urinary tract Absence of fever, worsening mental or
infection functional status, dizziness, anorexia, fatigue,
weakness
Bimodality of Age of Onset
of Clinical Conditions Source: Amella, E. J. (2004); Bell et al., 2016; Besdine (2016); Chmura & Chan
Understanding of the epidemiology of clinical conditions (2006); Peters (2010); Rehman & Qazi (2013); Rowe & Juthani-Mehta, M.
(2014); Van Duin (2011); Wester, Dunlop, Melby, Dahle, & Wyller (2013);
includes having the knowledge of etiology of the disease, Williams (2008).
 Chapter 1 ■ Changes With Aging 5

TABLE 1-2
Select Bimodal Presentations of Illness in Younger Adults versus Older Adults
TYPE OF CONDITION YOUNGER ADULTS OLDER ADULTS

Dermatological Late teens to 20s 50s—males

Psoriasis Irregular course which tends to generalize 60s—females
Hereditary factors Sporadic onset
Gastrointestinal 20–40 years old >60–75 years old a second peak occurs
Inflammatory bowel disease Right lower UC More often older women
Ulcerative colitis (UC) Insidious onset Proctitis
Crohn’s disease (CD) Left-sided UC
Higher rates of anemia
May present as chronic diarrhea
Fistula development
Increased cases of associated malnutrition
Extraintestinal manifestations including: arthritis spondylitis,
uveitis, and erythema nodosum
More comorbid conditions
May be confused with other forms of colitis
Malignancies 20–30 years old >50 years old
Hodgkin’s lymphoma Possible infectious etiology Increased mortality
Neurodegenerative Women 20–40 years old Men—50–70 years old
Myasthenia gravis (MG) More thymus abnormalities Women—70 years old
Dysphonia
More frequent ocular form MG
Increased rate of AChR seropositivity

Source: Alkhawajah & Oger (2015); del Val (2011); Henseler & Christophers (1985); Louis & Dogu (2007); Montero-Odasso (2006); Shenoy, Maggioncalda,
Malik, & Flowers (2011); Smith (2013); Smith, Kassab, Payne, & Beer (1993); Wester, Dunlop, Melby, Dahle, & Wyller (2013); Woon & Lim (2003); Živković,
Clemens, & Lacomis (2012).

prevalence and incidence rates, risk factors, age of onset, and and Human Services [USDHHS], Centers for Disease Control
gender distribution. There are a number of conditions that and Prevention [CDC], 2010). Treating patients with multi-
are known or suggested to have a bimodal age of onset. In morbidities can be very complex and can result in polyphar-
some conditions the difference is not only the decade(s) in macy. Patients with multimorbidities are known to have a
life that the disease more likely presents but the dominance treatment burden in terms of understanding and self-care
of the gender that the condition presents. Myasthenia gravis management of their conditions. This burden entails not
is one condition that tends to present initially in younger only patients managing the conditions but attending multi-
females, with a preponderance in older males (Alkhawajah ple appointments and comprehending and affording complex
& Oger, 2015). drug regimens (Wallace et al., 2015).
Often the presentation of the same illness is different for These conditions often impair functional capacity and
older adults as compared to their younger counterparts. The limit the person’s ability to perform activities of daily living
onset of the condition may be acute versus progressive, with (ADLs) such as bathing and dressing, and instrumental activ-
different symptomatology and clinical signs. For instance, ities of daily living (IADLs) such as managing medications
in patients with late onset rheumatoid arthritis the joint and traveling. More than 25% of community-dwelling Medi-
involvement is more often in the larger joints such as the care beneficiaries report difficulties performing ADLs, and
shoulder and they experience constitutional symptoms such 14% report difficulties performing IADLs (USDHHS, Admin-
as fever, malaise, weight loss, and depression (Evcik, 2013). istration on Aging [AOA], 2010).
Knowledge of the bimodality of age onset of certain disease
conditions will aid the advanced practice nurse in avoiding
SUMMARY
misdiagnosis or delay in diagnosis due to lack of recognition.
Table 1-2 describes medical conditions that present differ- ■ Assessment and management of older adults is different from
ently in younger versus older adults. that of younger adults, and it is of critical importance that the
advanced practice nurse working with the older adult has the
knowledge, skill, and ability to recognize these differences and
CHRONIC ILLNESS AND take them into consideration. This chapter highlighted how
the approach of the clinician might be different based on an
FUNCTIONAL CAPACITY understanding of the physiological changes of aging and the
impact of these changes on medication management and lab-
Approximately 80% of those 65 or older have one chronic oratory interpretation; how the presenting features of disease
disease, and 50% have two or more. The most common of and illness may be different in the older adult; and how the
these are related to heart disease, arthritis, respiratory prob- older adult are disproportionately affected with chronic
lems, cancer, diabetes, and stroke (U.S. Department of Health disease and functional impairments.
CHAPTER

2
Health Promotion
Lori Martin-Plank

The concept of health promotion includes activities to which Because older adults have only recently begun to partici-
an individual is committed and performs proactively to further pate in studies on health promotion (Bleijenberg et al., 2017)
his or her health and well-being. This includes not only pre- and because single-focused interventions for health promo-
ventive and health-protective measures but also actualization tion often do not “fit” with the interrelatedness of older adult
of one’s health potential. The broadest definition, identified health-promotion challenges, clear age-specific preventive
by the World Health Organization (WHO), includes healthy health guidelines for the older population are scarce. Many
lifestyle promotion, creation of supportive environments for disorders in older adults encompass multiple risk factors that
health, community action, redirection of health services, and involve several systems and interventions to achieve out-
healthy public policy formulation. According to the WHO, by comes. This presents a challenge when measuring and syn-
2050 the world population of those over 60 years old will thesizing evidence and reporting outcomes (AGS Guide to
be at 22%, nearly double what it was in 2015 (WHO, Aging Multimorbidity, 2012). Medicare will only pay for A and B
Facts, 2015). In its Global Strategy and Action Plan for Ageing level recommendations that meet the U.S. Preventive Services
and Health, the WHO identifies five priorities for member coun- Task Force (USPSTF) stringent evidence guidelines, leaving
tries: 1) A commitment to healthy ageing; 2) synchronizing other beneficial interventions without coverage. Another
the needs of older persons and health systems; 3) designing confounding factor is the way that outcomes for screening
age-friendly environments, 4) developing long-term care are measured in terms of years of life saved. For older adults,
systems; and 5) research (WHO, 2017). Within the United quality of life or functional life is a more realistic goal (Fried-
States, there are several resources for healthy aging, includ- man, Shah, & Hall, 2015).
ing the Centers for Disease Control and Prevention (CDC) and The Healthy People 2020 program has also set specific
Health Promotion Web site on Healthy Aging (https://www. objectives for prevention in older adults. These include
cdc.gov/aging/aginginfo/index.htm) and the American Geri- increased use of the Welcome to Medicare visit, an increased
atrics Society Health in Aging Web site geared to consumers percentage of older adults who are up to date on all preven-
(http://www.americangeriatrics.org/public). tive services, and decreased use of the emergency department
These resources are available and contain measures that for falls by older adults, among others. Because of the focus
are within the scope of practice for the nurse practitioner on chronic disease management and the complexities of mul-
(NP) to enhance the visibility of the role while advancing the tiple comorbidities in older adults, many primary health-care
needs of patients. NPs are in a unique and pivotal position to providers are not oriented toward the potential of healthy
guide and encourage health-promotion programs and individ- aging and discount the importance of health promotion in
ual efforts. From our nursing background, we bring a holis- this age group (Friedman et al., 2015).
tic orientation to health and wellness, as well as knowledge Current life expectancy is 78.8 years (CDC, National Center
of developmental tasks and the wellness–illness continuum. for Health Statistics [NCHS], 2017), with many people living
Our advanced practice education helps us diagnose and treat to 100 years and beyond. It behooves us to focus on preven-
patients in a way that supports their return to optimal level tion and health promotion in our older patients to maximize
of function and/or maximizes their coping abilities within the quality of these years. A collaborative plan should include
the limits of their existing function. This particular blend of consideration of the patient’s health beliefs and goals, present
NP competencies is especially valuable in working with older and anticipated levels of function, risks and benefits of pro-
patients. Heterogeneity increases with aging, presenting the posed interventions, and effectiveness of specific preventive
NP with the challenge of individualizing health-promotion interventions for older adults. The Welcome to Medicare visit
recommendations for each patient. Most of the literature on provides a good opportunity to focus solely on preventive
older adult health is devoted to treatment of frail older adults, services and health promotion; this is followed by the Medi-
those with geriatric syndromes and dementia (Friedman, care-supported annual prevention visit. Health-promotion
Shah, & Hall, 2015). There is a need to develop programs and activities should be incorporated into every patient encoun-
measure outcomes in promoting health in older adults. ter, as opposed to being addressed selectively, and should be

6
 Chapter 2 ■ Health Promotion 7

individualized to the patient. Recent efforts are being focused flexibility, increased muscle mass, maintenance of desirable
on partnering population-based, community-centered pro- weight, decreased insulin resistance, decreased peripheral
grams with personal health initiatives in older adults to make vascular resistance, lower blood pressure, and a sense of
interventions more available and more economical, and to well-being. Whenever possible, the components of aerobic
increase socialization opportunities and harness the power of activity (low to moderate), flexibility, balance, and strength-
group support. ening (weight training) should be included, and the physical
activity prescription should be individualized to the patient.
Active hobbies, such as gardening, golfing, tennis, dancing,
PRIMARY, SECONDARY, AND bowling, hiking, and swimming, are beneficial. Tai chi and
TERTIARY PREVENTION yoga are helpful for stretching and balance. Frail older adults
or older adults with impaired mobility can benefit from arm-
Preventive services are typically divided into the categories of chair exercises and modified ambulation.
primary, secondary, and tertiary. Primary prevention refers A recent study showed a decrease in risk of death in older
to those activities undertaken to prevent the occurrence adults with multiple morbidities who engaged in regular
of a disease or adverse health condition, including mental physical activity (Martinez-Gomez, Guallar-Castillon, Gar-
health. Health counseling and immunization are examples of cia-Esquinas, Bandinelli, & Rodriguez-Artalejo, 2017).
primary prevention. Patients need to be reassured that expensive equipment or
Secondary prevention refers to those tasks directed fitness memberships are not necessary to increase physical
toward detection of a disease or adverse health condition activity; motivation is the key. There are also many commu-
in an asymptomatic individual who has risk factors but no nity exercise programs targeted to older adults, as well as
detectable disease. Screening tests are examples of secondary Web sites that can be shared if the patient has access to the
prevention. The screening test must detect the condition at a Internet; these include Exercise is Medicine, the American
stage where it is treatable and a positive outcome is expected Association of Retired Persons (AARP), the National Council
after treatment. Mammography for breast cancer screening is on Aging (NCOA), and the National Institute on Aging (NIA).
an example of secondary prevention. Many programs are now targeting exercise and brain health
Tertiary prevention refers to management of existing to prevent cognitive decline. Several government and com-
conditions to prevent disability and minimize complications, munity group programs have handouts for patients.
striving for optimal level of function and quality of life. Pul- Before embarking on an exercise program, all patients
monary rehabilitation for a chronic obstructive pulmonary should have an evaluation of health history, including
disease (COPD) patient is an example of tertiary prevention. medications, present physical activity and functional level,
potential barriers to exercise, and a physical examination.
Older adults with known or suspected cardiac risk factors
HEALTHY LIFESTYLE should have a stress test before engaging in vigorous exer-
COUNSELING cise. All participants should be reminded of the need for ade-
quate hydration and use of caution during extreme weather
conditions.
The Welcome to Medicare visit (Centers for Medicare and
Medicaid, 2011) provides an ideal opportunity for healthy Nutrition
lifestyle counseling. In addition to a thorough history The heterogeneity of older adults is evident in the wide
(including some risk assessment, physical activity, diet, and range of nutritional issues affecting them. Before initiating
tobacco and alcohol use), home safety and depression assess- counseling on diet, obtain baseline information on current
ment are included. The Medicare MedLearn network has dietary intake and activity pattern, and combine this with
a link to guide providers covering all areas (www.cms.gov/ height and weight data and other health status information.
Outreach-and-Education/Medicare-Learning-Network-MLN/ For patients in the long-term care setting, this information
MLNProducts/downloads//MPS_QRI_IPPE001a.pdf ). is obtained easily from chart documentation. For communi-
Healthy lifestyle counseling should be addressed at each visit, ty-dwelling older adults, a brief nutrition screening tool such
using brief motivational interviewing (Lee, Choi, Royce, Yum, as the Mini Nutritional Assessment (MNA) can be helpful.
& Chair, 2016; Moral et al., 2015; Purath, Keck, & Fitzgerald, The abbreviated MNA consists of six questions, and there is a
2014). patient self-questionnaire that can be downloaded or mailed
in advance of the visit. The MNA Web site contains a section
Physical Activity on tools for clinicians, including a user guide and streaming
Older adults are the least active age group, although recent video (www.mna-elderly.com/tools_for_clinicians.html). It is
trends show an increase in physical activity in older adults. available in multiple languages as well.
The American College of Sports Medicine and the American The importance of a healthy, balanced diet to the overall
Heart Association issued updated recommendations for phys- health of older adults cannot be overemphasized. Chronic
ical activity in all adults, with additional recommendations illness and disability can interfere with the activities of daily
tailored to adults over age 65 and adults aged 50 to 64 with living such as shopping or preparing meals. Financial hard-
chronic conditions that are clinically significant or result in ship can limit food choices. Prescribed medications can affect
functional limitations (Nelson et al., 2007). Counseling on absorption of nutrients, sense of taste, or appetite. Depression
physical activity should include any type of activity that or social isolation can contribute to poor nutrition. Another
the patient is able and willing to do. The health benefits of problem commonly seen in community-dwelling older adults
regular physical activity are well documented and include is obesity. Close to one-half of U.S. older adults are overweight
8 Chapter 2 ■ Health Promotion

