Lesson 11: Core Elements of Evidence – Based Gerontological Nursing Practice

DEVELOPMENT OF GERONTOLOGICAL NURSING

 Nurses, long interested in the care of older adults, seem to have assumed more
responsibility than other professional disciplines for this segment of the population.
 In 1904, the American Journal of Nursing printed the first nursing article on the care of the
aged, presenting many principles that continue to guide gerontological nursing practice
today (Bishop, 1904): “You must not treat a young child as you would a grown person, nor
must you treat an old person as you would one in the prime of life.”
 Interestingly, this same journal featured an article entitled “The Old Nurse,” which
emphasized the value of the aging nurse’s years of experience (DeWitt, 1904).
 After the Federal Old Age Insurance Law (better known as Social Security) was passed in
1935, many older persons had an alternative to almshouses and could independently
purchase room and board.
 Because many of the homes that offered these services for older persons were operated
by women who called themselves nurses, such residences later became known as nursing
homes.
 For many years, care of older adults was an unpopular branch of nursing practice.
 Geriatric nurses—those nurses who care for ill older adults—were thought to be somewhat
inferior in capabilities, neither good enough for acute care settings nor ready to retire.
 Geriatric facilities may have further discouraged many competent nurses from working in
these settings by paying low salaries.
 Little existed to counter the negativism in educational programs, where experiences with
older persons were inadequate in both quantity and quality and attention focused on the
sick rather than the well, who were more representative of the older population.
 Although nurses were among the few professionals involved with older adults, gerontology
was missing from most nursing curriculums until recently.
 Frustration over the lack of value placed on geriatric nursing led to an appeal to the
American Nurses Association (ANA) for assistance in promoting the status of this area of
practice.
 After years of study, in 1961, the ANA recommended that a specialty group for geriatric
nurses be formed. In 1962, the ANA’s Conference Group on Geriatric Nursing Practice
held its first national meeting.
 This group became the Division of Geriatric Nursing in 1966, gaining full recognition as a
nursing specialty.
 An important contribution by this group was the development in 1969 of Standards for
Geriatric Nursing Practice, first published in 1970.
 Certification of nurses for excellence in geriatric nursing practice followed, with the first 74
nurses achieving this recognition in 1975.
 The birth of the Journal of Gerontological Nursing, the first professional journal to meet
the specific needs and interests of gerontological nurses, also occurred in 1975.
 Through the 1970s, nurses became increasingly aware of their role in promoting a healthy
aging experience for all individuals and ensuring the wellness of older adults.
 As a result, they expressed interest in changing the name of the specialty from geriatric to
gerontological nursing to reflect a broader scope than the care of the ill aged. In 1976, the
Geriatric Nursing Division became the Gerontological Nursing Division.
Landmarks in the Growth of Gerontological Nursing
 1902 First article on care of aged in American Journal of Nursing written by a physician
 1904 First article on care of aged in American Journal of Nursing written by a nurse
 1950 First geriatric nursing text published (Geriatric Nursing, K. Newton)
 1. First master’s thesis on care of aged (Eleanor Pingrey)
2. Geriatrics recognized as an area of specialization in nursing
 1952 First nursing study on care of aged published in Nursing Research
 1961 American Nurses Association (ANA) recommends specialty group for geriatric
nurses
 1962 First national meeting of ANA Conference on Geriatric Nursing Practice
 1966 Formation of Geriatric Nursing Division of ANA
1. First gerontological nursing clinical specialist nursing program (Duke University)
 1968 First nurse makes presentation at International Congress of Gerontology (Laurie
Gunter)
 1969 Development of standards for geriatric nursing practice
 1970 First publication of ANA Standards of Gerontological Nursing Practice
 1973 First offering of ANA Certification in Gerontological Nursing (74 nurses certified)
 1975 First specialty publication for gerontological nurses, Journal of Gerontological
Nursing
1. First nursing conference at International Congress of Gerontology
 1976 ANA changes name from Geriatric Nursing Division to Gerontological Nursing
Division.
1. Publication of ANA Standards of Gerontological Nursing.
2. ANA Certification of Geriatric Nurse Practitioners initiated.
 1980 Geriatric Nursing journal launched by American Journal of Nursing company.
 1981 First International Conference on Gerontological Nursing.
1. ANA Division of Gerontological Nursing develops statement on scope of practice.
 1982 Development of Robert Wood Johnson Teaching Home Nursing Program.
 1983 First university chair in gerontological nursing in the United States (Case Western
Reserve).
 1984 National Gerontological Nursing Association (NGNA) formed.
1. ANA Division of Gerontological Nursing Practice becomes Council on
Gerontological Nursing.
 1986 National Association for Directors of Nursing Administration in Long-Term Care
 (NADONA/LTC) formed.
 1987 ANA published combined Scope and Standards of Gerontological Nursing Practice
 1989 ANA Certification of Gerontological Clinical Specialists first offered.
 1990 Division of Long-Term Care established within ANA Council of Gerontological
Nursing.
 1996 Hartford Gerontological Nursing Initiatives funding launched by John A. Hartford
Foundation.
 2001 ANA publishes revised Standards and Scope of Gerontological Nursing Practice.
 2002 Nurse Competence in Aging initiative to provide gerontological education and
activities within specialty nursing associations.
 2004 American Association of Colleges of Nursing publishes competencies for advanced
practice programs in gerontological nursing.
 2007 American Association for Long-Term Care Nursing formed
 2008 Retooling for an Aging America published by the Institute of Medicine recommending
improved geriatric competencies for health care workers.
 In the past few decades, the specialty of gerontological nursing has experienced profound
growth.
  Whereas only 32 articles on the topic of the nursing care of older adults were listed in the
Cumulative Index to Nursing Literature in 1956, and only twice that number appeared a
decade later, the number of articles published has grown considerably since.
 Gerontological nursing texts grew from a few in the 1960s to dozens currently, and the
quantity and quality of this literature have been rising as well.
 Growing numbers of nursing schools are including gerontological nursing courses in their
undergraduate programs and offering advanced degrees with a major in this area.
 Certification offers a means by which the nurse’s knowledge and competencies are
validated through a professional nursing organization.
 Registered nurses can receive certification as a generalist in gerontological nursing with
a basic nursing degree and 2 years of experience in the specialty or advanced certification
as a clinical nurse specialist in gerontological nursing or gerontological nurse practitioner
with graduate education and additional experience.
 Nursing administration in long-term care, geropsychiatric nursing, geriatric rehabilitation,
and other areas of sub-specialization has evolved; many nursing specialty associations
have developed position papers related to the integration of geriatric nursing into their
unique specialty practice.
 The Hartford Institute for Geriatric Nursing, established in the 1990s, has significantly
contributed to the advancement of the specialty by identifying and developing best
practices and facilitating the implementation of these practices.
 In 2003, the Hartford Institute for Geriatric Nursing collaborated with the American
Academy of Nursing and the American Association of Colleges of Nursing to develop the
Hartford Geriatric Nursing Initiative that has significantly contributed to the growth of
evidence-based practice in the specialty. Gerontological nursing has indeed advanced
rapidly, and all indications are that this growth will continue. Along with the growth of the
specialty, there has been a heightened awareness of the complexity of gerontological
nursing.
 Older people exhibit great diversity in terms of health status, cultural background, lifestyle,
living arrangement, socioeconomic status, and other variables.
 Most have chronic conditions that uniquely affect acute illnesses, reactions to treatments,
and quality of life.
 Symptoms of illness can be atypical.
 Multiple health conditions can coexist and muddle the ability to chart the course of a single
disease or identify the underlying cause of symptoms.
 The conditions that older adults experience can cut across many clinical specialties,
thereby challenging gerontological nurses to have a broad knowledge base. The risk of
complications is high.
 Other factors, such as limited finances or social isolation, affect the state of health and
well-being.
Also, the elective status of geriatrics in many medical and nursing schools can limit the
pool of colleagues who are knowledgeable about the unique aspects of caring for older
adults.
CORE ELEMENTS OF GERONTOLOGICAL NURSING PRACTICE
 With the formalization and growth of the gerontological nursing specialty, nurses and
nursing organizations have developed informal and formal guidelines for clinical practice.
 Some of these core elements include evidence-based practice and standards and
principles of gerontological nursing.
 Evidence-Based Practice
 There was a time when nursing care was guided more by trial and error than sound
research and knowledge.
  Fortunately, that has changed, and nursing now follows a systematic approach that uses
existing research for clinical decision making—a process known as evidence-based
