The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Older adults also vary widely in their levels of functional ability. Most older adults are active and involved members of their communities. A smaller number have lost the ability to care for themselves, are confused or withdrawn, and/or are unable to make decisions concerning their needs. Most older adults live in noninstitutional settings. In 2008 54.6% of older adults in noninstitutional settings lived with a spouse (41.7% of older women, 72% of older men) (AOA, 2009); 30.5% lived alone (39.5% of older women, 18.5% of older men); and only 4.1% of all older adults resided in institutions such as nursing homes or centers.

Aging does not inevitably lead to disability and dependence. Most older people remain functionally independent despite the increasing prevalence of chronic disease. Nursing assessment provides valuable clues to the effects of a disease or illness on a patient’s functional status. Chronic conditions add to the complexity of assessment and care of the older adult. Most older persons have at least one chronic condition, and many have multiple conditions. The most frequently diagnosed chronic conditions occurring in 2005 to 2007 were arthritis (49%), hypertension (41%), all types of heart disease (31%), any cancer (22%), and diabetes (18%) (AOA, 2009). The physical and psychosocial aspects of aging are closely related. A reduced ability to respond to stress, the experience of multiple losses, and the physical changes associated with normal aging combine to place people at high risk for illness and functional deterioration. Although the interaction of these physical and psychosocial factors is often serious, do not assume that all older adults have signs, symptoms, or behaviors representing disease and decline or that these are the only factors you need to assess. You also need to identify the older adult’s strengths and abilities during the assessment and encourage independence as an integral part of your plan of care (Kresevic, 2008).

Some people stereotype older adults as ill, disabled, and physically unattractive. Although many older adults have chronic conditions or have at least one disability that limits their performance of activities of daily living (ADLs), most noninstitutionalized older adults (39.1%) assess their health as excellent or very good (AOA, 2009). Some people believe that older adults are forgetful, confused, rigid, bored, and unfriendly and that they are unable to understand and learn new information. Yet specialists in the field of gerontology view centenarians, the oldest of the old, as having an optimistic outlook on life, good memories, broad social contacts and interests, and tolerance for others. Although changes in vision or hearing and reduced energy and endurance sometimes affect the process of learning, older adults are lifelong learners. Use teaching techniques to compensate for sensory changes, provide additional time for remembering and responding, and present concrete rather than abstract material to facilitate learning by older adults. Other effective teaching techniques draw on the older adult’s past experiences and correspond to his or her identified interests rather than to the content areas that the health care professional believes are important. Box 14-1 presents additional teaching strategies to address the special learning needs of older adults.

Stereotypes about lifestyles include mistaken ideas about living arrangements and finances. Misconceptions about their financial status range from beliefs that many are affluent to beliefs that many are poor. According to the AOA (2009), 9.7% of persons over age 65 had incomes below the poverty level, with another 6.3% classified as near poor. The median income reported was $18,337, with 87% coming from Social Security.

In a society that values attractiveness, energy, and youth, these myths and stereotypes lead to the undervaluing of older adults. Some people equate worth with productivity; therefore they think that older adults become worthless after they leave the workforce. Others consider their knowledge and experience too outdated to have any current value. These ideas demonstrate ageism, which is discrimination against people because of increasing age, just as people who are racists and sexists discriminate because of skin color and gender. According to experts in the field of gerontology, unopposed ageism has the potential to undermine the self-confidence of older adults, limit their access to care, and distort caregivers’ understanding of the uniqueness of each older adult. Older adults who have a positive image about aging actually live 7.5 years longer than those with a negative image (Levy et al., 2002). Nursing can help promote a positive perception regarding the aging process when working with these patients.

