LEARNING CONTENT
In the first week of the school year you shall first be oriented with the course. Powerpoint
presentation will be uploaded in the LMS after the online discussion.
Gerontology nursing or geriatric nursing specializes in the care of older or elderly adults.
Geriatric nursing addresses the physiological, developmental, psychological, socio-economic,
cultural and spiritual needs of an aging individual.
Since aging is a normal and fundamental part of life. Providing nursing care for elderly clients
should not only be isolated to one field but is best given through a collaborative effort which
includes their family, community, and other health care team. Through this, nurses may be able
to use the expertise and resources of each team to improve and maintain the quality of life of
the elderly.
Geriatric nursing care planning centers on the aging process, promotion, restoration, and
optimization of health and functions; increased safety; prevention of illness and injury;
facilitation of healing.
Gerontology, or geriatric, nursing is a specialty focused on the care of older adults. Like other
nursing specialties, a profession in gerontological nursing requires an understanding of
anatomical and physiological changes with aging, keen assessment and monitoring skills, vast
knowledge about disease and conditions, and ongoing education related to recommended
treatment options. Gerontology nurses focus on preventive care as elderly patients are often at
greater risk of injuries and diseases such as osteoporosis, Alzheimer’s, and cancer. Gerontology
nursing is a broad specialty where nurses may work in long-term care facilities, with home healthcare
services and in hospice, caring for patients with limited mobility, impaired mental abilities, and
those in pain. These nurses care for medical or surgical patients and see patients through acute
illness and help them manage chronic disease.
Foundations of the Specialty of Gerontologic Nursing
The rich, diverse history of nursing has always been shaped by the population it serves. From
the early beginnings of Florence Nightingale’s experiences during the Crimean War to the present, as
nurses care for the growing immigrant and prison populations, those with mental illnesses, those
with substance abuse problems, teenage mothers, homeless individuals, and those infected
with the human immunodeficiency virus (HIV), nurses are reminded that these clients and their
problems define the knowledge and skills required for practice.
As of 2007, the population of Americans aged 65 or older comprised 37.9 million persons. The
number of older adults has grown steadily since 1900, and they are now the fastest growing
segment of the population (AOA, 2008). With a “gerontology boom” less than 10 years away,
gerontologic nursing is recognized as a specialty. This was not always the case, and the
struggle for recognition can be traced back to the beginning of the twentieth century.
History and Evolution
Burnside (1988) conducted an extensive review of the American Journal of Nursing (AJN) for
historical materials related to gerontologic nursing. Between 1900 and 1940, she found 23
writings, including works by Lavinia Dock, with a focus on older adults that covered such
topics as rural nursing, almshouses, and private duty nursing, as well as early case studies
and clinical issues addressing home care for fractured femur, dementia, and delirium.
Burnside discovered an anonymous column in AJN entitled “Care of the Aged” that was written
in 1925, and it is now thought to be one of the earliest references to the need for a specialty in
older adult care.
The modern health movement is constantly increasing life expectancy by its steady research
and implementation of medical actions fighting preventable disease. Therefore, nursing
professionals must expect to care for steadily increasing numbers of patients with chronic and
degenerative conditions.
During World War II and the postwar years (1940 to 1960), the population of older persons
steadily increased, but articles about the care of older adults were general and not particularly
comprehensive (Burnside, 1988). It was not until 1962, when the geriatric nursing conference
group was established during the American Nurses Association (ANA) convention, that the
question posed by the anonymous AJN columnist was finally addressed.
Professional Origins
In 1966 the ANA established the Division of Geriatric Nursing Practice and defined geriatric
nursing as “concerned with the assessment of nursing needs of older people; planning and implementing
nursing care to meet those needs; and evaluating the effectiveness of such care.” In 1976 the Division
of Geriatric Nursing Practice was changed to the Division of Gerontologic Nursing Practice to
reflect the nursing roles of providing care to healthy, ill, and frail older persons. The division
became the Council of
Gerontologic Nursing in 1984 to encompass issues beyond clinical practice. Certification for
Gerontologic Clinical Nurse Specialist was established through the ANA in 1989.
Standards of Practice
The years 1960 to 1970 were characterized by many “firsts,” as the specialty devoted to the care of
older adults began its exciting development (Table 1–1). Journals, textbooks, workshops and
seminars, formal education programs, professional certification, and research with a focus on
gerontologic nursing have since evolved. However, the singular event that truly legitimized the
specialty occurred in 1969, when a committee appointed by the ANA Division of Geriatric
Nursing Practice completed the first Standards of Practice for Geriatric Nursing (ANA, 1991).
These standards were widely circulated during the next several years; in 1976 they were
revised, and the title was changed to Standards of Gerontological Nursing Practice. In 1981 A
Statement on the Scope of Gerontological Nursing Practice was published. The revised
Standards and Scope of Gerontological Nursing Practice were published in 1987, 1995, and the
current 2010 edition is in press. The changes to this document reflect the comprehensive
concepts and dimensions of practice for the nurse working with older adults. In 1995 the revised
Scope and Standards of Gerontological Nursing Practice reflected the nature and scope of
current gerontologic nursing practice but also incorporated the concepts of health promotion,
health maintenance, disease prevention, and self-care. In 2004 all scope and standards of
practice were combined into a set of three books known as the Nursing Scope & Standards of Practice,
Nursing’s Social Policy Statement (ANA, 2003), and the Code of Ethics for Nurses with
Interpretive Statements (ANA, 2001). “These three resources provide a complete and definitive
description for better understanding by specialty nursing organizations, policy makers, and the public
of nursing practice and nursing’s
accountability to the public in the United States” (ANA, 2004, p. vi). This merging of the standards of
practice of all the specialties was an effort to outline the expectations of the professional role
within which all registered nurses must practice nursing. However, with the tremendous
increase in care of the older adult, the ANA has again published Scope and Standards of
Gerontological Nursing Practice with input from nurses across the United States before the final
publishing in 2010. This document can be obtained from the ANA website:
www.nursingworld.org/.
DEVELOPMENT OF GERONTOLOGIC NURSING:
1960–1970 YEAR
EVENT
1961 Formation of a specialty group for geriatric nurses is recommended by the American
Nurses Association (ANA).
1962 First national meeting of the ANA Conference on Geriatric Nursing Practice is held in
Detroit, Mich.
American Nurses’ Foundation receives a grant for a workshop on the aged.
First research in geriatric nursing is published in England (Norton D et al: An
investigation of geriatric nursing problems in hospital, London 1962, National Corporation for
the Care of Old People).
1966 First gerontologic clinical specialist nursing program is developed at Duke University by
Virginia Stone.
Geriatric Nursing Division of the ANA is formed; a monograph is published, entitled
Exploring Progress in Geriatric Nursing Practice.
1968 Laurie Gunter is the first nurse to present a paper at the International Congress of
Gerontology in Washington, DC. First gerontologic nursing interest group, Geriatric Nursing, is
formed.
Barbara Davis is the first nurse to speak before the American Geriatric Society.
First article on nursing curriculum regarding gerontologic nursing is published (Delora
JR, Moses DV: Specialty preferences and characteristics of nursing students in baccalaureate
programs, Nurs Res March/April, 1969).
The nine standards for geriatric nursing practice are developed.
1970
Standards of Geriatric Nursing Practice is first published.
First gerontologic clinical nurse specialists graduate from Duke University.
Modified from Burnside IM: Nursing and the aged: a self care approach, ed 3, New York, 1988,
McGraw- Hill.
Another hallmark in the continued growth of the gerontologic nursing specialty occurred in
1973, when the first gerontologic nurses were certified through the ANA. Certification is an
additional credential granted by the ANA, providing a means for recognizing excellence in a
clinical or functional area (ANA, 1995). Certification is usually voluntary, enabling the nurse to
demonstrate to peers and others that a distinct degree of knowledge and expertise has been
achieved. In some cases, certification can mean eligibility for third-party reimbursement for
nursing services rendered. From the initial certification offering as a generalist in gerontologic
nursing, to the first gerontologic nurse practitioner (GNP) examination offering in 1979, to the
most recent gerontologic clinical nurse specialist (GCNS) examination (first administered in
1989), this specialty has continued to grow and attract a high level of interest.
AMERICAN NURSES CREDENTIALING CENTER ELIGIBILITY REQUIREMENTS FOR
CERTIFICATION IN GERONTOLOGIC NURSING
Gerontologic Nurse (Registered Nurse—Board Certified [BC])
The nurse must meet all of the following requirements before application for examination:
1. Currently hold an active registered nurse (RN) license in the United States or its
territories or the professional, legally recognized equivalent in another country.
2. Have practiced the equivalent of 2 years, full time, as an RN.
3. Have completed clinical practice of at least 2000 hours in gerontologic nursing within the past 3
years.
4. Have had 30 contact hours of continuing education applicable to gerontology/gerontologic
nursing within the past 3 years.
More details on this option can be found by contacting the ANCC directly or
online at www.nursingworld.org/ancc/certification.
Gerontologic Nurse Practitioner (GNP—BC)
The nurse must meet all of the following requirements:
1. Currently hold an active RN license in the United States or its territories or the
professional, legally recognized equivalent in another country.
2. Hold a master’s, postmaster’s, or doctorate degree from a gerontologic nurse practitioner program
accredited by the Commission on the Collegiate of Nursing Education (CCNE) or the National
League for Nursing Accrediting Commission (NLNAC).
3. A minimum of 500 faculty-supervised clinical hours must be included in your
gerontologic nurse practitioner program. The GNP graduate program must include course
work in the following:
a. Advanced health assessment
b. Advanced pharmacology
c. Advanced pathophysiology, and
d. Content across the life span in health promotion and disease prevention; differential
diagnosis, and disease management.
4. Alternative eligibility is available for an Acute Care Nurse Practitioner, Adult Nurse
Practitioner, or Family Nurse Practitioner holding an active certification and who is licensed or
authorized to practice as a nurse practitioner by a state or territory. More details on this option
can be found by contacting the ANCC directly or online at
www.nursingworld.org/ancc/certification.
Clinical Specialist In Gerontologic Nursing (GCNS—BC)
The nurse must meet all the following requirements before the application process:
1. Currently hold an active RN license in the United States or its territories or the
professional, legally recognized equivalent in another country.
2. Hold a master’s, postmaster’s, or doctorate degree from a clinical nurse specialist in gerontologic
nursing program accredited by the CCNE or the NLNAC; CNS role and specialty must be
included in the educational program. This gerontologic CNS graduate program must include
course work in the following:
a. Advanced health assessment
b. Advanced pharmacology
c. Advanced pathophysiology
More details on this option can be found by contacting the ANCC directly or
online at www.nursingworld.org/ancc/certification.
Modified from American Nurses Credentialing Center Certification 2009, Washington DC, and
retrieved August 14, 2009 from website at www.nursingworld.org/ancc/certify.htm. To keep
current with the changing scope, standards, and education requirements, the eligibility criteria
are reviewed yearly and are subject to change. Therefore if applying to take a certification
examination, one must request a current catalog from the center; compliance with the current
eligibility criteria is required. Applications can be downloaded from the Internet.
Roles
The growth of the nursing profession as a whole, increasing educational opportunities,
demographic changes, and changes in health care delivery systems have all influenced the
development of the generalist role in gerontologic nursing, as well as the advanced practice
roles of gerontologic CNS and GNP. The generalist in gerontologic nursing has completed a
basic entry-level educational program. A generalist nurse may practice in a wide variety of
environments, including the home and community. The challenge of the gerontologic nurse
generalist is to identify older clients’ strengths and assist them with maximizing their independence.
Clients participate as much as possible in making decisions about their care. The generalist
consults with the advanced practice nurse and other interdisciplinary health professionals for
assistance in meeting the complex care needs of older adults.
The gerontologic CNS has at least a master’s degree in nursing. The first program was launched in
1966 at Duke University. The gerontologic master’s program typically focuses on the advanced
knowledge and skills required to care for older adults in a wide variety of settings, and the
graduate is prepared to assume a leadership role in the delivery of that care. GCNSs have an
expert understanding of the dynamics, pathophysiology, and psychosocial aspects of aging.
They use advanced diagnostic and assessment skills and nursing interventions to manage and
improve patient care (American Nurses Credentialing Center [ANCC], 2009). The GCNS
functions as a clinician, educator, consultant, administrator, or researcher to plan care or
improve the quality of nursing care for older adults and their families. Specialists provide
comprehensive care based on theory and research. Today, GCNSs can be found practicing in
acute hospitals, long-term care or home care settings, or independent practices.
The GNP may be educationally prepared in various ways. In the early 1970s the first GNPs
were prepared primarily through continuing education programs. Another early group of GNPs
received their training and clinical supervision from physicians. Only since the late 1980s has
master’s-level education with a focus on primary care been available. As a provider of primary
care and a case manager, the GNP conducts health assessments; identifies nursing
diagnoses; and plans, implements, and evaluates nursing care for older clients. A GNP has the
knowledge and skills to detect and manage limited acute and chronic stable conditions;
coordination and collaboration with other health care providers is a
related essential function. The GNP’s activities include interventions for health promotion,
maintenance, and restoration. GNPs provide primary ambulatory care in an independent practice
or a collaborative practice with a physician; they also practice in settings across the continuum
of care, including the acute care hospital, subacute care center, ambulatory care, and long-term
care setting. Health maintenance organizations (HMOs) are now including GNPs on their
provider panels. Certification can elevate the status of the nurse practicing with older adults in
any setting. More importantly, it enables the nurse to
ensure the delivery of quality care to older adult clients. In most states within the United States,
GNPs hold prescriptive authority for nearly all classes of medications. Each state has
determined the type and extent of prescriptive authority permitted.
