Health Care of the Older Adult

Geriatrics
the study of old age includes the

physiology, pathology, diagnosis, and management of the diseases of older adults.

Gerontology
study of the aging

process; draws from the biologic, psychological, and sociologic sciences

Gerontologic or geriatric nursing

field of nursing that specializes in the

care of the elderly. provided in acute care, skilled and assisted living, community, and home settings.

Goals:
promoting and maintaining functional status and

helping older adults to identify and use their strengths to achieve optimal independence

Nurse gerontologist

either a specialist or a generalist offering

comprehensive nursing care to older persons by combining the basic nursing process (ADPIE) with a specialized knowledge of aging. helps the older person to maintain dignity and maximum autonomy despite physical, social, and psychological losses.

Life expectancy
the average number of years that a person can be

expected to live

Aging
the normal process of time-related change, begins

with birth and continues throughout life.

Universality
the major criterion used to distinguish normal from

abnormal aging

Intrinsic aging
from within the person those changes caused by the normal aging process

that are genetically programmed and essentially universal within a species.

Extrinsic aging
results from influences outside the person Ex. Illness and disease, air pollution, sunlight can be eliminated or reduced through effective

health care interventions.

 Cellular and extracellular changes of old age cause a

change in physical appearance and a decline in function. Measurable changes in shape and body makeup occur. The bodys ability to maintain homeostasis becomes increasingly diminished with cellular aging, and organ systems cannot function at full efficiency

 Cells become less able to replace themselves, and

they accumulate a pigment known as lipofuscin. Degradation of elastin and collagen causes connective tissue to become stiffer and less elastic. Well-being of an aged person depends on physical, mental, social, and environmental factors.

Total assessment
includes an evaluation of all major body systems,

social and mental status, and the ability of the person to function independently despite a chronic illness.

Old age
A normal occurrence that encompasses all

experiences of life Care and concern for the elderly cannot be limited to one discipline, but is best provided through a cooperative effort. An interdisciplinary team, through comprehensive geriatric assessment, can combine expertise and resources to provide insight into all aspects of the aging process. Collaboration with the interdisciplinary team to obtain non-nursing services and provide a holistic approach to care.

HEALTH PROMOTION:
AGE-RELATED CHANGES IN BODY SYSTEMS AND HEALTH PROMOTION STRATEGIES

What is the leading cause of death in the aged?

Heart disease is the leading cause of death in the aged.

 heart valves -- thicker and stiffer heart muscle and arteries lose elasticity. Calcium and fat deposits accumulate within arterial

walls veins become increasingly tortuous.

Cardiovascular System Changes

Decreased cardiac output; diminished ability to

respond to stress Heart rate and stroke volume do not increase with maximum demand Slower heart recovery rate; increased blood pressure

Subjective and Objective findings: Complaints of fatigue with increased activity Increased heart rate recovery time Normal BP 140/90 mm Hg

A serious risk factor at all ages for cardiovascular disease and stroke:

Hypertension

Health promotion:
Exercise regularly; pace activities; Avoid smoking; eat a low-fat, low-salt diet; participate in stress-reduction activities;

check blood pressure regularly;

Medication compliance weight control

Cardiovascular dysfunction may manifest as :

CHF CAD Arteriosclerosis Hypertension PVD orthostatic hypotension Dysrhythmias CVAs _______?_____ (leg

pain caused by walking)

MI

The relationship between maximum HR and age:

Normal maximum HR for age = 220 age in years

diagnosis of hypertension
made only after it has been confirmed by at least two

subsequent readings.

 The current standard of therapy for HF includes

diuretics, angiotensin-converting enzyme inhibitors (ACE inhibitors) and digoxin.

In older people, hypertension is classified as follows:

Isolated systolic hypertension:

systolic reading 140 mm Hg; diastolic measurement is normal or near normal (less than 90 mm Hg) Primary hypertension: the diastolic pressure is 90 mm Hg regardless of the systolic pressure Secondary hypertension: hypertension due to an underlying cause

Cardiovascular health can be promoted by:

regular exercise, proper diet, weight control,

regular blood pressure measurements,

stress management, and smoking cessation.

possible falls caused by orthostatic hypotension

rise slowly (from a lying, to a sitting, to a standing

position avoid straining when having a bowel movement; consider having five or six small meals each day, rather than three, to minimize the hypotension

possible falls caused by orthostatic hypotension (contd)

