Intro gerontological nursing_fall 2013 abridged

1
Introduction to
Gerontological Nursing
NURS 4100 Care of the Older Adult
Fall 2013
Joy Shepard, PhD(c), MSN, RN, CNE, BC

2
Objectives
 Explain different ways older adults are viewed in
contemporary society
 Describe major characteristics of today’s older
population
 Discuss projected demographic changes in future
generations of older people and the implications for
health care
 Describe the nursing process in care of older adults
 Discuss standards, major roles, principles, and future
challenges for gerontological nurses

3
"Old age is like everything else.
To make a success of it you've
got to start young." Theodore
Roosevelt
"Anyone who stops learning is
old, whether at twenty or
eighty."
Henry Ford

4
Aging: A Natural Process…
NOT a disease!

5
Defining Old Age
Chronological age – Exact age
from birth
Biological age - Age determined by
physiology rather than chronology
Functional age – Age in terms of
functional performance

6
Activities of Daily Living (ADLs)
 Basic:
 Bathing (hygiene,
grooming)
 Dressing
 Eating
 Toileting
 Transferring
(mobility)
 Instrumental:
 Light housework
 Preparing meals
 Taking medications
 Shopping for
groceries or clothes
 Using the telephone
 Managing money

8
Characteristics of Aging
Population
 “Typical” older person?
 Age 65 start of “old
age?”
 Energetic, vibrant,
influential, diverse
 Gerontology - identifies
common
characteristics,
problems, disease
processes, & concerns
 Nurse must consider
individual differences &
characteristics when
planning & implementing
care

9
 “The purpose of gerontological nursing is
not to save lives, but to prevent untimely
death and needless suffering. Both these
goals include respect for human dignity –
the preservation of personhood as long as
life continues.”
 -Doris Schwartz, 1989

10
Definition of Terms
 Ageism - Prejudice, negative stereotyping based
solely on age
 Geriatrics - Branch of medicine that deals with
problems & diseases of old age, aging people
 Gerontology – Comprehensive, multidisciplinary
study of aging process & problems of older people
with holistic focus, including biologic, sociologic,
psychological, spiritual, & economic issues
 Graying of America – Increased number older
adults in US
 Senescence - Process of aging within cells and
organs accompanied by loss of organ function

11
Definition of Terms
 Primary prevention – Activities directed
toward the protection from or avoidance of
potential health risks
 Secondary prevention – Activities designed
for early diagnosis & treatment of disease
or illness
 Tertiary prevention – Activities designed to
restore disabled individuals to their optimal
level of functioning

12
Gerontological Nursing:
Specialty Area
 Nursing – caring for the vulnerable
 Gerontological nursing – newest &
youngest, most rapidly growing nursing
specialty
 ‘Nursing’s forgotten… little understood
specialty’
 Challenging practice areas: complex
 In just 50 yrs…. foremost concern of health care

GerontologyGerontology: ComplexComplex Field
Encompassing ThreeThree Levels of Complexity
 1. Normal aging
changes
 2. Chronic conditions
associated with aging
 3. Acute
exacerbations of
chronic conditions
13

14
Development of
 1904: First article on care of the aged published
in the American Journal of Nursing
 1914: Dr. I. L. Nascher—“Father of Geriatrics”—
first geriatric textbook
 1935: Federal Old Age Insurance Law, or Social
Security
 1950 – First geriatric nursing textbook
 1962: First meeting of the ANA’s Conference
Group on Geriatric Nursing Practice

15
Development of
 1965: formation of the Administration on Aging,
Older Americans Act, Medicare, & Medicaid
 1966: Division of Geriatric Nursing—
gerontological nursing as a nursing specialty
 1976 – Professional Standards for
Gerontological Nursing Practice (ANA)
– Certification – geriatric nurses
– 1st
certification program by ANA

16
Development of
 Growth in the last few decades
– Increase in gerontological nursing texts
– Increase in journal articles
– Gerontological nursing education
– Certification in gerontological nursing
– Subspecialization
– Hartford Institute for Geriatric Nursing