Terminology
Any discussion of older adult nursing is complicated by the wide variety of terms used
interchangeably to describe the specialty. Some terms are used because of personal
preference or because they suggest a certain perspective. Still others are avoided because of
the negative inferences they evoke. As described in the preceding overview of the evolution of
the specialty, the terminology has changed over the years. The following are the most
commonly used terms and definitions:
• Geriatrics—from the Greek geras, meaning “old age,” geriatrics is the branch of medicine that deals
with the diseases and problems of old age. Viewed by many nurses as having limited
application to nursing because of its medical and disease orientation, the term geriatrics is
generally not used when describing the nursing of older adults.
• Gerontology—from the Greek geron, meaning “old man,” gerontology is the scientific study of
the process of aging and the problems of aged persons; it includes biologic, sociologic,
psychologic, and economic aspects.
• Gerontologic nursing—this specialty of nursing involves assessing the health and functional
status of older adults, planning and implementing health care and services to meet the
identified needs, and evaluating the effectiveness of such care. Gerontologic nursing is the
term most often used by nurses specializing in this field.
• Gerontic nursing—this term was developed by Gunter and Estes in 1979 and is meant to
be more inclusive than geriatric or gerontologic nursing because it is not limited to diseases
or scientific principles. Gerontic nursing connotes the nursing of older persons—the art and
practice of nurturing, caring, and comforting. This term has not gained wide acceptance, but
it is viewed by some as a more appropriate description of the specialty.
These terms and their usage spark a great deal of interest and controversy among nurses
practicing with older adults. As the specialty continues to grow and develop, it is likely that the
terminology will also.
Demographic Profile of the Older Population
Far from the beginnings of gerontologic nursing practice in almshouses and nursing homes,
nurses today find themselves caring for older adults in a wider variety of settings. Emergency
rooms, medical-surgical and critical care units in hospitals, outpatient surgical centers, home
care agencies, clinics, and rehabilitation centers are just some of the sites where nurses are
caring for the older population that is rapidly growing. Nurses in any of these settings need only
count the number of adults 65 or older to understand firsthand what demographers have termed
the graying of America. Although this trend has already attracted the attention of the health care
marketplace, it promises to become an even greater influence on health care organizations. It is
clearly a trend that promises to shape the future practice of nursing in profound and dramatic
ways.
Demography is the science dealing with the distribution, density, and vital statistics of human
populations. In the following review of basic demographic facts about older persons, the
reader is cautioned against believing that age 65 automatically defines a person as being
old. The rate and intensity of aging is highly variable and individual. It occurs gradually and in
no predictable sequence.
Butler (1975), in his classic book, Why Survive? Being Old in America, cautions against using
chronologic age as a measure of being old. He offers the following on why age 65 is the
discretionary cutoff for defining old age:
Society has arbitrarily chosen ages 60 to 65 as the beginning of late life (borrowing the idea from
Bismarck’s social legislation in Germany in the 1880s) primarily for the purpose of determining a point
for retirement and eligibility for services and financial entitlements for the elderly.
When the social security program was established in 1935, it was believed that age 65 would
be a reasonable age for the purpose of allocating benefits and services. Today, with so many
older persons living productive, highly functional lives well beyond age 65, this age is
obviously an inappropriate one
for determining whether a person is old. However, demographic information and other forms of
data are still reported using age 65 as the defining standard for old. For example, older adults
are categorized by cohort for some research and public policy purposes. Consequently, it is not
uncommon to see older persons classified as young-old, middle-old, or old-old.
Although grouping older persons is useful in some circumstances, the nurse is cautioned
against thinking of all persons older than age 65 as similar. In fact, older persons are far from
being a homogenous group. Landmarks for human growth and development are well
established for infancy through middle age, but few norms have been as discretely defined for
older adulthood. In fact, most developmental norms that have been described for later life
categorize all older persons in the older-than-65 group.
One could argue from a developmental perspective that as great a difference exists among 65-,
75-, 85-, and 95-year-olds as it does among 2-, 3-, 4-, and 5-year-olds, yet no definitive
standards for older adult development have been established. Consequently, the nurse is urged
to view each older client as one would any client—a being with a richly diverse and unique
array of internal and external variables that ultimately influence how the person thinks and acts.
Understanding how the variables interact and affect older adults enables the nurse to provide
individualized care. Additionally, the nurse is
encouraged to use the individual client as the standard, comparing a client’s previous level and pattern
of health and function with the current
status. The Older Population
For several decades, the American Association of Retired Persons (AARP) maintained a
yearly update of the profile of older adults in America. This organization is a nonprofit,
nonpartisan membership organization for people age 50 or older. The AARP is dedicated to
enhancing the quality of life for all Americans as they age. The association acknowledges that
its members receive a wide range of unique benefits, special products, and services. Additional
information can be found at their website: www.aarp.org. In 1997 the organization stopped
compiling profile demographics and began to collect more specific data on a narrower scope.
The federal government maintains aging statistics that are available to the public. These
publications include an annual chart book with the name of the year.
Information can be found at
www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/OA_2008.pdf. Use the
exact year (e.g., 2010) at the end of the web address for a specific year. This is now a part of
public census and reporting efforts.
Before review of current statistics of older adults in America, a look at past issues that have
lead to these numbers is appropriate. The relatively high birth rate during the late nineteenth
and early twentieth centuries accounts in part for the large number of older persons today
(Burnside, 1988). Reduced infant and child mortality as a result of improved sanitation,
advances in vaccination, and the development of antibiotics has also contributed. The large
influx of immigrants before World War I is an additional important factor. The net effect,
associated with a reduction in mortality for all ages and fertility rates at a replacement level, has
been an increase in the older adult population.
The Impact of the Aging Population on Nursing
The proportion of elderly people in population is growing, and fast. According to the
Administration on Aging, people age 65 and older are expected to make up nearly 22 percent
of the population by 2040, compared to 14.5 percent in 2014.1 This demographic shift has
serious implications for many aspects of our society, but especially for the health care industry
— and for nurses in particular.
Older adults have specific health needs that nurses will need to anticipate and adjust to
accommodate to ensure optimal patient outcomes. Some of those include:
Multiple chronic conditions. As the human lifespan increases, so does the prevalence of chronic
illnesses: 68 percent of older adults have at least two chronic diseases.2 It is estimated that by
2040, almost 160 million people in the US, most of them elderly, will be living with chronic
conditions.3 Managing multiple chronic conditions successfully involves an awareness of
potential behavior changes, medication interaction and potential side effects, and strategies for
relieving pain and other symptoms.
A need for home-based care. Elderly and ill patients will require more in-home care because
they may no longer be able to handle tasks related to patient compliance. For instance, they
may need help with simple physical therapy exercises, organizing pills, diet and meal planning
and preparation, administering their own injections, doing blood-pressure tests, and other
requirements of their care plan. Their family members or other caregivers may also need to be
educated on how to help elderly patients fulfill these responsibilities.
These realities point to specific areas in which nursing is transforming in order to
continue to successfully deliver health care that meets the specific needs of elderly
patients.
Teamwork and Coordination
Nurses are already considered a vital part of a health care team and regularly collaborate with
their peers and other health care professionals. As nurses are usually the main point of contact
for patients, they are well suited to handle the coordination and communication of integrated
strategies for the extremely complex nature of senior patient care. When dealing with the
multilayered challenges posed by senior patients, these skills will be especially valuable.
Education
The Institutes of Medicine’s “The Future of Nursing” report outlines the importance of achieving
higher levels of nursing education to keep up with the changes and challenges of health care.
Similarly, the demographic shift toward a greater population of seniors indicates a need for
more nurses to be educated in gerontological issues. The Geriatric Nursing Education
Consortium advocates for enhanced instruction and coursework in geriatrics in Bachelor of
Science in Nursing programs.4 Nurses who have additional education in this area of health
care will be better able to anticipate, prepare for, and meet the needs of the influx of geriatric
patients.
Leadership
Nursing education at the bachelor’s level and up emphasizes leadership, communication, and critical
thinking skills. While these abilities are necessary in all settings, they are particularly important
when working with geriatric patients. Nurses will potentially serve as the primary care provider
for senior patients with multiple chronic issues that do not require substantial physician
intervention, requiring nurses to take on a larger role in patient care planning and treatment. In
addition, effective communication skills will be required as family members step in to help out
with care for senior patients. Nurses will need to be able to clearly explain treatment plans,
answer questions, and address the concerns of both patients and their caregivers.
Recognizing and Acting on Career Opportunities
One way that nurses can prepare for this demographic shift is to proactively consider potential
areas for professional development and opportunity. They may consider specializing in
geriatrics or related fields to fill the need for expertise and nurse leadership in these areas.
They may also focus on designing clinical and administrative home care plans for elderly
patients as part of a health care organization’s overall strategy for effective patient care
delivery. Or they can focus on educating future generations of nurses in the treatment of senior
patients.
These sweeping demographic changes will likely require legislative action and policy
development across many areas of American life. Health care is likely to act as the “canary in the coal
mine,” forced to deal with the realities and needs of an aging population before other industries
do.
Make sure you are prepared to handle the demands an aging population will make on the
nursing profession.
LEARNING CONTENT
PowerPoint presentation will be uploaded in the LMS after the online discussion.
Theories of Aging
Theories of aging have been debated since the time of the ancient Greeks. In the twelfth
century thoughts were centered on predetermination and an unalterable plan for life and
death. The philosopher Maimonides thought that precautions and careful living might
prolong life. In the late 1400s, Leonardo da Vinci attempted to explain aging as
physiologic changes while studying the structure of the human body. Studies were few
until the late 1900s when world populations began to have increasing numbers of older
adults. Scholars have sought to embrace a theory that can explain the entire aging
phenomenon. However, many scholars have concluded that no one definition or theory
exists that explains all aspects of aging; rather, scientists have found that several
theories may be combined to explain various aspects of the complex phenomena we call
aging.
Theories function to help make sense of a particular phenomenon; they provide a sense
of order and give a perspective from which to view the facts. Theories provide a
springboard for discussion and research. Some theories are presented in this chapter
because of their historical value; for the most part, they have been abandoned because
of lack of empiric evidence. Other theories are the result of ongoing advances made in
biotechnology and, as such, provide glimpses into our future.
Human aging is influenced by a composite of biologic, psychologic, social, functional,
and spiritual factors. Aging may be viewed as a continuum of events that occur from
conception to death (Ignatavicius & Workman, 2005). Biologic, social, and psychologic
theories of aging attempt to explain and explore the various dimensions of aging. This
chapter explores the prominent theories of aging as a guide for developing a holistic
gerontologic nursing theory for
practice application. No single gerontologic nursing theory has been accepted by this
specialty, which requires nurses to use an eclectic approach from other disciplines as
the basis of clinical decision making (Comfort, 1970)
THEORIES OF AGING
Biologic
Concerned with answering basic questions regarding physiologic processes that occur in
all living organisms over time (Hayflick, 1996).
Sociologic
Focused on the roles and relationships within which individuals engage in later life
(Hogstel, 1995).
Psychologic
Influenced by both biology and sociology; address how a person responds to the tasks
of his or her age.
Moral/Spiritual
Examine how an individual seeks to explain and validate his or her existence
(Edelman & Mandle, 2003).
By incorporating a holistic approach to the care of older adults, nurses can view this
ever- increasing portion of the population more comprehensively. Interactions between
gerontologic nurses and older adults are not limited to a specific disease or physiologic
process, absolute developmental tasks, or psychosocial changes. Nurses have the
ability to synthesize various aspects of the different aging theories, and they visualize
older adults interfacing with their total environment, including physical, mental/emotional,
social, and spiritual aspects. Therefore, an eclectic approach provides an excellent
foundation as nurses plan high-quality care for older adults.
Theories of aging attempt to explain this phenomenon of aging as it occurs over the life
span, which is thought to be a maximum of approximately 120 years (Cetron & Davies,
1998). Several basic assumptions and concepts have been accepted over the years as
guiding research and clinical practice related to aging. Human aging is viewed as a
total process that begins at conception. Because individuals have unique genetic,
social, psychologic, and economic factors
intertwined in their lives, the course of aging varies from individual to individual.
Senescence, defined as a change in the behavior of an organism with age, leading to a
decreased power of survival and adjustment, also occurs. The recognition of the
universal truths is what we attempt to discover through the theories of aging.
Biologic Theories of Aging
Biologic theories are concerned with answering basic questions regarding the
physiologic processes that occur in all living organisms as they chronologically age.
These age-related changes occur independent of any external or pathologic influence.
The primary question being addressed relates to the factors that trigger the actual aging
process in organisms. These theories generally view aging as occurring from a
molecular, cellular, or even a systems point of view. In addition, biologic theories are not
meant to be exclusionary. Theories may be combined to explain phenomena (Hayflick,
1996; Hayflick, 2007).
