INTRODUCTION

Declining fertility rates combined with steady improvements in life expectancy over the 20 th
century produced dramatic growth in the world’s elderly population. People aged over 65 and
over now compromise a greater share of the world’s population than ever before.

Population aging refers to an increase in the percentage of the elderly people (65 and older)

DEMOGRAPHY

As we enter the 21st century, population aging has emerged as a major demographic trend
worldwide. High birth rates and low death rates led to unpredicted changes in the demography of
humans.

 Population aging
 Increased longevity
 Trends in health practice
 Changes in medical technology

GERIATRICS

DEFINITION

Geriatrics is a sub-specialty of internal medicine that focuses on health care of the elderly people.
It aims to promote health by preventing and treating diseases and disabilities in older adults.

Geriatrics, care of the aged people, differs from gerontology, which is the study of the aging
process itself. However, geriatrics is sometimes called medical gerontology.

DEFINITION OF TERMS

GERONTOLOGY: this is the scientific study of the process and problem of aging that focuses
on the biological aspects of normal ageing.

GERONTOLOGIST: it includes researchers and practitioners in diverse fields such as

anatomy, medicine, nursing, dentistry, physical and occupational therapy, psychology,
psychiatry, sociology, economy, political science and social worker.
GERIATRIC NURSING: is the specialty that concerns itself with the provision of nursing
services to geriatric or aged individuals. It is also defined as the specialized nursing care of the
elderly adults that occurs in any setting , in which nurses use knowledge and expertise caring
abilities to promote optimal functioning.

AGING: is the accumulation of changes in an organism or object overtime. Aging in humans

refers to a multidimensional process of physical, psychological and social change.

THEORIES OF AGING

The two main aging theory categories are:

1. Programmed theories: aging has a biological timetable or internal biological clock.

2. Error theories: Aging is a result of internal or external assaults that damage cells or
organs so they can no longer function properly.

Many theories are a combination of programmed and error theories.

PROGRAMMED THEORIES OR NON-STOCKASTIC THEORIES

 Programmed senescence theory

 Endocrine theory
 Immunology theory

ERROR THEORIES

 Wear and tear

 Cross-linking
 Free radical theory
 Error catastroph theory
 Somatic mutation theory

In 1950s Hayflick in a series of classic experiments demonstrated the cultured skin fibroblasts
would reproduce or divide a finite number of times. From these observations rose the
programmed theory that there is an impairment in the ability of the cell to continue dividing.
The Hayflick limit theory of aging (after his discoverer Dr Leonard Hayflick) suggests that the
human cellis limited in the number of times it can divide. Dr Hayflick theorized that the human
cells ability to divide is limited to 50-times after which they stop dividing and hence die. He
showed that nutrtion has an effect on cells with over fed cells dividing much faster than underfed
cells. As cells divide to help repair and regenerate themselves, we may consider that the DNA
and genetic theory of aging may play a role here.

FACTORS INFLUENCING AGING

1. Hereditary factor: some families live longer than others given the same environmental
circumstances.
2. Environmental factor: Bourlier in 1973 has given 3 factors;
 Abiotic factor: are the physical and chemical components of the environment such as
climatic influences, pollutants and radiation.
 Biotic factors: Result from the influence of thousands of living organisms which are
affected by such things as pathogens, parasites, quality and availability of fodd
products
 Social economic factors: Adverse living and working conditions can increase wear
and tear of tissues to which the individual is exposed. Stressful living conditions are
likely to accelerate the process of aging
3. Stressful factors: are more prevalent in modern industrialized society. Income, poverty
and chronic health problem also affects aging.

OLDER ADULTS

The age of the older adult population that is growing most rapidly in the country today are those
persons aged 85 years and older. Although many older people maintain highly functional lives,
others have mental health deficits because of normal sensory losses related to aging, failing
physical health, difficulty performing activities of daily living, social deprivation or isolation .
For example, life changes related to work roles and retirement often result in reduced social
contacts and support. Other previously described losses are associated with the deaths of a
spouse, other family members and friends.
Reduced social networks and contacts brought about by these life events to serious state
depression.

Depression has an impact on functional independence and contributed to suicide. Another factor
linked to suicide in this age group is chronic illness.

Common physical problems of older adults include terminal illnesses associated with cancer and
chronic conditions such as arthritis, osteoporosis, cardiovascular and respiratory disease. Brain
disorders such as Alzheimer disease, dementia and stroke are also common among older adults.
All these conditions have an impact on the mental health status of individuals and their family
care givers.