17
Advanced Practice Nursing
Roles
 Gerontological Clinical Nurse Specialist
 Gerontological Nurse Practitioner
 Preparation: unique principles, best practices
for older adult
– Broad knowledge base
– Capacity for independent practice
– Leadership
– Complex clinical problem-solving abilities

Programs
 Adult-Gerontology Nurse Practitioner
– ECU College of Nursing (Online)
 Adult-Gerontology Nurse Practitioner
– UNC-Chapel Hill School of Nursing
 Adult Gerontological Nurse Practitioner Concentration
– UNC-Greensboro School of Nursing
 Gerontological Nurse Practitioner
– Duke University School of Nursing
 Adult-Gerontology CNS &
Adult-Gerontology Critical Care CNS
– Rush University (Online)

19
In Great Demand…
 Challenges for the
future
– Gerontological
nursing as a
dynamic specialty
– Multitude of
opportunities
– Development of new
practice models

20
Geriatric Patients… The
Core Business of Health
Care

21
An Aging Population
 Increased #’s older people, particularly “old-
old”
 41.4 million older adults in 2011 – 13.3% of
the population
 By 2030, adults ≥ 65 years, 20% of
population
 5.7 million 85+ population
– 2040: 14.1 million
– 2050: 19 million
Source: A Profile of Older Americans

23
An Aging Population
 As the aging population expands, it will affect
all aspects of society (esp healthcare)
 Currently 13.3% of U.S. population; consume
disproportionate amount of healthcare
resources
 Aging-associated diseases – complications
arising from senescense
 2025: need an extra 260,000 full-time nurses to
take care of aging population
Source: A Profile of Older Americans

24
Myths & Stereotypes of Aging

25
Ageism
 Prejudice towards any
age group
 Defined as “the
prejudices and
stereotypes that are
applied to older people
sheerly on the basis of
their age….”

True or False???
To be old is to be sick
?

27
Myths & Stereotypes of Aging
 Many cultures: older people accorded respect
 American society is youth-driven
– Aging synonymous with death
– Younger individuals – negative view of aging
process
– Fear & lack of exposure to older individuals
contribute to ageism
 Older adults stereotyped: ill, bald, hard of
hearing, forgetful, rigid, grumpy, or boring

28
Myths of Aging
 “You can’t teach an old dog new
tricks”
 “Dirty old man”
 Disease & disability are inevitable
part of aging
 Health promotion is wasted on
older people
 Elderly do not pull their own
weight
 Most people spend their last
years in nursing homes

29
Myths of Aging
 Senility is a result of aging
 Incontinence is a result of
aging
 Older adults are no longer
interested in sexuality
 All elderly persons are
financially impoverished

31
Myths of Aging Lead to:
 Ageism
 Reduced healthcare services
 Segregation of elders from mainstream society
 Nurse recruitment difficulties
 Health professionals must be diligent in
avoiding age prejudice, as believing
stereotypes can influence interactions between
older adults & caregivers

33
Subsets of the Older Adult
Population
 Young-old: 65-74 yrs
 Middle-old: 75-84 yrs
 Old-old: 85-100 yrs
 Centenarians: 100+ yrs
 Diversity rather than
homogeneity

The Graying of the Population
34

Distribution of the Projected Older
Population by Age for the US: 2010 to 2050

37
An Aging Population -
Increased Life Expectancy
 Older adults currently 13% of U.S. population
 By 2030 – 20% of population
 Increasing life expectancy:
– 1900: 47.3 years
– 1930: 59.7 years
– 1965: 70.2 years
– Present: 78.7 years (2010)
– 2050: projected to be 82.6 yrs
http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf

38
First Wave of 76 Million Baby
Boomers Started Turning 65
in 2011!

39
Age Distribution of U.S.
Population

40
Factors Influencing Increased
Life Expectancy
 Advancements in disease control & health
technology (esp. vaccines & antibiotics)
 Lower infant & child mortality rates
 Improved sanitation (clean water & sewage
disposal)
 Better living conditions