The foci of biologic theories include explanations of the following: (1) deleterious effects
leading to decreasing function of the organism, (2) gradually occurring age-related
changes that are progressive over time, and (3) intrinsic changes that can affect all
members of a species because of chronologic age. The decreasing function of an
organism may lead to a complete failure of either an organ or an entire system (Hayflick,
1996; Hayflick, 2004; Hayflick, 2007). In addition, according to these theories, all organs
in any one organism do not age at the same rate, and any single organ does not
necessarily age at the same rate in different individuals of the same species (Warner,
2004).
The biologic theories can be subdivided into two main divisions: stochastic and
nonstochastic. Stochastic theories explain aging as events that occur randomly and
accumulate over time, whereas nonstochastic theories view aging as certain
predetermined, timed phenomena (Box 2– 2).
BIOLOGIC THEORIES OF AGING
Stochastic
Theories Error
Theory
The error theory is based on the idea that errors can occur in the transcription of the
synthesis of DNA. These errors are perpetuated and eventually lead to systems that do
not function at the optimum level. The organism’s aging and death are attributable to these
events (Sonneborn, 1979).
Free Radical Theory
Free radicals are by products of metabolism. When these by products accumulate, they
damage the cell membrane, which decreases its efficiency. The body produces
antioxidants that scavenge the free radicals (Hayflick, 1996).
Cross-Linkage Theory
With age, according to this theory, some proteins in the body become cross-linked.
This does not allow for normal metabolic activities, and waste products accumulate in
the cells. The end result is that tissues do not function at optimum efficiency (Hayflick,
1996).
Wear and Tear Theory
The wear and tear theory equates humans with machines. It hypothesizes that
aging is the result of use.
Nonstochastic
Theories
Programmed Theory
Hayflick and Moorehead demonstrated that normal cells divide a limited number of
times; therefore they hypothesized that life expectancy was preprogrammed
(Hayflick, 1996).
Immunity Theory
Changes occur in the immune system, specifically in the T lymphocytes, as a result
of aging. These changes leave the individual more vulnerable to disease (Phipps et
al, 2003).
Stochastic
Theories Error
Theory
As a cell ages, various changes occur naturally in its deoxyribonucleic acid (DNA) and
ribonucleic acid (RNA), the building blocks of the cell. DNA, found in the nucleus of the
cell, contains the fundamental genetic code and forms the genes on all 46 human
chromosomes (Black & Hawks, 2005).
In 1963, Orgel proposed the Error Theory, sometimes called the Error Catastrophe
Theory. This theory’s hypothesis is based on the idea that errors can occur in the
transcription in any step of protein synthesis of DNA, and this eventually leads to either
the aging or the actual death of a
cell. The error would cause the reproduction of an enzyme or protein that was not an
exact copy of the original. The next transcription would again contain an error. As the
effect continued through several generations of proteins, the end-product would not even
resemble the original cell and its functional ability would be diminished (Sonneborn,
1979).
In recent years the theory has not been supported by research. Although changes do
occur in the activity of various enzymes with aging, studies have not found that all
aged cells contain altered or misspecified proteins, nor is aging automatically or
necessarily accelerated if misspecified proteins or enzymes are introduced to a cell
(Hayflick, 1996; Hayflick, 2004; Schneider, 1992; Weinert & Timiras, 2003).
Radical Theory
Free radicals are by products of fundamental metabolic activities within the body. Free
radical production can increase as a result of environmental pollutants such as ozone,
pesticides, and radiation. Normally, they are neutralized by enzymatic activity or natural
antioxidants. However, if they are not neutralized, they may attach to other molecules.
These highly reactive free radicals react with molecules in cell membranes, in particular,
cell membranes of unsaturated lipids such as mitochondria, lysosomes, and nuclear
membranes. This action monopolizes the receptor sites on the membrane, thereby
inhibiting the interaction with other substances that normally use this site; this chemical
reaction is called lipid peroxidation. Therefore the mitochondria, for example, can no
longer function as efficiently, and their cell membranes may become damaged, which
results in increased permeability. If excessive fluid is either lost or gained, the internal
homeostasis is disrupted and cell death may result.
Other deleterious results are related to free radical molecules in the body. Although
these molecules do not contain DNA themselves, they can cause mutations in the DNA–
RNA transcription, thereby producing mutations of the original protein. In nervous and
muscle tissue, to which free radicals have a high affinity, a substance called lipofuscin
has been found and is thought to be indicative of chronologic age.
Lipofuscin, a lipid- and protein-enriched pigmented material, has been found to
accumulate in
older adults’ tissues, and is commonly referred to as “age spots.” As the lipofuscin’s presence
increases, healthy tissue is slowly deprived of oxygen and nutrient supply. Further
degeneration of surrounding tissue eventually leads to actual death of the tissue. The
body does have naturally occurring antioxidants, or protective mechanisms. Vitamins C
and E are two of these substances and can inhibit the functioning of the free radicals or
possibly decrease their production in the body.
Harman (1956) was the first to suggest that the administration of chemicals terminating
the propagation of free radicals would extend the life span or delay the aging process.
Animal research has demonstrated that administration of antioxidants did increase the
average length of life, possibly because of the delayed appearance of diseases that may
have eventually killed the animals studied. It appears that administration of antioxidants
postpones the appearance of diseases such as cardiovascular disease and cancer, two
of the most common causes of death. Antioxidants also appear to have an effect on the
decline of the immune system and on degenerative neurologic diseases, both of which
affect morbidity and mortality (Hayflick, 1996; Weinert & Timiras, 2003; Yu, 1998, 1993).
Cross-Linkage Theory
The cross-linkage theory of aging hypothesizes that with age some proteins become
increasingly cross-linked or enmeshed and may impede metabolic processes by
obstructing the passage of nutrients and wastes between the intracellular and
extracellular compartments. According to this theory, normally separated molecular
structures are bound together through chemical reactions.
This primarily involves collagen, which is a relatively inert long-chain macromolecule
produced by fibroblasts. As new fibers are created, they become enmeshed with old
fibers and form an actual chemical cross-link. The end result of this cross-linkage
process is an increase in density of the collagen molecule but a decrease in the capacity
to both transport nutrients to the cells and remove waste products from the cells.
Eventually, this results in a decrease in the structure’s function. An example of this would be
the changes associated with aging skin. The skin of a baby is soft and pliable, whereas
aging skin loses much of its suppleness and elasticity. This aging process is similar to
the process of tanning leather, which purposefully creates cross-links (Bjorkstein, 1976;
Hayflick, 1996; Hayflick, 2004).
Cross-linkage agents have been found in unsaturated fats; in polyvalent metal ions like
aluminum, zinc, and magnesium; and in association with excessive radiation exposure.
Many of the medications ingested by the older population (such as antacids and
coagulants) contain aluminum, as does the common cooking ingredient baking powder.
Some research supports a combination of exercise and dietary restrictions in helping to
inhibit the cross-linkage process, as well as the use of vitamin C prophylactically as an
antioxidant agent (Bjorkstein, 1976).
One researcher, Cerani, has shown that blood glucose reacts with bodily proteins to
form cross- links. He has found that the crystallin of the lens of the eye, membranes of
the kidney, and
blood vessels are especially susceptible to cross-linking under the conditions of
increased glucose. Cerani suggests increased levels of blood glucose cause
increased amounts of cross- linking, which accelerate lens, kidney, and blood vessel
diseases (Schneider, 1992).
Cross-linkage theory proposes that as a person ages and the immune system
becomes less efficient, the body’s defense mechanism cannot remove the crosslinking agent before it becomes securely established. Cross-linkage has been
proposed as a primary cause of arteriosclerosis, a decrease in efficiency of the
immune system with age, and the loss of
elasticity often seen in older adult skin. The cross-linkage theory has emerged from
deductive reasoning, and aside from the previous examples, there is little empiric
evidence to support its claims (Hayflick, 1996).
Wear and Tear Theory
This theory proposed that cells wear out over time because of continued use. When
this theory was first proposed in 1882 by Weisman, death was seen as a result of
tissues being worn out because they could not rejuvenate themselves in an endless
manner (Hayflick, 1988).
Essentially, the theory reflects a belief that organs and tissues have a preprogrammed
amount of available energy and wear out when the allotted energy is expended.
Eventually this leads to the death of the entire organism.
Under this theory, aging is viewed as almost a preprogrammed process—a process
thought to be vulnerable to stress or to an accumulation of injuries or trauma, which
may actually
accelerate it. “Death,” said Weisman, “occurs because a worn out tissue cannot forever renew
itself” (Hayflick, 1996; Weinert & Timiras, 2003; Holliday, 2004).
Proponents of this theory cite microscopic signs of wear and tear that have been found
in striated and smooth muscle tissue and in nerve cells. Researchers question this
theory in light of research demonstrating increased functional abilities in individuals who
exercise daily. This effect occurs even in persons with chronic limiting states such as
rheumatoid arthritis. If exercise has been found to increase a person’s level of
functioning rather than decrease it, critics challenge, how can the wear and tear
hypothesis be correct? This theory was developed during the Industrial Revolution, when
people were attempting to explain and make sense of events in their world. These
people were trying to equate humans with the marvelous machines they were producing.
It eventually became clear just how different humans were from these machines.
Nonstochastic Theories
Programmed Theory or Hayflick Limit Theory
One of the first proposed biologic theories is based on a study completed in 1961 by
Hayflick and Moorehead. This study included an experiment on fetal fibroblastic cells
and their reproductive capabilities. The results of this landmark study changed the way
scientists viewed the biologic aging process.
Hayflick and Moorehead’s study showed that functional changes do occur within cells and are
responsible for the aging of the cells and the organism. The study further supported the
hypothesis that a cumulative effect of improper functioning of cells and eventual loss of
cells in organs and tissues are therefore responsible for the aging phenomenon. This
study contradicted earlier studies by Carrel and Ebeling in which chick embryo cells
were kept alive indefinitely in a laboratory; the conclusion from this 1912 experiment was
that cells do not wear out but continue to function normally forever. An interesting aspect
of the 1961 study was that freezing was found to halt the biologic cellular clock (Hayflick
& Moorehead, 1961).
Based on this 1961 study, unlimited cell division was not found to occur; the immortality
of individual cells was found to be more an abnormal than a normal occurrence.
Therefore this study seemed to support the Hayflick Limit Theory. Life expectancy was
generally seen as preprogrammed, within a species-specific range; this biologic clock for
humans was estimated at 110 to 120 years (Gerhard & Cristofalo, 1992; Hayflick, 1996).
Based on the conclusions of this experiment, the Hayflick Limit Theory is sometimes
called the “Biologic Clock,” “Cellular Aging,” or “Genetic Theory.”
Immunity Theory
The immune system is a network of specialized cells, tissues, and organs that provide
the body with protection against invading organisms. Its primary role is to differentiate
self from non self, thereby protecting the organism from attack by pathogens. It has
been found that as a person ages, the immune system functions less effectively. The
term immunosenescence has been given to this age-related decrease in function.
Essential components of the immune system are T lymphocytes, which are responsible
for cell- mediated immunity, and B lymphocytes, the antibodies responsible for humoral
immunity. Both T and B lymphocytes may respond to an invasion of the organism,
although one may provide more protection in certain situations. The changes that occur
with aging are most apparent in the T lymphocytes, although changes also occur in the
functioning capabilities of B lymphocytes. Accompanying these changes is a decrease in
the body’s defense against foreign pathogens, which manifests itself as an increased
incidence of infectious diseases and an increase in the production of autoantibodies,
which lead to a propensity to develop autoimmune-related diseases (Hayflick, 1996;
Weinert & Timiras, 2003) (Box 2–3).
CHANGES IN CELL-MEDIATED IMMUNE FUNCTION AS A RESULT OF AGING
• Increased autoantibodies as a result of altered immune system regulation. This predisposes an
individual to autoimmune diseases such as lupus and rheumatoid arthritis.
• Low rate of T-lymphocyte proliferation in response to a stimulus. This causes older
adults to respond more slowly to allergic stimulants.
• Reduced response to foreign material, resulting in an increased number of infections. This is a
result of a decrease in cytotoxic or killer T cells.
• Generalized T-lymphocyte dysfunctions, which reduce the response to certain viral
antigens, allografts, and tumor cells. This results in an increased incidence of cancer
in older adults.
The changes in the immune system cannot be precisely explained by an exact causeand-effect relationship, but they do seem to increase with advancing age. These
changes include a decrease in humoral immune response, often predisposing older
adults to (1) decreased resistance to a tumor cell challenge and the development of
cancer, (2) decreased ability to
initiate the immune process and mobilize the body’s defenses against aggressively attacking
pathogens, and (3) heightened production of autoantigens, often leading to an
increase in autoimmune-related diseases.
Immunodeficient conditions, such as the human immunodeficiency virus (HIV) and the
immune suppression of organ transplant recipients, have demonstrated a relationship
between immunocompetence and cancer development. HIV has been associated with
several forms of
cancer, such as Kaposi’s sarcoma. Recipients of organ transplants are 80 times more likely to
contract cancer than the rest of the population (Black & Hawks, 2005).