or obese (Batsis et al., 2017). A recent systematic review of for the patient because of a fall. In other cases, patients may
interventions targeting obesity in older adults found that pro- be fearful of ambulation as a result of a fall. Falls also pose a
grams combining physical activity and diet had better out- challenge in the long-term care environment. Education and
comes, although the findings were of low to moderate quality counseling combined with an assessment of the patient’s
(Batsis et al., 2017). There is a need for further research to environment are helpful. Keeping water, call bell, telephone,
guide clinical interventions to decrease obesity. Overweight and other necessities available and toileting regularly can
and obesity are associated with heart disease, certain types of minimize the potential for falling in nursing home patients.
cancer, type 2 diabetes, breathing difficulties, stroke, arthritis, Several home safety checklists are available on the Internet
and psychological problems. Although there is a decline in and can be given to patients for self-assessment.
the prevalence of overweight and obesity after age 60 years,
it remains a problem for many older adults. It is a major risk Aging in Place
factor for decreased mobility and functional impairment as In the past few years technology such as SMART HOMES
well as a cardiovascular risk. General guidelines for dietary and sensors have been introduced to facilitate aging in place.
counseling include: Most of these technologies are still in their infancy but offer
■ Limit fat and cholesterol. hope in delaying institutionalization and promoting healthy
■ Maintain a balanced caloric intake. functioning at home. Other programs, primarily in European
■ Emphasize the inclusion of grains, fruits, and vegeta- countries, are targeting at-risk “oldest old” and have designed
bles daily. comprehensive interventions to maintain them at home
■ Ensure an adequate calcium intake, especially for (Dahlin-Ivanoff et al., 2017). It is anticipated that more
women. technological interventions will be implemented to promote
■ Limit alcohol, if used, to one drink daily for women and healthy aging in place in the near future.
two drinks daily for men: one drink = 12 oz beer, 5 oz
wine, or 1.5 oz of 80-proof distilled spirits. Sexual Behavior
Assumptions regarding lack of sexual expression in the
Safety healthy older adult are unfounded. With the possibility of
pregnancy eliminated, many mature adults feel less restraint.
Prevention of injury in the older adult is of paramount impor-
As a result of divorce or widowhood, they may seek satis-
tance to continuing functionality and quality of life. Part of
faction with new partners yet lack the knowledge to protect
this counseling involves reinforcement of extant recommen-
themselves from sexually transmitted diseases, especially HIV.
dations, including wearing lap and shoulder seat belts in a
More than 42% of those living with HIV in the United States
motor vehicle, avoiding drinking and driving, having working
in 2013 were people more than 50 years old (CDC, 2017);
smoke detectors in the residence, and keeping hot water set
39% of deaths from HIV in 2014 were in adults more than
below 120°F. For older adults who drive a motor vehicle, peri-
55 years of age (CDC, 2017). Older adults need to be taught
odic assessment of their ongoing ability to drive safely is vital
methods for safe sex with use of a barrier to avoid sexually
to the older adult and the public at large. Most motor vehicle
transmitted diseases, including HIV and hepatitis B. Using the
accidents involve young drivers and older drivers.
patient’s sexual history, explore patient needs, preferences,
Two recommendations are especially important for ensur-
and medical or psychological obstacles to sexual expression.
ing the safety of the older adult. The first involves the safe
This exploration facilitates counseling and interventions to
storage and removal of firearms. Possession of a firearm com-
promote healthy sexual behavior.
bined with depression, caregiver stress, irreversible illness, or
decline in functional abilities can invite self-inflicted injury,
suicide pacts, or other acts of violence. Counsel patients to Dental Health
avoid firearms in the home and to use alternative means for Counseling regarding dental health in the older adult
self-protection such as alarm systems and pepper mace spray. includes the need for regular visits to the dental-care pro-
The second recommendation involves the prevention of falls, vider, daily flossing, and brushing with fluoride toothpaste.
the leading cause of nonfatal injuries and unintentional death Many elders have dentures or dental implants and assume
from injury in older persons. Certain combinations of phys- that dental checkups are no longer necessary. Oral screen-
iological and environmental factors place some patients at ing for cancer is still indicated, as is periodic assessment of
increased risk. About 85% of falls occur at home, in the later denture fit and functionality. Another concern is for the con-
part of the day. Office-based providers can assess for falls by dition of the remaining teeth of some older adults. Periodon-
asking if there is a history of falling and by performing the tal disease, erosion of dentin, or other problems may render
Get Up and Go test in the office. If indicated, evaluation of the teeth nonfunctional for chewing and a potential source
risk factors and a home safety assessment by a home health for infection. Dependence on others for transportation or lack
nurse or a geriatric assessment team can provide direction for of available dental resources for patients in long-term care
preventive intervention and education. Potential recommenda- settings further complicates the problem. Caregivers simply
tions include exercise programs to build strength, modification may overlook this aspect of preventive health or financial
of environmental hazards, monitoring and adjusting of med- considerations may preclude treatment. Patient and family
ications, external protection against falling on hard surfaces, education regarding dental health is essential.
and measures to increase bone density. If urinary incontinence
is a contributing factor, a urological work-up may be indicated. Substance Use
Falls are often alarming to patients and families. In some Counseling about substance use (tobacco, alcohol, and
cases, family members may desire nursing home placement drugs) and injury prevention can be combined naturally
 Chapter 2 ■ Health Promotion 9

within the issue of safety. Smoking is the leading prevent- interactions between alcohol and many prescription drugs,
able cause of death in the United States. Smoking cessation over-the-counter preparations such as acetaminophen, and
yields many benefits to former smokers in terms of reduction herbal remedies. The contribution of alcohol abuse to prob-
of risk for several chronic illnesses and stabilization of pul- lems such as insomnia, depression, aggressive behaviors,
monary status. Clear and specific guidelines are available to and deteriorating social relationships, should be addressed.
help health-care providers advise tobacco users to quit and to Likewise, the problem of dependence on prescription drugs
provide them with follow-up encouragement and relapse pre- such as analgesics, hypnotics, tranquilizers, and anxiolytics,
vention management. Quitting smoking may not be a choice should be assessed and addressed. Counseling in the form of
for the institutionalized older adult but rather dictated by individual follow-up sessions, group support, or outpatient
the policy of the institution. Health-care providers can offer or inpatient rehabilitation may be indicated. In a group-
support and encouragement, emphasizing the positive health living situation, the governing body (i.e., resident council)
changes that will result. may become involved if the patient’s behavior threatens the
Counseling regarding alcohol or other drug use can be safety or well-being of the other group members.
preventive or interventional, depending on the initial assess-
ment. Use the Michigan Alcohol Screening Test (MAST), the
CAGE questionnaire, or the Alcohol Use Disorders Identifi-
SCREENING AND PREVENTION
cation Test (AUDIT) to assess risk. Emphasize the dangers of
drinking and driving and the increased risk of falling while The following table contains the areas of screening and pre-
under the influence of alcohol or any drug that acts on the vention that are covered by Medicare for older adults and the
central nervous system. Teach patients about the coincidental relevant evidence to support these initiatives.

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES

The USPSTF concludes that the current evidence I Moyer for the USPSTF, 2012
is insufficient to assess the balance of benefits
and harms of screening for hearing loss in
asymptomatic adults aged 50 years or older.

The USPSTF recommends that clinicians screen A Moyer for the USPSTF, 2013
for HIV infection in adolescents and adults aged
15 to 65 years. Younger adolescents and older
adults who are at increased risk should also be
screened.

The USPSTF recommends that clinicians B Currently under revision, 2017

screen adults aged 18 years or older for alcohol https://www.uspreventiveservices
misuse and provide persons engaged in risky taskforce.org/Page/Document/
or hazardous drinking with brief behavioral UpdateSummaryDraft/unhealthy
counseling interventions to reduce alcohol -alcohol-use-in-adolescents-and
misuse. -adults-including-pregnant-women
-screening-and-behavioral
-counseling-interventions

The USPSTF recommends that clinicians ask A Siu for the USPSTF, 2015
all adults about tobacco use, advise them to
stop using tobacco, and provide behavioral
interventions and U.S. Food and Drug
Administration (FDA)–approved pharmacotherapy
for cessation to adults who use tobacco.

The USPSTF recommends screening for depression B Siu for the USPSTF, 2016
in the general adult population, including
pregnant and postpartum women. Screening
should be implemented with adequate systems
in place to ensure accurate diagnosis, effective
treatment, and appropriate follow-up.
Continued
10 Chapter 2 ■ Health Promotion

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES

The USPSTF recommends screening for high A Siu for the USPSTF, 2015
blood pressure in adults aged 18 years or
older. The USPSTF recommends obtaining
measurements outside of the clinical setting for
diagnostic confirmation before starting treatment.

The USPSTF recommends screening for abnormal B USPSTF, 2015

blood glucose as part of cardiovascular risk
assessment in adults aged 40 to 70 years who
are overweight or obese. Clinicians should offer
or refer patients with abnormal blood glucose to
intensive behavioral counseling interventions to
promote a healthful diet and physical activity.

The USPSTF recommends that adults without B Bibbins-Domingo for the USPSTF,
a history of cardiovascular disease (CVD) (i.e., 2016
symptomatic coronary artery disease or ischemic
stroke) use a low- to moderate-dose statin for the
prevention of CVD events and mortality when all
of the following criteria are met: 1) they are aged
40 to 75 years; 2) they have one or more CVD risk
factors (i.e., dyslipidemia, diabetes, hypertension,
or smoking); and 3) they have a calculated
10-year risk of a cardiovascular event of 10%
or greater. Identification of dyslipidemia and
calculation of 10-year CVD event risk requires
universal lipids screening in adults aged 40 to 75
years. See the “Clinical Considerations” section
for more information on lipids screening and the
assessment of cardiovascular risk.

The USPSTF recommends one-time screening Topic under revision, June 2017 by
for abdominal aortic aneurysm (AAA) by the USPSTF
ultrasonography in men aged 65 to 75 years who https://www.uspreventiveservices
have ever smoked. taskforce.org/Page/Name/topics-in
-progress

The USPSTF recommends screening all adults for Topic under revision, 2017
obesity. Clinicians should offer or refer patients https://www.uspreventiveservices
with a BMI of 30 kg/m2 or higher to intensive, taskforce.org/Page/Document/
multicomponent behavioral interventions. UpdateSummaryDraft/obesity-in
-adults-interventions1

The USPSTF recommends biennial screening B Siu for the USPSTF, 2016
mammography for women aged 50 to 74 years.

The USPSTF concludes that the current evidence I Siu for the USPSTF, 2016
is insufficient to assess the balance of benefits and
harms of screening mammography in women
aged 75 years or older.

The USPSTF concludes that the current evidence I Siu for the USPSTF, 2016
is insufficient to assess the balance of benefits and
harms of screening for impaired visual acuity in
older adults.
 Chapter 2 ■ Health Promotion 11

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES

The USPSTF recommends screening for B USPSTE, 2018
osteoporosis in women aged 65 years and older
and in younger women whose fracture risk is
equal to or greater than that of a 65-year-old
white woman who has no additional risk factors.

Prostate cancer is common in older men. USPSTF update in progress, 2017

https://screeningforprostatecancer.
org/

Screening for cognitive impairment in older USPSTF update in progress, 2017

adults. https://www.uspreventiveservices
taskforce.org/Page/Document/
UpdateSummaryDraft/cognitive
-impairment-in-older-adults
-screening1

The USPSTF recommends screening for A USPSTF, JAMA, 2016;

colorectal cancer (CRC) starting at age 50 315(23):2564–2575. doi:10.1001/
years and continuing until age 75 years (A jama.2016.5989
recommendation).

The decision to screen for colorectal cancer C

(CRC) in adults aged 76 to 85 years should be an
individual one, taking into account the patient’s
overall health and prior screening history (C
recommendation).

The decision to initiate low-dose aspirin use for C Bibbins-Domingo for the USPSTF,
the primary prevention of CVD and CRC in adults 2016
aged 60 to 69 years who have a 10% or greater
10-year CVD risk should be an individual one.
Persons who are not at increased risk for bleeding,
have a life expectancy of at least 10 years, and
are willing to take low-dose aspirin daily for at
least 10 years are more likely to benefit. Persons
who place a higher value on the potential benefits
than the potential harms may choose to initiate
low-dose aspirin.

The current evidence is insufficient to assess the I Bibbins-Domingo for the USPSTF,
balance of benefits and harms of initiating aspirin 2016
use for the primary prevention of CVD and CRC in
adults aged 70 years or older.

A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C = consensus,

disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to
www.aafp.org/afpsort.xml.
12 Chapter 2 ■ Health Promotion

TABLE 2-1
2017 Adult Immunization Schedule for Older Adults
VACCINE AGE GROUP DOSING

PCV13 Over 65 Single dose; for those with chronic health conditions
may administer a dose before age 65 and boost with
a second dose after age 65
PPSV23 Over 65 Give 1 year after PCV13
Diphtheria-tetanus-pertussis (Tdap) Any adult—one time substitute for Td Single dose
Tetanus diphtheria (Td) Every 10 years after single dose of DTaP Single dose every 10 years
Influenza All adults Annual
Hepatitis B All with risk factors due to lifestyle, history of Three doses
diabetes mellitus
Herpes zoster (HZV) Adults aged 50 years or older regardless of Two doses age 50 or older (Shingrix)
whether they had a prior episode of herpes
zoster; immunize those who have had Zostavax
with Shingrix

See full details and recommendations for special populations and contraindications at: Recommended adult immunization schedule—2017. Retrieved from
https://www.cdc.gov/vaccines/schedules/hcp/adult.html

and themselves better, visit friends and family, return to the

IMMUNIZATIONS land of their ancestors, volunteer, challenge themselves, and
because it is fun. They travel alone, in groups, and with their
Influenza vaccine is now recommended annually for all families. They go on cruises and they go on safaris. They
adults over 50 years old, unless contraindicated (Table 2-1). stay in five-star resorts and in host family homes. They take
Residents of long-term care facilities that house persons planes, buses, trains, jeeps, and rickshaws. They scuba dive,
with chronic medical conditions are at especially high risk hike the Himalayas, and bicycle in Tuscany. They teach and
for developing the disease. Health-care workers also should learn. They volunteer in Haiti, Ghana, and Honduras. But
receive the vaccine, preferably before the end of October travel can pose some unique health risks for the older trav-
(Resnick, 2018). Patients with a severe egg allergy or severe eler. The gerontology NP in primary care can provide pre-trip
reaction to the influenza vaccine in the past and patients advice to help ensure healthy and safe travel.
with a prior history of Guillain-Barré syndrome should talk
with their health-care provider before getting the vaccine. Travel Health and Nursing
Tetanus-diphtheria toxoids with acellular pertussis Travel health is an interdisciplinary specialty that has grown
(Tdap) vaccine is administered as a once-in-a-lifetime booster out of the need to protect travelers from illness and injury.
to every adult. Following this, a tetanus-diphtheria (Td) It developed in the 1970s as infectious disease and tropical
booster is recommended every 10 years. medicine clinicians treating returned travelers recognized
Pneumococcal vaccine is recommended as follows: that many of the problems they encountered could be pre-
Administer a one-time dose to PCV13-naïve adults at age 65 vented by pre-travel evaluations, immunizations, chemopro-
years, followed by a dose of PPSV23 12 months later. phylaxis, and counseling about safety, food and water, and
Hepatitis B vaccine is recommended for high-risk persons insect precautions.
such as IV drug users, persons who are sexually active with In 1991 the International Society of Travel Medicine
multiple partners, those living with someone with chronic (ISTM) (www.istm.org) was formed and established an
hepatitis B, patients less than 60 years old with diabetes, international body of knowledge to define travel medicine.
and all desiring protection from hepatitis B. The initial dose It is the only body offering an examination to demonstrate
is given, followed 1 month later by the second dose, then the competences for physicians, NPs, registered nurses (RNs),
third dose is given 4 to 6 months after the second dose. physician assistants (PAs), and pharmacists. Those who pass
Shingrix is a new vaccine for zoster and is recommended are awarded a Certificate in Travel Health. The American
over Zostavax. It is administered in two doses. The second Travel Health Nurses Association (ATHNA) (www.athna.org)
dose can be given from 2 to 6 months after the initial one. was formed in 2004 to promote and support travel health
Persons who have had Zostavax should now be immunized nursing in North America. ATHNA provides many resources
with Shingrix (Resnick, 2018). Those who have had a prior for nurses and NPs who specialize in travel health, as well as
episode of zoster should be vaccinated (CDC, Adult Immuni- for those in primary care.
zation Schedule, 2017; www.immunize.org). Travel health is rapidly evolving and growing as a spe-
cialty but is also growing as a part of primary care. NPs will
need to know how to evaluate older travelers and develop
TRAVEL AND LEISURE a plan of care to keep them healthy while they travel. They
need to know how, when, and where to refer to a travel health
Travel can be one of the most enjoyable experiences one can specialist. The majority of travelers who could benefit from
have. People travel to see new things, understand the world pre-travel consultations do not receive them (Zuckerman,
 Chapter 2 ■ Health Promotion 13