41
Life Expectancy: Race and
Gender
 Gap between women
& men (narrowing)
 Gap between Whites
& Blacks (narrowing)
– Societal issues
– Concern for nurses
Gender /
Race
Whites Blacks Total
Females 81.3 78.0 81.1
Males 76.5 71.8 76.2
Total 79 75.1 78.
7
http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_04.pdf

43
Marital Status & Living
Arrangements
Women more likely to be widowed,
living alone in old age
More than half of women ≥ 65 are
widowed
Older men more likely to be married
 Potential for living alone increases with age

44
Aging Women
 Women outlive men, outnumber
men 4 to 3
– Feminization of later life
Women predominate at older ages,
proportions increase with advancing
age
– Health & socioeconomic problems
of elderly = problems of elderly
women
 Study of gerontology – closely linked to
study of women’s health
 Potential problems:
– Widowhood
– Living alone
– Poor
– Coping with loss of mate
– Difficulty finding another
life companion
– Lack of a caregiver
– Financial problems

Gender Distribution of Elderly
Americans, by Age Group, 2010

46
Aging Men
 Shorter life expectancy,
die at younger age
 More likely to remarry if
widowed
– Widows outnumber
widowers 5 to 1
 Fewer financial
problems than women
– More likely to have worked 30
years or longer, qualify for full
Social Security benefits

Marital Status of Older Adults
48

49
Income of Older Adults
 8.7% live below poverty level
 “Fixed” income
 “Asset rich and cash poor” – What does this
mean?
 Median net worth twice national average related
to home ownership
 Dependent on Social Security for more than half
of their income
 Women & minority groups poorer than white
men

Geographic Distribution: Older
Adults
 Greatest number
(percentage wise):
Florida, Maine, West
Virginia, Pennsylvania,
Montana
 Dramatic increases in
past decade: Alaska,
Nevada, Arizona,
Idaho, Georgia
 Lowest percentage:
Alaska, Utah, Texas,
Georgia, Colorado
 North Carolina? 50

52
Illness in the Older Population

53
Health Status of Older Adults:
Acute Conditions (p. 8)
Relatively fewer acute illnesses (i.e.,
infections & parasites, colds, or
influenza)
Lower death rates from acute illnesses
After an acute illness…
– Longer period of recovery
– More complications

54
Illness in the Older Population
 Chronic illness – major concern for older adult
 Chronic illnesses – cause disabilities, complicate
care, need skilled nursing care
 80% – at least one chronic illness (i.e., heart
disease, diabetes, arthritis, or hypertension)
 Many elderly people with two or more chronic
illnesses (comorbid)
 Comorbidity: the presence of multiple chronic
conditions simultaneously
 Challenge: reach highest functional capacity

55
Health Status of Older Adults:
Chronic ConditionsChronic Conditions Major problem: increases
with age
 Most have at least one
chronic disease; many
have several (comorbidity)
 Comorbidity: the presence
of multiples chronic
conditions simultaneously
 Result: limitations in ADLs
& IADLs
 Leading cause: disability &
death

56
Leading Chronic Conditions
(Box 1-3, p. 8)
 1. Arthritis
 2. Hypertension
 3. Hearing
impairments
 4. Heart conditions
 5. Visual impairments
 6. Orthopedic
impairments

Question
The leading chronic condition
associated with older adults is:
 (A) Arthritis
 (B) Diabetes
 (C) Hearing impairments
 (D) Hypertension
 (E) Orthopedic impairments

58
Question
 Is the following statement true or false?
 Chronic disorders most prevalent in the
older adult population are ones that can
have a significant impact on independence
and the quality of life

CDC: Chronic Diseases are Leading
Causes of Death & Disability in U.S.
*7 of 10 deaths each year are from chronic diseases
*1 of 2 adults (of all ages) at least 1 chronic illness
*Obesity: major health concern: 1 in 3 adults
*One-fourth of people with chronic conditions: At least
one ADL limitation
*Arthritis: most common cause of disability: 19 million
Americans report ADL limitation
http://www.cdc.gov/chronicdisease/overview/index.htm#1
59