Emerging Theories
Neuroendocrine Control or Pacemaker Theory
The neuroendocrine theory examines the interrelated role of the neurologic and
endocrine systems over the life span of an individual (Box 2–4). The neuroendocrine
system regulates and controls many important metabolic activities. It has been observed
that there is a decline, or even a cessation, in many of the components of the
neuroendocrine system over the life span. The reproductive system, and its changes
over the life of an individual, provides an interesting model for the functional capability of
the neuroendocrine system.
EMERGING THEORIES OF AGING
Neuroendocrine Control or Pacemaker Theory
The neuroendocrine system controls many essential activities with regard to growth
and development. Scientists are studying the roles that the hypothalamus and the
hormones DHEA (dehydroepiandrosterone) and melatonin play in the aging process
(Guardiola-Lemaitre, 1997; Hayflick, 1996).
Metabolic Theory of Aging/Caloric Restriction
The role of metabolism in the aging process is being investigated (Hayflick, 1996).
DNA-Related Research
Two developments are occurring at this time in relationship to DNA and the aging
process. First, as scientists continue to map the human genome, they are identifying
certain genes that play a role in the aging process (Schneider, 1992). Second is the
discovery of telomeres, located at the ends of chromosomes, which may function as the
cells’ biologic clocks (Hayflick, 1996).
Research has shown there are complex interactions between the endocrine and the
nervous systems. It appears that the female reproductive system is governed not by the
ovaries or the pituitary gland but by the hypothalamus. Men do not experience a
reproductive event such as a menopause, although they do demonstrate a decline in
fertility. The mechanisms that trigger this decline may offer a template for understanding
the phenomena of aging (Hayflick, 1996; Weinert & Timiras, 2003).
Another hormone that has been receiving attention is dehydroepiandrosterone
(DHEA). This hormone, secreted by the adrenal glands, diminishes over the lifetime
of an individual.
Administration of this hormone to laboratory mice showed it increased longevity,
bolstered immunity, and made the animals appear younger. These mice also ate less,
so there is some question whether DHEA-fed mice exhibit the effect of calorie restriction
(Cupp, 1997; Guardiola- Lemaitre, 1997; Hayflick, 1996; Hayflick, 2004).
Melatonin is a hormone being investigated for its role as a biologic clock. Melatonin is
produced by the pineal gland, the function of which was a mystery until recently.
Melatonin has been found to be a regulator of biologic rhythms and a powerful
antioxidant that may enhance immune function. The level of melatonin production in the
body declines dramatically from just after puberty until old age.
The belief that melatonin has a role in aging comes not only from its effect on the
immune system and its antioxidant capability but also from studies on rodents that
demonstrated an increased life span when melatonin was administered. These studies
also found that rodents fed supplementary melatonin restricted their calorie intake. More
research needs to be performed regarding the safety and efficacy of melatonin.
However, in the United States melatonin can already be sold as a dietary supplement,
so there is little financial incentive for conducting research. In Europe melatonin is
considered a neurohormone, so there would be more financial gain to determining its
role in the aging process. At this time, no individual should take melatonin without his or
her primary health care provider’s knowledge (Guardiola-Lemaitre, 1997; Hayflick, 1996).
Metabolic Theory of Aging/Caloric Restriction
This theory proposes that all organisms have a finite metabolic lifetime and that
organisms with a higher metabolic rate have a shorter life span. Evidence for this theory
comes from research
showing that certain fish, when the water temperature is lowered, live longer than their
warm water counterparts. Extensive experimentation on the effects of caloric
restriction on rodents has demonstrated that caloric restriction increases the life span
and delays the onset of age- dependent diseases (Hayflick, 1996; Schneider, 1992).
Additional Readings
AGING THEORY:
ATTEMPTS TO DESCRIBE THE PROCESSES OF AGING BY EXAMINING VARIOUS CHANGES IN CELL
STRUCTURES OR FUNCTION
The programmed theory
Proposes that every person has a "biologic clock" that starts ticking at the time of conception. Each
person has a genetic "program" specifying an unknown but predetermined number of cell divisions. The
person experiences predictable changes such as atrophy of the thymus, menopause, skin changes,
graying of hair
Run out of program theory-Proposes that every person has a limited amount of genetic material that will
run out over time
The gene theory
Proposes the existence of one or more harmful genes that activate over time, resulting in the typical
changes seen with aging and limiting the life span of the individual
The molecular theories
Propose that aging is controlled by genetic materials that are encoded to predetermine both growth and
decline
The error theory
Proposes that errors in RIBONUCLEIC ACID protein synthesis cause errors to occur in cells in the body,
resulting in a progressive decline in biologic function
The somatic mutation theory
Proposes that aging results from DNA damage causes chromosomal abnormalities that lead to disease or
loss of function later in life
The cellular theories
Propose that aging is a process that occurs because of cell damage. when enough cells are damaged,
overall functioning of the body is decreased
The free radical theory
Provides one explanation for cell damage. Free radicals are unstable molecules produced by the body
during the normal processes of respiration and metabolism or following exposure to radiation and
pollution. Free radicals are suspected to cause damage to the cells, DNA and immune system, cause
arthritis, circulatory diseases, diabetes, atherosclerosis.
one free radical called-lipofuscin, has been identified to cause a buildup of fatty pigment
granules that cause age spots in older adults
individuals who support the FREE RADICAL THEORY
Propose that the number of free radicals can be reduced by the use of antioxidants such as vitamins,
carotenoids, selenium, and phytochemicals
A variation of the free radical theory is the CROSSLINK or CONNECTIVE TISSUE THEORY
Proposes that cell molecules from DNA and connective tissue interact with free radicals to cause bonds
that decrease the ability of tissue to replace itself, this results in skin changes from aging, this results in
skin changes from aging, such as dryness, wrinkles, loss of elasticity
CLINKER THEORY
Combines the somatic mutation, free radical, and cross link theories to suggest that chemicals produced
by metabolism accumulate in normal cells and cause damage to body organs such as the muscles, heart,
nerves, and brain
Wear and tear theory
Presumes that the body is similiar to a machine, which loses function when its parts wear out. cells are
damaged by internal or external stressors. Good health practices will reduce the rate of wear and tear,
results in longer and better body function
Neuroendocrine theory
Focuses on the complicated chemical interactions set off by the hypothalamus of the brain. with age the
hypothalamus appears to be less precise in function, decreased muscle mass, increased body fat,
changes in reproductive function. Hormone supplements may be designed to delay or control age
related changes
Immunologic theory
Proposes that aging is a function of changes in the immune system, it weakens over time, making aging
more susceptible to disease, also increase in autoimmune diseases and allergies seen with aging is
caused by changes in the immune system
Aging to caloric intake
Animal research has shown that a point of metabolic efficiency can be achieved by consuming a
high nutrient but low calorie diet, it is hypothesized that this diet, when combined with regular
exercise, may extend optimal health and life span
Psychosocial theories of aging
Do not explain why the physical changes of aging occur, rather they attempt to explain why older adults
have different responses to the aging process. most prominent psychosocial theories of aging are?
disengagement theory
activity theory
life course
developmental theories
variety of other personality theories
most prominent psychosocial theories of aging are?
disengagement theory
activity theory
life course
developmental theories
variety of other personality theories
disengagement theory (highly controversial)explains why the aging person separates from the
mainstream of society, older people are separated, excluded or disengaged because...
they dont benefit the society as a whole, they withdraw as they age, so it is mutally
beneficial. Critics believe that it attempts to justify ageism, oversimplifies the
psychosocial adjustment to aging, fails to address the diversity and complexity of older
adults
Activity theory
Proposes that activity is needed for sucessful aging, physical and mental activities helps maintain
function as we age. Will promote self esteem improve satisfaction with life, "busy work" and casual
interaction WERE NOT SHOWN to improve self esteem of older adults
Life course theories
Theories best known to NURSING. they trace personality and personal adjustment throughout a person's
life. Many of these theories are specific in identifying life oriented tasks for the aging person
Most common life course theories
Eriksons theory
8 stages of developmental tasks that an individual must confront throughout the lifespan
1. trust vs mistrust 2. autonomy vs shame & doubt
3. initiative vs guilt 4. industry vs inferiority
5. identity vs identify confusion 6. intimacy vs isolation
7. generativity vs stagnation 8. integrity vs despair
The last of Erikson's theories are the domain of late adulthood-failure to achieve success in tasks
earlier in life can cause problems later in life. late adulthood is when people review their lives
and determine whether they have been negative or positive overall, most positive outcomes of
this life review are wisdom, understanding and acceptance, NEGATIVE are doubt, gloom and
despair
Havighursts theory- details the process of aging and defines specific tasks for late life,
including
1. adjusting to decreased physical strength & health 2. adjusting to retirement & less income 3.
adjusting to loss of spouse 4. establishing a relationship with one's age group 5. adapting to
social roles in a flexible way 6. establishing satisfactory living arrangements
Newmans theory-identifies the tasks of aging as 1. coping with the physical changes of aging
2. redirecting energy to new activities and roles 3. accepting one's own life 4. developing a
point of view about death
Jung's theory- continues throughout life by a process of searching, questioning, and
setting goals. Ongoing search for the "TRUE SELF" they go through a reevaluation stage at
midlife, "MIDLIFE CRISIS" which can lead to a radical career or lifestyle change likely to shift
from an OUTWARD focus with concerns about success and social position to a more
INWARD focus,
successful aging includes acceptance and valuing of the self without regard to the view of others
Nursing can- help individuals achieve the longest, healthiest lives possible by promoting good
health maintenance practices and a healthy environment
 Psychosocial theories help explain the variety of behaviors seen in the aging population
understanding all of these theories can help nurses recognize problems and provide nursing
interventions that will help aging individuals successfully meet the developmental tasks of aging
 alternative and complementary therapies to slow or reverse aging
Antioxidant therapy
1. proposed as a method of neutralizing free radicals, which may contribute to aging and disease
processes
2. includes a number of vitamins and minerals, including A, B6, B12, C, E, beta carotene, folic acid,
selenium
3. generally safe when consumed as fruits and vegetables as part of the overall diet 2. high doses of
some antioxidants may cause more harm than benefits
4. no proof that antioxidants are effective
5. discuss with physician before starting use
Hormone therapy-1. proposed to replace a reduction in hormones, which naturally decrease with
aging
2. includes hormones such as DHEA, estrogen, testosterone, melatonin, human growth hormone
3. little evidence to support claims made by advocates
4. may actually cause more harm than benefits
5. usually requires prescription or supervised medical administration
Supplements1. proposed to replace or enhance nutritional status; often marketed as "Natural"
remedies
2. include substances such as ginseng, coral calcium, echinacea, and other herbal preparations
3. no proof of effectiveness
4. not regulated by FDA, so there is no control regarding amount of active ingredients
5. high risk for interaction with RX meds, doctor must be notified if these products are used
Calorie-restricted diet
1. proposes that calorie reduction can extend life; based on studies in rats, mice, fish, and worms;
not proven in humans
2. severe calorie restriction can result in inadequate consumption of necessary nutrients
3. studies show that severely underweight persons have a higher risk for some diseases and even
death
4. dietary changes should be discussed with a doctor or nutritionist to ensure that adequate
nutrition is maintained
 Many biologic, environmental, and psychosocial theories have been proposed to explain why we age
 These theories remain theories because the exact processes that cause the changes seen with aging
are not completely understood.
 To determine which theory or combination of theories is most accurate further research and studies
are needed.
 To date, hormone replacement therapy appears to have more risks than benefits
 Maximum life expectancy for human-110 year
LEARNING CONTENT
Gerontologic Assessment
The geriatric assessment is a multidimensional, multidisciplinary assessment designed to
evaluate an older person's functional ability, physical health, cognition and mental
health, and socio- environmental circumstances. It is usually initiated when the physician
identifies a potential problem
Specific elements of physical health that are evaluated include nutrition, vision, hearing,
fecal and urinary continence, and balance. The geriatric assessment aids in the
diagnosis of medical conditions; development of treatment and follow-up plans;
coordination of management of care; and evaluation of long-term care needs and optimal
placement. The geriatric assessment differs from a standard medical evaluation by
including nonmedical domains; by emphasizing functional capacity and quality of life;
and, often, by incorporating a multidisciplinary team. It usually yields a more complete
and relevant list of medical problems, functional problems, and psychosocial issues.
Well-validated tools and survey instruments for evaluating activities of daily living, hearing,
fecal and urinary continence, balance, and cognition are an important part of the geriatric
assessment. Because of the demands of a busy clinical practice, most geriatric
assessments tend to be less comprehensive and more problem-directed. When multiple
concerns are presented, the use of a “rolling” assessment over several visits should be
considered.
A complete assessment is usually initiated when the physician detects a potential
problem such as confusion, falls, immobility, or incontinence. However, older persons
often do not present in a typical manner, and atypical responses to illness are common. A
patient presenting with confusion may not have a neurologic problem, but rather an
infection. Social and psychological factors may also mask classic disease presentations.
For example, although 30 percent of adults older than 85 years have dementia, many
physicians miss the diagnosis.5,6 Thus, a more structured approach to assessment can
be helpful.
The geriatric assessment is a multidimensional, multidisciplinary assessment designed to
evaluate an older person's functional ability, physical health, cognition and mental
health, and socio- environmental circumstances. It includes an extensive review of
prescription and over-the- counter drugs, vitamins, and herbal products, as well as a
review of immunization status. This assessment aids in the diagnosis of medical
conditions; development of treatment and follow-up plans; coordination of management
of care; and evaluation of long-term care needs and optimal placement.