Today laws exist that ban discrimination on the basis of age. The economic and political power of older adults challenges ageist views. Older adults are a significant proportion of the consumer economy. As voters and activists in various issues, they have major influence in the formation of public policy. Their participation adds a unique perspective on social, economic, and technological issues because they have experienced almost a century of developments. In the past 100 years our nation has progressed from riding in horse-drawn carriages to tracking the adventures of the international space station. Gaslights and steam power have been replaced by electricity and nuclear power. Computers and copier machines replace typewriters and carbon paper. Many older adults lived through or were born during the Great Depression of 1929. They also experienced two world wars and wars in Korea, Vietnam, and the Persian Gulf and are now experiencing the war on terrorism. Older adults have seen changes in health care as the era of the family physician gave way to the age of specialization. After witnessing the government initiatives establishing the Social Security system, Medicare, and Medicaid, older adults are currently living with the changes imposed by health care reform and the uncertainty of the future of Social Security and Medicare. Living through all of these events and changes, they have stories and examples of coping with change to share.

The psychosocial theories of aging, developed during the 1960s, explain changes in behavior, roles, and relationships that come with aging. These theories reflect the values that the theorist and society held at the time the theory was developed. A sample of theories follows. Disengagement theory, the oldest psychosocial theory, states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities (Cummings and Henry, 1961). The activity theory, unlike the disengagement theory, considers the continuation of activities performed during middle age as necessary for successful aging (Havighurst et al., 1963). Continuity theory, or developmental theories, suggests that personality remains stable and behavior becomes more predictable as people age (Neugarten, 1964). The personality and behavior patterns developed during a lifetime determine the degree of engagement and activity in older adulthood. The more recent theory of gerotranscendence proposes that the older adult experiences a shift in perspective with age (Wadensten, 2007). The person moves from a materialistic and national view of the world to a more cosmic and transcendent one, causing an increase in overall life satisfaction (Jett, 2008). Critics suggest that theories either fail in some measure to consider the many factors that affect an individual’s response to aging or address those factors in a too-simplistic fashion. Rather, each individual ages uniquely.

Theories of aging are closely linked to the concept of developmental tasks appropriate for distinct stages of life. Although no two individuals age in the same way, either biologically or psychosocially, researchers have developed frameworks outlining developmental tasks for older adults (Box 14-2). These developmental tasks are common to many older adults and are associated with varying degrees of change and loss. The more common losses are of health, significant others, a sense of being useful, socialization, income, and independent living. How older adults adjust to the changes of aging is highly individualized. For some adaptation and adjustment are relatively easy. For others coping with aging changes requires the assistance of family, friends, and health care professionals. Be sensitive to the effect of losses on older adults and their families and be prepared to offer support.

The majority of older adults cope with the death of a spouse. In 2008 almost half (42%) of all older women were widows, and 14% of older men were widowers (AOA, 2010). Some older adults must cope with the death of adult children and grandchildren. All experience the deaths of friends. These deaths represent both losses and reminders of personal mortality. Coming to terms with them is often difficult. By assisting older adults through the grieving process, you help them resolve the issues posed by these deaths.

The redefining of relationships with children that occurred as the children grew up and left home continues as older adults experience the challenges of aging. A variety of issues sometimes occur, including but not limited to control of decision making, dependence, conflict, guilt, and loss. How these issues surface in situations and how they are resolved depend in part on the past relationship between the older adult and their adult children. All the involved parties have past experiences and powerful emotions. When adult children become their parents’ caregivers, they have to find ways to balance the demands of their own children and careers with the many challenges of family caregiving. As adult children and aging parents negotiate the aspects of changing roles, nurses are in the position to act as counselors to both the parents and the children. An aim is to help older adults find ways to maintain their quality of life. What defines quality of life is unique for each person.

Nurses encounter older-adult patients in a wide variety of community and institutional health care settings. Outside of an acute care hospital, nurses care for older adults in private homes and apartments, retirement communities, adult day care centers, assisted-living facilities, and nursing centers (extended care, intermediate care, and skilled nursing facilities). Chapter 2 describes these settings and the services provided in detail.