Avoid extremes in temperature --including hot

showers and whirlpool baths. Yard work limited to no more than 20 minutes on hot summer days. Avoid exposure to wind or cold weather -- risk of dizziness or falling associated with slower adjustments of blood pressure. Use elastic compression stockings to minimize venous pooling edema

Respiratory System Changes

Increase in residual lung volume Decrease in vital capacity; decreased gas exchange

and diffusing capacity Decreased cough efficiency

Subjective and Objective findings:

Fatigue and breathlessness with sustained activity Impaired healing of tissues as a result of decreased

oxygenation; Difficulty coughing up secretions

Health promotion:

Exercise regularly; avoid smoking Take adequate fluids to liquefy secretions; Receive yearly influenza immunization;

Avoid exposure to upper respiratory tract infections

 Hospitalized older adults should be frequently

reminded to cough and take deep breaths, particularly postoperatively (decreased lung capacity and decreased cough efficiency predispose them to respiratory infections and atelectasis.)

Integumentary System Changes

Decreased protection against trauma and sun

exposure; Decreased protection against temperature extremes; Diminished secretion of natural oils and perspiration

Subjective and Objective findings

Skin appears thin and wrinkled; Complaints of injuries, bruises, and sunburn; Complaints of intolerance to heat;

Prominent bone structure

Dry skin

Health promotion:
Avoid solar exposure (clothing, sunscreen, stay

indoors) Dress appropriately for temperature Maintain a safe indoor temperature Shower more preferable than tub bath Lubricate skin

Strategies to promote healthy skin function include:

Avoid exposure to the sun use a lubricating skin cream avoiding long soaks in the tub, and maintaining

adequate intake of water (8 to 10 eight-ounce glasses per day).

Reproductive System Changes

Female: Vaginal narrowing and decreased elasticity;

decreased vaginal secretions Male: Decreased size of penis and testes Male and female: Slower sexual response

 Subjective and Objective findings: Female: Painful intercourse

vaginal bleeding following intercourse

vaginal itching and irritation Delayed orgasm

Male: Delayed erection and achievement of orgasm

Sexual desire and activity decline but do not

disappear.

 Health promotion: May require vaginal estrogen replacement; gynecology/urology follow-up

use a water-based lubricant with intercourse

Sildenafil citrate (Viagra)-oral medication used for

ED; contraindicated in patients who are taking oral nitrates.

Musculoskeletal System Changes

Loss of bone density; loss of muscle strength and size degenerated joint cartilage

Subjective and Objective findings:

Height loss; prone to fractures kyphosis; back pain

loss of strength, flexibility, and endurance

joint pain

Health promotion:
Exercise regularly eat a high-calcium diet limit phosphorus intake

take calcium and vitamin D supplements as

prescribed

 A high calcium intake, 1500 mg/day. Dairy products and dark green vegetables ; soups and

broths made with a soup bone and cooked with added vinegar to leach calcium from the bone. Calcium supplements Low-phosphorus diet. A calcium-to-phosphorus ratio of 1:1 is ideal; Avoid red meats, cola drinks, and processed foods that are low in calcium and high in phosphorus Weight-bearing exercise. Reduce caffeine and alcohol.

 Selective estrogen receptor modulators, such as

raloxifene (Evista)- preserve bone mineral density without estrogenic effects on the uterus(indicated for both prevention and treatment of osteoporosis) Although hormone replacement therapy (HRT) has been the mainstay of therapy for perimenopausal women, recent studies have demonstrated greater risks than previously recognized The bisphosphate drugs (e.g., Fosamax, Actonel)- bind to mineralized bone surfaces to inhibit osteoclastic activity and promote bone formation.

Genitourinary System Changes

Male: Benign prostatic hyperplasia Female: Relaxed perineal muscles, detrusor

instability (urge incontinence), urethral dysfunction (stress urinary incontinence)

Subjective and Objective findings: Urinary retention

irritative voiding- symptoms: frequency, feeling of

incomplete bladder emptying, multiple nighttime voiding

 Changes in kidney function a decreased filtration rate diminished tubular function with less efficiency in

resorbing and concentrating the urine, and a slower restoration of acidbase balance in response to stress.

 Older women often suffer from stress or urge

incontinence, or both. Benign prostatic hyperplasia (enlarged prostate gland) a common finding in older men -causes a gradual increase in urine retention and overflow incontinence.