 Heart diseaseHeart disease
 Malignant neoplasms (cancer)Malignant neoplasms (cancer)
 Chronic lower respiratory dz (COPD)Chronic lower respiratory dz (COPD)
 Cerebrovascular dz (stroke)Cerebrovascular dz (stroke)
 Alzheimer’s diseaseAlzheimer’s disease
 Diabetes mellitusDiabetes mellitus
 Influenza/ pneumoniaInfluenza/ pneumonia
 Nephritis, nephrotic syndrome, nephrosis
 Accidents
 Septicemia 60
Leading Causes of Death for
Persons 65 Yrs of Age & Older
(Table 1-3, p. 9)

http://www.cdc.gov/nchs/data/databriefs/db64.pdf

63
Question
 When planning a course about mortality rates for
a group of elderly clients, emphasis should be
given to which of these topics because it is the
leading cause of death for ages over 65?
– A. Heart disease
– B. Cancer
– C. Infectious diseases
– D. Accidents

64
Health Promotion & Disease
Prevention

65
Health Promotion
 Health promotion: “the science and art of helping people
change their lifestyle to move toward a state of optimal
health" (American Journal of Health Promotion, 1986)
 Multidimensional, enhances wellness, self-actualization &
individual fulfillment (Pender, 2002)
 Purpose:
– Help older adults achieve a sense of well-being
– Reduce premature mortality, enhance quality of life
The Health Continuum
Balance of physical, emotional, social, spiritual, and intellectual health

Healthy People 2020
 Vision:
 A society in which all people live long, healthy livesA society in which all people live long, healthy lives
 Overarching Goals:
 Attain high quality, longer lives free of preventable
disease, disability, injury, and premature death
 Achieve health equity, eliminate disparities, and improve
the health of all groups
 Create social and physical environments that promote
good health for all
 Promote quality of life, healthy development and healthy
behaviors across all life stages

67
Proposed Healthy People 2020 Goals
for Older Adults
 Reduce the proportion of older adults who have moderate to
severe functional limitations.
 (Developmental) Reduce the proportion of unpaid caregivers of
older adults who report an unmet need for caregiver support
services.
 (Developmental) Increase the proportion of older adults with one
or more chronic health conditions who report confidence in
managing their conditions.
 (Developmental) Reduce the proportion of noninstitutionalized
older adults with disabilities who have an unmet need for long-
term services and supports.

68
Proposed Healthy People 2020 Goals
for Older Adults Cont’d…
 Reduce the rate of pressure ulcer-related hospitalizations among
older adults.
 Increase the proportion of the health care workforce with geriatric
certification.
 Increase the number of States and Tribes that publicly report
elder maltreatment and neglect.
 Increase the proportion of older adults with reduced physical or
cognitive function who engage in light, moderate, or vigorous
leisure-time physical activities.
 Reduce the rate of emergency department visits due to falls
among older adults.
Healthy People 2020: The Road Ahead

69
70% Physical Decline due to
Modifiable Risk Factors
Inactivity
Poor nutrition
Tobacco
Alcohol
 Lack of preventive
care

70
70% Physical Decline
Modifiable Through
 Physical activity
 Improved nutrition
 Smoking cessation
 Alcohol in moderation
 Prevention of injuries from
falls
 Improved use Medicare-
covered preventive services

71
Question
Name modifiable risk factors for
physical decline and illness in older
adults…
Name non-modifiable risk factors for
older adults…

72
Health Promotion & Disease
Prevention
 Chronic conditions develop
over time
 Older adults must be
alerted to means of
preventing disease and
reducing risks
 Important components of
health maintenance:
– Knowledge of self-care
– Participating in screening
tests
 Nurses intervene using
three levels of prevention
– Primary
– Secondary
– Tertiary

73
Health Promotion and Disease
Prevention
 Nurses should be aggressive in health promotion efforts
 Older adults must be alerted to means of preventing
disease & reducing risks
– Take advantage preventive health services
– Make healthy lifestyle changes
 Preventive care: most effective strategy to reduce
risk of disability & chronic illness
– HP 2020 goal: “Attain high quality, longer lives free of
preventable disease, disability, injury, and premature
death”