Brunette, & Leggat, 2015). NPs are in a unique position to travelers are very healthy, many have comorbidities that
educate patients and the public about the benefits of this contribute to the development of health problems abroad.
service. Patients with chronic disease that is well managed at home
may decompensate in foreign environments because of heat,
Medical Tourism humidity, altitude, fatigue, changes in diet, and exposure to
Some people travel abroad to receive medical care. The most infectious diseases.
common procedures sought outside the United States include It is very important that older travelers know what to do
joint replacements, cosmetic surgery, cataract lens replace- if they become ill or injured away from home. Advise the
ment, cardiovascular surgery, and dental procedures. Some traveler to obtain travel health insurance that includes emer-
people travel for organ transplants, stem cell treatments, and gency medical evacuation and repatriation of remains. Medi-
anti-aging and cancer treatments not available or banned care does not cover the cost of health care outside the United
in the United States. While there are some options for high States. Have the patient bring a hard or electronic copy of his
quality, less expensive health care abroad, the patient must or her medical history, medication list, allergies, and copies of
do careful research to ensure safe, quality care is rendered pertinent imaging studies or electrocardiograms (EKGs). The
by competent providers. Traveling with a patient advocate is NP with expertise in gerontology can provide pre-travel care
advised, as elders recovering from surgery or who are in poor that will not only reduce the morbidity and mortality asso-
health are more vulnerable to complications and being taken ciated with travel but also enhance the elder’s travel expe-
advantage of (Brunette & Kozarsky, 2018). rience. When destinations or itineraries are complicated or
when a patient’s condition poses special risks, a visit to or a
The Older Traveler consultation with a travel health specialist is warranted.
Some of the physiological and psychosocial changes that
can occur with aging pose special risks during travel. How a Preparing the Elder in a Primary Care
patient functions at home may not be indicative of how well
Setting for Travel
he or she will function in an unfamiliar environment. Dimin-
ished musculoskeletal strength, agility, mobility, and endur- To develop an individualized pre-travel plan of care, the NP
ance can affect a person’s ability to navigate safely. Travel needs to evaluate the traveler, the destination, and the itiner-
often involves more walking and standing than an elder may ary. Assessing the traveler consists of reviewing these areas:
be accustomed to. Many places abroad are not handicapped ■ Current health status—stability of preexisting
accessible. Uneven stairs and walkways, lack of handrails, conditions
and lack of elevators can be challenging. ■ Past medical history
Cardiopulmonary function can decrease with age and ■ Medications and allergies
contribute to fatigue. Long flights in low humidity and ■ Diet
lowered oxygen, in cramped seats, can increase risk of ■ Mental status
thromboembolic events. The older adults are at increased risk ■ Immunization status
of altitude illness, which affects cardiac and cerebral func-
tioning. Increased air pollution is a significant problem in CURRENT MEDICAL STATUS
many countries and affects pulmonary function. The ability
Ideally, the traveler should be seen at least 6 to 8 weeks before
to tolerate temperature changes affects the older traveler.
the trip to allow for time to optimize preexisting chronic
Heat and humidity can aggravate underlying conditions, and
disease and adequate immune response to vaccine-prevent-
older travelers will become dehydrated more easily. They are
able diseases (Gerstenlauer, 2017). Evaluate the patient’s
more prone to thermal damage in colder climates. Central
current medications. Simplifying medication schedules
nervous system changes affect the older traveler’s ability to
enhances compliance. Are there any that do not need to
deal with the stresses of travel. It can be anxiety inducing to
be taken on this trip? Are there any factors that will affect
be in a place where everything is so different—the language,
your patient’s ability to take any medications during travel?
food, customs, and climate. Jet lag is harder to cope with as
Does the patient know how to adjust medication schedules
one ages. Any traveler can experience unexpected delays and
to accommodate air travel and time zone changes? All pre-
be without food and sleep for hours. This can take an even
scription medications should be brought in original bottles
greater toll on the older traveler.
and not in unlabeled pill containers. If your patient gets
Sensory changes may result in decreased hearing, which
his or her prescriptions in 90-day supplies, give the patient
is especially difficult on airplanes or trains with background
new prescriptions for smaller amounts for travel, including a
engine noise. Decreased vision can result in greater risk of
few extra in case of delays. Does the patient need to bring a
injuries. Decreased night vision, longer reaction time, and
wheelchair, walker, glucometer, hearing aids, C Pap, or neb-
driving on unfamiliar, poorly lit roads increase the risk of
ulizer? Remind them to check all batteries and bring extras.
accidents. Bathroom stops may be at longer intervals than
Is adequate electricity reliably available at a current that will
needed for an older traveler with diminished bladder capac-
work with the equipment? Will adapters be needed and will
ity or any degree of incontinence. Some facilities may consist
they work properly?
only of holes in the floor that the elder may have to balance
over to use. MEDICATIONS AND ALLERGIES
Older travelers have less robust immune systems. Fever is
not always a reliable indicator of illness in the older adult. ■ Is the patient taking any medication that could prove
Seroconversion rates decrease with age, rendering some vac- life threatening if lost or stolen? If so, is it accessible at
cines less effective for older travelers. Although many older the patient’s destination?
14 Chapter 2 ■ Health Promotion

■ Does the patient have any life-threatening allergies? of the live virus vaccine rule (Brunette & Kozarsky, 2018).
■ Does the patient take any medications that require Yellow fever and herpes zoster vaccine are the only live virus
refrigeration? Decompose from heat and humidity? vaccines that people over age 50 receive. Immune response
Require syringes? Need a nebulizer? can be impaired if live virus vaccines are given within a
■ Is the patient on oxygen? If so, he or she must notify the 28- to 30-day interval of each other. Yellow fever vaccine
airline well in advance of travel. is not effective until 10 days after administration. If the NP
gives a patient a herpes zoster vaccine, that patient cannot
All medications should be packed in carry-on luggage, not
receive a yellow fever vaccine for 30 days. If the patient is
in checked bags. Certain countries restrict bringing in any
required to have a yellow fever vaccine for travel, he or she
controlled substances and some other drugs whether legally
cannot enter a yellow fever country until 10 days after
prescribed in the United States or not. Caution patients about
receiving the yellow fever vaccine (or 40 days after receiving
purchasing pharmaceuticals abroad which may be cheaper
a herpes zoster vaccine). If the administration of a herpes
but also could be counterfeit.
zoster vaccine precludes the administration of a time-sensi-
DIET tive yellow fever vaccine, travel plans could be interrupted,
with serious financial consequences for the traveler. If the NP
Does the patient have any special dietary restrictions? Air-
has any questions about when to vaccinate a patient whose
lines offer diabetic and vegetarian options but may not offer
trip is imminent, discuss this with a travel health specialist.
gluten-free or sodium-restricted comestibles. These must be
If a patient receives a yellow fever vaccine, he or she cannot
ordered in advance. Cruise ships accommodate many spe-
receive a herpes zoster vaccine for 28 days. The patient may
cialty diets but also offer many temptations. Restaurant
receive both vaccines on the same day with no decrease in
menus in many countries do not list all the ingredients in
immune response (Brunette & Kozarsky, 2018). Typhoid oral
the dishes offered, which can be problematic for those with
vaccine is a live bacterial vaccine and will not interfere with
severe food allergies.
live viral vaccine administration.
MENTAL STATUS After assessing the destination and itinerary (see the fol-
lowing section), decide which vaccines to recommend for this
Short-term memory decreases with age. Many elders cope
specific patient for this specific trip. The most common vac-
with these changes by adhering to routines that travel may
cines used for protecting travelers are hepatitis A, hepatitis
disrupt. Misplacing passports, room keys, or wallets or not
B, typhoid fever, yellow fever, adult booster polio, Japanese
remembering hotel names or addresses can be distressing.
encephalitis, meningococcal, and rabies. If the NP does not
Family members or travel companions may need to offer
have access to these vaccines, referral to a travel health spe-
additional assistance. Advise that elders carry a hotel’s busi-
cialist will be needed. To help the patient make an informed
ness card that includes the hotel’s name, address, and phone
decision about which recommended vaccines to receive, con-
number. Taking photographs of hotels, cruise ships, or tour
sider the indications, contraindications, side effects, timing
company’s names can help the memory impaired who may
of doses for immune response, and costs. Medicare will cover
become confused.
hepatitis B in very limited patient populations and will not
IMMUNIZATION STATUS cover the cost of the other recommended vaccines (Official
U.S. Government Web site for Medicare, n.d.). Federal regu-
All routine immunizations should be current. This includes
lations require the NP to give patients Vaccine Information
influenza, pneumococcal, Td/Tdap (tetanus, diphtheria, and
Statements (VISs), which are available in many different lan-
acellular pertussis), zoster, and for some, hepatitis B vaccina-
guages at http://www.cdc.gov/vaccines/hcp/vis/index.html.
tion. The current schedule of adult vaccination recommen-
The most important vaccine a traveler should receive is the
dations from the CDC (updated February 2016) is available
influenza vaccine.
at http://www.cdc.gov/vaccines/schedules/hcp/adult.html.
All patients should have a copy of their immunization
Certain vaccines may be recommended based on destina-
record. If a patient has an incomplete vaccine series, con-
tion, and some vaccines are required for entry into some
tinue the series but do not restart it. For example, if a patient
African and South American countries (Table 2-2) (Brunette
received one dose of hepatitis A several years ago but never
& Kozarsky, 2018).
received the second, final injection, give the next and final
Yellow fever vaccinations can only be given by certified
dose now. If the patient received only one dose of hepatitis
yellow fever centers. If the patient is seeing a primary care
B years ago, give the second dose now and the third dose 5
provider before getting a yellow fever vaccine, be aware
months from now, and the series will be complete (Immuni-
zation Action Coalition, n.d.).
TABLE 2-2 If a patient cannot complete a series before travel, partial
Adult Vaccinations for Travel immunization may confer enough protection. Some vac-
REQUIRED ADULT cines can be given on an accelerated schedule; otherwise, do
RECOMMENDED ADULT VACCINATIONS FOR not give a vaccine sooner than the recommended interval
VACCINATIONS FOR TRAVEL TRAVEL between doses. One dose of hepatitis A given just before travel
will confer enough protection to make it worth giving to the
Hepatitis A; others are specific Yellow fever for some African
to area where traveling and South American countries last-minute traveler. Hepatitis A and B vaccines are also
including hepatitis B, typhoid, available as a combined vaccine given at 0, 1, and 6 months.
Meningococcal for Saudi Arabia If there are at least 21 days before the patient’s departure,
polio, meningococcal, Japanese
during the Hajj the vaccine can be given in an accelerated schedule of 0, 7,
encephalitis, rabies
and 21 to 30 days with a booster at 12 months (Brunette
 Chapter 2 ■ Health Promotion 15

& Kozarsky, 2018). Typhoid fever vaccine is available in two written information for review at home. Handouts for insect,
forms, a single-dose injectable and orally as a series of four food, and water precautions are found on the CDC Web site.
capsules given every other day for 1 week. The oral vaccine
then takes a week to be effective. The injectable vaccine SAFETY
needs to be boostered every 2 years and the oral vaccine at 5 Accidents and injuries are the most common cause of pre-
years, if needed. Before prescribing the oral form, be sure the ventable death and disability for travelers. Tourists are 10
patient can comply with the proper administration (Brunette times more likely to die from trauma than infectious disease
& Kozarsky, 2018). (Brunette & Kozarsky, 2018). The most common risks travel-
Because of worldwide efforts to eradicate polio, only a ers face from trauma result from motor vehicle, pedestrian,
few countries require adults to get a polio booster for travel. and water accidents; personal safety/crime; natural disasters
If your patient has had polio in the past, he or she does not and environmental hazards; and animal-related injuries.
need vaccination. If your patient has been fully vaccinated In many parts of the world, roads and vehicles are poorly
for polio, a single booster dose as an adult will protect him or maintained. Seat belts and helmets are typically unavail-
her. Japanese encephalitis vaccine, meningococcal vaccine, able. Roads are shared by pedestrians, animals, motorbikes,
and rabies pre-exposure vaccine are not usually administered bicycles, trucks, buses, and rickshaws. Traffic accidents are
to elders for travel in a primary care setting. Japanese enceph- more common because the traveler is unfamiliar with the
alitis vaccine is only advised for long-term stays in high-risk roads, may be driving on the opposite side of the road, and
areas. Meningococcal vaccine is only licensed for people ages may need to drive to the left on roundabouts. Road signs and
2 to 55. Depending on the country visited, length of stay, lighting are suboptimal. To help prevent accidents, always
and potential exposure to rabid animals, decisions regarding take these precautions:
rabies pre-exposure vaccine are usually made with a travel
■ Wear seat belts when available.
health specialist. Cost and vaccine availability play a role
■ Avoid driving or riding at night in underdeveloped
in deciding pre-exposure vaccination (Brunette & Kozarsky,
countries.
2018). It is important to warn travelers of the risk of rabies
■ Avoid motorcycles and mopeds altogether.
and to educate them in animal bite prevention strategies,
■ Do not drive impaired by alcohol or fatigue or ride with
especially concerning dogs, which are the biggest vector for
someone who is.
rabies worldwide.
■ Do not use cell phones or text or type on GPS systems
The CDC Yellow Book 2018 is an invaluable resource for
while driving.
vaccine administration and is available in paperback and
■ Avoid overcrowded buses and vans.
online in its entirety for free and as a free app. Clinicians and
■ Be alert when crossing the street.
travelers can research recommendations for specific coun-
tries at http://wwwnc.cdc.gov/travel/. The Advisory Council The Association for International Road Travel (ASIRT) has
on Immunization Practice (ACIP) has a section on its Web a very helpful Web site with patient handouts for accident
site (www.immunize.org) called Ask the Expert that can be prevention (www.asirt.org).
searched for answers to immunization questions. Listings for Drowning is the leading cause of accidental death for
travel health specialists and clinics can be found at the ISTM U.S. travelers visiting countries where water recreation is a
Web site (www.istm.org) and the CDC Web site (wwwnc.cdc. major activity (Brunette & Kozarsky, 2018). Warn travelers
gov/travel/page/find-clinic). to avoid diving into shallow water or swimming or boating
under the influence of alcohol and remind them to use life
ASSESSING THE DESTINATION AND ITINERARY vests. Boating in unfamiliar waters, and in unfamiliar boats,
The NP needs to know where the traveler is going and what increases risk of accidents. Many countries do not have laws
he or she will do there to provide anticipatory guidance for and regulations concerning public safety to the same extent
risk reduction. The NP may decide to refer to a travel clinic as the United States. Outfitters may not be as careful about
for the remainder of the pre-trip evaluation. Either way, the safety. Divers Alert Network (DAN) (www.DAN.org) pro-
following overview will help the NP to understand what com- vides education, support, and travel and health insurance
prises a comprehensive pre-travel evaluation. worldwide for scuba divers. They staff a 24-hour hotline
Mexico, China, India, Peru, Kenya, Australia, Europe, and for divers and health-care providers for medical support at
the Caribbean all pose different risks for the elder traveler. The 1-919-684-9111.
time of year, duration of the trip, type of accommodations, The U.S. Department of State Web site provides current
modes of transportation, and purpose of the trip all influ- information about worldwide safety and security at https://
ence travel risk. A 70-year-old couple going to the Dominican travel.state.gov/content/travel/en.html. Personal crime rates
Republic who plan to stay at an all-inclusive resort will need vary from country to country. While risk of harm from ter-
different advice than a 70-year-old couple traveling to build rorist activities is low, travelers should be aware of emergency
an orphanage and staying in a host family home. There are exits and routes and know the location of the U.S. embassy in
Web sites that offer current advice about destinations that the countries they are in. Homicide was the second leading
the NP can use. Some are free, such as the CDC Web site, cause of death from injuries for U.S. citizens. In Honduras,
and some are subscription based, such as Shoreland (www. Colombia, Guatemala, and Haiti, 38% to 52% of all deaths
travax.com) and Tropimed (www.tropimed.com). from injuries for U.S. travelers were homicides (Brunette &
The most common risks for travel to tropical, subtropical, Kozarsky, 2018). Older adult travelers are seen as wealthy,
and low-resource countries are trauma and food-, water-, vulnerable targets and can travel in high-poverty, high-crime
and insect-borne diseases. Because so much information areas. Travel during civil unrest or travel at night in unfamil-
is relayed at the pre-travel visit, it is important to provide iar places increases the risk of assault.
16 Chapter 2 ■ Health Promotion