Health aging activities improve the mental health of older adults, developing habits that promote
balanced nutrition and physical activity along with establishing social network. Last, like those
in age groups across the life span, older adults are victims of violence in the environment and in
their homes. Therefore, national health objectives related to these issues include reducing the
incidence of abuse. Strategies that address these problems include early screening for risk factors
in all primary care setting and organizing health promotion programmes through senior centres
or other community-based settings that serve older adults.

BIOGRAPHIC DATA

 Present health history

 Past health history
 Family history
 Personal history
 Nutritional history
 Social economic history
 Environmental history
 Detailed physical history
 Investigations
 Treatment
 Diseases aspect and management
 Nursing plan
  Drug study
 Evaluation
 Diet plan
 Discharge plan

NURSING PROBLEMS/DIAGNOSIS

 Impairment of vision related to aging like cataract, long- sight, night blind, difficulty in
reading etc.
 Accidental falls, diseases condition
 Altered in smell and taste
 Poor hygiene self care deficit
 Inability to recognize
 Impaired mobility due to fracture, arthritis
 Impaired memory, slow speech, slow body movements.
 Hypertension related to aging
 Anxiety related to aging process.

NURSING IMPLICATION

 Provide bright light for reading

 No glare or dim light burning in bedroom , bathroom at night
 Safety rails
 Furniture in convenient place
 Regular eye check ups
 Check temperature of water
 Serve food attractively
 Maintain good oral hygiene
 Special attention to pressure points and change of position
 Provide hearing aids, eye glasses
 Bed without wrinkles
 Treat the problems affecting the nervous system, cardiovascular, respiratory ystem,
gastro intestinal, genito-urinary system.
  Avoid any kind of abuse such as physical and psychological.

FACTORS HELPING A SUCCESSFUL AGING

Physical health

 Regular medical check ups

 Adequate and appropriate treatment of diseases
 Adequate nutrition
 Good personal and environmental hygiene
 Adequate time to rest and sleep
 Assistance in meeting the activities of daily living

Physical Activities

 Passive and active exercises

 Daily walking, jogging
 Participation in household works
 Rehabilitation of the physical handicapped

Mental health

 Use effective communication skill

 Listen attentively
 Speak slowly and clearly
 Provide reading materials
 Create humor
 Provide hearing and other aids
 Meet the needs
 Encourage people to visit old people home or their children should take care of their
parents

ROLE OF THE NURSE

Whenever the nurse visits the home or she is assigned withhold client, she will have to:
 1. Carry on the prescription and treatment of the patient
2. Assure the family about old age health problems and how to cope with them, personal
hygiene, nutrition , exercise and rest.
3. Nurse has responsibility to protect, promote and extend life.
4. Tenderness towards old age

CHANGES ASSOCIATED WITH AGING

A number of physiological change occur as we grow older. It is important to recognize the

changes of normal aging versus the effect of disease. Untreated disease can result in “Excess
disability” and reduce the quality of life of individuals.

CARDIOVASCULAR CHANGES

 Heart rate decreases and it takes longer for heart rate to and blood pressure to return to
normal after exertion
 The aorta and other arteries become thicker and stiffer which may bring a moderate
increase in systolic blood pressure with aging.
 The valves between the chambers of the heart thicken and become stiffer causing
varicose veins and ulcer
 The baro receptors which monitor blood pressure become less sensitive. Quick changes I
position may cause dizziness from orthostatic hypotension

PARAMETERS OF CARDIOVASCULAR ASSESSMENT

 Cardiac assessment: ECG, heart rate , rhythm, murmurs, heart sounds

 Assess B/P (lying , sitting, standing) and pulse pressure
 Palpate carotid artery and peripheral pulses for symmetry.

NURSING CARE STRATEGIES FOR CARDIOVASCULAR PROBLEMS

 Safety precautions for orthostatic hypotension

 Encourage life style, practices to attain a healthy body weight (BMI 18.5- 24.9kg/m 2 )

and normal blood pressure

 Healthful diet
  Physical activity

 Smoking cessation

CHANGES IN THE PULMONARY SYSTEM

 The lungs become stiffer, muscle strength diminishes and the chest wall becomes more

rigid

 Total lung capacity remains constant but vital capacity decreases and residual volume

increases

 The alveolar surface area decreases by 20% . Alveoli tend to collapse sooner on

expiration

 There is increase in mucus production and a decrease in activity and number of cilia

 The body become less efficient in monitoring and controlling breathing

PARAMETERS OF PULMONARY ASSESSMENT

 Assess respiratory rate, rhythm, regularity, volume, depth, exercise capacity. Auscultate

breath sounds throughout lung fields.