The geriatric assessment differs from a typical medical evaluation by including
nonmedical domains; by emphasizing functional capacity and quality of life; and, often,
by incorporating a multidisciplinary team including a physician, nutritionist, social worker,
and physical and occupational therapists. This type of assessment often yields a more
complete and relevant list of medical problems, functional problems, and psychosocial
issues.7
Because of the demands of a busy clinical practice, most geriatric assessments tend to
be less comprehensive and more problem-directed. For older patients with many
concerns, the use of a “rolling” assessment over several visits should be considered. The
rolling assessment targets at least one domain for screening during each office visit.
Patient-driven assessment instruments are also popular. Having patients complete
questionnaires and perform specific tasks not only saves time, but also provides useful
insight into their motivation and cognitive ability.
Comprehensive Geriatric Assessment
Geriatric conditions such as functional impairment and dementia are common and frequently
unrecognized or inadequately addressed in older adults. Identifying geriatric conditions by
performing a geriatric assessment can help clinicians manage these conditions and prevent or
delay their complications.
"Geriatric syndrome" is a term that is often used to refer to common health conditions in older
adults that do not fit into distinct organ-based disease categories and often have multifactorial
causes. The list includes conditions such as cognitive impairment, delirium, incontinence,
malnutrition, falls, gait disorders, pressure ulcers, sleep disorders, sensory deficits, fatigue, and
dizziness. These conditions are common in older adults, and they may have a major impact on
quality of life and disability. Geriatric syndromes can best be identified by a geriatric
assessment.
Although the geriatric assessment is a diagnostic process, the term is often used to include both
evaluation and management. Geriatric assessment is sometimes used to refer to evaluation by
the individual clinician (usually a primary care clinician or a geriatrician) and at other times is
used to refer to a more intensive multidisciplinary program, also known as a comprehensive
geriatric assessment (CGA).
Comprehensive geriatric assessment (CGA) is defined as a multidisciplinary diagnostic and
treatment process that identifies medical, psychosocial, and functional limitations of a frail older
person in order to develop a coordinated plan to maximize overall health with aging. The health
care of an older adult extends beyond the traditional medical management of illness. It requires
evaluation of multiple issues, including physical, cognitive, affective, social, financial,
environmental, and spiritual components that influence an older adult's health. CGA is based on
the premise that a systematic evaluation of frail, older persons by a team of health professionals
may identify a variety of treatable health problems and lead to better health outcomes.
CGA programs are usually initiated through a referral by the primary care clinician or by a
clinician caring for a patient in the hospital setting. The content of the assessment varies
depending on different settings of care (eg, home, clinic, hospital, nursing home). CGA is not
available in all settings, due to issues related to the time required for evaluation, need for
coordination of multidisciplinary specialties, and lack of reimbursement for some components
(eg, outpatient social work, pharmacy, and nutrition).
The best evidence for comprehensive geriatric assessment (CGA) is based on identifying
appropriate patients (ie, excluding patients who are either too well or are too sick to derive
benefit). No criteria have been validated to readily identify patients who are likely to benefit from
CGA. Specific criteria used by CGA programs to identify patients include:
● Age
● Medical comorbidities such as heart failure or cancer
● Psychosocial disorders such as depression or isolation
● Specific geriatric conditions such as dementia, falls, or functional disability
● Previous or predicted high health care utilization
● Consideration of change in living situation (eg, from independent living to assisted living, nursing home,
or in-home caregivers)
One outpatient approach would be to refer patients for CGA who are found to have problems in
multiple areas during geriatric assessment screens. Major illnesses (eg, those requiring
hospitalization or increased home resources to manage medical and functional needs) should
also prompt referral for CGA, particularly for functional status, fall risk, cognitive problems, and
mood disorders.
An inpatient approach would be to refer older patients admitted for a specific medical or surgical
reason (eg, fractures, failure to thrive, recurrent pneumonia, pressure sores). Another approach
would be to have all patients above a certain age (eg, 85 years) or above a threshold on
instruments predicting hospital readmission receive preliminary screening to determine whether
a full multidisciplinary evaluation is needed.
Most outpatient CGA programs exclude patients who are unlikely to benefit because of terminal
illness, severe dementia, complete functional dependence, and inevitable nursing home
placement. However, some of these patients (eg, those with severe dementia) may benefit by
increasing the capabilities of caregivers when the assessment is accompanied by ongoing care
management Exclusionary criteria have also included identifying older persons who are "too
healthy" to benefit, such as those who are completely functional without any medical
comorbidities.
The range of health care professionals working in the assessment team varies based on the
services provided by individual comprehensive geriatric assessment (CGA) programs. In many
settings, the CGA process relies on a core team consisting of a clinician, nurse, and social
worker and, when appropriate, draws upon an extended team of physical and occupational
therapists, dietitians, pharmacists, psychiatrists, psychologists, dentists, audiologists, podiatrists,
and opticians. Although these professionals are usually on-staff in the hospital setting and are
also available in the community, access to and reimbursement for these services have limited
the availability of CGA programs. Increasingly, CGA programs are moving towards a "virtual
team" concept in which members are included as needed, assessments are conducted at
different locations on different days, and team communication is completed via telephone or
electronically, often through the electronic health record.
Traditionally, the various components of the evaluation are completed by different members of
the team, with considerable variability in the assessments. The medical assessment of older
persons may be conducted by a physician (usually a geriatrician), nurse practitioner, or
physician assistant. The core team (geriatrician, nurse, social worker) may conduct only brief
initial assessments or screens for some
dimensions. These may be subsequently augmented with more in-depth evaluations by
additional professionals. As an example, a dietitian may be needed to assess dietary intake and
provide recommendations on optimizing nutrition, or an audiologist may need to conduct a more
extensive assessment of hearing loss and evaluate an older person for a hearing aid.
CONDUCTING THE
ASSESSMENT
Framework — Conceptually, comprehensive geriatric assessment (CGA) involves several
processes of care that are shared over several providers in the assessment team. The overall
care rendered by CGA teams can be divided into six steps:
● Data-gathering
● Discussion among the team, increasingly including the patient and/or caregiver as a member of the
team
● Development, with the patient and/or caregiver, of a treatment plan
● Implementation of the treatment plan
● Monitoring response to the treatment plan
● Revising the treatment plan
Each of these steps is essential if the process is to be successful at achieving maximal health and
functional benefits.
Several different models for CGA have been implemented in various health care settings. Some
CGA programs rely on post-discharge assessment due to the decrease in length of hospital
stay. Furthermore, while most of the early CGA programs focused on restorative or rehabilitative
goals (tertiary prevention), many newer programs are aimed at primary and secondary
prevention
Assessment tools — Although the amount of potentially important information may seem
overwhelming, formal assessment tools and shortcuts can reduce this burden on the clinician
performing the initial CGA. A pre-visit questionnaire sent to the patient or caregiver prior to the
initial assessment can be a timesaving method to gather a large amount of information. These
questionnaires can also be completed through secure portals of electronic health records.
These questionnaires can be used to gather information about general history (eg, past medical
history, medications, social history, review of systems), as well as gather information specific to
CGA, such as:
● Ability to perform functional tasks and need for assistance
● Fall history
● Urinary and/or fecal incontinence
● Pain
● Sources of social support, particularly family or friends
● Depressive symptoms
● Vision or hearing difficulties
● Whether the patient has specified a durable power of attorney for health care
Office staff can be trained to administer screening instruments to both save time and help the
clinician to hone in on specific disabilities that need more detailed evaluation.
MAJOR
COMPONENTS
Core components of comprehensive geriatric assessment (CGA) that should be evaluated
during the assessment process are as follows:
● Functional capacity
● Fall risk
● Cognition
● Mood
● Polypharmacy
● Social support
● Financial concerns
● Goals of care
● Advance care preferences
Additional components may also include evaluation of the following:
● Nutrition/weight change
● Urinary continence
● Sexual function
● Vision/hearing
● Dentition
● Living situation
● Spirituality
This section will focus on the core components of CGA. Although other aspects of the geriatric
assessment are usually addressed during the CGA (eg, vision/hearing, nutrition), these
components are discussed separately.
Functional status — Functional status refers to the ability to perform activities necessary or
desirable in daily life. Functional status is directly influenced by health conditions, particularly in
the context of an elder's environment and social support network. Changes in functional status
(eg, not being able to bathe independently) should prompt further diagnostic evaluation and
intervention. Measurement of functional status can be valuable in monitoring response to
treatment and can provide prognostic information that assists in long-term care planning.
Activities of daily living — An older adult's functional status can be assessed at three levels:
basic activities of daily living (BADLs), instrumental or intermediate activities of daily living
(IADLs), and advanced activities of daily living (AADLs).
BADLs refer to self-care tasks which include:
● Bathing
● Dressing
● Toileting
● Maintaining continence
● Grooming
● Feeding
● Transferring
IADLs refer to the ability to maintain an independent household which include:
● Shopping for groceries
● Driving or using public transportation
● Using the telephone
● Performing housework
● Doing home repair
● Preparing meals
● Doing laundry
● Taking medications
● Handling finances
Other possible IADLs that reflect the increased reliance on technology, which have not been
validated, include:
● Ability to use a cellphone or smartphone
● Ability to use the internet
● Ability to keep a schedule of activities
AADLs vary considerably from individual to individual. These advanced activities include the ability
to fulfill societal, community, and family roles as well as participate in recreational or occupational
tasks.
Gait speed — In addition to measures of ADLs, gait speed alone predicts functional decline and
early mortality in older adults. Assessing gait speed in clinical practice may identify patients who
need further evaluation, such as those at increased risk of falls. Additionally, assessing gait
speed may help identify frail patients who might not benefit from treatment of chronic
asymptomatic diseases such as hypertension. For example, elevated blood pressure in
individuals age 65 and older was associated with increased mortality only in individuals with a
walking speed ≥0.8 meters/second (measured over 6 meters or 20 feet)
Falls/imbalance — Approximately one-third of community-dwelling persons age 65 years and
one-half of those over 80 years of age fall each year. Patients who have fallen or have a gait or
balance problem are at higher risk of having a subsequent fall and losing independence. An
assessment of fall risk should be integrated into the history and physical examination of all
geriatric patients.
Cognition — The incidence of dementia increases with age, particularly among those over 85
years, yet many patients with cognitive impairment remain undiagnosed. The value of making
an early diagnosis includes the possibility of uncovering treatable conditions. The evaluation of
cognitive function can include a thorough history and brief cognition screens. If these raise
suspicion for cognitive impairment, additional evaluation is indicated, which may include detailed
mental status examination, neuropsychologic testing, tests to evaluate medical conditions that
may contribute to cognitive impairment (eg, B12, thyroid-stimulating hormone [TSH]),
depression assessment, and/or radiographic imaging (computed tomography [CT] or magnetic
resonance imaging [MRI]).
Mood disorders — Depressive illness in the elder population is a serious health concern
leading to unnecessary suffering, impaired functional status, increased mortality, and excessive
use of health care resources.
Late-life depression remains underdiagnosed and inadequately treated. Depression in elder
adults may present atypically and may be difficult to assess in patients with cognitive
impairment. A two-question screener is easily administered and likely to identify patients at risk
if both questions are answered affirmatively. The questions are:
● "During the past month, have you been bothered by feeling down, depressed, or hopeless?"
● "During the past month, have you been bothered by little interest or pleasure in doing things?"
This two-question screen is sensitive but not specific Thus, a positive screen should be
supplemented with seven additional questions to complete the Patient Health Questionnaire-9
(PHQ-9) The PHQ-9 has increasingly been used to detect and monitor depression symptoms
among elder adults The PHQ-9 provides a reliable and valid measure of depression severity.
A variety of other screens for depression are available and each has its advantages and
disadvantages.
Polypharmacy — Older persons are often prescribed multiple medications by different health
care providers, putting them at increased risk for drug-drug interactions and adverse drug events.
The clinician should review the patient's medications at each visit. The best method of detecting
potential problems with polypharmacy is to have patients bring in all of his/her medications
(prescription and nonprescription) in their bottles. Discrepancies between what is documented in
the medical record and what the patient is actually taking must be reconciled. As health systems
have moved towards electronic health records and e-prescribing, the potential to detect potential
medication errors and interactions has increased substantially. Although this can improve safety,
record-generated messages about unimportant or rare interactions may lead to "reminder
fatigue."
Elder patients should also be asked about alternative medical therapy. As an example, herb use
can be assessed by questioning: "What prescription medications, over the counter medicines,
vitamins, herbs, or supplements do you use?".)
Social and financial support — The existence of a strong social support network in an elder's
life can frequently be the determining factor of whether the patient can remain at home or needs
placement in an institution. A brief screen of social support includes taking a social history and
determining who would be available to the elder to help if he or she becomes ill. Early
identification of problems with social support can help planning and timely development of
resource referrals. For patients with functional impairment, the clinician should ascertain who
the person has available to help with activities of daily living
Caregivers should be screened periodically for symptoms of depression or caregiver burnout
and, if present, referred for additional caregiving services, counseling, or support groups. Elder
mistreatment should be considered in any geriatric assessment, particularly if the patient
presents with contusions, burns, bite marks, genital or rectal trauma, pressure ulcers, or
malnutrition with no clinical explanation. The financial situation of a functionally impaired older
adult is important to assess. Elders may qualify for state or local benefits, depending upon their
income. Older patients occasionally have other benefits such as long-term care insurance or
veteran's benefits that can help in paying for caregivers or prevent the need for
institutionalization.