FOODBORNE AND WATERBORNE ILLNESSES cruise ships are designed to greatly reduce motion sickness.
It is not safe to drink the water in many places in the world. Commonly used medications for motion sickness include
Food and water precautions must be carefully adhered to for dimenhydrinate, promethazine, diphenhydramine, and anti-
preventing disease. The easiest way for travelers to remember cholinergic agents such as scopolamine. Review possible side
this is to tell them to boil it, peel it, cook it, or forget it. Bottled effects and drug and alcohol interactions carefully. Methods
water; carbonated beverages without ice; and coffee, tea, and such as closing your eyes, focusing on the horizon line, and
alcohol are safe to drink. Do not brush teeth or soak dentures acupressure wrist bands can also be helpful.
in tap water. Some travelers tie a ribbon or small rope around
the faucet to remind them not to drink the water. Despite best Jet Lag
efforts, traveler’s diarrhea is common, and often the health- Jet lag can be mitigated by getting proper rest before travel
care provider will prescribe drugs for the traveler to take and maintaining proper hydration during flight. Zolpidem
with him or her in the event that this occurs. Mild diarrhea has been shown to be more effective in the treatment of jet
can be treated with bismuth subsalicylate (BSS). Significant lag than melatonin (Suhner, Schlagenhauf, & Hofer, 2001).
diarrhea can be treated very effectively with azithromycin, The patient should try a dose of zolpidem at bedtime at home
500 mg once daily for 1 to 3 days (Brunette & Kozarsky, before travel to test tolerance. Confusion, ataxia, and falls are
2018), as 90% of the cases are bacterial. Oral rehydration potential side effects of zolpidem.
solution (ORS) packets or effervescent tablets help prevent
dehydration. Heat and Humidity
Hyperthermia occurs more frequently in the older adult.
INSECT-BORNE DISEASES Acclimatization to heat and humidity may take several days.
Dengue, chikungunya, and Zika viruses have spread through- Many of the drugs frequently used by the older adult, such
out much of the temperate zones of the world, including as antihistamines, anticholinergics, calcium channel block-
Central America, the Caribbean, and southern areas of the ers and beta blockers, diuretics, and anti-Parkinson’s medi-
United States, areas where large numbers of older travelers go cations, impair thermoregulation. The older adult traveler
for extended stays in the winter. When traveling to areas where should use caution in hot and humid environments, drink
insect-borne diseases are a risk, the older traveler should be adequate fluids, avoid caffeine and alcohol, and avoid overex-
advised to avoid bites day and night by using insect repellents ertion. Self-treatment measures may also include using ORS
on exposed skin, treating clothing with permethrin prior to packets/tablets in clean bottled water.
packing, and covering up with clothing, hats, and footwear.
Morbidity and mortality for Zika is greater in the older adult. Altitude Illness
Because there is still much to be learned about this infection, Altitude illness can range from mild shortness of breath to
the NP needs to stay informed about new developments at life-threatening acute mountain sickness (AMS). Prior toler-
https://www.cdc.gov/zika/. NPs can subscribe to Morbidity ance of altitude does not predict future tolerance. Those with
and Mortality Weekly Review (MMWR) for free at http://www. underlying cardiopulmonary disease may experience greater
cdc.gov/mmwr/mmwrsubscribe.html and receive the table of hypoxia. Because the body’s normal response to lowered
contents and links to articles when published. oxygen is to increase the pulse rate, beta blockers can reduce
Prevention of malaria is essential for any traveler going to the body’s compensatory response. Acetazolamide is used to
a malaria-endemic area, regardless of age. Malaria is more prevent AMS but needs to be started 24 to 48 hours before
severe in the older adult, and mortality risk from malaria ascent, and side effects versus benefits need to be carefully
increases with age (Zuckerman et al., 2015). When traveling evaluated. If symptoms of AMS develop, descent, if possible,
to malaria-endemic areas, travelers should always practice is the best treatment. Many areas, such as Cusco, Peru, are
bite avoidance and consider chemoprophylaxis depending experienced in treating AMS in tourists because it is such a
on their specific itinerary and season of travel. Mosquitoes common occurrence.
that transmit malaria bite from sunset to sunrise. If a traveler
is taking a cruise and spends the day in port in a malaria- Respiratory Infections
endemic area but returns to the ship before sunset, insect Low humidity from airline travel and exposure to crowds and
repellent and protective clothing may suffice. air pollution will make the older adult more prone to respi-
Malaria chemoprophylaxis is generally well tolerated ratory infections during travel. If your patient has chronic
in the older adult. Drug choice depends on the destination, pulmonary disease, consider giving him or her an antibiotic
side effects, drug interactions, and cost. All medications are to self-treat, if infection occurs.
started before travel, taken during travel, and taken for a
period of time after travel. The CDC provides maps of malar- Sexually Transmitted Infections
ia-endemic areas and guidelines for prescribing (Brunette &
Older people may be at increased danger from sexually trans-
Kozarsky, 2018). It is important for patients who are being
mitted infections (STIs) because of the decreased perception
evaluated for fever or flu-like symptoms for up to a year post
of risk by both health-care providers and patients, resulting
travel tell their health-care providers that they have traveled
in less screening and treatment. Older adults are less likely
so that insect-borne diseases can be ruled out.
to practice safe sex and use condoms. The rate of casual
sex increases with travel (Jong & Sanford, 2008). Encoun-
Motion Sickness ters may be with fellow travelers, locals, or commercial sex
Motion sickness can be prevented with pharmacological workers. Many older women are told they do not need Pap
and nonpharmacological methods. Many large, modern smears based on their age alone. Current sexual history may
 Chapter 2 ■ Health Promotion 17

determine the need for continued screening for STIs, human

TABLE 2-3
papillomavirus (HPV), and cervical cancer. Online Resources for Travel Health
Travel Clinic CDC: https://wwwnc.cdc.gov/travel/page/
Fitness for Travel Locator and find-clinic
Travel can be strenuous. Airports and cruise ships are huge. Certified Yellow ISTM: http://istmsite.membershipsoftware.org/
If a trip involves a higher level of activity than what travelers Fever Centers AF_CstmClinicDirectory.asp
are accustomed to, they need to be sure they are fit for that Practice Protocols ATHNA: www.athna.org
trip. Tour operators will often give specific suggestions for and Standing ISTM: www.istm.org
fitness for walking, hiking, or bicycling trips but not for sight- Orders ACIP: www.immunize.org
seeing tours. Each traveler should bring a first aid kit and an Immunizations CDC: wwwnc.cdc.gov/travel
emergency dental kit and have a plan for getting health care ACIP: www.immunize.org
abroad if needed.
National and international travel by the older adult will Safety and Accident Association for International Road Travel:
Prevention www.asirt.org
continue to increase. A knowledgeable NP, either alone or
U.S. Department of State: www.state.gov/
in conjunction with a travel health specialist, can prepare travel/
the older patient to safely enjoy travel to many destinations
around the world (Table 2-3). It is imperative to not only Continuing ATHNA, nursing: www.athna.org
protect our elder travelers but to help prevent the importa- Education in Travel CDC, nursing: CDC: www2a.cdc.gov/
Health TCEOnline/
tion of infectious diseases back to communities in the United
ISTM, general: www.istm.org
States.
Vaccine Information CDC: https://www.cdc.gov/vaccines/index.html
Statements See quick link for Vaccine Information Sheets
SUMMARY (VIS).
■ Evidence-based health promotion for older adults is an evolv- Journals Journal of Travel Medicine: www.istm.org
ing science. As the population of older adults increases,
Destination Tropimed: www.tropimed.com
lifestyle management for prevention of chronic illness,
Information— Shoreland—Travax: www.shoreland.com
self-management of chronic conditions, safety, and quality- subscription
of-life issues will be more at the forefront. NPs are well posi-
tioned to advance health-promotion efforts and keep older Destination CDC: https://wwwnc.cdc.gov/travel
adults healthy and functional (Gerstenlauer, 2017). Information—free

C A S E S T U DY
J. S. is a 66-year-old African American woman who 1. What additional subjective data are you seeking?
presents to your practice for a well-adult physical checkup. 2. What additional objective data will you be assessing
She is widowed and works part-time as a mental health for?
technician to support herself. Family history includes
father deceased from a stroke at age 50 years, mother 3. What national guidelines are appropriate to consider?
living with hypertension and type 2 diabetes mellitus, a 4. What tests will you order?
half-sister deceased with breast cancer, and a brother with
5. Are there any screening tools that you want to use?
pancreatic cancer and coronary artery disease and end-
stage renal disease secondary to type 2 diabetes mellitus. 6. What are the priorities for primary, secondary, and
J. S. has not seen a health-care provider for several tertiary prevention?
years because she had no health insurance. Now she has 7. What is your plan of care?
Medicare, so she is coming in for care. She is a former
8. Are there any Healthy People 2020 objectives that you
smoker who quit 5 years ago after smoking 1 pack per day
should consider?
since age 20 years. She has four grown children, all of
whom live nearby, and she has eight grandchildren. Vital 9. What additional patient teaching may be needed?
signs are blood pressure (BP) 150/92, heart rate (HR) 10. Will you be looking for a consultation?
76 (reg), respiratory rate 18 breaths per minute (bpm)
(afebrile), and body mass index (BMI) 32.1.
18 Chapter 2 ■ Health Promotion

REFERENCES recommendation statement. Journal of the American Medical Associa-

tion, 315(4), 380–387. doi:10.1001/jama.2015.18392.
Bibbins-Domingo, K. on behalf of the U.S. Preventive Services Task Force.
Siu, A. L. on behalf of the U.S. Preventive Services Task Force. (2015).
(2016). Aspirin use for the primary prevention of cardiovascular
Behavioral and pharmacotherapy interventions for tobacco smoking
disease and colorectal cancer: U.S. Preventive Services Task Force rec-
cessation in adults, including pregnant women: U.S. Preventive Ser-
ommendation statement. Annals of Internal Medicine, 164, 836–845.
vices Task Force recommendation statement. Annals of Internal Medi-
doi:10.7326/M16-0577.
cine, 163, 622–634. doi:10.7326/M15-2023.
Bibbins-Domingo, K. on behalf of the U.S. Preventive Services Task
Siu, A. L. on behalf of the U.S. Preventive Services Task Force. (2015).
Force. (2016). Statin use for the primary prevention of cardiovascular
Screening for high blood pressure in adults: U.S. Preventive Services
disease in adults: U.S. Preventive Services Task Force recommendation
Task Force recommendation statement. Annals of Internal Medicine,
statement. Journal of the American Medical Association, 316(19),1997–
163, 778–786. doi:10.7326/M15-2023.
2007. doi:10.1001/jama.2016.15450.
Siu, A. L. on behalf of the U.S. Preventive Services Task Force. (2015).
Moyer, V. A. on behalf of the U.S. Preventive Services Task Force. (2012).
Screening for abnormal blood glucose and type 2 diabetes mellitus:
Screening for hearing loss in older adults: U.S. Preventive Services Task
U.S. Preventive Services recommendation statement. Annals of Inter-
Force recommendation statement. Annals of Internal Medicine, 157,
nal Medicine, 163, 861–868.
655–661.
U.S. Preventive Services Task Force Recommendation Statement June
Moyer, V. A. on behalf of the U.S. Preventive Services Task Force. (2013).
21. (2016). Screening for colorectal cancer: U.S. Preventive Services
Screening for HIV: U.S. Preventive Services Task Force recommenda-
Task Force recommendation statement. U.S. Preventive Services Task
tion statement. Annals of Internal Medicine, 159, 51–60.
Force article information. Journal of the American Medical Association,
Siu, A. L. on behalf of the U.S. Preventive Services Task Force. (2016).
315(23), 2564–2575. doi:10.1001/jama.2016.5989.
Screening for breast cancer: U.S. Preventive Services Task Force rec-
U.S. Preventive Services Task Force Recommendation Statement. (2018).
ommendation statement. Annals of Internal Medicine, 164, 279–296.
Screening for osteoporosis to prevent fractures. Journal of the American
doi:10.7326/M15-2886.
Medical Association, 319(24), 2521–2531.
Siu, A. L. on behalf of the U.S. Preventive Services Task Force. (2016).
Screening for depression in adults: U.S. Preventive Services Task Force
 CHAPTER