 Health promotion: Male: Seek referral to urology specialist

have ready access to toilet

wear easily manipulated clothing drink adequate fluids

avoid bladder irritants (eg, caffeinated beverages,

alcohol, artificial sweeteners) pelvic floor muscle exercises, preferably learned via biofeedback; consider urologic workup

 Female: Wear easily manipulated clothing Drink adequate fluids;

avoid bladder irritants (eg, caffeinated beverages,

alcohol, artificial sweeteners); pelvic floor muscle exercises, preferably learned via biofeedback; consider urologic workup

 URINARY URGENCY AND FREQUENCY: Avoid

bladder irritating substancescaffeinated, carbonated, and acidic beverages, Nutra-sweet, and alcohol ; increase water intake

 STRESS AND URGE INCONTINENCE- Pelvic floor

exercises (first described by Kegel) Teach patient how to do the exercises ; begins with

identifying the pubococcygeus muscle, which is the same muscle used to hold back flatus or to voluntarily stop the flow of urine without contracting the abdomen, buttocks, or inner thigh muscles.

KEGELS EXERCISES:
-The pelvic muscles are first tightened and then

relaxed, maintaining a 5-second contraction with 10second rest interval; routinely practiced for 30 to 80 repetitions each day; additional repetitions are discouraged because of the risk of fatigue of the muscle

 CONSTIPATION- encourage to eat a high-fiber diet,

drink adequate fluids, and increase mobility to promote regular bowel function.

 URINARY TRACT INFECTIONS are prevalent in

older women.

 Why women?

reasons: effects of decreased estrogen, which shortens the urethral length, allowing easier passage of bacteria into the bladder; less overall fluid consumption, which causes a concentrated urine in which bacteria can proliferate; introduction of bacteria from the rectum as a result of poor bathroom hygiene secondary to impaired mobility and joint changes.

Gastrointestinal System Changes

Decreased salivation difficulty swallowing food delayed esophageal and gastric emptying

reduced gastrointestinal motility

Subjective and Objective findings:

Complaints of dry mouth; complaints of fullness,

heartburn, and indigestion; constipation, flatulence, and abdominal discomfort

 Health promotion: Use ice chips, mouthwash; brush, floss, and massage gums daily receive regular dental care eat small, frequent meals sit up and avoid heavy activity after eating limit antacids

eat a high-fiber, low-fat diet;

limit laxatives; toilet regularly drink adequate fluids

Nervous System Changes

Reduced speed in nerve conduction; increased confusion with physical illness and loss of environmental cues; reduced cerebral

circulation (becomes faint, loses balance)

Subjective and Objective findings:

Slower to respond and react learning takes longer becomes confused with hospital admission

faintness; frequent falls

Health promotion:
Pace teaching with hospitalization, encourage visitors enhance sensory stimulation

with sudden confusion, look for cause

Encourage slow rising from a resting position

Special Senses Changes

A.Vision: Diminished ability to focus on close objects; inability to tolerate glare Difficulty adjusting to changes of light intensity Decreased ability to distinguish colors

Subjective and Objective findings

Holds objects far away from face-- Complains of glare poor night vision

confuses colors

 As new cells form on the outside surface of the lens

of the eye, the older central cells accumulate and become yellow, rigid, dense, and cloudy, leaving only the outer portion of the lens elastic enough to change shape (accommodate) and focus at near and far distances.

 As the lens becomes less flexible, the near point of

focus gets farther away. This condition, presbyopia, usually begins in the fifth decade of life, and requires the wearing of reading glasses to magnify objects. the yellowing, cloudy lens causes light to scatter and makes the older person sensitive to glare. The ability to discern blue from green decreases.

 The pupil dilates slowly and less completely because

of increased stiffness of the muscles of the iris the older person takes longer to adjust when going to and from light and dark environments or settings and needs brighter light for close vision

SENSORY LOSS VS SENSORY DEPRIVATION

Sensory losses- can often be helped by assistive

devices such as glasses and hearing aids. Sensory deprivation- the absence of stimuli in the environment or the inability to interpret existing stimuli ; can lead to boredom, confusion, irritability, disorientation, and anxiety.