Goals of care — Most older adult patients who are appropriate for CGA have limited potential
to return to fully healthy and independent lives. Hence, choices must be made about what
outcomes are most important for them and their families. Goals of care often differ from advance
care preferences that focus on future states of health that would be acceptable, determination of
surrogates to make decisions, and medical treatments. Generally, advance directives are
framed in the context of future deterioration in health status
By contrast, a patient’s goals of care are often positive (eg, regaining a previous health status, attending
a future family event). Frequently, social (eg, living at home, maintaining social activities) and
functional
(eg, completing ADLs without help) goals assume priority over health-related goals (eg, survival).
They are also patient-centric and individualized. For example, regaining independent ambulation
after a hip fracture may be a goal for one patient whereas another might be content with use of a
walker. Both short- term and longer-range goals should be considered and progress towards
meeting these goals should be monitored, including reassessment if goals are not met within a
specified time period. One approach that has been used in CGA is Goal Attainment Scaling.
However, clinicians can establish and monitor patient goals more informally by determining
these in the course of clinical care and asking about them during subsequent visits.
Advance care preferences — Clinicians should begin discussions with all patients about
preferences for specific treatments while the patient still has the cognitive capacity to make
these decisions. These discussions should include preparation for in-the-moment decisionmaking [27], which includes choosing an appropriate decision-maker (ie, appointing a durable
power of attorney, also known as a health care proxy, to serve as a surrogate in the event of
personal incapacity), clarifying and articulating patients’ values over time, and thinking about
factors other than the patient's stated preferences in surrogate decision-making. As an example,
patients who want to extend their life as long as possible might be asked about what should be
done if the patient’s health status changes and doctors recommend against further treatment, or if it
becomes too hard for loved ones to keep them at home. Advance directives help guide therapy
if a patient is unable to speak for him or herself and are vital to caring optimally for the geriatric
population
Tools have been developed to help providers elicit and document care preferences and promote
shared end-of-life decision-making among seriously ill patients including the Physician Orders
for Life Sustaining Treatment (POLST)
EFFICACY
Most meta-analyses have found that comprehensive geriatric assessment (CGA) leads to
improved detection and documentation of geriatric problems]. However, the ability of CGA to
improve outcomes (eg, decreased hospitalization, nursing home admission, and mortality)
depends on specific CGA models and the settings where they have been implemented.
Several meta-analyses of randomized trials have evaluated five models of CGA
● Home geriatric assessment
● Acute geriatric care units
● Post-hospital discharge
● Outpatient consultation
● Inpatient consultation
Home geriatric assessment and acute geriatric care units have been shown to be consistently
beneficial for several health outcomes. By contrast, the data are conflicting for post-hospital
discharge, outpatient geriatric consultation, and inpatient geriatric consultation services.
New applications of comprehensive geriatric assessment — Principles and processes of
CGA are increasingly being applied to subspecialties and subspecialty conditions, including
cancer patients undergoing chemotherapy infective endocarditis considerations of surgery or
transcatheter aortic valve replacement (TAVR) for patients with aortic stenosis vascular surgery
and postoperative mortality
SUMMARY AND
RECOMMENDATIONS
● Comprehensive geriatric assessment (CGA) is defined as a multidisciplinary diagnostic and treatment
process that identifies medical, psychosocial, and functional capabilities of an older adult in
order to develop a coordinated plan to maximize overall health with aging. CGA is based on the
premise that a systematic evaluation of frail older persons by a team of health professionals
may identify a variety of treatable health problems and lead to better health outcomes
● No standard criteria are available to readily identify patients who are likely to benefit from CGA.
Specific criteria used by CGA programs to identify patients include:
•Age
•Medical comorbidities (eg, hip fracture, transcatheter aortic valve replacement [TAVR])
•Psychosocial problems
•Specific geriatric conditions such as functional disability
•Previous or predicted high health care utilization
•Consideration of change in living situation (eg, from independent living to assisted living, nursing home,
or in-home caregivers
● Community-dwelling older patients with functional disability, increased fall risk, cognitive
decline, depression, or those at high risk for high health care utilization are appropriate
candidates for CGA. Follow-up support is needed to ensure implementation of the findings
of the CGA
● Inpatients admitted with fractures, failure to thrive, recurrent pneumonia, and pressure sores may
benefit from hospitalization on a geriatric unit that provides CGA. Patients age ≥85 years who
have geriatric conditions such as dementia or immobility should also be considered for care
on these units.
● The assessment team usually consists of a clinician, nurse, and social worker. Depending on
the setting and patient's condition, the team may also include physical and occupational
therapists, dietitians, pharmacists, psychiatrists, psychologists, dentists, audiologists,
podiatrists, and opticians.
● There are several components of CGA that should be evaluated, including
•Functional capacity
•Fall risk
•Cognition
•Mood
•Polypharmacy
•Nutrition/weight change
•Urinary incontinence
•Sexual function
•Vision/hearing
•Dentition
•Living situation
•Social support
•Financial concerns
•Goals of care
•Spirituality
•Advance care preferences
● Home geriatric assessment has been shown to be effective in improving functional status, preventing
institutionalization, and reducing mortality. CGA performed in the hospital, especially in
dedicated units, also has benefit on survival. Most programs of hospital discharge management
with in-home follow-up have reduced readmission rates. However, studies of CGA have found
inconsistent benefit for outpatient and inpatient geriatric consultation, except in the context of
specific conditions (eg, hip fracture).
LEARNING CONTENT
Health assessment of older adults can be done on several levels, ranging from simple
screenings to complex, in-depth evaluations. To perform assessments accurately, nurses and
other health care providers who interact with older adults must possess the necessary
knowledge and skill to perform the assessments correctly. They must know how to use
diagnostic tools and equipment safely. Furthermore, they must be knowledgeable and sensitive
to the unique needs of older adults.
In-depth health assessments are time-consuming and must be performed by skilled
professionals. Nurses perform health assessments of older adults in the community, in clinics,
and in institutional settings. Health assessment includes the collection of all of the important
health-related data using a variety of techniques.
Data includes all of the information gathered about a person. This information is used to formulate
nursing diagnoses and to plan patient care; therefore, accurate and complete data should be
collected. Data can be either objective or subjective.
Objective data include information that can be gathered using the senses of vision, hearing,
touch, and smell. Objective information is collected by means of direct observation, physical
examination, and laboratory or diagnostic tests. Because objective data are concrete by nature,
all trained observers should report similar findings about a person or that person’s behavior at any
given point in time.
Subjective data are information gathered from the older person’s point of view. Fear, anxiety,
frustration, and pain are examples of subjective information. Subjective data are best described in
the individual’s own words, such as “I’m so afraid of what is going to happen to me here” or “It hurts so
much I could die!”
INTERVIEWING OLDER ADULTS. Interviews conducted during admission to a facility are likely
to be planned and conducted in a formal manner. Other interviews may be spontaneous,
informal, and based on an immediate need recognized by the nurse. Before beginning an
interview with an older adult, plan ways to establish and maintain a climate that promotes
comfort and develops trust. This includes preparing the physical setting, establishing rapport,
and structuring the flow of the interview. During this planning phase, take into consideration the
unique needs of the older person.
PREPARING THE PHYSICAL SETTING. Choose the interview environment carefully. Minimize
distractions: Noise from televisions, radios, and public address systems should not be loud
enough to distract the older
adult or interfere with his or her ability to distinguish words and understand questions. Lighting
should be diffused, because bright lights or glare may make it difficult to see clearly. Furniture
should be comfortable. Privacy is very important. Conduct the interview in a room where there is
little chance of interruption. If such a place is not available, the patient’s room may provide sufficient
privacy; the curtains should be drawn and the door closed. Ensure the room is comfortably warm
and free from drafts. Because many older adults experience urinary frequency or urgency, it is
advisable to either assist them to the bathroom or inform them that a bathroom is available
nearby should they require it.
ESTABLISHING RAPPORT. It is most appropriate to begin the interview by greeting the older
adult and introducing yourself. During this first contact, it is best to address the person using his
or her formal name (e.g., “Mr. Smith” or “Mrs. Adams”). Appropriate use of names indicates respect
and helps build rapport. Use of the individual’s first name only without the person’s consent is
presumptuous and overly familiar. This familiarity may be resented by the older person even if it is
not verbalized. If there is any doubt about someone’s preference, it is best to ask the person how
he or she wishes to be addressed.
OBTAINING THE HEALTH HISTORY. Before starting a physical assessment, the nurse will use
interviewing techniques to obtain a health history. This history starts with basic identifying data
followed by a history of past health concerns and then a review of current health issues. Some
older adults are able to provide information easily, whereas others may be poor historians. Much
will depend on the cognitive level of the individual and the complexity of his or her particular
medical history. When the older adult is unsure of answers, it is often wise to move on to other
topics and attempt to gather the information from a family member at a later time. In addition, you
may want to obtain information regarding the person’s family and psychosocial status. The health
history data will help the nurse form an overall impression of the older person and help determine
those areas most in need of further exploration and assessment
PHYSICAL ASSESSMENT OF OLDER ADULTS. Once the history is obtained, you are ready to
proceed to the physical assessment. During this assessment, objective information is obtained
to accompany the subjective information offered by the older adult. Objective information further
helps determine the person’s abilities and limitations. It may verify the subjective information
given by the older adult; it may also reveal problems that were previously unrecognized. When
assessing older adults, pay close attention not only to obvious physiologic changes, but also to
changes in mood or behavior that may signal a change in condition. Seemingly small pieces of
information can be important to the total assessment. Older adults have different physiologic
responses than do younger persons. For example, a temperature change of just a few tenths of a
degree may indicate the onset of an infection in an older person, rather than rising above the
100°F reading, which is expected in younger people. Other changes can be equally meaningful
and may be missed or ignored if nurses are not especially careful.
SENSORY ASSESSMENT OF OLDER ADULTS. Simple assessments of vision and hearing
ability are based on empiric data (the way the individual responds to visual or auditory clues).
Observe whether the person is able to read or do close work that requires good central vision or
whether he or she participates in television viewing or other sight-related activities. If the older
person uses eyeglasses, assess the ability to see with and without them. Talking with older
adults can reveal the presence or absence of hearing. Indicators of hearing problems include
difficulty in gaining attention, the frequent need to repeat information, or mistakes in
understanding directions. If applicable, perform the hearing-aid assessment when the older
person is wearing the aid but only after checking it for proper functioning. Special assessment
by a vision or audiometric specialist can reveal more precise information regarding vision and
hearing. PSYCHOSOCIAL ASSESSMENT OF OLDER ADULTS A psychological assessment
is performed to
determine whether the older person is alert and aware of the surroundings or suffers from some
level of confusion, delirium, or dementia.
ASSESSMENT OF CONDITION CHANGE IN OLDER ADULTS. Health status changes in older
adults are often subtle and different from younger adults. Early recognition and treatment of
change in status can prevent serious harm for older adults. This is true in at-home care, in
extended-care facilities, and in the hospital setting. A number of evidence-based instruments
have been developed to help the nurse perform a systematic and comprehensive assessment.
FULMER SPICES. SPICES is an acronym for six common “marker conditions” in older adults
that can identify potential health-related problems. This screening tool can be used routinely
during assessments to identify and/or prevent potential problems and to monitor health status
over time (Fulmer, 2012). Identification of one or more of these problems indicates an increased
risk for functional decline and even death. More in-depth assessments are required when a
problem is identified. This assessment is not a total list of significant problems; for example, pain
and elimination are not included, but the assessment does address the most common and
relevant issues. Additional information and tools designed to help the nurse perform effective
assessments of older adults are available online.
FANCAPES When the nurse suspects that an actual emergency or serious problem is present
or might be developing, in
these situations, deep, focused assessments are more appropriate and necessary. The
following mnemonic can be used to organize this assessment: F—fluid A—aeration
(oxygenation) N—nutrition C— cognition, communication A—activity/abilities P—pain E—
elimination S—skin/socialization Once the status assessment is completed, the nurse must still
decide the most appropriate action.
SYSTEMATIC GERIATRIC ASSESSMENT. The nurses’ assessment of older adults requires
the ability to actively listen as well as to use all other senses to gather data. This often
draws upon experience and expertise gained over time in working with the older
population. An inexperienced nurse is often frustrated by the length of time needed for
the geriatric assessment, and the inability of some older adults to keep focused on
providing the necessary information.
For example, consider an 86-year-old woman with mild cognitive impairment (MCI) who
presents to a medical unit with a small bowel obstruction (SBO). This assessment will
probably take a long time, and it may be necessary to consistently encourage the client
to focus on answering the questions. In an effort not to be rude, the nurse may allow the
patient to continue providing unessential information. Written forms and checklists can
help the nurse to keep the client more focused.