Primary Prevention
In primary prevention, a disorder
is actually prevented from
developing…
74

75
Primary Prevention – Health
Promotion Behaviors
 Education: Patient, family, caregiver; health care provider
– Falls prevention
– Pressure ulcer prevention
 Immunizations
– Influenza, pneumococcal, tetanus/diphtheria, hepatitis B
 Maintain body weight (± 10% age-adjusted normal weight)
 Regular physical activity (as appropriate)
 Nutritional assessment & guidance
– Well-balanced diet
↑ Fiber, calcium, vitamin D
 Avoidance of tobacco
 Alcohol in moderation

76
Primary Prevention – Health
Promotion Behaviors
 Eight hours of sleep a night
 Positive mental attitude
– Encourage family members to participate in positive life
review with elderly client
 At least one friend to trust & confide in
 Self-discipline to enjoy pleasant things in moderation
 Relaxing & pleasant activities to look forward to
 Limiting exposure or avoiding known carcinogens

Secondary Prevention
In secondary prevention, disease
that has not yet become symptomatic
is detected and treated early, thereby
minimizing serious consequences…
77

78
Secondary Prevention – Early
Diagnosis, Prompt Treatment
 Important components of
health maintenance practices
– Self-care, screening
– Regular visits PCP
– Reduce cholesterol
– Monitor blood pressure
 Appropriate diagnostic,
screening tests:
– Fecal occult blood test
– Glaucoma screen (tonometry &
visual field testing)
– Fasting glucose
– Colonoscopy
– Prostate exam: PSA & DRE
– Mammogram
– Pap test, pelvic
– Bone mass screening

Tertiary Prevention
 In tertiary prevention, an existing, usually
chronic disease is managed to prevent
complications or further damage. For example,
tertiary prevention for people with diabetes
focuses on tight control of blood sugar, excellent
skin care, frequent examination of the feet, and
frequent exercise to prevent heart and blood
vessel disease…
79

80
Tertiary Prevention –
Restoration, Rehabilitation
 Manage clinical diseases (esp chronic diseases) to prevent
them from progressing
– Aim: optimal functioning; avoid disability & complications
 Rehabilitation (physical, occupational, speech, recreational
therapy)
– Short-term placement or
– Aggressive in-home rehabilitation
 Appropriate services/ aids to increase independence
– Walkers, canes, homemaker/ home health aid, visiting nurse
 Disaster relief
– Safe housing, counseling, physical care

Question
 Which of the following is an example of
primary prevention?
 A. Administering digoxin to treat heart failure
 B. Obtaining a smear for a screening test
 C. Using occupational therapy to help a patient
cope with arthritis
 D. Vaccinating an older adult during the flu
season

82
Question
 The gerontological nurse is teaching 86-year-old
Patricia Smith and her family about exercise programs
for the elderly. Which of the following statements about
arthritis is an example of tertiary preventive care?
– A. Exercise cures arthritis
– B. Exercise can help control and manage the symptoms of
arthritis and prevent complications
– C. Exercise is important for healthy joints and it also
strengthens the surrounding muscles
– D. Exercise helps prevent arthritis from developing

Question
 Which of the following describes secondary
prevention?
 A. aims to prevent disease from developing in the first place
 B. aims to detect and treat disease that has not yet become
symptomatic
 C. directed at those who already have symptomatic disease,
in an attempt to prevent further deterioration, recurrent
symptoms and subsequent events
 D. set of health activities that mitigate or avoid the
consequences of unnecessary or excessive interventions in
the health system

Question
 As they get older, men are more likely to be
screened for prostate cancer: 48% of men 50 to 59
years as compared to 56% of men 80 years and
older. The nurse concludes that this is:
 A. An example of ageism and negative stereotyping
 B. An illustration of the belief that primary prevention
strategies should be promoted in the older adult population
 C. A proper allocation of scarce health care resources
 D. A societal trend based on higher numbers of aging men