Meaningful sensory stimulation

For sensory deprivation. One sense can substitute for another in observing

and interpreting stimuli. The nurse can enhance sensory stimulation in the environment with colors, pictures, textures, tastes, smells, and sounds. meaningful if they are interpreted to the older person and if they are changed often Cognitively impaired persons respond well to touch and to familiar music

Health promotion:
Wear eyeglasses, use sunglasses outdoors; avoid abrupt changes from dark to light; use adequate indoor lighting with area lights and

nightlights use large-print books use magnifier for reading Avoid night driving use contrasting colors for color coding avoid glare of shiny surfaces and direct sunlight

 B. Hearing: Decreased ability to hear high frequency

sounds
Subjective and Objective findings:
Gives inappropriate responses asks people to repeat words

strains forward to hear

Health promotion:
Recommend a hearing examination Reduce background noise face person; enunciate clearly

speak with a low-pitched voice;

use nonverbal cues

WHAT DO YOU CALL A LOSS OF THE ABILITY TO HEAR HIGH-FREQUENCY TONES?

Presbycusis, a loss of the ability to hear highfrequency tones

attributed toirreversible inner ear changes, occurs

in midlife. Older people are often unable to follow conversation because tones of high-frequency consonants (letters f, s, th, ch, sh, b, t, p) all sound alike.

 Hearing loss may cause the older person to respond

inappropriately, misunderstand conversation, and avoid social interaction. This behavior may be erroneously interpreted as confusion. Wax buildup or other correctable problems may also be responsible for major hearing difficulties. A properly prescribed and fitted hearing aid may be useful in reducing hearing deficits.

 Taste and smell: Decreased ability to taste and smell Subjective and Objective findings:

Uses excessive sugar and salt

Health promotion: Encourage use of lemon, spices, herbs

Nutritional Health
Decreased physical activity and a slower metabolic

rate reduce the number of calories needed by the older adult to maintain an ideal weight Education regarding healthy versus empty-calorie foods is helpful.

Health promotion:
encouraging a diet that is low in sodium and

saturated fats and high in vegetables, fruits, and fish. Maintain balanced nutrition. Reduce salt intake Protein intake should remain the same in later adulthood as in earlier years

 Carbohydrates, a major source of energy, should

supply the diet with 55% to 60% of the daily calories Simple sugars should be avoided and complex carbohydrates encouraged. Potatoes, whole grains, brown rice, and fruit provide the person with minerals, vitamins, and fiber and should be encouraged.

 Drinking 8 to 10 eight-ounce glasses of water per day

is recommended unless contraindicated by a medical condition. A multivitamin each day helps to maintain daily nutritional needs

SLEEP DISTURBANCES
sleep hygiene behaviors: avoiding daytime napping eating a light snack before bedtime

decreasing the overall time in bed to adjust for the

fewer hours of sleep needed than when the patient was younger

Stress and Coping in the Older Adult

Coping patterns and the ability to adapt to stress are

developed over the course of a lifetime and remain consistent later in life. Experiencing success in younger adulthood helps a person develop a positive self-image that remains solid through even the adversities of old age. A persons abilities to adapt to changes, make decisions, and respond predictably are also determined by past experiences. A flexible, well-functioning person will probably continue as such. Losses may accumulate within a short period of time, however, and become overwhelming.

 Common stressors of old age: normal aging changes that impair physical function,

activities, and appearance; disabilities from chronic illness; social and environmental losses related to loss of income decreased ability to perform previous roles and activities; the deaths of significant others.

 Many older adults rely strongly on their spiritual

beliefs for comfort during stressful times. Lack of social engagement (interaction with people within their environment) may be a modifiable risk factor for death in older persons residing in nursing homes.

Developmental Theories of Aging

Erikson (1963)

the major developmental task of old age is to either

achieve ego integrity or suffer despair. ego integrity: accepting ones lifestyle believing that ones choices were the best that could be made at a particular time, being in control of ones life. Despair results when an older person feels dissatisfied and disappointed with his or her life, and would live differently if given another chance.

Havighurst (1972)
tasks of the older person include; adjusting to retirement after a lifetime of

employment with a possible reduction of income decreases in physical strength and health the death of a spouse establishing affiliation with ones age group adapting to new social roles in a flexible way establishing satisfactory physical living arrangements

Havighurst:

developmental tasks for the older adult: (1) maintenance of self-worth (2) conflict resolution (3) adjustment to the loss of dominant roles (4) adjustment to the deaths of significant others (5) environmental adaptation (6) maintenance of optimal levels of wellness.