 Inspect thorax symmetry of chest expansion. Obtain smoking history

 Monitor secretions , breathing rate during sedation, positioning, aterial blood gases, pulse

oximetry

 Assess cough, need for suctioning

NURSING CARE STRATEGIES

 Maintain patient airways through rightful positioning/ repositioning, suctioning and

bronchodilators
  Provide oxygen as needed

 Incentive spirometry as indicated particularly if immobile or declining in function

 Maintain hydration and mobility

 Education on cough enhancement and smoking cessation

CHANGES IN THE GENITO-URINARY SYSTEM

 Kidney mass decreases by 25-30% and the number of glomeruli decrease by 30 -40%.

These changes reduce the ability to filter and concentrate urine and to clear drugs.

 With aging , there is reduced hormonal response (vasopressin), impaired ability to

conserve salt which may ncrease risk for dehydration

 Bladder capacity decreases and there is an increase in residual urine and frequency

 These changes increases the chances of urinary infections (cystitis and urinary tract

infection), incontinence and urinary obstruction, prostate gland enlargement

PARAMETERS OF RENAL AND GENITO-URINARY ASSESSMENT

 Assess renal function (creatinine clearance)

 Assess need/ dose of nephrotoxic drugs

 Assess for fluid / electrolyte balance and acid/base imbalances

 Evaluate nocturnal polyuria , urinary incontinence, BPH, assess UTI symptoms

NURSING CARE STRATEGIES

 Monitor nephrotoxic and renal cleared drug levels

  Maintain fluid/ electrolyte balance, minimum 1,500- 2,500 ml/ day from fluids and foods

for 50 to 80kg adults to prevent dehydration.

 For nocturnal polyuria, limit fluids in the evening, and caffeine, use prompted voiding

schedule

CHANGES IN THE GASTROINTESTINAL SYSTEM

 Decreased in strength of muscle of mastication , taste, and thirst perception.

 Decreased gastric motility with delayed emptying. Atrophy of protective mucosa

 Malabsorption of carbohydrates, vitamin B12 and D , folic acid , calcium

 Impaired sensation to defecate

 Reduced hepatic reserve

 Decreased metabolism of drugs

STOMACH

 Atrophic gastritis

 Achorhydria refers to an insufficient production of stomach acid.

 Gastric ulcers (ulcers in the stomach) are more common after the age of 60 and can

be benign or malignant

LIVER

 Reduced blood flow

 Altered clearance of some drugs and a diminished capacity to regenerate damaged liver

cells.

INTESTINES
  The prevalence of diverticulosis increases with age

 Studies of motility in older adults show reduced peristalsis (intestinal muscle

contractions) of the large intestine.

PARAMETERS OF GASTROINTESTINAL ASSESSMENT

 Assess oral cavity, chewing and swallowing capacity, dysphagia (coughing, choking with

food/fluid intake)

 Monitor weight, calculate BMI, compare to standards

 Determine dietary intake, compare to nutritional guidelines

 Assess for GERD, constipation and fecal incontinence, fecal impaction by didgital

examination of rectum or palpation of abdomen.

NURSING – CARE STRATEGIES

 Monitor drug levels and liver function tests if on medications metabolized by the liver

 Assess nutritional indicators

 Educate on life style modifications

 Educate on normal bowel frequency diet, exercise, recommended laxatives

 Encourage mobility , provide laxatives if on constipating medicatons

 Encourage participation in community based nutrition programmes, educate on healthful

diets.

CHANGES IN THE IMMUNE SYSTEM

 Increase vulnerability to infections, tumors and immune disease.

 Less production of antibodies which are important in fighting infections.

  The mortality rate is much higher than in the young. Older adults are 3 times more likely

to die of pneumonia or sepsis, 5 to 10 times more likely to die of urinary tract infections.

CHANGES IN THE MUSCULAR SKELETAL SYSTEM

 Muscles generally decrease in strength, endurance , size and weight

 Loss of about 23 percent of muscle mass by age 80 as both the number and size of fibers

decrease.

 Loss of an average of about 2 inches of height

 Compression of vertebrae, changes in posture and increased curvature of the hips and

kness.

BONES

Bone mass begins to gradually decline as aging disrupts the balance between the cells that

produce bone and the cells that absorb bone. Bones become thin and become more porous.

Women have more rapid bone loss than men with the most rapid losses occurring in the 5years

following menopause.