The physical assessment of the older adult demands that the health care team include
special considerations that are unique to the geriatric population. Environmental
adaptations are usually necessary to compensate for the older adult’s physiological and
psychological changes of aging. Modifications to the physical environment start with a
room that is comfortably warm to the client and not exposing the client any more than is
necessary. Changes in subcutaneous tissue, fat, and muscle among older adults provide
less protection against temperature extremes; consequently, older adults are more
sensitive to temperature changes.
Amella (2004) states that the “key to providing appropriate treatment to older adults is going
beyond the usual history and physical parameters to examine mental, functional,
nutritional and social- support status”. The room should be adequately bright but with
indirect lighting to compensate for diminished visual acuity. Fluorescent lighting and
window glare should be avoided. Straight-backed chairs with arms that are cushioned for
comfort should be utilized, making sure that the client’s height allows for ease in rising
from them. The examination table should be low and well-padded to protect from
discomfort. The head of the examination table should rise up, as some older adults may
have difficulty lying flat for any amount of time. There should be adequate space in the
examination room to accommodate mobility aides. The room should be free from
distraction and background noises. It is important to take into consideration the energy
level of the older adult and conduct the physical examination at the individual’s own pace.
Minimize skin exposure of the older adult to prevent chilling. These factors may indicate
the need to conduct the examination over more than one session. It is helpful to organize
the examination to reduce the changes in body positions and conserve the client’s energy.
Because the older adult may become disoriented in a different environment and/or have
sensory impairments, various techniques need to be utilized to assess each individual
adequately. At the start of the examination, it may be worthwhile for the examiner to
spend some extra time establishing a nonthreatening relationship. As a sign of respect,
older adults should be addressed by their last name and title. The first name should be
used only if invited to do so. The nurse must allow the older client enough time to
respond to questions. The nurse should speak facing the client and use commonly
accepted wording. Allowing hearing-impaired clients to see the nurse’s entire face and
body so that they may detect lip reading and body language may be helpful. If the client
wears hearing aids, make sure they are on and working properly. For clients with visual
deficits, nurses must make sure that the clients have their glasses on and plan to use
visual cues as needed. Family members can provide important information, but the
examiner needs to focus on the client. Older adult health assessment, which requires a
substantial amount of nursing time and resources, often conflicts with the hurried and
short-staffed health care environment in which older adults receive care (Hogstel, 2001).
Geriatric interdisciplinary teams (GITs)—made up of physicians, nurses, physical
therapists, occupational therapists, recreational therapists, social workers, psychologists,
and nursing assistants—make assessment more efficient by assigning components of
the assessment to the most qualified member of the team. After completing assigned
components of the assessment, GIT members gather together to plan care for the older
adult, which is generally more comprehensive and effective than when individual team
members work alone (Fulmer et al., 2005).Geriatric interdisciplinary team care has been
effective in managing the complex syndromes experienced by chronically ill and frail
older adults with
multiple co-morbidities, because such care requires skills that are not possessed by any
one professional. Positive outcomes of geriatric teams have been revealed in multiple
studies.
REMINISCENCE AND LIFE REVIEW. The term reminiscence has been in use for many
years as a manner in which to help older adults experience memories of earlier times. It
was originally defined as thinking about or relating past experiences, especially those
personally significant (McMahon & Rhudick, 1961). The concepts of reminiscence and
life review are often used interchangeably but are similar in their ability to help older
adults recall memories from an earlier period of time in order to experience emotions
associated with these memories, or reach resolution regarding past events. Haight
(2005) suggests that one method of reminiscence or life review that may be helpful
during the health assessment is the oral history or narrative therapy in which the client is
asked to tell the story about a particular problem or reason for seeking health care. In the
process of storytelling, new insights are gained by both the client and health care
provider, and the storytelling becomes therapeutic. Reminiscence may also be
accomplished by asking an older adult about their memories of certain events, smells, or
photographs. In order to stimulate reminiscence, older adults may be asked to write
about or tape record memories of past events, develop a family tree, or write to old
friends. Tornstam’s theory of gerotranscendence, suggests that reminiscence
contributes to the reconstruction of identity and the understanding of reality as a process
of reorganization and reconstruction.
PHYSICAL ASSESSMENT.A head-to-toe physical examination should follow the health
history and a complete review of systems. The physical assessment begins with the
evaluation of vital signs, including temperature, pulse, respiration, height, and weight.
Because of the potential for orthostatic hypertension, blood pressure should be evaluated
in three different positions: sitting, immediate standing, and one-minute standing,
especially if the older adult is currently taking antihypertensive medications. Decreases in
blood pressure of more than 20 mm Hg, are indicative of orthostatic hypertension and
require further evaluation. Respirations should fall within the normal range of 12 to 18
breaths per minute with regular heart rates averaging between 60 and 100 beats per
minutes. The temperature response to infection among older adults varies greatly; some
Assessing Older Adults 113 older adults respond to infections with elevated
temperatures and others with aggressive infections show no febrile response. Gathering
information on clients’ weight and height is also essential to develop a baseline for further
comparison of nutritional and hydration levels, as well as bone loss. Body mass indexes
(BMI) less than 25 are considered ideal and should be measured when possible.
Following the gathering of vital signs, a head-to-toe physical assessment is necessary. The
client’s skin should be evaluated for any unusual findings, including cherry hemangiomas,
liver spots, skin tags, keratoses, and precancerous and cancerous lesions. The presence
of herpes zoster and decubitus ulcers, which occur commonly in older adulthood, should
be evaluated. Hair growth and nails should be assessed for uniformity, with diminished
hair growth and fungal infections of the nails requiring further evaluation. Evaluation of
the head and neck for the presence of lesions or trauma should occur next, including the
evaluation of the sclera for whiteness and a notation of the arcussenilis, if present.
Evaluation for cataracts and macular degeneration should also be conducted, as these
conditions occur
commonly in older adulthood. Visual acuity declines as people age, so evaluation of
vision and proper referral to an ophthalmologist for follow-up of abnormal findings of the
eye should occur. Tympanic membrane and the light reflex in the ear should be
identified, and an evaluation of hearing should be conducted. The nose should be
palpated for tenderness and signs and symptoms of infection. The mouth and teeth
should also be evaluated for deviations from normal, and referrals should be made to a
dentist for further management of mouth and tooth disorders. The thyroid gland should
be palpated for enlargement and nodules. The evaluation of the heart and lungs begins
with the evaluation of the carotid arteries and jugular beings in the neck. The carotid
arteries should be symmetrical, nonbounding, and absent of bruits and adventitious
sounds. The jugular veins should not be distended. The heart should be inspected and
auscultated beginning at the apex. The first two heart sounds should be auscultated and
any adventitious sounds, murmurs, rhythms, and pulsations should be noted. The lungs
should be inspected and palpated for tactile fremitus and equal expansion. The lung
fields should be percussed for areas of hyper-resonance or dullness. Lung sounds
should be evaluated in all fields and adventitious sounds noted. Inspection and palpation
of the musculoskeletal system should begin at the temporomandibular joint and proceed
inferiorly to the feet. Each joint, bone, and muscle group should be evaluated for
abnormalities, tenderness, bilateral equality, strength, and range of motion. The
abdomen should be inspected for abnormal scars, pulsations, or distention, and bowel
sounds should be auscultated in all four quadrants. Older women should also be
examined for breast masses and gynecological abnormalities, and older men should
undergo an annual examination for prostate enlargement or malignancies. An important
part of the physical exam is the evaluation of laboratory tests. The proper use of these
laboratory tests in evaluating older adults requires both knowledge of the normal ranges
for age and the nurses’ awareness of the clients’ health and medication history. Among
older adults, altered lab values often put them at risk for the development of disease. For
example, an increase in glucose as part of the normal aging process likely plays a role in
the high incidence of Type 2 diabetes among older adults. Moreover, a decrease in
serum calcium plays a role in the higher risk of older adults for osteoporosis.
Consequently evaluation of appropriate laboratory tests should be conducted as part of
the health assessment among older adults. In addition to lab values, it is important for
nurses to understand the normal physiological changes associated with aging and
compare them with abnormal change detected in organ systems. Misidentifying an
agerelated change as disease- induced may lead to therapeutic attempts to reverse
normal aging. This may result in iatrogenic harm to the older adult. For example,
consider a 72-year-old man visiting a health care clinic. The admitting nurse takes a
routine fasting glucose level and finds it slightly elevated. If the nurse did not understand
that a slight increase in fasting glucose commonly occurs with aging, this client would be
sent for more expensive testing and possibly costly and painful treatment for Type 2
diabetes. Conversely, incorrectly assuming it is an age-related change may lead to
therapeutic neglect of potentially or possibly treatable conditions. For example, one of the
common myths of aging is that all older adults are cognitively impaired. While becoming
cognitively impaired as one age is of large concern to the aging population and their
families, many older adults live well into their 10th decade with high cognitive and
intellectual functioning as they were in their twenties and thirties. Memory losses are
common in older adulthood, but the development of dementia is
not a normal change of aging. Instead, it is a pathological disease process used to
describe over 60 pathological cognitive disorders. Altered presentation of illness is
another challenge in the physical assessment of older adults. Diseases may present with
atypical clinical signs and symptoms that can be confusing. Severe, acute illnesses will
often present with nonspecific or vague symptoms. Typical signs may be absent, such as
a cough in an older adult with pneumonia. At other times, disease may present merely as
failure to thrive, changes in mental status, falls, anorexia, or self-neglect. All health care
providers need to be aware of these differences.
A comprehensive geriatric assessment is an interdisciplinary approach to the
evaluation of older adults’ physical, psychological, social, and spiritual functioning. These
types of assessments are generally conducted in teams that include nurses, physicians,
social workers, and therapists that assess and plan care addressing the multiple needs
of older adults. As discussed earlier, when multiple disciplines collaborate in care
planning, this ensures the best communication and the most comprehensive and
effective plan for older adults. A comprehensive geriatric assessment should always
involve family members and caregivers, as appropriate. Frequently, family members and
direct caregivers can contribute information that might be overlooked if they are not
included in the assessment process. Involving family members in the planning of care for
older adults not only gives the nurse the opportunity to assess the status of their
relationship with the older adult client, but it also allows the nurse the opportunity to
involve the caregivers in planning, education, and decision making. It is important to
mention the potential mistakes health care providers can make in regards to
family/caregiver involvement. One common mistake is to ignore the client and focus
primarily on the caregiver to answer all the questions, receive information, and make
decisions. Nurses may make ageist assumptions, underestimate clients’ abilities, and not allow
them to be active participants in their own care. On the other hand, nurses may receive
inaccurate information if they do not involve the family or caregivers when needed.
Individuals with cognitive impairment may still be quite socially skilled and may make the
health care provider think they are cognitively intact and able to give accurate
information. Also, some older adults may overestimate their abilities out of fear that the
health care provider might uncover certain information that could result in loss of
independence or institutionalization. There are two critical components of geriatric
assessment that must be discussed here: function and cognition. When older adults
experience the onset of disease, changes in function and cognition are often the first
symptoms. A savvy clinician may detect these early symptoms, conduct.
LEARNING CONTENT
Health is determined by behavior in many ways. The most well-known types of health-related
behavior – smoking, alcohol use and exercise/eating habits – are only a selection of the
behavioral aspects of health. A healthy lifestyle can be promoted by various means, ranging from
educational and counseling programs to financial incentives for a healthy lifestyle. These
interventions are further offered in various ways, ranging from general legislative measures to
programmatic interventions. Health promotion interventions can take different forms, from small
projects to large national programs. They can be funded and organized by donations from
individuals or NGOs, or through taxation by national governments. In short, health promotion is
typified by heterogeneity in every conceivable aspect.
Health promotion is meant for the entire population. If a specific group within a population is
singled out as the recipient of health promotion interventions, it is because of a valid reason,
such as epidemiological concerns or preferences in social policy (e.g. measures targeting
vulnerable or disadvantaged groups). This explains the focus of many health promotion
activities on youth, citizens of big cities, workers in certain industries or occupations.
Focus of many health promotion activities on youth, citizens of big cities, workers in certain
industries or
occupations.
The elderly have long been neglected as the addressee of health promotion activities. The need
to promote health among older people was first highlighted in the 1990s . Before that, it was
commonly assumed that the older generations were not a good target for health promotion as it
was thought it was too late to change their lifestyle. Requiring the elderly to radically change
their diet and start exercising was perceived as disturbing to their peace and wellness.
Therefore, it was only after 2001, when WHO experts unanimously stated the importance of a
healthy lifestyle at every stage of life, health promotion measures targeted to the elderly started
to grow in numbers. Evidence has shown that exercising, quitting smoking and limiting alcohol
consumption, participating in learning activities and integrating in the community can help to
inhibit the development of many diseases and prevent the loss of functional capacity, thus
improving quality of life and lengthening life expectancy. Most of these health promotion
activities among the elderly focus on the relatively younger seniors. Within the group of those
aged 85+, the emphasis is more on appropriate medical attention from physicians and care
givers rather than on their health behavior.
Health promotion targeted to older people differs significantly from that addressing younger
generations. This partly stems from the fact that the health of older people is generally less than
perfect. Seniors are more likely to be suffering from chronic conditions and multi-morbidities,
and their functional capacity is frequently limited. This implies that the health promotion
programs for the elderly have to account for these limitations in health and daily activities, and
require more involvement of professional health promoters and more individualized approaches.