Sociologic Theories of Aging

ACTIVITY THEORY - life satisfaction in normal

aging requires maintaining the active lifestyle of middle age (Havighurst, 1972). CONTINUITY THEORY- successful adjustment to old age requires continuing life patterns across a lifetime (Atchley, 1989; Neugarten, 1961).

 Continuity and a connection to the past are

maintained through a continuation of wellestablished habits, values, and interests that are integral to the persons present lifestyle.

COGNITIVE ASPECTS OF AGING

Intelligence Environment and health have a considerable influence on

scores and that certain types of intelligence (eg, spatial perceptions and retention of nonintellectual information) decline problem-solving ability based on past experiences, verbal comprehension, mathematical ability do not decline Cardiovascular health, a stimulating environment, high levels of education, occupational status, and income all have a positive effect on intelligence scores in later life.

Learning and Memory

The ability to learn and acquire new skills and information decreases in the older

adult, particularly after the seventh decade of life. Motivation, speed of performance, and physical status all are important influences on learning. The components of memory, an integral part of learning, include short-term memory (5 to 30 seconds), recent memory (1 hour to several days), and long-term memory (lifetime). Acquisition of information, registration (recording), retention (storing), and recall (retrieval) are essential components of the memory process. Sensory losses, distractions, and disinterest interfere with acquiring and recording information. Age-related loss occurs more frequently with short-term and recent memory; in the absence of a pathologic process, this is called benign senescent forgetfulness.

Strategic process by which older adults learn:

Supplies mnemonics to enhance recall of related data Encourages ongoing learning Links new information with familiar information Uses visual, auditory, and other sensory cues Encourages learners to wear prescribed glasses and hearing aids Provides glare-free lighting Provides a quiet, nondistracting environment Sets short-term goals with input from the learner Keeps teaching periods short Paces learning tasks according to the endurance of the learner Encourages verbal participation by learners Reinforces successful learning in a positive manner

Life Care Plans

an individualized document that assesses and evaluates a

clients present and future health care and living needs. ; provides valuable information regarding factors that can radically affect the individuals health care and quality of life. often requested for individuals with catastrophic injuries or illness (eg, traumatic brain injury, amputation, multiple sclerosis) who will require ongoing rehabilitative and medical services. A life care plan may also serve as the blueprint for what will be expected in long-term care.

Life care components:

Medical history Social history Family issues Vocational/educational history Projected medical evaluations Projected physical and occupational therapy needs Future medical care and medications Therapeutic supplies
Personal items Diagnostic testing Medical equipment and supply

needs Recreational equipment Aids for independent function Home/facility care Transportation needs Architectural renovations Potential medical complications Compromised financial status

PHARMACOLOGIC ASPECTS OF AGING

Pharmacokinetics - study of the actions of

medications in the body, including the processes of absorption, Distribution, metabolism, and excretion.

Nursing Implications
The nurse administering medications to older people must be aware of the following: Medications removed from the body primarily by renal excretion remain in the body for a longer time in people with decreased renal function. Often dosages must be reduced, because overdosage and medication toxicity at usual therapeutic dosages are common. Medications with a narrow safety margin (eg, digitalis glycosides) must be administered cautiously. A decline in cardiac output may decrease the delivery rate to the target organ or storage tissue.

 Teaching self-administration of medication

requires asking the patient questions and requesting return demonstrations to ensure that learning has occurred.

 Sensory and memory losses, as well as decreased

manual dexterity, can affect the patients ability to carry out instructions properly, and the teaching plan will need to be adjusted to meet each patients needs.

The following steps taken by the nurse can help the patient to manage his or her medications and improve compliance:

Explain the action, side effects, and dosage of each medication. Write out the medication schedule. Encourage the use of standard containers without safety lids (if there are no children in the household). Suggest the use of a multiple-day, multiple-dose medication dispenser to help patients adhere to the medication schedule Destroy old, unused medications. Review the medication schedule periodically. Discourage the use of over-the-counter medications and herbal agents without consulting a health professional. Encourage the patient to take all medications, including over-the-counter medications, with him or her regularly when visiting the primary health care provider.