practice.
 Testing, evaluating, and using research findings in the nursing care of older adults are of
such importance that it is among the ANA Standards of Professional Gerontological
Nursing Performance.
 Evidence-based practice relies on the synthesis and analysis of available information from
research.
 Among the more popular ways to report this information are the meta-analysis and cost-
analysis.
 Metanalysis is a process of analyzing and compiling the results of published research
studies on a specific topic. This process combines the results of many small studies to
allow more significant conclusions to be made. With cost-analysis reporting, cost-related
data are gathered on outcomes to make comparisons.
 Performance also can be compared with best practices or industry averages through a
process of benchmarking. For instance, the rate of pressure ulcers in one facility may be
compared with another facility that has similar characteristics.
 The data can be used to stimulate improvements.
 Best practices are evidence based and are built on the expertise of the nurse.
Standards
 Professional nursing practice is guided by standards.
 Standards reflect the level and expectations of care that are desired and serve as a model
against which practice can be judged. Thus, standards serve to both guide and evaluate
nursing practice.
 Standards arise from a variety of sources.
 State and federal regulations outline minimum standards of practice for various health
care workers (e.g., nurse practice acts) and agencies (e.g., nursing homes).
 The Joint Commission has developed standards for various clinical settings that strive to
describe the maximum attainable performance levels.
 The ANA Scope and Standards of Practice for Gerontological Nursing are the only
standards developed by and for gerontological nurses.
 Nurses must regularly evaluate their actual practices against all standards governing their
practice areas to ensure their actions reflect the highest quality care possible.
ANA Standards of Practice for Gerontological Nursing
STANDARD 1. ASSESSMENT
 The gerontological nurse collects comprehensive data pertinent to the older adult’s
physical and mental health or situation.
STANDARD 2. DIAGNOSIS
 The gerontological nurse analyzes the assessment data to determine the diagnoses or
issues.
STANDARD 3. OUTCOME IDENTIFICATION
 The gerontological nurse identifies expected outcomes for a plan individualized to the
older adult or situation.
STANDARD 4. PLANNING
 The gerontological nurse develops a plan to attain expected outcomes.
STANDARD 5. IMPLEMENTATION
 The gerontological nurse implements the identified plan.
STANDARD 5A: COORDINATION OF CARE
 The gerontological nurse coordinates care delivery.
STANDARD 5B: HEALTH TEACHING AND HEALTH PROMOTION
 The gerontological registered nurse employs strategies to promote health and a safe
environment.
STANDARD 5C: CONSULTATION
 The gerontological advanced practice registered nurse provides consultation to influence
the identified plan, enhance the abilities of others, and effect change.
STANDARD 5D: PRESCRIPTIVE AUTHORITY AND TREATMENT
 The gerontological advanced practice registered nurse uses prescriptive authority,
procedures, referrals, treatments, and therapies in accordance with state and federal laws
and regulations.
STANDARD 6. EVALUATION
 The gerontological nurse evaluates the older adult’s progress toward attainment of
expected outcomes.
Competencies
 Nurses who work with older adults need to have competencies specific to gerontological
nursing to promote the highest possible quality of care to older adults.
 Although they can vary based on educational preparation, level of practice, and practice
setting, some basic competencies of the gerontological nurse include the ability to:
1. differentiate normal from abnormal findings in the older adult
2. assess the older adult’s physical, emotional, mental, social, and spiritual status
and function
3. engage the older adult in all aspects of care to the maximum extent possible
4. provide information and education on a level and in a language appropriate for the
individual
5. individualize care planning and implementation of the plan
6. identify and reduce risks
7. empower the older adult to exercise maximum decision making
8. identify and respect preferences arising from the older adult’s culture, language,
race, gender, sexual preference, lifestyle, experiences, and roles
9. assist the older adult in evaluating, deciding, locating, and transitioning to
environments that fulfill living and care needs
10. advocate for and protect the rights of the older person facilitate discussion of and
honor advance directives
 To maintain and improve competencies, nurses need to stay abreast of new research,
resources, and best practices. This is a personal responsibility of the professional nurse.
Principles
 Scientific data regarding theories, life adjustments, normal aging, and pathophysiology of
aging are combined with selected information from psychology, sociology, biology, and
other physical and social sciences to develop nursing principles.
 Nursing principles are those proven facts or widely accepted theories that guide nursing
actions. Professional nurses are responsible for using these principles as the foundation
for nursing practice and ensuring through educational and managerial means that other
caregivers use a sound knowledge base.
 In addition to the basic principles that direct the delivery of care to persons in general,
specific and unique principles guide care for individuals of certain age groups or those
who possess particular health problems.
Principles of Gerontological Nursing Practice
1. Aging is a natural process common to all living organisms.
2. Various factors influence the aging process.
 3. Unique data and knowledge are used in applying the nursing process to the older
population.
4. Older adults share similar self-care and human needs with all other human beings.
5. Gerontological nursing strives to help older adults achieve wholeness by reaching
optimum levels of physical, psychological, social, and spiritual health.
1. Aging: A Natural Process
 Every living organism begins aging from the time of conception. The process of maturing
or aging.
 The process of maturing or aging helps the individual achieve the level of cellular, organ,
and system function necessary for the accomplishment of life tasks. Constantly and
continuously, every cell of every organism ages.
 Despite the normality and naturalness of this experience, many people approach aging as
though it were a pathologic experience. For example, commonly heard comments
associate aging with:
1. “looking gray and wrinkled”
2. “losing one’s intellectual function”
3. “becoming sick and frail”
4. “obtaining little satisfaction from life”
5. “returning to child-like behavior”
6. “being useless”
 These are hardly valid descriptions of the outcomes of aging for most people. Aging is not
a crippling disease; even with limitations that could be imposed by pathologies of late life,
opportunities for usefulness, fulfillment, and joy are readily present.
 A realistic understanding of the aging process can promote a positive attitude toward old
age.
2. Factors Influencing the Aging Process
 Heredity, nutrition, health status, life experiences, environment, activity, and stress
produce unique effects in everyone.
 Among the variety of factors either known or hypothesized to affect the usual pattern of
aging, inherited factors are believed by some researchers to determine the rate of aging.
 Malnourishment can hasten the ill effects of the aging process, as can exposure to
environmental toxins, diseases, and stress.
 In contrast, mental, physical, and social activity can reduce the rate and degree of
declining function with age.
 Every person ages in an individualized manner, although some general characteristics are
evident among most people in a given age category.
 Just as one would not assume that all 30-year-old people are identical but would evaluate,
approach, and communicate with each person in an individualized manner, nurses must
recognize that no two persons 60, 70, or 80 years of age are alike.
Nurses must understand the multitude of factors that influence the aging process and
recognize the unique outcomes for each individual.
3. The Nursing Process Framework
 Scientific data related to normal aging and the unique psychological, biological, social,
and spiritual characteristics of the older person must be integrated with a general
knowledge of nursing.
 The nursing process provides a systematic approach to the delivery of nursing care and
integrates a wide range of knowledge and skills.
 The scope of nursing includes more than following a medical order or performing an
isolated task; the nursing process involves a holistic approach to individuals and the care
they require.
  The unique physiologic, psychological, social, and spiritual challenges of older adults are
considered in every phase of the nursing process.
4. Common Needs
 Core needs that promote health and optimum quality of life for all patients are:
1. Physiological balance: respiration, circulation, nutrition, hydration, elimination,
movement, rest, comfort, immunity, and risk reduction
2. Connection: familial, relational, societal, cultural, environmental, spiritual, and self
3. Gratification: purpose, pleasure, and dignity
 Through self-care practices, people usually perform activities independently and
voluntarily to meet these life requirements.
 When an unusual circumstance interferes with an individual’s ability to meet these
demands, nursing intervention could be warranted.
5. Optimal Health and Wholeness
 One can view aging as the process of realizing one’s humanness, wholeness, and unique
identity in an everchanging world.
 In late life, people achieve a sense of personhood that allows them to demonstrate
individuality and move toward self-actualization.
 By doing so, they can experience harmony with their inner and external environment,
realize their self-worth, enjoy full and deep social relationships, achieve a
sense of purpose and develop the many facets of their being.