3
Exercise in Older Adults
Lori Martin-Plank

Current population statistics (www.agingstats.gov) indicate Services (USDHHS) (Physical Activity Guidelines Advi-
that Americans over 65 years of age now represent the most sory Committee, 2008). The Healthy People 2020 initiative
rapidly growing segment of the U.S. population, comprising has several sections dedicated to health promotion in older
15% of the population in 2014. As those born from 1946 adults. Numerous agencies, such as the Centers for Disease
to 1964 enter the over-65 age group, these numbers will Control and Prevention (CDC), American Osteopathic Asso-
increase exponentially, expected to reach 21% by 2030, and ciation (AOA), National Institute on Aging, and Center for
with that growth is an anticipated skyrocketing of medical Medicare and Medicaid, have programs to promote wellness
costs for chronic health conditions. Lifestyle interventions at and quality of life in older adults, including physical activ-
any stage can mitigate the effects of chronic illness (Hupin ity projects. The ACSM has a Web site, Exercise is Medicine,
et al., 2015), but they are usually given short shrift during with extensive resources for providers and the public (http://
patient encounters (Weiss et al., 2012). Many providers exerciseismedicine.org), and the Preventive Cardiovascu-
feel inadequately prepared to initiate realistic discussions lar Nurses Association has a Heart Healthy Toolbox (http://
about lifestyle changes with older adult patients. Accord- pcna.net/clinical-tools/tools-for-healthcare-providers/heart-
ing to one report, less than 32% of primary care providers healthy-toolbox) with a variety of free tools for use by clini-
and health professionals offer exercise counseling or educate cians. Despite the availability of these tools, they are largely
older patients on the benefits of physical activity during an unknown to most health-care providers, who are focused on
office visit and physical examination (Barnes & Schoenborn, the day-to-day activities of disease management (Friedman,
2012). Shah, & Hall, 2015).
Recent statistics related to exercise in older adults (Federal Since the publication of the exercise guidelines for older
Interagency Forum on Aging Statistics, 2016) show that 12% adults, several studies have demonstrated that adapting
of adults over age 65 years had an exercise program that met these guidelines to individuals and specific populations,
federal physical activity guidelines in 2014, compared to 6% such as the oldest old and those with frailty (Bleijenberg
in 1998. This report (Older Americans, 2016) also reveals et al., 2017; Dahlin-Ivanoff et al., 2015; Lee & Kim, 2017;
an increase in obesity in older adults, from 22% in 1988 to Tarazona-Santabalbina, 2016), can be successful. One large
1994 to 35% in 2011 to 2014. Women over 65 years old study at the Veterans Association (VA) also demonstrated
were more obese than men. These facts underscore the need the effectiveness of physical activity counseling in primary
for a new paradigm to promote increased physical activity in care in decreasing overall health-care costs (Cowper et al.,
older adults as part of a program of lifestyle intervention for 2017). Additional studies are now focusing on the relation-
wellness and quality of life. Nurse practitioners are uniquely ship of physical activity and cognitive changes, some includ-
positioned to assume the primary role in health promotion of ing diet and supplements (Jonasson et al., 2015; Kobe et al.,
both healthy persons and those with chronic illness. 2016; Tarazona-Santabalbina et al., 2016; Tse, Wong, & Lee,
2015). While this area (cognitive benefits and exercise) is
inconclusive, the future holds promise.
AVAILABLE RESOURCES Another area that is being addressed is the relationship
of exercise of any kind to a decrease in mortality, both with
Guidelines and position statements for increasing phys- and without cardiovascular risk factors (Hupin et al., 2015;
ical activity in adults and older adults have been issued by Kim et al., 2017; Martinez-Gomez et al., 2017; Morey, 2017;
several authorities, including the American College of Sports Villareal et al., 2017). Specific programs for older adults with
Medicine (ACSM) (Chodzo-Zajko et al., 2009; Nelson et al., osteoarthritis are also effective (Bartels et al., 2016; Fransen
2007), American Heart Association (AHA) (Artinian et al., et al., 2015). Finally, the American Academy of Family Phy-
2010; Marcus et al., 2006), U.S. Preventive Services Task sicians (AAFP) (Lee, Jackson, & Richardson, 2017; Pescatello,
Force (Moyer, 2012), U.S. Department of Health and Human 2014; Zaleski et al., 2015) and other exercise professionals

19
20 Chapter 3 ■ Exercise in Older Adults

have given detailed descriptions of how to design an exercise ■ Severe anemia

program and write a prescription, as well as how to engage ■ Uncontrolled blood glucose
the patient. LeTorneau and Goodman (2014) and Lee and ■ Unstable aortic aneurysm
colleagues (2016) have addressed the role of motivational ■ Uncontrolled hypertension or tachycardia
interviewing in facilitating older adult engagement in phys- ■ Severe dehydration or heat stroke
ical activity and exercise. ■ Low oxygen saturation

BARRIERS AND FACILITATORS TO

EXERCISE FOR OLDER ADULTS PLAN FOR INCORPORATING
EXERCISE INTO PATIENT
In 2006, a subcommittee of the AHA Council on Nutri- ENCOUNTER
tion, Physical Activity, and Metabolism undertook a review
of existing physical activity intervention studies, focus-
ing on subpopulations and settings to gain perspective on The ACSM has designed a program for primary care pro-
the state of the science and to help identify future goals viders called Exercise is Medicine. The goal of this program
(Marcus et al., 2006). Studies that focused on older adults is to counsel the patient at every visit to increase physical
and exercise found that short-term interventions, both indi- activity. In conjunction with the AHA, the ACSM has also
vidual and group, face-to-face and by phone, were effective issued guidelines for physical activity in older adults (Nelson
in increasing physical activity when delivered as part of a et al., 2007). These guidelines can be used to incorporate
multifaceted program of educational and cognitive-behav- physical activity and exercise recommendations into patient
ioral participation. Health education alone was ineffective encounters.
in this population. Health-care personnel–recommended All authorities agree that whenever possible, older adults
physical activity and an exercise prescription were effective should engage in physical activities that strengthen muscles,
in the short term. None of the studies reviewed had a long maintain flexibility, promote good balance, and are aerobic
enough duration to measure persistence of effort (Marcus in nature; further qualifications include the development
et al., 2006). of a plan incorporating both preventive and therapeutic
goals, and risk management and reducing sedentary lifestyle
Patient Barriers (Artinian et al., 2010; Chodzko-Zajko et al., 2009; National
Institute on Aging, 2011; Nelson et al., 2007). The preferred
■ Lack of time amount of exercise is 30 minutes per day for 5 days a week of
■ Perceived need for equipment moderate exercise; if weight management is part of this, 60
■ Perceived barrier to beginning exercise/physical minutes per day is advised (Villareal et al., 2016). This can
activity be broken up into as little as 10-minute intervals throughout
■ Disability or functional limitation the day. Any increase in physical activity is desirable and has
■ Unsafe neighborhood or weather conditions some value over sedentary behavior (Nelson et al., 2007). If
■ No parks or walking trails older adults with chronic health conditions cannot achieve
■ Depression the 150 minutes per week of aerobic activity recommended,
■ High body mass index (BMI) they should be as physically active as possible within the
■ Lack of motivation constraints of their conditions and abilities (Chodzko-Zajko
■ Interpersonal loss or significant life event et al., 2009).
■ Ignorance of what to do The initial Welcome to Medicare visit can focus on healthy
lifestyle counseling, including assessment of current physical
Patient Facilitators activity level and specific guidance or exercise prescription
for the patient. In the case of a patient with disabilities or
■ Social support functional limitations, referral to physical therapy or a com-
■ Positive self-efficacy munity-based program targeting those with physical restric-
■ Motivation to engage in physical activity tions is appropriate and more effective. For those who are
■ Good health, no functional limitations already very active, an exercise physiologist or ACSM-certi-
■ Frequent contact with prescriber fied personal fitness trainer can help them to maximize their
■ Regular schedule, planned program program benefits. Following up at each visit will emphasize
■ Satisfaction with program the importance of ongoing exercise in maintaining or pro-
■ Insurance incentive moting healthy aging. Health coaches from the insurance
■ Improvement in mobility or health condition carrier can also be used to keep the patient engaged. Strate-
■ Staff (of exercise facility) support (Franco et al., 2015; gies, such as using motivational interviewing (LeTourneau &
Lee et al., 2017; Simmonds et al., 2015) Goodman, 2014), can be helpful in persuading the patient to
adopt a new behavior.
Medical Contraindications for The annual Medicare wellness visit can also be used to
Exercise Therapy reinforce or expand on the importance of lifestyle changes.
Exercise prescriptions that are individualized to fit the
■ Unstable angina patient’s abilities and preferences are most likely to be imple-
■ Uncompensated heart failure mented (Lee et al., 2017; Zaleski et al., 2015). Actually
 Chapter 3 ■ Exercise in Older Adults 21

handing the patient a program or exercise prescription is KEY GUIDELINES FOR SAFE
more effective than just speaking about it. Knowing resources
that are available in the community for group exercise or PHYSICAL ACTIVITY (PHYSICAL
individual walking programs is a valuable adjunct to coun- ACTIVITY GUIDELINES ADVISORY
seling. Knowledge of Internet resources for computer-savvy
patients is also helpful. Goal setting and self-monitoring by COMMITTEE, 2008)
the patient are very effective. A clinician who is aware of
To perform physical activity safely and reduce risk of injuries
some common excuses (e.g., lack of time, no equipment) can
and other adverse events, people should:
counter these with positive suggestions, such as acknowl-
edging the 10-minute benefit, using stairs in the home, or ■ Understand the risks and yet be confident that physical
walking around the block. activity is safe for almost everyone.
Clinician judgment should be exercised in assessing the ■ Choose to do types of physical activities that are appro-
patient and prescribing an exercise routine. Major authori- priate for their current fitness level and health goals,
ties agree that all adults who do not have symptoms and have because some activities are safer than others.
no diagnosed chronic health condition, such as osteoarthri- ■ Increase physical activity gradually over time whenever
tis, heart disease, or diabetes mellitus, do not need to consult more activity is necessary to meet guidelines or health
with a health-care professional about increasing physical goals. Inactive people should “start low and go slow” by
activity (Office of Disease Prevention and Health Promotion, gradually increasing how often and how long activities
2008). Patients with chronic conditions should consult a are done.
health-care provider for physical activity goals that are real- ■ Protect themselves by using appropriate gear and sports
istic and safe (Physical Activity Guidelines Advisory Commit- equipment, looking for safe environments, following
tee, 2008). Healthy adult men over 45 years old and healthy rules and policies, and making sensible choices about
women over 55 years old who are considering a vigorous when, where, and how to be active.
exercise program need health-care provider screening and ■ Be under the care of a health-care provider if they have
routine stress testing. Sedentary older adults and all adults chronic conditions or symptoms. People with chronic
with cardiac disease or strong risk factors should undergo conditions and symptoms should consult their health-
screening and stress test if they are undertaking a vigorous care provider about the types and amounts of activity
exercise program (Lee et al., 2017). appropriate for them.

Examples of Common Health Conditions in Older Adults With Exercise Recommendations

HEALTH CONDITION:
CONSIDER RECOMMENDED ACTIVITIES: START LOW COMMENTS: CONSIDER COMORBIDITIES
COMORBIDITIES FOR ALL INTENSITY, GO SLOW FOR ALL

Osteoarthritis Walking, aquatic activities, tai chi, resistance Vary type and intensity to avoid overstressing joints;
exercises, cycling heated pool
Coronary artery disease Walking, treadmill walking, cycle ergometry Supervised program with BP and heart rate monitoring
Congestive heart failure Walking, treadmill walking, cycle ergometry Individualize to client; supervised program
Type 2 diabetes mellitus Resistive, aerobic, aquatic, recreational activities Proper shoe fit; may need insulin reduction if insulin
dependent
Anxiety disorders Walking, biking, weight lifting If able to do high-intensity exercise, this benefits
anxiety
Depression Walking, cycling, recreational activities Group participation helpful to keep patient engaged
Fibromyalgia Aerobic, aquatic therapy, strengthening, tai chi, Pilates Heated pool, gentle stretches, counsel about possible
increased pain initially
Chronic obstructive Cycle ergometer, treadmill walking; individualize Supervised program—consider pulmonary
pulmonary disease rehabilitation program
Chronic venous insufficiency Walking, standing exercises Supervised program
Osteoporosis Weight-bearing exercises, weight training Assess balance and risk for falls before beginning
Parkinson’s disease Walking, treadmill walking, stationary bike, dancing, Assess balance and risk for falls before beginning;
tai chi, Pilates, boxing American Parkinson’s Disease Association resources
Peripheral arterial disease Lower extremity exercises, treadmill walking, walking Very short intervals initially, progress as tolerated
Age-related sleep disorders Tai chi, walking, aquatherapy, biking Assess balance and risk for falls before beginning
Dementia Walking, recreational activities Provide safe environment, assess fall risk and ability to
participate

Source: Adapted from Goodman, C., & Helgeson, K. (2011). Exercise prescriptions for medical conditions. Philadelphia: F.A. Davis.
22 Chapter 3 ■ Exercise in Older Adults

CLINICAL RECOMMENDATION EVIDENCE RATING REFERENCES

To promote and maintain health, older adults need moderate-intensity A Nelson et al., 2007
aerobic activity for a minimum of 30 min on 5 days each week or
vigorous-intensity aerobic activity for a minimum of 20 min on 3 days
each week.

To promote and maintain health and physical independence, older A Nelson et al., 2007
adults will benefit from performing activities that maintain or increase
muscular strength and endurance for a minimum of 2 days each week.
It is recommended that 8–10 exercises be performed on two or more
nonconsecutive days per week using the major muscle groups.

Participation in aerobic and muscle-strengthening activities above A Nelson et al., 2007

minimum recommended amounts provides additional health benefits
and results in higher levels of physical fitness.

To maintain the flexibility necessary for regular physical activity A Nelson et al., 2007
and daily life, older adults should perform activities that maintain or
increase flexibility on at least 2 days each week for at least 10 min each
day.

To reduce risk of injury from falls, community-dwelling older adults A Nelson et al., 2007
with substantial risk of falls (e.g., with frequent falls or mobility Lee & Kim, 2017
problems) should perform exercises that maintain or improve balance.

Older adults with one or more medical conditions for which physical A Nelson et al., 2007
activity is therapeutic should perform physical activity in the manner Lee & Kim, 2017
that effectively and safely treats the condition(s).

Older adults should have a plan for obtaining sufficient physical activity C Nelson et al., 2007
that addresses each recommended type of activity. Those with chronic
conditions for which activity is therapeutic should have a single plan
that integrates prevention and treatment. For older adults who are
not active at recommended levels, plans should include a gradual
(or stepwise) approach to increase physical activity over time. Many
months of activity at less than recommended levels is appropriate for
some older adults (e.g., those with low fitness), because they increase
activity in a stepwise manner. Older adults should also be encouraged to
self-monitor their physical activity on a regular basis and to reevaluate
plans as their abilities improve or as their health status changes.

A = consistent, good-quality, patient-oriented evidence; B = inconsistent or limited-quality, patient-oriented evidence; C = consensus,

disease-oriented evidence, usual practice, expert opinion, or case series. For information about SORT evidence rating system, go to www.
aafp.org/afpsort.xml.