ALTERED PHARMACOKINETICS IN ELDERLY

Age-Related changes and their effect:

Absorption Reduced gastric acid; increased pH (less acid) Reduced gastrointestinal motility; prolonged

gastric emptying Effect: Rate of drug absorptionpossibly delayed Extent of drug absorptionnot affected

 Distribution Decreased albumin sites

Effect: Serious alterations in drug binding to plasma proteins (the unbound drug gives the pharmacologic response); highly protein-bound medications have fewer binding sites, leading to increased effects and accelerated metabolism and excretion

Selected highly protein-binding medications:

Oral anticoagulants (warfarin) Oral hypoglycemic agents (sulfonylureas) Barbiturates Calcium channel blockers Furosemide (Lasix) Nonsteroidal anti-inflammatory drugs (NSAIDs) Sulfonamides Quinidine Phenytoin (Dilantin

 Reduced cardiac output Effect: Decreased perfusion of many bodily organs

 Impaired peripheral blood flow Effect:

Decreased perfusion

 Increased percentage of body fat Proportion of body fat increases with age,

resulting in increased ability to store fat-soluble

medications; this causes drug accumulation prolonged storage, and delayed excretion

Selected fat-soluble medications:

Barbiturates Diazepam (Valium) Lidocaine

Phenothiazines (antipsychotics)
Ethanol Morphine

 Decreased lean body mass Effect:

Decreased body volume allows higher peak levels of

medications

 Excretion Decreased renal blood flow; loss of functioning

nephrons; decreased renal efficiency

Effect: Decreased rates of elimination and increased

duration of action; danger of accumulation and drug toxicity

Selected medications with prolonged action:

Aminoglycoside antibiotics Cimetidine (Tagamet) Chlorpropamide (Diabinase)

Digoxin
Lithium Procainamide

Falls and Falling

Falling- a common and preventable source of

mortality and morbidity in older adults. -major cause of trauma in the elderly -not often fatal but do threaten health and the quality of life. -Normal and pathologic consequences of aging that contribute to increased falls:

 Visual changes Neurologic changes include Cardiovascular changes

Cognitive changes
Musculoskeletal changes include altered posture and

decreased muscle strength.

 Use of many medications, medication interactions,

and alcohol precipitate falls by causing drowsiness, incoordination, and postural hypotension. Osteoporosis-related fractures can have a negative effect on the individuals ability to maintain an independent living arrangement

 Common Mental Health Problems in Older

Populations DEPRESSION DELIRIUM

DEMENTIA VS DELIRIUM
(SEE TABLE)

Nursing interventions:
aimed at maintaining the patients physical safety;

reducing anxiety and agitation; improving communication; promoting independence in selfcare activities; providing for the patients needs for socialization, self-esteem, and intimacy; maintaining adequate nutrition; managing sleep pattern disturbances; and supporting and educating family caregivers.

SUPPORTING COGNITIVE FUNCTION

provide a calm, predictable environment Environmental stimuli are limited, and a regular routine is followed. A quiet, pleasant manner of speaking, clear and simple explanations,

and use of memory aids and cues give the patient a sense of security. Prominently displayed clocks and calendars may Color-coding the doorway may help the patient who has difficulty locating his or her room. Active participation may help the patient to maintain cognitive, functional, and social interaction abilities for a longer period. Physical activity and communication ( to slow some of the cognitive decline of Alzheimers disease

PROMOTING PHYSICAL SAFETY

A safe environment -- all obvious hazards are removed. Nightlights are helpful. Monitor patients intake of medications and food Smoking is allowed only with supervision. A hazard-free environment allows the patient maximum independence and a sense of autonomy Because of a short attention span and forgetfulness, wandering behavior can often be reduced by gently persuading or distracting the patient. Restraints are AVOIDED because they may increase agitation. Doors leading from the house must be secured. Outside the home, all activities must be supervised to protect the patient, and the patient should wear an identification bracelet or neck chain in case he or she becomes separated from the caregiver.