 Gerontological nurses play an important role in promoting health and helping people
achieve wholeness.
 Within the framework of the self-care theory, nursing actions toward this goal are:
1. Strengthening the individual’s self-care capacity
2. Eliminating or minimizing self-care limitations
3. Providing direct services by acting for, doing for, or assisting the individual when
demands cannot be met independently
 The thread woven throughout the above nursing actions is the promotion of maximum
independence.
 Although it may be more time consuming and difficult, allowing older persons to do as
much for themselves as possible produces many positive outcomes for their
biopsychosocial health.
HOLISTIC GERONTOLOGICAL CARE
 Holism refers to the integration of the biologic, psychological, social, and spiritual
dimensions of an individual in which the synergy creates a sum that is greater than its
parts; within this framework, healing the whole person is the goal of nursing (Dossey &
Keegan, 2012).
 Holistic gerontological care incorporates knowledge and skills from a variety of disciplines
to address the physical, mental, social, and spiritual health of individuals.
 Holistic gerontological care is concerned with:
1. Facilitating growth toward wholeness
2. Promoting recovery and learning from an illness
3. Maximizing quality of life when one possesses an incurable illness or disability
4. Providing peace, comfort, and dignity as death is approached
 In holistic care, the goal is not to treat diseases but to serve the needs of the total person
through the healing of the body, mind, and spirit.
 Gerontological nurses help older individuals achieve a sense of wholeness by guiding
them in understanding and finding meaning and purpose in life; facilitating harmony of the
mind, body, and spirit; mobilizing their internal and external resources; and promoting self-
care behaviors.
  Health promotion and healing through a balance of the body, mind, and spirit of individuals
are at the core of holistic care and have relevance for gerontological care.
 The impact of age-related changes and the effects of highly prevalent chronic conditions
can easily threaten the well-being of the body, mind, and spirit; therefore, nursing
interventions to reduce such threats are essential.
 Because chronic diseases and the effects of advanced age cannot be eliminated, healing
rather than curative efforts will be most beneficial in gerontological nursing practice.
 Equally significant is assisting older adults toward self-discovery in their final phase of life
so that they find meaning, connectedness with others, and an understanding of their place
in the universe.
HOLISTIC ASSESSMENT OF NEEDS
 There are many evidence-based assessments tools that can be useful to gerontological
nurses.
 One of the most comprehensive listings of these tools can be found at the Hartford Institute
for Geriatric Nursing which includes resources for assessment of activities of daily living
(ADL), hearing, sleep, sexuality, elder mistreatment, dementia, hospital admission risk,
and other topics.
 These tools can be used to supplement the holistic assessment, which has a slightly
different emphasis.
 Holistic assessment identifies patient needs related to health promotion and health
challenges and identifies the older adult’s requisites to meet these needs.
Health Promotion–Related Needs
 The concept of health seems simple, yet it is quite complex. Viewing health as the absence
of disease offers little more clarity than defining cold as the absence of hot and creates an
image that begs for a more positive, broad understanding.
 Regarding older adults, most of whom are living with chronic conditions, this definition
would relegate most of them to the ranks of the unhealthy.
 When asked to describe the factors that contribute to health, most people would be likely
to list the basic life-sustaining needs such as breathing, eating, eliminating, resting, being
active, and protecting oneself from risks.
 These are essential to maintaining the physiological balance that sustains life.
 However, the reality that we can have all of our physiological needs satisfied, yet still not
feel well, demonstrates that physiological balance is but one component of overall health.
 Connection with ourselves, others, a higher power, and nature are important factors
influencing health.
 The fulfillment of physiological needs and a sense of being connected promote well-being
of the body, mind, and spirit that enables us to experience gratification through achieving
purpose, pleasure, and dignity.
 This holistic model demonstrates that optimal health includes those activities that not only
enable us to exist but also help us to realize effective, enriched lives
HEALTH PROMOTION
 The concept of health promotion includes activities to which an individual is committed
and performs proactively to further his or her health and well-being.
 This includes not only preventive and health-protective measures but also actualization of
one ’ s health potential.
 BENEFITS• Even in the very elderly, preventive interventions can limit disease and
disability
 CONSIDERATIONS• selecting appropriate interventions requires consideration of life
expectancy and care goals.
  Patients should perform comprehensive geriatric assessment through which the following
measures were considered
1. Prevention of Disease in the Elderly
2. Prevention of Frailty
3. Prevention of Injuries in the Elderly
4. Prevention of Iatrogenic Complications in the Elderly
5. Prevention of Psychosocial Problems in the Elderly
 Preventive services are typically divided into the categories of primary, secondary, and
tertiary.
 Primary prevention refers to those activities undertaken to prevent the occurrence of a
disease or adverse health condition, including mental health. Health counseling and
immunization are examples of primary prevention.
 Secondary prevention refers to those tasks directed toward detection of a disease or
adverse health condition in an asymptomatic individual who has risk factors but no
detectable disease. Screening tests are examples of secondary prevention. The screening
test must detect the condition at a stage where it is treatable and a positive outcome is
expected after treatment. Mammography for breast cancer screening is an example of
secondary prevention.
 Tertiary prevention refers to management of existing conditions to prevent disability and
minimize complications, striving for optimal level of function and quality of life. Pulmonary
rehabilitation for a chronic obstructive pulmonary disease (COPD) patient is an example
of tertiary prevention.
PREVENTION OF DISEASES
 CATEGORIES
 Preventive interventions are typically categorized as primary, secondary, or tertiary.•
1. Primary prevention refers to prevention of disease (eg, immunizations,
chemoprophylaxis).
2. Secondary prevention is the early detection of disease before it becomes symptomatic
(eg, mammography to detect early breast cancer)
3. Tertiary prevention refers to activities to optimize health once disease is already
detected.
PRIMARY PREVENTION
1. Counselling, lifestyle modification
1. Diet
2. Physical activity
3. Safety and injury prevention
4. Smoking cessation
5. Dental care
2. Immunizations:
1. Influenza: Recommended for all 65 yr or < 65 yr with comorbidities
2. Pneumococcal pneumonia: For all 65 yr or < 65 yr with comorbidities. Revaccinate
high-risk persons every 7-10 yr. Repeat after 5 years if person was vaccinated before
age 65
3. Tetanus: Primary series: 2 doses 0.5 mg IM 1 to 2 months apart, then 1 dose 6 to 12
months later. Booster every 10 years
3. Chemoprophylaxis
1. ASA to prevent MI
2. Calcium (1200mg) and vitamin D (≥800IU) to prevent osteoporosis
3. Omega-3 fatty acids to prevent MI, stroke
4. Multivitamin
SECONDARY PREVENTION
4. SCREENING:
1. Hypertension- Check blood pressure atleast monthly
2. Obesity or malnutrition- measure weight and height at least annually
3. Visual deficits- Routine screening with a Snellen chart annually
4. Hearing impairment- It is recommended to periodically questioning older adults about
their hearing abilities annually
5. Dyslipidemia- Patients with prior MI or angina should be screened for lipid
abnormalities annually
6. Osteoporosis- women aged > 65 and screened at least once by using bone density
measurement, for those at high risk for osteoporotic fractures, it is recommended to
begin screening at younger age group.
7. Cancer screening measures-
1. Breast: mammography/ 2-3 years at age 50-74 and breast self-examination/month
2. Colorectal: Annual FOBT and/or flexible sigmoidoscopy every 3-5 years or
colonoscopy once.
3. Cervical cancer: Pap smear every 1-3 years if woman is sexually active, Cut-off
after 65 with history of normal smears or after 2 normal smears 1 year apart
Recommendations for Primary Prevention
1. Bone mineral density (women)
2. BP screening
3. Diabetes mellitus screening
4. Herpes zoster immunization
5. Influenza immunization
6. Lipid disorder screening
7. Obesity (height and weight)
8. Pneumonia immunization
9. Smoking cessation
10. Tetanus immunization
11. ASA to prevent MI
12. Bone mineral density (men)
13. Calcium (1200mg) and vitamin D (≥800IU) to prevent osteoporosis
14. Measurement of serum C‐reactive protein
15. Omega-3 fatty acids to prevent MI, stroke
16. Multivitamin
Recommendations for Secondary Prevention
1. Abdominal aortic aneurysm ultrasonography
2. Alcohol abuse screening
3. Depression screening
4. FOBT/sigmoidoscopy/colonoscopy
5. Hearing impairment screening
6. Mammography
7. Pap smear
8. Skin examination
9. Cognitive impairment screening
10. Glaucoma screening
11. Inquiry about falls
12. TSH in women
13. Visual impairment screening
REHABILITATIVE AND RESTORATIVE CARE
  Rehabilitative care involves therapies developed by physicians and therapists focused on
returning individuals to their previous level of function.
 Usually the need for rehabilitative services arises after a problem has occurred that
affected function, such as a stroke, fracture, or prolonged state of immobility.
 Skilled rehabilitative care involves services offered by physical, occupational, and speech
therapists, and is eligible for Medicare reimbursement.