SUMMARY 2015; Martinez-Gomez et al., 2017; Tarazona-Santabalbina,

■ There is strong evidence from a variety of sources that increas- 2016). Primary care practitioners can play an important role
ing physical activity in older adults will improve health and in promoting physical activity for all older adult patients at
quality of life in both healthy adults and those with chronic every visit, using an individualized approach. Resources are
health conditions (Avers, 2016; Bleijenberg et al., 2016; Dah- available to assist with this effort; further research is needed
lin-Ivanoff et al., 2016; Fransen et al., 2016; Hupin et al., regarding effective counseling methods and outcomes.
 Chapter 3 ■ Exercise in Older Adults 23

C A S E S T U DY
A. G., a 72-year-old man, comes in for follow-up of despite cutting back on soda. He asks you, “What else can
laboratory test results. He has coronary artery disease I do? I don’t want to get diabetes.” You encourage him to
(CAD), hypertension (controlled), impaired fasting glucose increase his physical activity level gradually, beginning
(IFG), benign prostatic hyperplasia, and mild degenerative with walking.
joint disease (DJD). Since being diagnosed with IFG he 1. What strategies will you use to promote increased
has cut back on soda consumption and is also seeing a physical activity in this patient?
dietitian for counseling. He is a former smoker (last use
12 years ago) and admits to being a “couch potato.” 2. What additional objective data will you be assessing
Current medications: Lisinopril 20 mg orally (PO) daily, for?
hydrochlorothiazide 12.5 mg PO daily, simvastatin 20 mg 3. What national guidelines are appropriate to consider?
PO daily in the evening, and tamsulosin 0.4 mg PO daily.
4. Will you need to order any tests before he begins this
He has a prescription for nitroglycerin 0.4 mg sublingually
program? If so, what tests?
as needed for chest pain but has never needed to use it.
He occasionally takes Tylenol Arthritis Pain or Aleve if 5. Are there any screening tools that you want to use?
the DJD bothers him. Vital signs are blood pressure (BP) 6. What is your plan of care?
134/72, heart rate (HR) 70 (reg), respiratory rate 18
7. Are there any Healthy People 2020 objectives that you
breaths per minute (bpm) (afebrile), and BMI 34.2. Pulse
should consider?
oximetry is 99% on room air. Laboratory test results are
unremarkable except for high-density lipoprotein (HDL) 8. What additional patient teaching may be needed?
32 and fasting blood sugar (FBS) 125. Mr. G expresses 9. How will you follow up on the planned increase in
frustration at the lack of change in his fasting glucose physical activity?

Nelson, M. E., Rejeski, W. J., Blair, S. N., Duncan, P. W., Judge, J. O., King,
REFERENCES A. C., . . . Castaneda-Sceppa, C. (2007). Physical activity and public
Lee, S. H., & Kim, H. S. (2017). Exercise interventions for preventing falls health in older adults: Recommendation from the American College
among older people in care facilities: A meta-analysis. Worldviews on of Sports Medicine and the American Heart Association. Medicine and
Evidence-Based Nursing, 14(1), 74–80. Science in Sports and Exercise, 39(8), 1435–1445.
 unit II
Assessment
Other documents randomly have
different content
 VII.

AT FAULT.

Four weeks went by so rapidly that every one refused to believe it

when the major stated the fact at the breakfast-table, for all had
enjoyed themselves so heartily that they had been unconscious of
the lapse of time.
“You are not going away, uncle?” cried Amy, with a panic-stricken
look.
“Next week, my dear; we must be off, for we’ve much to do yet,
and I promised mamma to bring you back by the end of October.”
“Never mind Paris and the rest of it; this is pleasanter. I’d rather
stay here—”
There Amy checked herself and tried to hide her face behind her
coffee-cup, for Casimer looked up in a way that made her heart
flutter and her cheeks burn.
“Sorry for it, Amy; but go we must, so enjoy your last week with
all your might, and come again next year.”
“It will never be again what it is now,” sighed Amy; and Casimer
echoed the words “next year,” as if sadly wondering if the present
year would not be his last.
Helen rose silently and went into the garden, for of late she had
fallen into the way of reading and working in the little pavilion which
stood in an angle of the wall, overlooking lake and mountains.
A seat at the opposite end of the walk was Amy’s haunt, for she
liked the sun, and within a week or two something like constraint
had existed between the cousins. Each seemed happier apart, and
each was intent on her own affairs. Helen watched over Amy’s
health, but no longer offered advice or asked confidence. She often
looked anxious, and once or twice urged the major to go, as if
conscious of some danger.
But the worthy man seemed to have been bewitched as well as
the young folks, and was quite happy sitting by the plump, placid
widow, or leisurely walking with her to the chapel on the hillside.
All seemed waiting for something to break up the party, and no
one had the courage to do it. The major’s decision took every one by
surprise, and Amy and Casimer looked as if they had fallen from the
clouds.
The persistency with which the English lessons had gone on was
amazing, for Amy usually tired of everything in a day or two. Now,
however, she was a devoted teacher, and her pupil did her great
credit by the rapidity with which he caught the language. It looked
like pleasant play, sitting among the roses day after day, Amy
affecting to embroider while she taught, Casimer marching to and
fro on the wide, low wall, below which lay the lake, while he learned
his lesson; then standing before her to recite, or lounging on the turf
in frequent fits of idleness, both talking and laughing a great deal,
and generally forgetting everything but the pleasure of being
together. They wrote little notes as exercises—Amy in French,
Casimer in English, and each corrected the other’s.
All very well for a time; but as the notes increased the corrections
decreased, and at last nothing was said of ungrammatical French or
comical English, and the little notes were exchanged in silence.
As Amy took her place that day she looked forlorn, and when her
pupil came her only welcome was a reproachful—
“You are very late, sir.”
“It is fifteen of minutes yet to ten clocks,” was Casimer’s reply, in
his best English.
 “Ten o’clock, and leave out ‘of’ before minutes. How many times
must I tell you that?” said Amy, severely, to cover her first mistake.
“Ah, not many times; soon all goes to finish, and I have none
person to make this charming English go in my so stupide head.”
“What will you do then?”
“I jeter myself into the lake.”
“Don’t be foolish; I’m dull to-day, and want to be cheered up;
suicide isn’t a pleasant subject.”
“Good! See here, then—a little plaisanterie—what you call joke.
Can you will to see it?” and he laid a little pink cocked-hat note on
her lap, looking like a mischievous boy as he did so.
“‘Mon Casimer Teblinski;’ I see no joke;” and Amy was about to
tear it up, when he caught it from destruction, and holding it out of
reach, said, laughing wickedly,—
“The ‘mon’ is one abbreviation of ‘monsieur,’ but you put no little—
how do you say?—period at the end of him; it goes now in English
—‘My Casimer Teblinski,’ and that is of the most charming address.”
Amy colored, but had her return shot ready.
“Don’t exult; that was only an oversight, not a deliberate
deception like that you put upon me. It was very wrong and rude,
and I shall not forgive it.”
“Mon Dieu! where have I gone in sinning? I am a polisson, as I
say each day, but not a villain, I swear to you. Say to me that which
I have made of wrong, and I will do penance.”
“You told me ‘Ma drogha’ was the Polish for ‘My pupil,’ and let me
call you so a long time; I am wiser now,” replied Amy, with great
dignity.
“Who has said stupidities to you, that you doubt me?” and
Casimer assumed an injured look, though his eyes danced with
merriment.
 “I heard Hoffman singing a Polish song to little Roserl, the burden
of which was, ‘Ma drogha, Ma drogha,’ and when I asked him to
translate it, those two words meant, ‘My darling.’ How dare you do
it, ungrateful creature that you are!”
As Amy spoke, half-confusedly, half-angrily, Casimer went down
upon his knees, with folded hands and penitent face, exclaiming, in
good English,—
“Be merciful to me a sinner. I was tempted, and I could not resist.”
“Get up this instant, and stop laughing. Say your lesson, for this
will be your last,” was the stern reply, though Amy’s face dimpled all
over with suppressed merriment.
He rose meekly, but made such sad work with the verb “To love,”
that his teacher was glad to put an end to it, by proposing to read
her French to him. It was “Thaddeus of Warsaw,” a musty little
translation which she had found in the house, and begun for her
own amusement. Casimer read a little, seemed interested, and
suggested that they read it together, so that he might correct her
accent. Amy agreed, and they were in the heart of the sentimental
romance, finding it more interesting than most modern readers, for
the girl had an improved Thaddeus before her, and the Pole a fairer,
kinder Mary Beaufort.
Dangerous times for both, but therein lay the charm; for, though
Amy said to herself each night, “Sick, Catholic, and a foreigner,—it
can never be,” yet each morning she felt, with increasing force, how
blank her day would be without him. And Casimer, honorably
restraining every word of love, yet looked volumes, and in spite of
the glasses, the girl felt the eloquence of the fine eyes they could
not entirely conceal.
To-day, as she read, he listened with his head leaning on his hand,
and though she never had read worse, he made no correction, but
sat so motionless, she fancied at last that he had actually fallen
asleep. Thinking to rouse him, she said, in French,—
 “Poor Thaddeus! don’t you pity him?—alone, poor, sick, and afraid
to own his love.”
“No, I hate him, the absurd imbecile, with his fine boots and
plumes, and tragedy airs. He was not to be pitied, for he recovered
health, he found a fortune, he won his Marie. His sufferings were
nothing; there was no fatal blight on him, and he had time and
power to conquer his misfortunes, while I—”
Casimer spoke with sudden passion, and pausing abruptly, turned
his face away, as if to hide some emotion he was too proud to show.
Amy’s heart ached, and her eyes filled, but her voice was sweet
and steady, as she said, putting by the book, like one weary of it,—
“Are you suffering to-day? Can we do anything for you? Please let
us, if we may.”
“You give me all I can receive; no one can help my pain yet; but a
time will come when something may be done for me; then I will
speak.”
And, to her great surprise, he rose and left her, without another
word.
She saw him no more till evening; then he looked excited, played
stormily, and would sing in defiance of danger. The trouble in Amy’s
face seemed reflected in Helen’s, though not a word had passed
between them. She kept her eye on Casimer, with an intentness that
worried Amy, and even when he was at the instrument Helen stood
near him, as if fascinated, watching the slender hands chase one
another up and down the keys with untiring strength and skill.
Suddenly she left the room and did not return. Amy was so
nervous by that time, she could restrain herself no longer, and
slipping out, found her cousin in their chamber, poring over a glove.
“Oh, Nell, what is it? You are so odd to-night I can’t understand
you. The music excites me, and I’m miserable, and I want to know
what has happened,” she said, tearfully.
 “I’ve found him!” whispered Helen, eagerly, holding up the glove
with a gesture of triumph.
“Who?” asked Amy, blinded by her tears.
“The baron.”
“Where?—when?” cried the girl, amazed.
“Here, and now.”
“Don’t take my breath away; tell me quick, or I shall get
hysterical.”
“Casimer is Sigismund Palsdorf, and no more a Pole than I am,”
was Helen’s answer.
Amy dropped in a heap on the floor, not fainting, but so amazed
she had neither strength nor breath left. Sitting by her, Helen rapidly
went on,—
“I had a feeling as if something was wrong, and began to watch.
The feeling grew, but I discovered nothing till to-day. It will make
you laugh, it was so unromantic. As I looked over uncle’s things
when the laundress brought them this afternoon, I found a collar
that was not his. It was marked ‘S. P.,’ and I at once felt a great
desire to know who owned it. The woman was waiting for her
money, and I asked her. ‘Monsieur Pologne,’ she said, for his name is
too much for her. She took it into his room, and that was the end of
it.”
“But it may be another name; the initials only a coincidence,”
faltered Amy, looking frightened.
“No, dear, it isn’t; there is more to come. Little Roserl came crying
through the hall an hour ago, and I asked what the trouble was. She
showed me a prettily-bound prayer-book which she had taken from
the Pole’s room to play with, and had been ordered by her mother to
carry back. I looked into it; no name, but the same coat-of-arms as
the glove and the handkerchief. To-night as he played I examined his
hands; they are peculiar, and some of the peculiarities have left
traces on the glove. I am sure it is he, for on looking back many
things confirm the idea. He says he is a polisson, a rogue, fond of
jokes, and clever at playing them. The Germans are famous for
masquerading and practical jokes; this is one, I am sure, and uncle
will be terribly angry if he discovers it.”
“But why all this concealment?” cried Amy. “Why play jokes on us?
You look so worried I know you have not told me all you know or
fear.”
“I confess I do fear that these men are political plotters as well as
exiles. There are many such, and they make tools of rich and
ignorant foreigners to further their ends. Uncle is rich, generous, and
unsuspicious; and I fear that while apparently serving and enjoying
us they are using him.”
“Heavens, it may be! and that would account for the change we
see in him. I thought he was in love with the widow, but that may
be only a cloak to hide darker designs. Karl brought us here, and I
dare say it is a den of conspirators!” cried Amy, feeling as if she were
getting more of an adventure than she had bargained for.
“Don’t be alarmed! I am on the watch, and mean to demand an
explanation from uncle, or take you away on my own responsibility,
if I can.”
Here a maid tapped to say that tea was served.
“We must go down, or some one will suspect trouble. Plead
headache to excuse your paleness, and I’ll keep people away. We
will manage the affair and be off as soon as possible,” said Helen, as
Amy followed her, too bewildered to answer.
Casimer was not in the room, the major and Mrs. Cumberland
were sipping tea side by side, and the professors roaming vaguely
about. To leave Amy in peace, Helen engaged them both in a lively
chat, and her cousin sat by the window trying to collect her
thoughts. Some one was pacing up and down the garden, hatless, in
the dew.
 Amy forgot everything but the danger of such exposure to her
reckless friend. His cloak and hat lay on a chair; she caught them up
and glided unperceived from the long window.
“You are so imprudent I fear for you, and bring your things,” said
a timid voice, as the little white figure approached the tall black one,
striding down the path tempestuously.
“You to think of me, forgetful of yourself! Little angel of kindness,
why do you take such care of me?” cried Casimer, eagerly taking not
only the cloak, but the hands that held it.
“I pitied you because you were ill and lonely. You do not deserve
my pity, but I forgive that, and would not see you suffer,” was the
reproachful answer, as Amy turned away.
But he held her fast, saying earnestly,—
“What have I done? You are angry. Tell me my fault and I will
amend.”
“You have deceived me.”
“How?”
“Will you own the truth?” and in her eagerness to set her fears at
rest, Amy forgot Helen.
“I will.”
She could not see his face, but his voice was steady and his
manner earnest.
“Tell me, then, is not your true name Sigismund Palsdorf?”
He started, but answered instantly,—
“It is not.”
“You are not the baron?” cried Amy.
“No; I will swear it if you wish.”
“Who, then, are you?”
 “Shall I confess?”
“Yes, I entreat you.”
“Remember, you command me to speak.”
“I do. Who are you?”
“Your lover.”
The words were breathed into her ear as softly as ardently, but
they startled her so much she could find no reply, and, throwing
himself down before her, Casimer poured out his passion with an
impetuosity that held her breathless.
“Yes, I love you, and I tell it, vain and dishonorable as it is in one
like me. I try to hide it. I say ‘it cannot be.’ I plan to go away. But
you keep me; you are angel-good to me; you take my heart, you
care for me, teach me, pity me, and I can only love and die. I know
it is folly; I ask nothing; I pray to God to bless you always, and I say,
Go, go, before it is too late for you, as now for me!”
“Yes, I must go—it is all wrong. Forgive me. I have been very
selfish. Oh, forget me and be happy,” faltered Amy, feeling that her
only safety was in flight.
“Go! go!” he cried, in a heart-broken tone, yet still kissed and
clung to her hands till she tore them away and fled into the house.
Helen missed her soon after she went, but could not follow for
several minutes; then went to their chamber and there found Amy
drowned in tears, and terribly agitated.
Soon the story was told with sobs and moans, and despairing
lamentations fit to touch a heart of stone.
“I do love him—oh, I do; but I didn’t know it till he was so
unhappy, and now I’ve done this dreadful harm. He’ll die, and I can’t
help him, see him, or be anything to him. Oh, I’ve been a wicked,
wicked girl, and never can be happy any more.”
Angry, perplexed, and conscience-stricken, for what now seemed
blind and unwise submission to the major, Helen devoted herself to
calming Amy, and when at last the poor, broken-hearted little soul
fell asleep in her arms, she pondered half the night upon the still
unsolved enigma of the Baron Sigismund.
 VIII.