Question
 While Medicare pays for some medical screenings for older
Americans, nine of every ten adults over the age of 65 go
without screenings, such as bone mass screenings, colorectal
cancer screening, glaucoma screenings, mammograms, and
pap tests and pelvic examinations. Findings show that primary
care providers are less aggressive when recommending
preventive measures to the elderly.
 The nurse concludes that this is:
 A. An example of ageism
 B. An illustration of the belief that tertiary prevention strategies are
wasted on elders
 C. A proper allocation of scarce health care resources
 D. Correct, since there is no need for aggressive screening measures
within this age group

86
Prolongation of Frailty vs
Compression of Morbidity?

87
Functional Assessment of the
Older Adult

88
Nursing Process and the Older
Adult
 Assessment
– Health History
– Physical Examination
 Goal: Individualize & tailor assessments
and interventions to each patient
 Functional abilities should be a central
focus of comprehensive assessment

89
Assessment of Function
 Three domainsThree domains: ADLs, IADLs, & mobility
 Systematic, focus on individual needs
 Two approaches: asking & observing
 Basis for care planning, goal setting, &
discharge planning
 Eligibility to obtain many services

90
Assessment
Health History
– Nurse draws facts and interpretations from
older client that will shed light on current
health status and health concerns
– Eliciting data requires time & patience on the
part of both the nurse and client
– Nurse may interview client & client’s support
members

91
Assessment
Physical Examination
• Nurse must be
knowledgeable about normal
physical changes of aging in
order to conduct physical
examination
• Client may need assistance
with disrobing or position
changes
• Be alert to potential for injury

92
Challenges in Health and
Functioning
 Adjustment to a new body image
 Effect on body image and self-concept
 Self-concept and roles
 Acceptance of bodily changes
 Declining function resulting in illness and
disability
 Loss of independence

93
Diagnoses Frequently Seen in
the Older Adult
 Impaired Physical Mobility
 Activity Intolerance
 Risk for Injury, Falls
 Risk for Infection
 Self-Care Deficits
 Social Isolation
 Risk for Loneliness
 Acute, Chronic Confusion
 Imbalanced Nutrition
 Impaired Home
Maintenance
 Ineffective Role
Performance
 Ineffective Health
Maintenance
 Ineffective Therapeutic
Regimen Management

94
Important Qualities of the
Gerontological Nurse

95
 “The care of old people requires just as much skill, tact,
ingenuity, and patience as the care of children, and
perhaps more, because one must keep in mind that old
people cannot be treated like children and that
feebleness of physical and mental powers is not
accompanied by forgetfulness of early experiences. A
genuine affection, gentleness, sympathy, and
imagination sufficient to grasp the patient’s point of view
are necessary.”
 Jessie Breeze, private duty nurse, 1909

96
Important Qualities of the
Gerontological Nurse
 Ability to form a
therapeutic relationship
with elderly adults
 Appreciation of the
uniqueness of elders
 Clinical competence
in basic nursing skills
 Good communication
skills
 Knowledge of physical &
psychosocial changes
that occur with age
 Ability to work with &
supervise others

97
Therapeutic Communication
Ongoing,
continuous,
dynamic process
Includes verbal
and nonverbal
signals

98
Nonverbal Communication
 Nonverbal communication
composes up to 80% of
information exchange
– Body language
– Position
– Eye contact
– Touch
– Tone of voice
– Facial expression

99
Verbal Communication
Guidelines
 Do not yell or speak too
loudly to patients
– Yelling into a hearing aid can
be disturbing and painful
 Try to be at eye level
 Minimize background
noise

100
Guidelines
 Touch if appropriate
and acceptable
 Supplement with
written instructions as
needed
 Avoid complicated
explanations

101
Guidelines
 Ask how the patient
would like to be
addressed
 Avoid demeaning
terms such as sweetie,
honey, or dearie
 Use caring responses
and careful listening

102
Guidelines
 Use open-ended statements
– “Tell me more…” or “How does
this affect you?”
 Avoid misunderstandings by
clarifying
– “I’m not sure what you mean…”
 Encourage reminiscing

Intro gerontological nursing_fall 2013 abridged

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