 Nurses assist in supporting the rehabilitation plan.
 Many of the effects of aging and disabilities cannot be eliminated or significantly improved.
 Damaged lungs, amputations, diseased heart muscle, partial blindness, presbycusis, and
deformed joints may accompany patients for the remainder of their lives.
 Often, these chronic disabilities receive the least intervention; reimbursement and
aggressive attention are given to restore the function of someone who has suffered a
stroke or fracture, but those who have reached their maximum functional ability from
rehabilitative therapies or who have “no rehabilitation potential” may be overlooked in their
need to maintain function and prevent further decline.
 For these individuals, restorative care is beneficial.
 Restorative care is primarily offered by nursing staff and does not require a medical order.
 It can occur in any setting and includes efforts to help individuals:
1. Maintain their current level of function
2. Improve their functional ability
3. Prevent decline and complications
4. Promote the highest possible quality of life
5. Restorative care enables people to better cope, be maximally independent, have
a sense of well-being, and enjoy a satisfying life. Based on its aims, restorative
care can be appropriate for every older adult.
 Frailty is a particular challenge to older persons that must be considered in rehabilitative
and restorative care. Although definitions of frailty can vary, it usually describes a clinical
state in which the person has poor endurance, fatigue, low activity level, reduced speed
in ambulation, weak grip strength, and increased risk for adverse outcomes (Buckinx et
al., 2015).
 Some of the frailty is the result of sarcopenia— age-related changes to the skeletal muscle
tissues. The following factors can contribute to sarcopenia: immobility and lack of exercise,
poor blood flow to muscles, increased levels of proinflammatory cytokines, increased
production of oxygen free radicals or impaired detoxification, a decline in anabolic
hormones, malnutrition, and reduced neurological drive (Morley, Anker, & von Haehling,
2014).
 There is a vicious cycle in that conditions that contribute to frailty can foster the
development of sarcopenia, and in turn, sarcopenia can lead to the development of
conditions that further threaten function and quality of life.
 Older adults who are frail are at high risk for falls, disability, hospitalization, nursing home
admission, and death.
 Positive health practices and effective management of health conditions, however, are
beneficial in helping older adults to avoid becoming frail.
 Early recognition and intervention for symptoms of frailty (e.g. Correcting weight loss and
assisting with muscle-strengthening exercises) can prevent or delay some of the frailty
older adults experience. For this reason, it is especially useful to review symptoms of frailty
during nursing assessments of older adults.
PRINCIPLES OF REHABILITATIVE NURSING
 The principles guiding gerontological nursing care are of significance in rehabilitative and
restorative care and include the following actions:
 1. increase self-care capacity
2. eliminate or minimize self-care limitations
3. act for or do for when the person is unable to act for himself or herself
 Efforts to increase self-care capacity could include building the patient’s arm muscles to
enable better transfer to and propelling of a wheelchair or teaching the patient how to
inject insulin with the use of only one hand.
 Relieving pain and having a ramp installed for easier wheelchair mobility are efforts that
minimize or eliminate limitations.
 Obtaining a new prescription from the pharmacy and assisting with range-of-motion
exercises are ways in which nurses act for or do for the patient. Whenever nurses act or
do for patients, they need to question what could be done to enable patients to perform
the action independently.
 Patients may always be dependent on others for some activities, but for other actions
patients can assume responsibility with sufficient education, time allocation,
encouragement, and assistive devices.
 The following guidelines should be remembered in rehabilitative and restorative nursing:
1. Know the unique capacities and limitations of the individual. Assess the patient’s self-care
capacity, mental status, level of motivation, and family support.
2. Emphasize function rather than dysfunction and capabilities rather than disabilities.
3. Provide time and flexibility. At times, institutional routines (e.g., having all baths completed
by 9 AM, collecting all food trays 45 minutes after delivery) cause caregivers to do tasks
for patients so that they may be completed efficiently. Staff desires for efficiency and
orderliness should never supersede the patient’s need for independence.
4. Recognize and praise accomplishments. Seemingly minor acts, such as combing hair or
wheeling themselves to the hallway, can be the result of tremendous effort and
determination on the part of disabled persons.
5. Do not equate physical disability with mental disability. Treat disabled persons as mature,
intelligent adults.
6. Prevent complications. Recognize potential risks (e.g., skin breakdown, social isolation,
and depression) and actively prevent them.
7. Demonstrate hope, optimism, and a sense of humor. It is difficult for disabled persons to
feel positive about rehabilitation if their caregivers appear discouraged or disinterested.
8. Keep in mind that rehabilitation is a highly individualized process, requiring a
multidisciplinary team effort for optimal results.
Legal Issues and Concerns
 Nurses in every specialty must be cognizant of the legal aspects of their practice, and
gerontological nurses are no exception. In fact, legal risks can intensify and legal
questions can arise when working in geriatric care settings. Frequently, gerontological
nurses are in highly independent and responsible positions in which they must make
decisions without an abundance of professionals with whom to confer.
 They are also often responsible for supervising unlicensed staff and ultimately are
accountable for the actions of those they supervise.
 In addition, gerontological nurses are likely to face difficult situations in which their advice
or guidance may be requested by patients and families; they may be asked questions
regarding how to protect the assets of the wife of a patient with Alzheimer’s disease, how
to write a will, what can be done to cease life-sustaining measures, and who can give
consent for a patient. Also, the multiple problems faced by older adults, their high
prevalence of frailty, and their lack of familiarity with laws and regulations may make them
easy victims of unscrupulous practices.
  Advocacy is an integral part of gerontological nursing, reinforcing the need for nurses to
be concerned about protecting the rights of their older patients.
 To fully protect themselves, their patients, and their employers, nurses must have
knowledge of basic laws and ensure that their practice falls within legally sound
boundaries.
LAWS GOVERNING GERONTOLOGICAL NURSING PRACTICE
 Laws are generated from several sources. Because many laws are developed at the state
and local levels, variation exists among the states.
 This variation necessitates nurses’ familiarity with the unique laws within their specific
states, particularly those governing professional practice, labor relations, and regulation
of health care agencies.
 There are both public and private laws. Public law governs relationships between private
parties and the government and includes criminal law and regulation of organizations and
individuals engaged in certain practices.
 The scope of nursing practice and the requirements for being licensed as a home health
agency fall under the enforcement of public law.
 Private law governs relationships among individuals or between individuals and
organizations and involves contracts and torts (i.e., wrongful acts against another party,
including assault, battery, false imprisonment, and invasion of privacy). These laws protect
individual rights and also set standards of conduct, which, if violated, can result in liability
of the wrongdoer.
 In addition to laws, there are voluntary standards by which a nurse can be judged. The
American Nurses Association publication Scope and Standards of Gerontological Nursing
provides guidelines for gerontological nurses that offer descriptions of what is considered
safe and effective care.
LEGAL RISKS IN GERONTOLOGICAL NURSING
 Most nurses do not commit wrongful acts intentionally; however, certain situations can
increase the nurse’s risk of liability.
 Such situations include working without sufficient resources, not checking agency policy
or procedure, bending a rule, giving someone a break, taking shortcuts, or trying to work
when physically or emotionally exhausted.
 Not only repeated episodes of carelessness but also the one-time deviation from
standards can result in serious legal problems.
 Nurses must be alert to all the potential legal risks in their practice and make a conscious
effort to minimize them.
 Some of the issues that could present legal risks for nurses are presented below.
1. ASSAULT
 A deliberate threat or attempt to harm another person that the person believes
could be carried through (e.g., telling a patient that he will be locked in a room
without food for the entire day if he does not stopbeing disruptive).
2. BATTERY
 Unconsented touching of another person in a socially impermissible manner or
carrying through an assault. Even a touching act done to help a person can be
interpreted as battery (e.g., performing a procedure without consent).
3. DEFAMATION OF CHARACTER
 An oral or written communication to a third party that damages a person’s
reputation. Libel is the written form of defamation; slander is the spoken form. With
slander, actual damage must be proven, except when:
1. Accusing someone of a crime
2. Accusing someone of having a loathsome disease
 3. Making a statement that affects a person’s professional or business activity
4. Calling a woman unchaste
 Defamation does not exist if the statement is true and made in good faith to