MORE MYSTERY.

“Uncle, can I speak to you a moment?” said Helen, very gravely, as

they left the breakfast-room next morning.
“Not now, my dear, I’m busy,” was the hasty reply, as the major
shawled Mrs. Cumberland for an early promenade.
Helen knit her brows irefully, for this answer had been given her
half a dozen times lately when she asked for an interview. It was
evident he wished to avoid all lectures, remonstrances, and
explanations; and it was also evident that he was in love with the
widow.
“Lovers are worse than lunatics to manage, so it is vain to try to
get any help from him,” sighed Helen, adding, as her uncle was
gallantly leading his stout divinity away into the garden: “Amy has a
bad headache, and I shall stay to take care of her, so we can’t join
your party to Chillon, sir. We have been there once, so you needn’t
postpone it for us.”
“Very well, my dear,” and the major walked away, looking much
relieved.
As Helen was about to leave the salon Casimer appeared. A single
glance at her face assured him that she knew all, and instantly
assuming a confiding, persuasive air that was irresistible, he said,
meekly,—
“Mademoiselle, I do not deserve a word from you, but it desolates
me to know that I have grieved the little angel who is too dear to
me. For her sake, pardon that I spoke my heart in spite of prudence,
and permit me to send her this.”
 Helen glanced from the flowers he held to his beseeching face,
and her own softened. He looked so penitent and anxious, she had
not the heart to reproach him.
“I will forgive you and carry your gift to Amy on one condition,”
she said, gravely.
“Ah, you are kind! Name, then, the condition, I implore you, and I
will agree.”
“Tell me, then, on your honor as a gentleman, are you not Baron
Palsdorf?”
“On my honor as a gentleman, I swear to you I am not.”
“Are you, in truth, what you profess to be?”
“I am, in truth, Amy’s lover, your devoted servant, and a most
unhappy man, with but a little while to live. Believe this and pity me,
dearest Mademoiselle Helène.”
She did pity him, her eyes betrayed that, and her voice was very
kind, as she said,—
“Pardon my doubts. I trust you now, and wish with all my heart
that it was possible to make you happy. You know it is not, therefore
I am sure you will be wise and generous, and spare Amy further
grief by avoiding her for the little time we stay. Promise me this,
Casimer.”
“I may see her if I am dumb? Do not deny me this. I will not
speak, but I must look at my little and dear angel when she is near.”
He pleaded so ardently with lips and hands, and eager eyes, that
Helen could not deny him, and when he had poured out his thanks
she left him, feeling very tender toward the unhappy young lover,
whose passion was so hopeless, yet so warm.
Amy was at breakfast in her room, sobbing and sipping, moaning
and munching, for, though her grief was great, her appetite was
good, and she was in no mood to see anything comical in cracking
eggshells while she bewailed her broken heart, or in eating honey in
the act of lamenting the bitterness of her fate.
Casimer would have become desperate had he seen her in the
little blue wrapper, with her bright hair loose on her shoulders, and
her pretty face wet with tears, as she dropped her spoon to seize his
flowers,—three dewy roses, one a bud, one half and the other fully
blown, making a fragrant record and avowal of the love which she
must renounce.
“Oh, my dear boy! how can I give him up, when he is so fond, and
I am all he has? Helen, uncle must let me write or go to mamma.
She shall decide; I can’t; and no one else has a right to part us,”
sobbed Amy, over her roses.
“Casimer will not marry, dear; he is too generous to ask such a
sacrifice,” began Helen, but Amy cried indignantly,—
“It is no sacrifice; I’m rich. What do I care for his poverty?”
“His religion!” hinted Helen, anxiously.
“It need not part us; we can believe what we will. He is good; why
mind whether he is Catholic or Protestant.”
“But a Pole, Amy, so different in tastes, habits, character, and
beliefs. It is a great risk to marry a foreigner; races are so unlike.”
“I don’t care if he is a Tartar, a Calmuck, or any of the other wild
tribes; I love him, he loves me, and no one need object if I don’t.”
“But, dear, the great and sad objection still remains—his health.
He just said he had but a little while to live.”
Amy’s angry eyes grew dim, but she answered, with soft
earnestness,—
“So much the more need of me to make that little while happy.
Think how much he has suffered and done for others; surely I may
do something for him. Oh, Nell, can I let him die alone and in exile,
when I have both heart and home to give him?”
 Helen could say no more; she kissed and comforted the faithful
little soul, feeling all the while such sympathy and tenderness that
she wondered at herself, for with this interest in the love of another
came a sad sense of loneliness, as if she was denied the sweet
experience that every woman longs to know.
Amy never could remain long under a cloud, and seeing Helen’s
tears, began to cheer both her cousin and herself.
“Hoffman said he might live with care, don’t you remember? and
Hoffman knows the case better than we. Let us ask him if Casimer is
worse. You do it; I can’t without betraying myself.”
“I will,” and Helen felt grateful for any pretext to address a friendly
word to Karl, who had looked sad of late, and had been less with
them since the major became absorbed in Mrs. Cumberland.
Leaving Amy to compose herself, Helen went away to find
Hoffman. It was never difficult, for he seemed to divine her wishes
and appear uncalled the moment he was wanted. Hardly had she
reached her favorite nook in the garden when he approached with
letters, and asked with respectful anxiety, as she glanced at and
threw them by with an impatient sigh,—
“Has mademoiselle any orders? Will the ladies drive, sail, or make
a little expedition? It is fine, and mademoiselle looks as if the air
would refresh her. Pardon that I make the suggestion.”
“No, Hoffman, I don’t like the air of this place, and intend to leave
as soon as possible.” And Helen knit her delicate dark brows with an
expression of great determination. “Switzerland is the refuge of
political exiles, and I hate plots and disguises; I feel oppressed by
some mystery, and mean to solve or break away from it at once.”
She stopped abruptly, longing to ask his help, yet withheld by a
sudden sense of shyness in approaching the subject, though she had
decided to speak to Karl of the Pole.
“Can I serve you, mademoiselle? If so, pray command me,” he
said, eagerly, coming a step nearer.
 “You can, and I intend to ask your advice, for there can be
nothing amiss in doing so, since you are a friend of Casimer’s.”
“I am both friend and confidant, mademoiselle,” he answered, as
if anxious to let her understand that he knew all, without the
embarrassment of words. She looked up quickly, relieved, yet
troubled.
“He has told you, then?”
“Everything, mademoiselle. Pardon me if this afflicts you; I am his
only friend here, and the poor lad sorely needed comfort.”
“He did. I am not annoyed; I am glad, for I know you will sustain
him. Now I may speak freely, and be equally frank. Please tell me if
he is indeed fatally ill?”
“It was thought so some months ago; now I hope. Happiness
cures many ills, and since he has loved, he has improved. I always
thought care would save him; he is worth it.”
Hoffman paused, as if fearful of venturing too far; but Helen
seemed to confide freely in him, and said, softly,—
“Ah, if it were only wise to let him be happy. It is so bitter to deny
love.”
“God knows it is!”
The exclamation broke from Hoffman as if an irrepressible impulse
wrung it from him.
Helen started, and for a moment neither spoke. She collected
herself soonest, and without turning, said, quietly,—
“I have been troubled by a strong impression that Casimer is not
what he seems. Till he denied it on his honor I believed him to be
Baron Palsdorf. Did he speak the truth when he said he was not?”
“Yes, mademoiselle.”
“Then, Casimer Teblinski is his real name?”
No answer.
 She turned sharply, and added,—
“For my cousin’s sake, I must know the truth. Several curious
coincidences make me strongly suspect that he is passing under an
assumed name.”
Not a word said Hoffman, but looked on the ground, as motionless
and expressionless as a statue.
Helen lost patience, and in order to show how much she had
discovered, rapidly told the story of the gloves, ring, handkerchief,
prayer-book and collar, omitting all hint of the girlish romance they
had woven about these things.
As she ended, Hoffman looked up with a curious expression, in
which confusion, amusement, admiration and annoyance seemed to
contend.
“Mademoiselle,” he said, gravely, “I am about to prove to you that
I feel honored by the confidence you place in me. I cannot break my
word, but I will confess to you that Casimer does not bear his own
name.”
“I knew it!” said Helen, with a flash of triumph in her eyes. “He is
the baron, and no Pole. You Germans love masquerades and jokes.
This is one, but I must spoil it before it is played out.”
“Pardon; mademoiselle is keen, but in this she is mistaken.
Casimer is not the baron; he did fight for Poland, and his name is
known and honored there. Of this I solemnly assure you.”
She stood up and looked him straight in the face. He met her eye
to eye, and never wavered till her own fell.
She mused a few minutes, entirely forgetful of herself in her
eagerness to solve the mystery.
Hoffman stood so near that her dress touched him, and the wind
blew her scarf against his hand; and as she thought he watched her
while his eyes kindled, his color rose, and once he opened his lips to
speak, but she moved at the instant, and exclaimed,—
 “I have it!”
“Now for it,” he muttered, as if preparing for some new surprise or
attack.
“When uncle used to talk about the Polish revolution, there was, I
remember a gallant young Pole who did something brave. The name
just flashed on me, and it clears up my doubts. Stanislas Prakora
—‘S. P.’—and Casimer is the man.”
Helen spoke with an eager, bright face, as if sure of the truth now;
but, to her surprise, Hoffman laughed, a short, irrepressible laugh,
full of hearty but brief merriment. He sobered in a breath, and with
an entire change of countenance said, in an embarrassed tone,—
“Pardon my rudeness; mademoiselle’s acuteness threw me off my
guard. I can say nothing till released from my promise; but
mademoiselle may rest assured that Casimer Teblinski is as good
and brave a man as Stanislas Prakora.”
Helen’s eyes sparkled, for in this reluctant reply she read
confirmation of her suspicion, and thought that Amy would rejoice to
learn that her lover was a hero.
“You are exiles but, still hope and plot, and never relinquish your
heart’s desire?”
“Never, mademoiselle!”
“You are in danger?”
“In daily peril of losing all we most love and long for,” answered
Karl, with such passion that Helen found patriotism a lovely and
inspiring thing.
“You have enemies?” she asked, unable to control her interest,
and feeling the charm of these confidences.
“Alas! yes,” was the mournful reply, as Karl dropped his eyes to
hide the curious expression of mirth which he could not banish from
them.
 “Can you not conquer them, or escape the danger they place you
in?”
“We hope to conquer, we cannot escape.”
“This accounts for your disguise and Casimer’s false name?”
“Yes. We beg that mademoiselle will pardon us the anxiety and
perplexity we have caused her, and hope that a time will soon arrive
when we may be ourselves. I fear the romantic interest with which
the ladies have honored us will be much lessened, but we shall still
remain their most humble and devoted servants.”
Something in his tone nettled Helen, and she said sharply,—
“All this may be amusing to you, but it spoils my confidence in
others to know they wear masks. Is your name also false?”
“I am Karl Hoffman, as surely as the sun shines, mademoiselle. Do
not wound me by a doubt,” he said, eagerly.
“And nothing more?”
She smiled as she spoke, and glanced at his darkened skin with a
shake of the head.
“I dare not answer that.”
“No matter; I hate titles, and value people for their own worth,
not for their rank.”
Helen spoke impulsively, and, as if carried away by her words and
manner, Hoffman caught her hand and pressed his lips to it ardently,
dropped it, and was gone, as if fearing to trust himself a moment
longer.
Helen stood where he left her, thinking, with a shy glance from
her hand to the spot where he had stood,—
“It is pleasant to have one’s hand kissed, as Amy said. Poor Karl,
his fate is almost as hard as Casimer’s.”
Some subtile power seemed to make the four young people shun
one another carefully, though all longed to be together. The major
appeared to share the secret disquiet that made the rest roam
listlessly about, till little Roserl came to invite them to a fête in honor
of the vintage. All were glad to go, hoping in the novelty and
excitement to recover their composure.
The vineyard sloped up from the chateau, and on the hillside was
a small plateau of level sward, shadowed by a venerable oak now
hung with garlands, while underneath danced the chateau servants
with their families, to the music of a pipe played by little Freidel. As
the gentlefolk approached, the revel stopped, but the major, who
was in an antic mood and disposed to be gracious, bade Freidel play
on, and as Mrs. Cumberland refused his hand with a glance at her
weeds, the major turned to the Count’s buxom housekeeper, and
besought her to waltz with him. She assented, and away they went
as nimbly as the best. Amy laughed, but stopped to blush, as
Casimer came up with an imploring glance, and whispered,—
“Is it possible that I may enjoy one divine waltz with you before I
go?”
Amy gave him her hand with a glad assent, and Helen was left
alone. Every one was dancing but herself and Hoffman, who stood
near by, apparently unconscious of the fact. He glanced covertly at
her, and saw that she was beating time with foot and hand, that her
eyes shone, her lips smiled. He seemed to take courage at this, for,
walking straight up to her, he said, as coolly as if a crown-prince,—
“Mademoiselle, may I have the honor?”
A flash of surprise passed over her face, but there was no anger,
pride, or hesitation in her manner, as she leaned toward him with a
quiet “Thanks, monsieur.”
A look of triumph was in his eyes as he swept her away to dance,
as she had never danced before, for a German waltz is full of life
and spirit, wonderfully captivating to English girls, and German
gentlemen make it a memorable experience when they please. As
they circled round the rustic ball-room, Hoffman never took his eyes
off Helen’s, and, as if fascinated, she looked up at him, half
conscious that he was reading her heart as she read his. He said not
a word, but his face grew very tender, very beautiful in her sight, as
she forgot everything except that he had saved her life and she
loved him. When they paused, she was breathless and pale; he also;
and seating her he went away to bring her a glass of wine. As her
dizzy eyes grew clear, she saw a little case at her feet, and taking it
up, opened it. A worn paper, containing some faded forget-me-nots
and these words, fell out,—
“Gathered where Helen sat on the night of August 10th.”
There was just time to restore its contents to the case, when
Hoffman returned, saw it, and looked intensely annoyed as he
asked, quickly,—
“Did you read the name on it?”
“I saw only the flowers;” and Helen colored beautifully as she
spoke.
“And read them?” he asked, with a look she could not meet.
She was spared an answer, for just then a lad came up, saying, as
he offered a note,—
“Monsieur Hoffman, madame, at the hotel, sends you this, and
begs you to come at once.”
As he impatiently opened it, the wind blew the paper into Helen’s
lap. She restored it, and in the act, her quick eye caught the
signature, “Thine ever, Ludmilla.”
A slight shadow passed over her face, leaving it very cold and
quiet. Hoffman saw the change, and smiled, as if well pleased, but
assuming suddenly his usual manner, said deferentially,—
“Will mademoiselle permit me to visit my friend for an hour?—she
is expecting me.”
“Go, then, we do not need you,” was the brief reply, in a careless
tone, as if his absence was a thing of no interest to any one.
 “Thanks; I shall not be long away;” and giving her a glance that
made her turn scarlet with anger at its undisguised admiration, he
walked away, humming gayly to himself Goethe’s lines,—
“Maiden’s heart and city’s wall
Were made to yield, were made to fall;
When we’ve held them each their day,
Soldier-like we march away.”
 IX.