REDUCING ANXIETY AND AGITATION

Constant emotional support that reinforces a positive self-image. When losses of skills occur, goals are adjusted to fit the patients

declining ability. The environment should be kept uncluttered, familiar, and noise free. Excitement and confusion can be upsetting and may precipitate a combative, agitated state known as a catastrophic reaction (overreaction to excessive stimulation). remain calm and unhurried. Measures such as listening to music, stroking, rocking, or distraction may quiet the patient. Frequently, the patient forgets what triggered the reaction. Structuring of activities Becoming familiar with the patients predicted responses to certain stressors Dementia education for caregivers

IMPROVING COMMUNICATION
To promote the patients interpretation of messages, the

nurse remains unhurried and reduces noises and distractions. The nurse uses clear, easy-to-understand sentences to convey messages, because Lists and simple written Patient can point to an object or use nonverbal language to communicate. Tactile stimuli, such as a hug or a hand pat, are usually interpreted as signs of affection, concern, and security

PROMOTING INDEPENDENCE IN SELF-CARE ACTIVITIES

The nurse should help the person remain functionally

independent for as long as possible. --- simplify daily activities by organizing them into short, achievable steps Direct patient supervision is sometimes necessary, but maintaining personal dignity and autonomy is important for Encourage patient to make choices when appropriate and to participate in self-care activities as much as possible.

INTIMACY NEEDS

visits, letters and phone calls are encouraged. Visits should be brief and nonstressful; limiting visitors to one or two at a time helps

to reduce overstimulation. Because recreation is important, the person is encouraged to enjoy simple activities. Realistic goals that provide satisfaction are appropriate. Hobbies and activities such as walking, exercising, and socializing can improve the quality of life. Nonjudgmental friendliness of a pet may provide a lonely person with stimulation, comfort, and contentment. Care of the pet by the patient can also provide a satisfying activity and an outlet for energy. The patient and his or her spouse may or may not continue to enjoy sexual activity. Simple expressions of love, such as touching and holding, are often meaningful.

PROMOTING ADEQUATE NUTRITION

Mealtime should be kept simple and calm, without confrontations. familiar foods that look appetizing and taste good one dish is offered at a time. Food is cut into small pieces to prevent choking. Liquids may be easier to swallow if they are converted to gelatin. Hot food and beverages are served warm, but the temperature of the foods should be checked to prevent burns. When lack of coordination interferes with self-feeding, adaptive equipment is helpful. Some patients may do well eating with their fingers. Forgetfulness, disinterest, dental problems, incoordination, overstimulation, and choking can all serve as barriers to good nutrition.

PROMOTING BALANCED ACTIVITY AND REST

Adequate sleep and physical exercise are essential. If sleep is interrupted or the patient is unable to fall

asleep, music, warm milk, or a back rub may help the person relax. During the day, the patient should be given sufficient opportunity to participate in exercise activities, because a regular pattern of activity and rest will enhance nighttime sleep. Long periods of daytime sleeping are discouraged.

ALTERED PAIN AND FEBRILE RESPONSES

Response to pain in older people may be lessened

because of reduced acuity of touch, alterations in neural pathways, and diminished processing of sensory data. . Acute abdominal conditions, such as mesenteric infarction and appendicitis, often go unrecognized in elderly people because of atypical signs and absence of pain

 The baseline body temperature for older people is

about 1F lower than it is for younger people. In the event of illness, therefore, the body temperature of an older person may not reach a sufficient elevation to qualify as a traditionally defined fever. A temperature of 37.8C (100F), in combination with systemic symptoms, may signal infection. A temperature of 38.3C (101F) is almost certainly a serious infection that needs prompt attention.

 A blunted fever in the face of an infection often

indicates a poor prognosis. Elevations in temperature rarely exceed 39.5C (103F). The nurse must be alert to other subtle signs of infection: mental confusion, increased respirations, tachycardia, and changed facial appearance and color

ALTERED EMOTIONAL IMPACT

An illness that requires hospitalization or a change in lifestyle is an

imminent threat to well-being. Admission to the hospital is often feared and actively avoided. Economic concerns and fear of becoming a burden to the family often lea to high anxiety in older people. The nurse must recognize the implications of fear, anxiety, and dependency in elderly patients. Autonomy and independent decision making are encouraged. A positive and confident demeanor in the nurse and the family promote a positive mental outlook in the elderly patient. In addition to anxiety and fear, older people are at high risk for disorientation, confusion, change in level of consciousness, and other symptoms of delirium if they are admitted to the hospital

ALTERED SYSTEMIC RESPONSE

The older person may be unable to respond

effectively to an acute illness or, if a chronic health condition is present, he or she may be unable to sustain appropriate responses over a long period. The older persons ability to respond to definitive treatment is impaired. Nurse must monitor all of the older adults body system functions closely, being alert to signs of impending systemic complication.