persons with a legitimate reason to receive the information.
 Stating on a reference that an employee was fired from your agency for physically
abusing patients is not defamation if, in fact, the employee was found guilty of
those charges. However, stating on a reference that an employee was a thief
because narcotics were missing every time he or she was on duty can be
considered defamation if the employee was never proved guilty of those charges.
4. FALSE IMPRISONMENT
 Unlawful restraint or detention of a person. Preventing a patient from leaving a facility
is an example of false imprisonment, unless it is shown that the patient has a
contagious disease or could harm himself or herself or others.
 Actual physical restraint need not be used for false imprisonment to occur: telling a
patient that he or she will be tied to the bed if he or she tries to leave can be considered
false imprisonment.
5. FRAUD
 Willful and intentional misrepresentation that could cause harm or cause a loss to a
person or property (e.g., selling a patient a ring with the claim that memory will be
improved when it is worn).
6. INVASION OF PRIVACY
 Invading the right of an individual to personal privacy. Can include unwanted publicity,
releasing a medical record to unauthorized persons, giving patient information to an
improper source, or having one’s private affairs made public. (The only exceptions are
reporting communicable diseases, gunshot wounds, and abuse.)
 Allowing a visiting student to look at a patient’s pressure ulcers without permission can
be an invasion of privacy.
7. LARCENY
 Unlawful taking of another person’s possession (e.g., assuming that a patient will not
be using his or her personally owned wheelchair anymore and giving it away to another
patient without permission).
8. NEGLIGENCE
 Omission or commission of an act that departs from acceptable and reasonable
standards, which can take several forms:
1. Malfeasance: committing an unlawful or improper act (e.g., a nurse performing a
surgical procedure)
2. Misfeasance: performing an act improperly (e.g., including the patient in a research
project without obtaining consent)
3. Nonfeasance: failure to take proper action (e.g., not notifying the physician of a
serious change in the patient’s status)
4. Malpractice: failure to abide by the standards of one’s profession (e.g., not
checking that a nasogastric tube is in the stomach before administering a tube
feeding)
5. Criminal negligence: disregard to protecting the safety of another person (e.g.,
allowing a confused patient, known to have a history of starting fires, to have
matches in an unsupervised situation)
Legal Issues Associated with Aging
1. Consent for treatment
2. Establishing competence
3. Use of restraints
4. Injuries
5. Consent for participation in research
6. Maintenance of patient rights
7. Advanced directives
8. Do not resuscitate orders
9. Malpractice
10. Confidentiality
11.
Malpractice
 Nurses are expected to provide services to patients in a careful, competent manner
according to a standard of care. The standard of care is considered the norm for what
a reasonable individual in a similar circumstance would do.
 When performance deviates from the standard of care, nurses can be liable for
malpractice.
 Examples of situations that could lead to malpractice include the following:
1. Administering the incorrect dosage of a medication to a patient, thereby causing the
patient to experience an adverse reaction
2. Identifying respiratory distress in a patient but not informing the physician in a timely
manner
3. Leaving an irrigating solution at the bedside of a confused patient, who then drinks
that solution
4. Forgetting to turn an immobile patient during the entire shift, resulting in the patient
developing a pressure ulcer
5. Having a patient fall because one staff member attempted to lift the patient manually
when the use of a lift device was the standard
 The fact that a negligent act occurred does not warrant that damages be recovered;
instead, it must be demonstrated that the following conditions were present:
 Duty: a relationship between the nurse and the patient in which the nurse has assumed
responsibility for the care of the patient
 Negligence: failure to conform to the standard of care (i.e., malpractice)
 Injury: physical or mental harm to the patient or violation of the patient’s rights resulting
from the negligent act.
Confidentiality
 It is the rare patient who is seen by only one health care provider. More often, the patient
visits a variety of medical specialists, therapists, diagnostic facilities, pharmacies, and
institutions.
 These providers often need to communicate information about the patient to ensure
coordinated, quality care. However, with the potentially high number of individuals who
have access to patients’ personal medical information and the ease with which information
is able to be transferred, there are increased opportunities for confidential information to
fall into unintended hands.
Patient Consent
 Patients are entitled to know the full implications of procedures and make an independent
decision as to whether they choose to have them performed. This may sound simple
enough, but it is easy for consent to be overlooked or improperly obtained by health care
providers.
  For instance, certain procedures may become so routine to staff that they fail to realize
patient permission must be granted, or a staff member may obtain a signature from a
patient who has a fluctuating level of mental competency and who does not fully
understand what he or she is signing.
 In the interest of helping patients and delivering care efficiently, or from a lack of
knowledge concerning consent, staff members can subject themselves to considerable
legal liability.
 Consent must be obtained before performing any medical or surgical procedure;
performing procedures without consent can be considered battery.
 Usually, when patients enter a health care facility, they sign consent forms that authorize
the staff to perform certain routine measures (e.g., bathing, examination, care-related
treatments, and emergency interventions). These forms, however, do not qualify as carte
blanche consent for all procedures.
 Even blanket consent forms that patients may sign, authorizing staff to doanything
required for treatment and care, are not valid safeguards and may not be upheld in a court
of law.
 Consent should be obtained for anything that exceeds basic, routine care measures.
 Particular procedures for which consent definitely should be sought include any entry into
the body, either by incision or through natural body openings; any use of anesthesia,
cobalt or radiation therapy, electroshock therapy, or experimental procedures; any type of
research participation, invasive or not; and any procedure, diagnostic or treatment, that
carries more than a slight risk.
 Whenever there is doubt regarding whether consent is necessary, it is best to err on the
safe side.
 Consent must be informed. It is unfair to the patient and legally unsound to obtain the
patient’s signature for a procedure without telling the patient what that procedure entails.
 Ideally, a written consent that describes the procedure, its purpose, alternatives to the
procedure, expected consequences, and risks should be signed by the patient, witnessed,
and dated .
 It is best that the person performing the procedure (e.g., the physician or researcher) be
the one to explain the procedure and obtain the consent. Nurses or other staff members
should not be in the position of obtaining consent for the physician because it is illegal and
because they may not be able to answer some of the medical questions posed by the
patient.
 Patients who do not fully comprehend or who have fluctuating levels of mental function
are incapable of granting legally sound consent. Nurses can play an important role in the
consent process by ensuring that it is properly obtained, answering questions, reinforcing
information, and making the physician aware of any misunderstanding or change in the
desire of the patient.
 Finally, nurses should not influence the patient’s decision in any way.
Patient Competency
 Increasingly, particularly in long-term care facilities, nurses are caring for patients who are
confused, demented, or otherwise mentally impaired. Persons who are mentally
incompetent are unable to give legal consent.
 Often in these circumstances, staff will turn to the next of kin to obtain consent for
procedures however, the appointment of a guardian to grant consent for the incompetent
individual is the responsibility of the court.
 When the patient’s competency is questionable, staff should encourage family members
to seek legal guardianship of the patient or request the assistance of the state agency on
aging in petitioning the court for appointment of a guardian.
  Unless they have been judged incompetent by a judge, people are entitled to make their
own decisions.
Staff Supervision
 In many settings, gerontological nurses are responsible for supervising other staff, many
of whom may be unlicensed personnel.
 In these situations, nurses are responsible not only for their own actions but also for the
 actions of the staff they are supervising. This falls under the doctrine of respondeat
superior (“let the master answer”).
 Nurses must understand that if a patient is injured by an employee they supervise while
the employee is working within the scope of the applicable job description, nurses can be
liable.
 Various types of situations can create risks for nurses:
1. Permitting unqualified or incompetent persons to deliver care
2. Failing to follow up on delegated tasks
3. Assigning tasks to staff members for which they are not qualified or competent
4. Allowing staff to work under conditions with known risks (e.g., being short staffed and
improperly functioning equipment)
 These are considerations that nurses need to keep in mind when they accept responsibility
for covering the house, sending an aide into a home to deliver care without knowing the
aide’s competency, or allowing registry or other employees to work without fully orienting