Nurses help older adults and their families by providing information and answering questions as they make choices among care options. The assistance of the nurse is especially valuable when decisions about moving to a nursing center must be made. Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult or when convalescence (recovery) from hospitalization requires more assistance than the family is able to provide. Although the decision to enter a nursing center is never final and a nursing center resident is sometimes discharged to home or another less-acute facility, many older adults may view the nursing center as their final residence. Results of state and federal inspections of nursing centers are available to the public at the nursing center, on-line, and at the inspectors’ offices. The best way to evaluate the quality of a nursing center in a community is for the patient and family to visit that facility and inspect it personally. The Medicare website (http://www.Medicare.gov/NHcompare) is an excellent resource for you to learn about the quality rating of a nursing center based on the health inspections, staffing, and quality measures of the facility. It also offers a nursing center checklist. Box 14-3 summarizes some features to look for in a nursing center.

Nursing assessment takes into account five key points to ensure an age-specific approach: (1) the interrelation between physical and psychosocial aspects of aging, (2) the effects of disease and disability on functional status, (3) the decreased efficiency of homeostatic mechanisms, (4) the lack of standards for health and illness norms, and (5) altered presentation and response to a specific disease (Meiner, 2011). A comprehensive assessment of an older adult takes more time than the assessment of a younger adult because of the longer life and medical history and the potential complexity of the history. During the physical examination allow rest periods as needed or conduct the assessment in several sessions because of the reduced energy and limited endurance of some frail older adults. Remember to review both prescribed and over-the-counter medications carefully with the patient.

Sensory changes also affect data gathering. Your choice of communication techniques depends on visual or hearing impairments of the older adult. If older adults are unable to understand your visual or auditory cues, assessment data may be inaccurate or misleading. For example, if an older adult has difficulty hearing a nurse’s questions, inappropriate responses might lead the nurse to believe that the person is confused. Chapter 49 explains in detail techniques to use when communicating with older adults who have a hearing impairment. When a person has a visual impairment, use these communication techniques:

During all aspects of the assessment you are responsible for providing culturally competent care. See Chapter 9 for a detailed description of the components of a cultural assessment. There are ways to provide culturally competent care while communicating with older adults during the assessment process (Box 14-4).

During assessment use caution when interpreting the signs and symptoms of diseases and laboratory values. Historically researchers have used younger populations to establish these signs and norms. However, the classic signs and symptoms of diseases are sometimes absent, blunted, or atypical in older adults (Gray-Miceli et al., 2010). This is especially true in the case of bacterial infection, pain, acute myocardial infarction, and heart failure. The masquerading of disease is possibly caused by age-related changes in organ systems and homeostatic mechanisms, progressive loss of physiological and functional reserves, or coexisting acute or chronic conditions. As a result the older adult with a urinary tract infection may present with confusion, incontinence, and an elevation of body temperature (within normal limits) instead of having fever, dysuria, frequency, or urgency. Some older adults with pneumonia have tachycardia, tachypnea, and confusion with decreased appetite and functioning, without the more common symptoms of fever and productive cough. Instead of crushing, substernal chest pain and diaphoresis, the older adult with a myocardial infarction experiences a sudden onset of dyspnea often accompanied by anxiety and confusion. Variations from the usual norms for laboratory values are sometimes caused by age-related changes in cardiac, pulmonary, renal, and metabolic function (Amella, 2006).

It is important to recognize early indicators of an acute illness in older adults. Note changes in mental status, occurrence and reason for falls, dehydration, decrease in appetite, loss of function, dizziness, and incontinence because these may be indicators not presented in younger adults. A key principle of providing age-appropriate nursing care is timely detection of these cardinal signs of illness so early treatment can begin (Box 14-5). Mental status changes commonly occur as a result of disease and psychological issues. Some mental changes are often drug related, caused by drug toxicity or adverse drug events. A fall can be a common event for an older adult and can be injury producing and costly (Ferrari et al., 2010). A fall is a complex event that needs careful investigation to find out if it was the result of environmental causes or the symptom of a new-onset illness. Problems with the cardiac, respiratory, musculoskeletal, neurological, urological, and sensory body systems can present with a fall as a chief symptom of a new-onset condition. Dehydration is common in older adults because of decreased oral intake related to a reduced thirst response and less free water as a consequence of a decrease in muscle mass. When vomiting and diarrhea accompany the onset of an acute illness, the older adult is at risk for further dehydration. Decrease in appetite is a common symptom with the onset of pneumonia, heart failure, and urinary tract infection. Loss of functional ability occurs in a subtle fashion over a period of time; or it occurs suddenly, depending on the underlying cause. Thyroid disease, infection, cardiac or pulmonary conditions, metabolic disturbances, and anemia are common causes of functional decline; thus nurses play an essential role in early identification, referral, and treatment of health problems.