CHANGES IN THE INTEGUMENTARY SYSTEM

SKIN

 Wrinkling , pigment alteration and thinning of the skin.

 A thinning of the area between the dermis and epidermis by about 20 %

 Elastin and collagen decrease

 Reduction in size of cells

 Loss of subcutaneous layers of fatty deposites

  Inability of skin to retain moisture

HAIR

 By age 50 years, the hair of more than half of all is 50% gray. Hair grays because of a

gradual decrease in the production of melanin, the pigment cells in the hair bulbs. The

graying of hair is also influenced by heredity and hormones

 Fewer hair follicles on the scalp and the growth rate of hair decreases.

 Older women often have an increase in facial hair as their estrogen levels decrease

CHANGES IN THE SENSORY SYSTEM

VISION

 Visual impairment is the most common. About 95% of individuals aged 65 and older

report wearing glasses or need glasses to improve their vision.

 The pupil decreases in size , by 60. It is 1/3 the size it was at 20.

 The lens of the eye becomes yellowed, more rigid and slightly cloudy

 The iris, colored part of the eye becomes more rigid overtime.

HEARING

Generally, hearing is diminished with age. There is a drying and wrinkling of auricle with a

noticeable increase of hair in the auditory canal. Cerumen becomes drier and can cause

impaction , which blocks transmission of sounds. The hearing loss associated with old age is

called “Presbycusis”. In the middle ear, bony joints show some degeneration. However the major

changes occur in the middle ear, where degeneration of the vestibular system and simultaneous

atrophy of the cochlea and organ of corti produce deficits in equilibrium and hearing.
Nurses need to be patient in their approach to the older client with anticipated changes in sensory

perception, it is important that nurses face their clients , speak shortly and clearly and protect

them from injury . it is important when teaching clients that nurses asks for feedback and

evaluate comprehension.

SMELL

 The number of functioning smell receptors decreases

 There is increase in the threshold for smell. It takes a more intense smell to be identified

and differentiated from other smells.

TASTE

 Taste also diminishs with age

 Atrophy of the tongue occurs with age and this may diminish sensitivity to taste

TOUCH

 Sense of touch and response to painful stimuli decreases

 The actual number of touch receptors decreases which result in a higher threshold for

touch

CHANGES IN THE NERVOUS SYSTEM

 Older nerve cells may have fewer dendrites (branches) and some may become

demyelinated (lose its coating) which can slow the speed of message transmission.
  Impairment in cognitive capacity can threaten autonomy and the ability to manage our

daily activities.

 The incidence of cognitive impairment increases with age so that by age of 85, up to 1/3

of older persons have some degree of cognitive impairment.

MEMORY

 Poor recall of verbal words

 Perform less well on tasks involving encoding , retention and retrieval of information

 Conceptualization , mental flexibility and the capacity for abstraction decline with age.

GENERAL INTELLIGENCE

 Performance scores which measure

 Problem solving ability tend to decline

COGNITIVE CHANGES

There is problem of cognition in old age giving rise to:

 Delirium

 Dementia

 Depression

DELIRIUM : or acute confusional state, is a potentially reversible cognitive impairment that is

due to physiological cause.

CAUSES

 Electrolyte imbalance
  Cerebral anoxia

 Hypoglycemia

 Medications, drug effect

 Cerebral vascular infaction or haemorrhage

DEMENTIA: is a generalized impairment of intellectual functioning that interferes with social

and occupational functioning, cognitive function. Deterioration leads to a decline in the ability to

perform activities of daily living . unlike delirium, dementia is characterized by gradual

progressive irreversible , cerebral dysfunction. It presents with the following sysmptoms:

 Deficits of memory

 Deficits of language

 Disturbed perception

 Impaired learning and problem solving

 Impaired judgment

DEPRESSION: 20% older adults may experience late life depression . depression reduces

happiness and well being. It contributes to physical and social limitations. It increases the risk of

suicide.

CHANGES IN THE ENDOCRINE SYSTEM

PANCREAS (INSULIN RESPONSE): insulin continues to be produced in sufficient quantities

in older adults but their muscle cells may become less sensitive to the effects of insulin (probably

due to a loss in the number of insulin receptor sites in the cell wall). The normal fasting glucose
level rises 6 to 14 milligrams per deciliter every 10years. Type II diabetes occurs when the body

develops resistance to insulin.

ADRENAL GLANDS: Aldosterone levels are 30% lower in adults aged 70 to 80 years than in

young adults. Lower aldosterone levels may cause orthostatic hypotension (a drop in blood

pressure with change in position). Secretion of cortisol diminishes by 25% with age.