them to agency policies and procedures.
Medications
 Nurses are responsible for the safe administration of prescribed medications. Preparing,
compounding, dispensing, and retailing medications fall within the practice of pharmacy,
not nursing, and, when performed by nurses, can be interpreted as functioning outside
their licensed scope of practice.
Restraints
 The Omnibus Budget Reconciliation Act (OBRA) heightened awareness of the serious
impact of restraints by imposing strict standards on their use in long-term care facilities.
 This increased concern regarding and sensitivity to the use of chemical and physical
restraints has had a ripple effect on other practice settings.
 Anything that physically or mentally restricts a patient’s movement (e.g., protective vests,
trays on wheelchairs, safety belts, geriatric chairs, side rails, and medications) can be
considered a restraint.
 Improperly used restraining devices can not only violate regulations concerning their use
but also result in litigation for false imprisonment and negligence.
 At no time should restraints be used for the convenience of staff.
 Older adults with deliriums and dementias can pose challenges to staff in terms of
behavioral management. There are several medications (e.g., haloperidol,
benzodiazepines, and lorazepam) that can be useful in reducing agitation and the need
for physical restraints; however, these can result in complications such as aspiration due
to depression of the gag reflex and pneumonia due to reduced respiratory activity.
 It must be recognized that these drugs are forms of chemical restraints and should only
be employed after other measures have proven ineffective. Further, nonpharmacological
strategies to manage behaviors can reduce the amount of drug needed.
 Consultation with geropsychiatric specialists or psychologists can prove beneficial in
identifying other strategies.
 Alternatives to restraints should be used whenever possible. Measures to help manage
behavioral problems
  and protect the patient include alarmed doors, wristband alarms, bed alarm pads, beds
and chairs close to the floor level, and increased staff supervision and contact.
 Specific patient behavior that creates risks to the patient and others should be
documented.
 Assessment of the risk posed by the patient not being restrained and the effectiveness of
alternatives should be included.
 When restraints are deemed necessary, a physician’s order for the restraints must be
obtained, stating the specific conditions for which the restraints are to be used, the type of
restraints, and the duration of use.
 The patient requires close observation while restrained.
Telephone Orders
 In home health and long-term care settings, nurses often do not have the benefit of an on-
site physician.
 Changes in the patient’s condition and requests for new or altered treatments may be
communicated over the telephone and, in response, physicians may prescribe orders
accordingly.
 Accepting telephone orders predisposes nurses to considerable risks because the order
can be heard or written incorrectly or the physician can deny that the order was given. It
may not be realistic or advantageous to patient care to totally eliminate telephone orders,
but nurses should minimize their risks in every way possible.
 Try to have the physician immediately fax the written order, if possible.
 Do not involve third parties in the order (e.g., do not have the order communicated by a
secretary or other staff member for the nurse or the physician).
 Communicate all relevant information to the physician, such as vital signs, general status,
and medications administered.
 Do not offer diagnostic interpretations or a medical diagnosis of the patient’s problem.
 Write down the order as it is given and immediately read it back to the physician in its
entirety.
 Place the order on the physician’s order sheet, indicating it was a telephone order, the
physician who gave it, time, date, and the nurse’s signature.
 Obtain the physician’s signature within 24 hours.
 Recorded telephone orders may be a helpful way for nurses to validate what they have
heard, but they may not offer much protection in the event of a lawsuit unless the physician
is informed that the conversation is being recorded or unless special equipment with a 15-
second tone sound is used.
Do Not Resuscitate Orders
 The caseloads of many gerontological nurses contain a high prevalence of terminally ill
patients.
 It may be understood by all parties involved that these patients are going to die and that
resuscitation attempts would be inappropriate; however, unless an order specifically states
that the patient should not be resuscitated, failure to attempt to save that person’s life
could be viewed as negligence.
 Nurses must ensure that DNR (do not resuscitate) orders are legally sound, remembering
several points.
 First, DNR orders are medical orders and must be written and signed on the physician’s
order sheet to be valid.
 DNR placed on the care plan or a special symbol at the patient’s bedside is not legal
without the medical order.
  Next, unless it is detrimental to the patient’s well-being or the patient is incompetent,
consent for the decision not to resuscitate should be obtained; if the patient is unable to
consent, family consent should be sought. .
Elder abuse
 “Elder maltreatment" refers to the seven types of abuse and neglect are physical abuse,
sexual abuse, emotional or psychological abuse, financial or material exploitation,
abandonment, neglect, and self-neglect.
 At risk: female, frail, 80+, dependent on child or spouse
 Mandatory reporting yielded 18% of all reports, families
PRESENTING FEATURES OF ILLNESS/DISEASE IN THE OLDER ADULT
 The manifestations of illness and disease in the older adult can be very different, even if
the underlying pathological process is the same as in younger individuals.
 The advanced practice nurse should be aware of what can influence the presentation.
 Underreporting of symptoms by older adults may occur if they attribute the new sign or
symptom to age itself (Amella, 2004).
 By erroneously associating aging with disease, disuse, and disability, older adults perceive
this change as inevitable and either fail to present to the health-care provider or, if they
do, fail to challenge the assumption that this represents normal aging.
 At times an acute symptom such as pain or dyspnea is superimposed on a chronic
symptom, and the older adult may not recognize that it represents a new or exacerbated
pathology (Bell et al., 2016).
 The advanced practice nurse is well advised to never attribute something to normal aging
without doing a careful and methodical search for a treatable condition.
 Certain diseases are more common in the older adult and an understanding of the
epidemiology is critical in the interpretation.
 Certain neoplasms and malignancies such as basal cell carcinoma, chronic lymphocytic
leukemia, and prostate cancer have a high prevalence beginning in older adulthood.
 Neurological conditions such as Parkinson ’ s disease, dementias, stroke, and complex
partial seizures are more common to have initial onset in older age.
 Polymyalgia rheumatica along with giant cell arteritis almost exclusively begins in patients
over the age of 50 (Besdine, 2016).
 Complicating the care of older adults is when patients develop geriatric syndromes that
often involve multiple body systems and have more than one underlying cause (Bell et al.,
2016).
 For patients presenting with one or more of new geriatric giants: frailty, anorexia of aging,
sarcopenia, and cognitive impairment, the risk escalates for falls, delirium, injuries, and
depression, subsequently placing these patients at dangers for iatrogenic events that
could lead to hospitalization, institutionalization, and subsequently, death (Morley, 2017).
Altered Presentation of Illness
 Advanced practice nurses managing the care of older adults are challenged to recognize
altered, atypical, vague, or even nonspecific signs and symptoms of common conditions
in older adults (Auerhahn & Kennedy-Malone, 2010).
 It is well documented that disease progress may be different for the older adult, especially
the frail older adult (Bell et al., 2016).
 The failure to develop an elevated temperature or fever with an underlying infectious
process differs greatly from presentation of illness in a younger patient. The patient with
depression may not present with a dysphoric mood but rather agitation and psychotic
features.
 The older adult may present with cardiac manifestations of undiagnosed thyroid disease
(Amella, 2004).
  Additional illustrative examples include jaundice, which is suggestive of viral hepatitis in
younger individuals but may represent gallbladder disease or a malignancy in the older
adult, and delusions or hallucinations, which are suggestive of bipolar disorder in younger
individuals but may represent dementia or medication side effects in the older adult
(Williams, 2008).
 Because the symptoms or signs of illness or disease may be vague and nonspecific, even
a modest change in functional level or behavior should alert the clinician to carefully
explore the potential for a treatable condition.
 Family members or caregivers may report that a patient may no longer be cooperating or
participating in individual care.
 Unusual changes such as these become red flags to the beginning of an atypical
presentation of illness. In many cases the progression of the condition is insidious, often
presenting as a change in cognition or an alteration in functional status.
 Other significant changes in patients with altered presentation of illness often include new
onset of falls, weakness, fatigue, anorexia, and unexplained tachypnea (Auerhahn &
Kennedy-Malone,2010).
Presentation of Illness in Older Adults
Illness Atypical Presentation
Acute abdomen  Absence of symptoms or vague symptoms
 Acute confusion
 Mild discomfort and constipation
 Some tachypnea and possibly vague respiratory
symptoms
 Appendicitis pain may begin in right lower
quadrant and become diffuse
Depression  Anorexia, vague abdominal complaints, new onset of
constipation, insomnia, hyperactivity, lack of sadness