Cognitive Changes

A common misconception about aging is that cognitive impairments are widespread among older adults. Because of this misconception, older adults often fear that they are, or soon will be, cognitively impaired. Younger adults often assume that older adults will become confused and no longer able to handle their affairs. Forgetfulness as an expected consequence of aging is a myth. Some structural and physiological changes within the brain are associated with cognitive impairment. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes. There are standard assessment forms for determining a patient’s mental status, including the Mini-Mental State Exam (MMSE), the Confusion Assessment Method (CAM) and the NEECHAM Confusion Scale (Ebersole et al., 2008).

The three common conditions affecting cognition are delirium, dementia, and depression (Table 14-2). Distinguishing among these three conditions is challenging. Complete a careful and thorough assessment of older adults with cognitive changes to distinguish among them. Select appropriate nursing interventions that are specific to the cause of the cognitive impairment.

TABLE 14-2

Comparison of Clinical Features of Delirium, Dementia, and Depression

CLINICAL FEATURE	DELIRIUM	DEMENTIA	DEPRESSION
Onset	Sudden/abrupt; depends on cause	Insidious/slow and often unrecognized	Happens with major life changes; often abrupt but can be gradual
Course	Short, daily fluctuations in symptoms; worse at night, in darkness, and on awakening	Long, no diurnal effects; symptoms progressive yet relatively stable over time; some deficits with increased stress	Diurnal effects, typically worse in the morning; situational fluctuations but less than with delirium
Progression	Abrupt	Slow but uneven	Variable; rapid or slow but even
Duration	Hours to less than 1 month; longer if unrecognized and untreated	Months to years	At least 6 weeks; sometimes several months to years
Consciousness	Reduced/disturbed	Clear	Clear
Alertness	Fluctuates; lethargic or hypervigilant	Generally normal	Normal
Attention	Impaired; fluctuates; inattention; distractible	Generally normal	Minimal impairment but is easily distracted
Orientation	Generally impaired; severity varies	Generally normal to person but not to place or time	Selective disorientation
Memory	Recent and immediate impaired; forgetful; many need instructions for simple tasks one step at a time	Recent and remote impaired	Selective or “patchy” impairment; “islands” of intact memory; evaluation often difficult because of low motivation
Thinking	Disorganized, distorted, fragmented, illogical; incoherent speech, either slow or accelerated	Difficulty with abstraction; thoughts diminished; judgment impaired; words difficult to find	Intact but with themes of hopelessness, helplessness, or self-deprecation
Perception	Distorted, illusions, delusions, and hallucinations; difficulty distinguishing between reality and misperceptions	Misperceptions usually absent	Intact; delusions and hallucinations absent except in severe cases
Psychomotor behavior	Variable; hypokinetic, hyperkinetic, and mixed	Normal; some have apraxia	Variable; psychomotor retardation or agitation
Sleep/wake cycle	Disturbed; cycle reversed	Fragmented	Disturbed; usually early morning awakening
Associated features	Variable affective changes; symptoms of autonomic hyperarousal; exaggeration of personality type; associated with acute physical illness	Affect tends to be superficial, inappropriate, and labile (changing); attempts to hide deficits in intellect; personality changes, aphasia, agnosia sometimes present; lacks insight	Affect depressed; dysphoric mood; exaggerated and detailed complaints; preoccupied with personal thoughts; insight present; verbal elaboration; somatic complaints, poor hygiene, neglect of self
Assessment	Distracted from task; makes numerous errors	Failings highlighted by family, frequent “near miss” answers; struggles with test; great effort to find an appropriate reply; frequent requests for feedback on performance	Failings highlighted by individual, frequent “don’t knows”; little effort; frequently gives up; indifferent toward test; does not care or attempt to find answer

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