COMMON PROBLEMS IN OLD AGE

 Alzheimer’s disease

 Rheumatoid arthritis

 Osteoarthritis

 Heart disease

 Diabetes

 Stroke

 Urinary incontinence

 Social isolation: causes of isolation include;

i. Loss of work role

ii. Health problems i.e impaired hearing, diminished vision and reduced mobility

iii. Feeling of rejection

iv. Feeling of unattractiveness

GERIATRIC REHABILITATION

The primary goal is restoring the older adult to maximum functional level.

 Prevention of further impairments is imperative.

  Focus on skin wound care

 Maintain bowel and bladder function, independent medication use, good nutritional

status, psychological support. Encourage smoking cessation, encourage physical activity.

Installing handrails,

 Nurses can help the older adult by identifying specific hazards for example, installing

hand rails on stair case, keep poisons and medications out of reach of the elderly

 Regular medical check ups, adequate nutrition, good personal appearance, good personal

and environmental hygiene, daily shaving, cutting of hair, proper rest and sleep to meet

the daily activities of living.

 To keep physical health, do daily working, jogging as per health permits, participate in

the outdoor and indoor games, do household work

 Take part in social activities such as participating in meetings, birthday parties, religious

activities, to meet friends, watching TV and get part time employment

 Prevent yourself from falls, use walkers, have adequate lightings over staircases, use low

height cots, use well fitted shoes, prevent falls during acute illnesses, avoid unfamiliar

environment, wear new spectacles, check the temperature of water before bath

SPECIAL HEALTH PROBLEMS OF THE OLDER ADULT/PHYSIOLOGIACAL

AGING

 Altered responses to medication- maintain awareness that the older adult is at greater risk

for adverse medication reaction, ability to read drugs, swallowing difficulty, lack of

knowledge of drug, side effects of drugs.

 Altered nutritional status- Encourage good mouth care, avoid alcohol, five to six small

meals
 Urinary incontinence- Teach kegel /pelvic muscle exercise, bladder retaining, schedule

daily activities of life (DAL) habit training.

 Urinary retention- if prostatic disease condition is suspected refer, evaluate medication

regimen

 Fecal incontinence- it is an inability to voluntarily control the passage of gas and faeces

 Pressure sores/ Decubitus ulcers- inspect skin , wash skin with mild soap, use pressure

matrass, frequently shifting prevent pressure sore development, relieve the pressure ,

clean and debris the wound, cover the wound with protective dressing

 Injuries

 Hypothermia- Give warmth through hot bath, blankets

 Arthritis, osteoporosis

 Vision- Decreased visual activity, cataract, senile macular degeneration, diabetic

retinopathy, glaucoma.

 Hearing loss due to auditory nerve changes- aged related hearing loss called

“Presbycusis”, attributes to irreversible inner ear changes. Wax build up or other

problems maybe responsible for hearing difficulties

 Sensory deprivation: it is the absence of stimuli. This deprivation can lead to boredom,

confusion, irritability, disorientation and anxiety. Meaningful sensory stimulation offered

to the older person is often helpful in correcting this problem. The nurse can enhance

sensory stimulation of the environment with colors, pictures, textures, taste, smells,

sounds etc.

 Smell loss

 Kinesthetic sense with age, the receptors of joints and muscles lose ability to function
 Cardiovascular –the valves of the heart become thick and rigid because of sclerosis and

fibrosis

 Pulmonary system: there is a weakening of the intercostal respiratory muscles and the

elastic recoil of the chest wall diminishes.

 Immunological system: atrophy of the thymus gland

 Neurological system: brain tissues atrophy

 Musculoskeletal system: decline muscle mass and endurance with age, decreased bone

density, stiffness of joints

 Endocrine system: decrease secretion of hormones

 Reproductive system: menopause

 Renal and body composition: increased body fat, decreased lean muscle mass, even

weight remains stable

 Skin: thinning of all layers, decrease elasticity

 Hematopoietic declining, marrow activity

 Mental health: delirium (acute confusion state) begins with confusion and progresses to

disorientation and changes in level of consciousness, which may range from level of

stupor to excessive activity. Thinking is disorganized, attention span is characteristically

short. Hallucinations, dilutions, fear anxiety and paranoia may be evident because of the

acute and unexpected onset of symptoms and the unknown underlying cause, this

situation represents a medical emergency. The nurse must recognize the grave

implications of the acute symptoms and report them immediately. If the delirium goes

unrecognized and the underlying causes are not treated, permanent brain damage or death

can follow.