Hyperthyroidism  Hyperthyroidism presenting as “apathetic thyrotoxicosis,” i.e.,

fatigue and weakness; weight loss may result instead of
weight gain; patients report palpitations, tachycardia, new
onset of atrial fibrillation, and heart failure may occur with
undiagnosed hyperthyroidism
Hypothyroidism  Hypothyroidism often presents with confusion and agitation;
new onset of anorexia, weight loss, and arthralgias may
occur
Malignancy  New or worsening back pain secondary to metastases from
slow growing breast masses
 Silent masses of the bowel

Myocardial  Absence of chest pain

infarction (MI)  Vague symptoms of fatigue, nausea, and a decrease in
functional and cognitive status; classic presentations:
dyspnea, epigastric discomfort, weakness, vomiting; history
of previous cardiac failure
 Higher prevalence in females versus males
 Non-Q-wave MI
Overall infectious  Absence of fever or low-grade fever
diseases process  Malaise
  Sepsis without usual leukocytosis and fever
 Falls, anorexia, new onset of confusion and/or alteration in
change in mental status, decrease in usual functional status
Peptic ulcer  Absence of abdominal pain, dyspepsia, early satiety
disease  Painless, bloodless
 New onset of confusion, unexplained tachycardia, and/or
hypotension
Pneumonia  Absence of fever; mild coughing without copious sputum,
. especially in dehydrated patients; tachycardia and
tachypnea; anorexia and malaise are common; alteration in
cognition
Pulmonary edema  Lack of paroxysmal nocturnal dyspnea or coughing; insidious
onset with changes in function, food or fluid intake, or
confusion
Tuberculosis (TB)  Atypical signs of TB in older adults include
hepatosplenomegaly, abnormalities in liver function tests,
and anemia
Urinary tract  Absence of fever, worsening mental or functional status,
infection dizziness, anorexia, fatigue, weakness

Comprehensive Geriatric assessment

 Because older individuals represent a richly diverse population, the components of
assessment may vary from person to person.
 People age at different rates and within one-person organ systems age at different rates.
 Psychosocial adaptations, environmental supports, and functional ability can differ
dramatically among individuals of the same chronological age.
 A comprehensive approach to geriatric assessment is recommended because the
physical health of the older adult is inextricably related to functional ability, psychosocial
health, and a safe and enabling environment.
 Older individuals who can benefit the most from this approach are the vulnerable older
adult (those at risk for decline) and the frail older adult (those already demonstrating
decline).
 This population has less physiological reserve and is at increased risk of iatrogenic
complications.
 Comprehensive geriatric assessment (CGA) helps not only to diagnose treatable
conditions and improve patient outcomes, but also to identify potentially preventable
conditions. It facilitates the goal of patient-centered care.
 CGA has been defined as a multidimensional, interprofessional, diagnostic process to
identify care needs, plan care, and improve outcomes for older people (Morley, Little, &
Berg-Weger, 2017; Ramani, Furmedge, & Reddy, 2014).
 CGA may be undertaken by an individual provider initially, with the interprofessional team
called in for selected patients.
 Advanced practice nurses may be a part of a team that works together to complete a CGA,
or may apply the concepts of CGA to their own patients.
 Domains of CGA include:
1. physical health
2. psychological health
3. socio-environmental supports,
 4. mobility,
5. functional status,
6. measure of quality of life
 A number of geriatric assessment instruments are focused on these domains. These tools
can facilitate the assessment, diagnosis, and evaluation processes.
 Each of these domains is described in greater detail as follows.
PHYSICAL HEALTH
 The physical assessment of the older adult includes:
1. all the components of a conventional medical history (chief complaint, history of
present illness, past history, family and social history, and a review of systems),
2. the conventional physical examination
3. appropriate diagnostics basedon the findings.
 The approach to the physical assessment process, however, needs to be tailored to the
older adult.
 Assessment begins with observation of the patient’ s appearance, language, and
behaviors.
1. Does the individual look the stated age?
2. Are they dressed appropriately?
3. Is there evidence of neglect in self-care?
4. What is the manner and content of speech?
5. What behaviors are observed, including facial expressions, eye contact, gestures,
or abnormal movements?
6. If a family member or caregiver accompanies the patient, how do they interact?
 Interviewing begins before the physical examination and typically continues throughout
the examination.
 Many providers send a geriatric history-taking form to the patient in advance so that they
or their family can complete it and the details can be reviewed and expanded on during
the visit.
 Any impairment in vision, hearing, speech, or cognition may affect the patient’ s ability to
communicate effectively. Impairments should be addressed, and measures taken to
accommodate them during the visit, to prevent the common trap of talking to the family or
caregiver rather than the older adult to facilitate the visit.
 The patient’ s permission needs to be acquired before interviewing the family in most
cases.
 The input of the family or caregiver may provide valuable information about the patient’ s
behavioral or functional changes, which can indicate a change in the patient \’ s overall
health status.
 It is important to address what the patient or their family considers significant, which often
differs from what the provider considers significant.
 Many older adults suffer from multiple chronic diseases that require monitoring. There may
not be a new chief concern, but if one is reported it is important to put it into the context of
the patient ’ s previous health and illness.
 The history of chronic diseases should be identified and updated with any symptoms of
decompensation. If a new concern is identified, a history of present illness is recorded
using the seven dimensions of symptomatology as a guide (location and radiation, quantity
and quality, aggravating and alleviating factors, associated symptoms and signs, absence
of associated symptoms and signs, evolution and course of the symptom, and effect of
the symptom on normal daily activities).
 After taking the history, the provider should summarize for the patient what was heard.
 This gives the patient the opportunity to clarify or deny any parts of the discussion.
Sample Focused Geriatric Physical Examination

SIGNS PHYSICAL SIGN OR DIFFERENTIAL DIAGNOSES

SYMPTOM
Vital Signs  Hypertension  Adverse effects from medication,
1.Blood pressure autonomic dysfunction
 Orthostatic  Adverse effects from medication,
hypotension atherosclerosis, coronary artery
2. Heart rate
 Bradycardia  Adverse effects from medication,
heart block
 Irregularly irregular  Atrial fibrillation
heart
3. Respiratory
Rate  Increased  Chronic obstructive pulmonary
respiratory rate >24 disease, congestive heart failure,
breaths per min Pneumonia
4. Temperature
 Hyperthermia,  Hyperthyroidism and
hypothermia hypothyroidism, infection
5. General loss  Unintentional weight  Cancer, depression
loss
 Weight gain  Adverse effects from congestive
heart failure, medication
6. Head  Asymmetrical facial  Bell’ s palsy, stroke, transient
or extraocular ischemic attack
muscle weakness or
paralysis

 Frontal bossing  Paget disease

 Temporal artery  Temporal arteritis

tenderness
7. Eyes  Eye pain  Glaucoma, temporal arteritis

 Impaired visual  Presbyopia

acuity
 Loss of central vision  Age-related macular degeneration

 Loss of peripheral  Glaucoma, stroke

vision
 Ocular lens  Cataracts
opacification
8. Ears  Hearing loss  Acoustic neuroma, adverse effects
from medication, cerumen
impaction, faulty or ill-fitting hearing
aids, Paget’ s disease
9. Mouth,  Gum or mouth sores  Dental or periodontal disease,
ill-fitting dentures
10. Throat  Leukoplakia  Cancerous and precancerous
lesions
 Xerostomia  Age-related, Sjögren ’ s syndrome
11. Neck  Carotid bruits  Aortic stenosis, cerebrovascular
disease

 Thyroid enlargement  Hyperthyroidism and

and nodularity hypothyroidism
12. Cardiac  Fourth heart sound  Left ventricular thickening
(S4)

 Systolic ejection,  Valvular arteriosclerosis

regurgitant murmurs
13. Pulmonary  Barrel chest  Emphysema

 Shortness of breath  Asthma, Cardiomyopathy, COPD,

CHF
14. Breast  Masses  Cancer, Fibroadenoma
15. Abdomen  Pulsatile Mass  Aortic Aneurysm

16.  Constipation  Adverse effects from medication,

Gastrointestinal colorectal cancer, dehydration,
hypothyroidism, inactivity,
inadequate fiber intake
17. Genital/  Fecal incontinence  Fecal impaction, rectal cancer,
rectal rectal prolapse

 Atrophy of the  Estrogen deficiency

vaginal mucosa

 Prostate  Benign prostatic hypertrophy

enlargement
 Prostate nodules  Prostate cancer

 Rectal mass, occult  Colorectal cancer

blood

Urinary  Urinary incontinence Bladder or uterine prolapse, detrusor

instability, estrogen deficiency

Extremities  Abnormalities of the  Bunions, onychomycosis
feet
 Diminished or  Peripheral vascular disease,
absent lower venous insufficiency
extremity pulses
 Heberden ’ s nodes  Osteoarthritis

 Swan neck  Rheumatoid arthritis

deformity
  Pedal edema  Adverse effects from medication,
venous insufficiency, congestive
heart failure
Musculoskeletal  Diminished range of  Arthritis, fracture
motion, pain