The prevalence of certain lifestyle issues is also higher among the elderly. Elderly people are –
for example – more likely to suffer from loneliness and social isolation. Also, because of their
relatively shorter remaining life expectancy, the focus is more on health promotion activities that
yield immediate effects. That is why health promotion programs for older people in European
countries are mainly implemented at the local level by primary health care providers and nurses,
and by NGOs, self-governing public authorities and voluntary organizations. These programs
sometimes lack sustainable sources of funding.
Health promotion strategies for the elderly generally have three basic aims: maintaining and
increasing functional capacity, maintaining or improving self-care, and stimulating one’s social
network. The idea behind these strategies is to contribute to a longer, independent and selfsufficient quality of life. It should be noticed that there is an additional objective to be considered:
the significance of social participation and integration of the elderly to maintain quality of life at
old age. There is ample evidence to support the claim that social bonds and social activities, e. g.
continuing professional work, learning activities later on, participation in cultural events and
social work and maintaining a social network are essential for healthy aging. For this, health
promotion focuses on the inclusion of seniors into the social activities in the community. These
measures are not always formal and do not always need direct external financing but they
frequently require an appropriate social and transport infrastructure.
A man's life is normally divided into five main stages namely infancy, childhood, adolescence,
adulthood and old age. In each of these stages an individual has to find himself in different
situations and face different problems. The old age is not without problems. In old age physical
strength deteriorates, mental stability diminishes; money power becomes bleak coupled with
negligence from the younger generation.
Elderly is an individual over 65 years old who have a functional impairments Elderly care, or
simply eldercare, is the fulfilment of the special needs and requirements that are unique to
senior citizens. This broad term encompasses such services as assisted living, adult day care,
long term care, nursing homes (often referred to as residential care), hospice care, and home
care
Aging is not merely the passage of time. It is the manifestation of biological events that occur
over a span of time. • It is important to recognize that people age differently. The aging body does
change. Some systems slow down, while others lose their "fine tuning." • As a general rule, slight,
gradual changes are common, and most of these are not problems to the person who
experiences them. Sudden and dramatic changes might indicate serious health problems.
Biological theories:
At present, the biological basis of ageing is unknown. Most scientists agree that substantial
variability exists in the rates of ageing across different species, and that this to a large extent is
genetically based. In model organisms and laboratory settings, researchers have been able to
demonstrate that selected alterations in specific genes can extend lifespan (quite substantially in
nematodes, less so in fruit flies, and less again in mice) Even in the relatively simple and shortlived organisms, the mechanism of ageing remain to be elucidated.
Non-biological theories
1. Disengagement Theory
This is the idea that separation of older people from active roles in society is normal and
appropriate, and benefits both society and older individuals.
There are research data suggesting that the elderly who do become detached from
society as those were initially reclusive individuals, and such disengagement is not
purely a response to ageing.
2. Activity Theory
In contrast to disengagement theory, this theory implies that the more active elderly
people are, the more likely they are to be satisfied with life. The view that elderly adults
should maintain well- being by keeping active has had a considerable history • However,
this theory may be just as inappropriate as disengagement for some people as the current
paradigm on the psychology of ageing is that both disengagement theory and activity
theory may be optimal for certain people in old age, depending on both circumstances
and personality traits of the individual concerned
3. Selectivity Theory
Mediates between Activity and Disengagement Theory, which suggests that it may
benefit older people to become more active in some aspects of their lives, more
disengaged in others.
4. Continuity Theory
The view that in ageing people are inclined to maintain, as much as they can, the same
habits, personalities, and styles of life that they have developed in earlier years.
Continuity theory is Atchley's theory that individuals, in later life, make adaptations to
enable them to gain a sense of continuity between the past and the present, and the
theory implies that this sense of continuity helps to contribute to well-being in later life
HEALTH PROMOTION IN ELDERLY
Health maintenance and health promotion
• Exercise and activity:
• Nutrition and diet:
• Stress management:
• Self care and responsibility:
• Community services:
Exercise and activity: • Balance between exercise and activity is most important for elder person as it
decrease risk of many health issues. Exercise also improve nutrition and reduce stress. In
addition it decrease risk of hypertension or maintain blood pressure in hypertensive elder person.
It increase oxygen saturation and increase lungs capacity. Elder person should do exercise on
regular basis as tolerated. They should do light exercise like walking and slow running.
Nutrition and diet: • Maintenance of nutritional status in elder persons are also important because with
increase in age digestive capacity diminish. The nutrition should be well balance that has higher
amount of calcium, iron and other essential nutrients. Following things should be considered by
elder person regarding diet • Meal time should be kept simple and calm. • Food is cut in to small
pieces to prevent choking. • Liquids food may be easier to swallow. • Temperature of the food should be
checked to prevent
burns. • Encourage for good mouth care. • Avoid alcohol. • Review all prescription and over the counter
medication with patient and evaluate nutritional status.
• Stress management: • By the time individuals reach 60-70 yrs. of age, they have experienced
numerous losses, and stress has become a lifelong process. In addition hormonal changes also
cause stress among elderly. So stress management is essential for them. Long term stress
cause hypertension, stroke and heart disease. Explain older person about stress management
techniques like yoga, exercise meditation etc.
• Self care and responsibility: • Older person also need to learn about self care and responsibility. So
following instruction can be given to them about self care: • Monitor blood pressure and blood
sugar regularly. • Diet control and balance diet. • Stop alcohol consumption and smoking • Get
vision and hearing checked periodically. • Advice to take proper rest and sleep. • Exercise regularly.
• Community services: • Many community supports exist that help the older person maintain
independence. Informal sources of help, such as family, friends, the mail carrier, church
members, and neighbors, can all keep an informal watch. Area Agencies on Aging perform
many community services, including telephone reassurance, friendly visitors, home repair
services, and home- delivered meals. Homemaker and chore services can be obtained at an
hourly rate through these agencies or through local community nursing services.
• Most commonly used services are as follow: • Group counseling centre • Adult day centre •
Rehabilitation centre • Hospice care • Ambulatory care centre
LEARNING CONTENT
Today, people are living longer than ever before, and as the baby boomers age, the number of
older adults is expected to increase exponentially over the coming decades. Combined, these 2
demographic shifts will lead to enormous challenges for society. They will require us to identify
strategies to allow older adults to live independently for as a long as possible; provide health
care and education for older adults who are self-managing multiple chronic illnesses; ensure
that older adults in long-term care settings receive high- quality care; and support family
members and friends who are caring for an older loved one with one or more disabilities.
Nineteenth century medical pioneer Florence Nightingale defined health as the absence of
disease and illness.
Over time, that definition has evolved. For example, the World Health Organization (WHO)
currently defines health as “a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity.”
WHO also defines health promotion as “the process of enabling people to increase their control over
and improve their health.” Both definitions have implications for those working in the
healthcare profession, especially nurses who play a vital role in the practice of health
promotion and preventive care.
A more focused area of nursing known as public health primarily focuses on bringing health
promotion and preventive care to large, at-risk populations. The role of a public health nurse
includes collaborating and partnering with communities and populations to address obstacles to
health.
While public health nurses have been credited with critical improvements in health for
vulnerable populations, all nurses should be aware of the critical role that health promotion
and preventive care play when it comes to the well-being of their patients.
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Management Health Promotion
Through the practice of health promotion, nurses provide patients the information they need to
manage and ultimately improve their health. A nurse’s work environment makes it easy to take
advantage of a routine interaction with a patient and use it as an opportunity to educate.
For example, a nurse can educate new parents at their baby’s wellness visit on their child’s upcoming
vaccines. Or a nurse can use the time treating a patient’s diabetes-related foot ulcer to review tips
and tricks regarding how to best control blood sugar levels. Equipping patients with accurate
information, while also advocating for a healthy lifestyle, can help them gain better control of
their health.
It can also have a big effect on healthcare costs. With an industry-wide focus on cost reduction
and staffing shortages in healthcare facilities, effective health promotion can reduce the
frequency with which an individual must seek out treatment.
The Journal of Professional Nursing acknowledged health promotion has become a popular
buzzword, and concluded health promotion is aimed at mitigating the determinants of health
through community action, action by health professionals and group action.
Health promotion focuses on holistically addressing health issues, as opposed to lecturing
individuals concerning habits that are negatively affecting their health. Often, individuals may be
aware of health practices they should make habits (exercise) or stop (smoking). However, health
promotion is more about ensuring access to the resources needed to improve healthy behavior.
On a much higher level, nurses might also be able to advocate for societal changes to reduce
resource scarcity that may impede health promotion.
There are a number of conceptual models that attempt to organize the main elements that
affect health. Some models list five elements, some six. In general, though, there are six
main dimensions of health that comprise most models:
Biophysical: Physical risk factors for disease, including age, genetics and any anatomical
abnormalities
Psychological and emotional: Coping mechanisms, ability to adapt level of cognition, and
inclination and drive to adapt healthy behaviors
Behavioral: Lifestyle choices that impact health, whether beneficial, like an exercise
regimen or detrimental, like a smoking habit
Social-cultural: Individual-level attributes like socioeconomic status and support systems,
as well as broader social influences including beliefs, practices and values influenced by
culture
Physical environment: Anything in a patient’s environment that may impact health, including water and
air quality
Health systems: A patient’s ability to access healthcare systems, both because of the individual’s
willingness to do so and his or her ability to pay for and access appropriate care
As technology continues to develop, educating patients through the practice of health
promotion will become easier. Nurses no longer must be face-to-face with their patients in to
share information.
Medical technology improvements such as telehealth have expanded patient access to
nurses, which allows patients to contact a healthcare professional via phone or a video chat.
Preventive Care
As healthcare costs continue to rise, preventive care has become a more valued service. For
example, most insurance companies now fully cover any services that fall under this category.
The practice of preventive care focuses on helping patients maintain their health instead of
merely treating diseases and illnesses as they arise.
Preventive care goes hand in hand with health promotion and consists of three levels:
Primary prevention, which involves developing strategies to prevent risk factors and the
development of unhealthy behaviors
Identifying people who currently possess risk factors for various diseases such as
heart disease Managing illness and disease that has already occurred to avoid further
deterioration
At its core, preventive care centers on the patient, which is a focus of nurses’ clinical education. The
daily interactions nurses have with patients are opportunities to educate them and monitor for
the development of certain risk factors.
When practiced regularly, preventive care can save lives. According to the Centers for Disease
Control and Prevention, chronic illnesses cause seven out of 10 American deaths annually, and
almost half of all American adults suffer from some type of chronic disease – many of which can
be prevented.
When the Affordable Care Act went into effect, the National Prevention Strategy was created to
provide better health and wellness to America. The four strategic goals of the strategy include:
Building health and safe community environments
Making more quality preventive services available in both clinical and community
settings Educate people so they can make healthy choices
Eliminate health disparities
To help achieve these strategic goals, seven evidence-based recommendations were identified
that are projected as most likely to reduce the leading causes of preventable deaths and major
illnesses. These recommendations include:
Tobacco-free living
Preventing drug and alcohol
abuse Healthy eating
Active lifestyles
Living free from injury and
violence Reproductive and
sexual health Mental and
emotional wellness
Some of the main challenges nurses face when it comes to providing preventive care are
language, literacy, religious beliefs, mental challenges and/or physical limitations. For example,
the CDC reports that racial and ethnic minorities report higher rates of chronic disease, including
obesity, cancer, diabetes and AIDS.
However, approaching patient education with varied methods that take cultural differences into
account can help combat these barriers. Understanding and adapting the approach to patient
education is critical not just for nurses, but all healthcare professionals.
Item 1
The elderly share similar self care and human needs with all among other human beings.
Correct answer: True
Score: 0 out of 2 No
Item 2
Geriatric nursing addresses the developmental, psychological, socio-economic, cultural
and spiritual needs of an aging individual.
Correct answer: False
Score: 0 out of 2 No
Item 3
One of the purposes of geriatric nursing is to provide our clients a peaceful death
Correct answer: True
Score: 0 out of 2 No
Item 4
Aging is one of major risk factors for many acute inflammatory diseases, e.g., diabetes,
CVD, atherosclerosis, dementia, cancer, and others including COPD, and can impact
differently on organs and tissues affecting their functions and structure
Correct answer: False
Score: 0 out of 2 No
Item 5
Since aging is a reversible and fundamental part of life, providing nursing care for elderly
clients should not only be isolated to one field but is best given through a collaborative
effort which includes their family, community, and other health care team.
Correct answer: False
Score: 2 out of 2 Yes
Item 6
Geriatrics—from the Latin geras, meaning “old age,” geriatrics is the branch of medicine
that deals with the diseases and problems of old age.
Correct answer: False
Score: 2 out of 2 Yes
Item 7
Gerontology, or geriatric, nursing is a non specialty focused on the care of older adults
Correct answer: False
Score: 2 out of 2 Yes
Item 8
Elderly patients also have rights that should be respected.
Correct answer: True
Score: 2 out of 2 Yes
Item 9
There is only one greatest factor that causes aging and that is the physiological self.
Correct answer: False
Score: 2 out of 2 Yes
Item 10
. A generalist nurse may practice in a wide variety of environments, including the home
and community. The challenge of the gerontologic nurse generalist is to identify older
clients’ strengths and assist them with maximizing their independence
Correct answer: True
Score: 2 out of 2