“S. P.” AND THE BARON.

Dinner was over, and the salon deserted by all but the two young
ladies, who sat apart, apparently absorbed in novels, while each was
privately longing for somebody to come, and with the charming
inconsistency of the fair sex, planning to fly if certain somebodies did
appear.
Steps approached; both buried themselves in their books; both
held their breath and felt their hearts flutter as they never had done
before at the step of mortal man. The door opened; neither looked
up, yet each was conscious of mingled disappointment and relief
when the major said, in a grave tone, “Girls, I’ve something to tell
you.”
“We know what it is, sir,” returned Helen, coolly.
“I beg your pardon, but you don’t, my dear, as I will prove in five
minutes, if you will give me your attention.”
The major looked as if braced up to some momentous
undertaking; and planting himself before the two young ladies,
dashed bravely into the subject.
“Girls, I’ve played a bold game, but I’ve won it, and will take the
consequences.”
“They will fall heaviest on you, uncle,” said Helen, thinking he was
about to declare his love for the widow.
The major laughed, shrugged his shoulders, and answered,
stoutly,—
 “I’ll bear them; but you are quite wrong, my dear, in your
surmises, as you will soon see. Helen is my ward, and accountable
to me alone. Amy’s mother gave her into my charge, and won’t
reproach me for anything that has passed when I explain matters.
As to the lads they must take care of themselves.”
Suddenly both girls colored, fluttered, and became intensely
interested. The major’s eyes twinkled as he assumed a perfectly
impassive expression, and rapidly delivered himself of the following
thunderbolt,—
“Girls, you have been deceived, and the young men you love are
impostors.”
“I thought so,” muttered Helen, grimly.
“Oh, uncle, don’t, don’t say that!” cried Amy, despairingly.
“It’s true, my dears; and the worst of it is, I knew the truth all the
time. Now, don’t have hysterics, but listen and enjoy the joke as I
do. At Coblentz, when you sat in the balcony, two young men
overheard Amy sigh for adventures, and Helen advise making a
romance out of the gloves one of the lads had dropped. They had
seen you by day; both admired you, and being idle, gay young
fellows, they resolved to devote their vacation to gratifying your
wishes and enjoying themselves. We met at the Fortress; I knew
one of them, and liked the other immensely; so when they confided
their scheme to me I agreed to help them carry it out, as I had
perfect confidence in both, and thought a little adventure or two
would do you good.”
“Uncle, you were mad,” said Helen; and Amy added, tragically,—
“You don’t know what trouble has come of it.”
“Perhaps I was; that remains to be proved. I do know everything,
and fail to see any trouble, so don’t cry, little girl,” briskly replied the
inexplicable major, “Well, we had a merry time planning our prank.
One of the lads insisted on playing courier, though I objected. He’d
done it before, liked the part, and would have his way. The other
couldn’t decide, being younger and more in love; so we left him to
come into the comedy when he was ready. Karl did capitally, as you
will allow; and I am much attached to him, for in all respects he has
been true to his word. He began at Coblentz; the other, after doing
the mysterious at Heidelberg, appeared as an exile, and made quick
work with the prejudices of my well-beloved nieces—hey, Amy?”
“Go on; who are they?” cried both girls, breathlessly.
“Wait a bit; I’m not bound to expose the poor fellows to your
scorn and anger. No; if you are going to be high and haughty, to
forget their love, refuse to forgive their frolic, and rend their hearts
with reproaches, better let them remain unknown.”
“No, no; we will forget and forgive, only speak!” was the
command of both.
“You promise to be lenient and mild, to let them confess their
motives, and to award a gentle penance for their sins?”
“Yes, we promise!”
“Then, come in, my lads, and plead for your lives.”
As he spoke the major threw open the door, and two gentlemen
entered the room—one, slight and dark, with brilliant black eyes; the
other tall and large, with blond hair and beard. Angry, bewildered,
and shame-stricken as they were, feminine curiosity overpowered all
other feelings for the moment, and the girls sat looking at the
culprits with eager eyes, full of instant recognition; for though the
disguise was off, and neither had seen them in their true characters
but once, they felt no doubt, and involuntarily exclaimed,—
“Karl!”
“Casimer.”
“No, young ladies; the courier and exile are defunct, and from
their ashes rise Baron Sigismund Palsdorf, my friend, and Sidney
Power, my nephew. I give you one hour to settle the matter; then I
shall return to bestow my blessing or to banish these scapegraces
forever.”
And, having fired his last shot, the major prudently retreated,
without waiting to see its effect.
It was tremendous, for it carried confusion into the fair enemy’s
camp; and gave the besiegers a momentary advantage of which
they were not slow to avail themselves.
For a moment the four remained mute and motionless: then Amy,
like all timid things, took refuge in flight, and Sidney followed her
into the garden, glad to see the allies separated. Helen, with the
courage of her nature, tried to face and repulse the foe; but love
was stronger than pride, maiden shame overcame anger, and,
finding it vain to meet and bear down the steady, tender glance of
the blue eyes fixed upon her, she drooped her head into her hands
and sat before him, like one conquered but too proud to cry
“Quarter.” Her lover watched her till she hid her face, then drew
near, knelt down before her, and said, with an undertone of deep
feeling below the mirthful malice of his words,—
“Mademoiselle, pardon me that I am a foolish baron, and dare to
offer you the title that you hate. I have served you faithfully for a
month, and, presumptuous as it is, I ask to be allowed to serve you
all my life. Helen, say you forgive the deceit for love’s sake.”
“No; you are false and forsworn. How can I believe that anything
is true?”
And Helen drew away the hand of which he had taken possession.
“Heart’s dearest, you trusted me in spite of my disguise; trust me
still, and I will prove that I am neither false nor forsworn. Catechise
me, and see if I was not true in spite of all my seeming deception.”
“You said your name was Karl Hoffman,” began Helen, glad to gain
a little time to calm herself before the momentous question came.
“It is; I have many, and my family choose to call me Sigismund,”
was the laughing answer.
 “I’ll never call you so; you shall be Karl, the courier, all your life to
me,” cried Helen, still unable to meet the ardent eyes before her.
“Good; I like that well; for it assures me that all my life I shall be
something to you, my heart. What next?”
“When I asked if you were the baron, you denied it.”
“Pardon! I simply said my name was Hoffman. You did not ask me
point blank if I was the baron; had you done so, I think I should
have confessed all, for it was very hard to restrain myself this
morning.”
“No, not yet; I have more questions;” and Helen warned him
away, as it became evident that he no longer considered restraint
necessary.
“Who is Ludmilla?” she said, sharply.
“My faith, that is superb!” exclaimed the baron, with a triumphant
smile at her betrayal of jealousy. “How if she is a former love?” he
asked, with a sly look at her changing face.
“It would cause me no surprise; I am prepared for anything.”
“How if she is my dearest sister, for whom I sent, that she might
welcome you and bring the greetings of my parents to their new
daughter?”
“Is it, indeed, so?”
And Helen’s eyes dimmed as the thought of parents, home and
love filled her heart with tenderest gratitude, for she had long been
an orphan.
“Leibchen, it is true; to-morrow you shall see and know how dear
you already are to them, for I write often and they wait eagerly to
receive you.”
Helen felt herself going very fast, and made an effort to harden
her heart, less too easy victory should reward this audacious lover.
 “I may not go; I also have friends, and in England we are not won
in this wild way. I will yet prove you false; it will console me for
being so duped if I can call you traitor. You said Casimer had fought
in Poland.”
“Cruelest of women, he did, but under his own name, Sidney
Power.”
“Then, he was not the brave Stanislas?—and there is no charming
Casimer?”
“Yes, there are both,—his and my friends, in Paris; true Poles, and
when we go there you shall see them.”
“But his illness was a ruse?”
“No; he was wounded in the war and has been ill since. Not of a
fatal malady, I own; his cough misled you, and he has no scruples in
fabling to any extent. I am not to bear the burden of his sins.”
“Then, the romances he told us about your charity, your virtues,
and—your love of liberty were false?” said Helen, with a keen
glance, for these tales had done much to interest her in the
unknown baron.
Sudden color rose to his forehead, and for the first time his eyes
fell before hers,—not in shame, but with a modest man’s annoyance
at hearing himself praised.
“Sidney is enthusiastic in his friendship, and speaks too well for
me. The facts are true, but he doubtless glorified the simplest by his
way of telling it. Will you forgive my follies, and believe me when I
promise to play and duel no more?”
“Yes.”
She yielded her hand now, and her eyes were full of happiness,
yet she added, wistfully,—
“And the betrothed, your cousin, Minna,—is she, in truth, not dear
to you?”
 “Very dear, but less so than another; for I could not learn of her in
years what I learned in a day when I met you. Helen, this was
begun in jest,—it ends in solemn earnest, for I love my liberty, and I
have lost it, utterly and forever. Yet I am glad; look in my face and
tell me you believe it.”
He spoke now as seriously as fervently, and with no shadow on
her own, Helen brushed back the blond hair and looked into her
lover’s face. Truth, tenderness, power, and candor were written there
in characters that could not lie; and with her heart upon her lips, she
answered, as he drew her close,—
“I do believe, do love you, Sigismund!”
Meanwhile another scene was passing in the garden. Sidney,
presuming upon his cousinship, took possession of Amy, bidding her
“strike but hear him.” Of course she listened with the usual
accompaniment of tears and smiles, reproaches and exclamations,
varied by cruel exultations and coquettish commands to go away
and never dare approach her again.
“Ma drogha, listen and be appeased. Years ago you and I played
together as babies, and our fond mammas vowed we should one
day mate. When I was a youth of fourteen and you a mite of seven I
went away to India with my father, and at our parting promised to
come back and marry you. Being in a fret because you couldn’t go
also, you haughtily declined the honor, and when I offered a farewell
kiss, struck me with this very little hand. Do you remember it?”
“Not I. Too young for such nonsense.”
“I do, and I also remember that in my boyish way I resolved to
keep my word sooner or later, and I’ve done it.”
“We shall see, sir,” cried Amy, strongly tempted to repeat her part
of the childish scene as well as her cousin, but her hand was not
free, and he got the kiss without the blow.
“For eleven years we never met. You forgot me entirely, and
‘Cousin Sidney’ remained an empty name. I was in India till four
years ago; since then I’ve been flying about Germany and fighting in
Poland, where I nearly got my quietus.”
“My dear boy, were you wounded?”
“Bless you, yes; and very proud of it I am. I’ll show you my scars
some day; but never mind that now. A little while ago I went to
England, seized with a sudden desire to find my wife.”
“I admire your patience in waiting; so flattering to me, you know,”
was the sharp answer.
“It looks like neglect, I confess; but I’d heard reports of your
flirtations, and twice of your being engaged, so I kept away till my
work was done. Was it true?”
“I never flirt, Sidney, and I was only engaged a little bit once or
twice. I didn’t like it, and never mean to do so any more.”
“I shall see that you don’t flirt; but you are very much engaged
now, so put on your ring and make no romances about any ‘S. P.’ but
myself.”
“I shall wait till you clear your character; I’m not going to care for
a deceitful impostor. What made you think of this prank?”
“You did.”
“I? How?”
“When in England I saw your picture, though you were many a
mile away, and fell in love with it. Your mother told me much about
you, and I saw she would not frown upon my suit. I begged her not
to tell you I had come, but let me find you and make myself known
when I liked. You were in Switzerland, and I went after you. At
Coblentz I met Sigismund, and told him my case; he is full of
romance, and when we overheard you in the balcony we were glad
of the hint. Sigismund was with me when you came, and admired
Helen immensely, so he was wild to have a part in the frolic. I let
him begin, and followed you unseen to Heidelberg, meaning to
personate an artist. Meeting you at the castle, I made a good
beginning with the vaults and the ring, and meant to follow it up by
acting the baron, you were so bent on finding him, but Sigismund
forbade it. Turning over a trunk of things left there the year before, I
came upon my old Polish uniform, and decided to be a Thaddeus.”
“How well you did it! Wasn’t it hard to act all the time?” asked
Amy, wonderingly.
“Very hard with Helen, she is so keen, but not a bit so with you,
for you are such a confiding soul any one could cheat you. I’ve
betrayed myself a dozen times, and you never saw it. Ah, it was
capital fun to play the forlorn exile, study English, and flirt with my
cousin.”
“It was very base. I should think you’d be devoured with remorse.
Aren’t you sorry?”
“For one thing. I cropped my head lest you should know me. I was
proud of my curls, but I sacrificed them all to you.”
“Peacock! Did you think that one glimpse of your black eyes and
fine hair would make such an impression that I should recognize you
again?”
“I did, and for that reason disfigured my head, put on a mustache,
and assumed hideous spectacles. Did you never suspect my
disguise, Amy?”
“No. Helen used to say that she felt something was wrong, but I
never did till the other night.”
“Didn’t I do that well? I give you my word it was all done on the
spur of the minute. I meant to speak soon, but had not decided
how, when you came out so sweetly with that confounded old cloak,
of which I’d no more need than an African has of a blanket. Then a
scene I’d read in a novel came into my head, and I just repeated it
con amore. Was I very pathetic and tragical, Amy?”
“I thought so then. It strikes me as ridiculous now, and I can’t
help feeling sorry that I wasted so much pity on a man who—”
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