 Dorsal kyphosis,  Cancer, compression fracture,

vertebral osteoporosis
tenderness, back
pain

 Gait disturbances  Adverse effects from medication,

arthritis, deconditioning, foot
abnormalities, Parkinson ’ s
disease, stroke
 Leg pain  Intermittent claudication,
neuropathy, osteoarthritis,
radiculopathy,
venous insufficiency

 Muscle wasting  Atrophy, malnutrition

 Proximal muscle  Polymyalgia rheumatica

pain and weakness

Skin  Erythema, ulceration  Anticoagulant use, elder abuse,

over pressure idiopathic thrombocytopenic
points, unexplained Purpura
bruises

 Premalignant or  Actinic keratoses, basal cell

malignant lesions carcinoma, malignant melanoma,
pressure ulcer, squamous cell
carcinoma
Neurological  Tremor with rigidity  Parkinson ’ s disease

Medication
 Medication review should be completed at every encounter.
 Because older adults are the population most likely to suffer from multiple chronic
diseases, they are also most likely to take more medications, both prescribed and over
the counter.
 The more medications a person is taking the more likely they are to have an adverse drug
reaction.
Examination
  The collection of objective data usually begins with the vital signs. These may be
completed by ancillary staff, but any abnormalities need to be verified by the provider.
 A common issue is the necessity to rule out orthostatic hypotension, which is prevalent in
older adults due to volume depletion and medication effects. If concerns indicate the
possibility of orthostatic drop, the provider needs to accurately measure the blood
pressure (BP).
 Pulse oximetry is now readily available in practice settings, and this gives a measure of
oxygen saturation. If the respiratory rate is greater than 20 respirations per minute it is
classified as tachypnea and may be a sign of infection or sepsis, lung disease, heart
failure, or a metabolic disorder.
 Weight is another measurement in which accuracy is important, because it is a marker for
both nutritional and fluid status.
 Pain is the fifth vital sign and quantifying pain can be accomplished in various ways,
although older adults may prefer verbally descriptive scales.
 The physical examination is of critical significance in CGA.
 In examination of the older adult, functional assessment is as important as careful
examination of each body system.
 In younger adults, neurological and musculoskeletal examination may be less of a focus
because health of those systems is obvious, but older adults may have unrecognized
muscle weakness, limitations in range of joint motion, or contractures requiring thorough
examination.
 Sensory loss often precludes the ability of the older adult to live independently, and visual
and hearing acuity is part of the functional assessment.
 Measured visual acuity (corrected with lenses) equal to or worse than 20/40 constitutes a
visual impairment.
 Screening for hearing loss can be accomplished using a handheld audiometer, which is
more accurate than the whispered voice test. Abnormality in the six cardinal fields of gaze
with nystagmus or lack of a downward gaze may reveal neurological disease.
 Otoscopic examination can identify cerumen impaction, a common cause of conductive
hearing loss.
 After completing the examination, discuss the general findings with the patient. Patient
teaching should reinforce the positive behaviors taken to improve or maintain health and
teach self-assessment and self-care management strategies.
Diagnostics
 Tests used to screen geriatric patients and tests used to aid in diagnosis have different
objectives.
 Screening can be defined as the presumptive identification of unrecognized disease or
defect by the application of tests, examinations, or other procedures.
 One of the considerations in ordering tests for diagnostic purposes is whether the test
result will alter the diagnosis, prognosis, or management of a condition.
 Some guidelines for use of diagnostics in decision making include: What is the prevalence
of the disease being screened for with the test? Is the test necessary to make the
diagnosis? Will the test be accepted and tolerated by the patient? Does the cost or benefit
of the test outweigh the risk? Is it the least invasive test available? Can the results be
interpreted? Will the results change the treatment of the patient? What is the sensitivity
and specificity of the test?
 To be of diagnostic value, a test for a given disease must produce patient results that differ
substantially from normal results, as well as from results in patients with other diseases
that may be mistaken for that disease.
Nutritional Assessment
  Several age-associated changes influence the nutritional status of older adults. These
primarily include the loss of lean body mass, a decrease in the basal metabolic rate, and
an increase in body fat.
 Although overall caloric intake should decrease due to decreased metabolism and often
decreased physical activity, certain nutrient needs may change as one ages.
 A nutrient-rich diet is required to meet these changing needs.
 A nutritional assessment needs to be a part of the CGA, because inadequate intake is
common in older adults.
 An estimated 5% to 30% of older adults living in the community are malnourished; 23% to
60% of hospitalized older adults and 16% to 70% of those in long-term care facilities
experience malnutrition (Guyonnet & Rolland, 2015).
 Obesity is the most common nutritional disorder in the older adult living in the community,
and undernutrition is most common in those in acute and long-term care facilities.
 There are four components of nutritional assessment:
1. nutritional history using a validated tool.
2. food intake diary of 1 to 3 days.
3. physical assessment, including anthropometric measurements and signs of
nutritional deficiencies; and
4. biochemical markers, if applicable.
FUNCTIONAL HEALTH
 Although functional decline is common with advanced aging, the two are not synonymous.
 Although functional decline occurs in every system, the distinction between functional
usual aging and functional successful aging remains unclear.
 The goal in geriatric care is to improve function, if possible, and, if not, to prevent functional
decline or at least slow down the process of functional deterioration.
 The parameters of function include both activities of daily living (ADLs) and instrumental
activities of daily living (IADLs).
 Basic ADLs include three components: basic self-care, mobility, and continence. IADLs
measure community interactions within the home and outside the home.

Selected Elements of Functional Independence/Dependence

ADLs IADLs
Bathing Food preparation
Dressing Household chores
Toileting Laundry
Feeding oneself Managing medications
Move from bed to a standing position or chair Using the telephone
Ability to walk with or without assistive device Shopping
Continence of urine Managing finances
Continence of stool Transportation

PSYCHOLOGICAL HEALTH
 Cognitive and affective disorders, specifically dementia, delirium, and depression, are
more prevalent in older adults, and clinical definitions of these disorders are addressed in
the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), 5th ed. (2013).
 The DSM-5 describes the characteristics of delirium and mild or moderate neurocognitive
disorders.
 There are few validated tools used to screen for cognitive dysfunction.
  Older adults are at greater risk of delirium, which is under-recognized and
underdiagnosed.
 Depression is also under-recognized in older adults. There are several screening tools for
depression, though the most widely used in the clinical practice is the Geriatric Depression
Scale: Short Form (GDS:SF)
SOCIOENVIRONMENTAL SUPPORTS
 Social isolation in community-dwelling older adults is all too common.
 Social isolation has been shown to contribute to all-cause mortality. While social isolation
is not always assessed in the primary care setting, it should be an essential component of
a CGA.
 In 1995, Kane recommended including the following statements in a geriatric assessment
to help improve understanding of the patient ’ s social support:
1. Is there any one special person you could call or contact if you need help? (If yes,
identify.)
2. In general, other than your children, how many relatives do you feel close to and
have contact with at least once a month? (Number.
3. In general, how many friends do you feel close to and have contact with at least
once a month? (Number.)
 Additional social and economic resources are assessed by exploring the following:
1. Living situation
2. Housing
3. Transportation
4. Income
5. Assets
6. Degree of financial burden resulting from health concerns
The Multidisciplinary Team in CGA
1. Physician
2. Nurse Practitioner or Physician Assistant
3. Nurse Social Worker
4. Physical/Occupational/Speech /psychological Therapist
5. Pharmacist
6. Dietician
7. Dentist
 Each member of team sees every patient
Goal
 Highest priority:
1. Prevention of decline in the independent performance of ADLs
2. Drives the diagnostic process and clinical decision making
 Screen for preventable diseases
 Screen for functional impairments that may result in physical disability and amenable to
intervention
 Improve diagnostic accuracy
 Guide selection of interventions to restore or preserve health
 Recommend optimal living environment
 Monitor clinical change over time
 Predict outcomes
Who should be evaluated?
1. Healthy elderly persons – living in the community
2. Frail elderly persons – living in the community.
3. Institutionalized or severely impaired elderly persons
Patients who benefit most
1. Frail because of age
2. Decrease in functional status
3. Change in mental status- cognition/affect
4. Multiple medical problems
5. Multiple psychosocial problems
6. Take multiple medication
7. New onset urinary or fecal incontinence
8. Involuntary weight loss
9. Frequent falls
10. One or more sensory impairment
11. Disruptive behavior or personality changes
Geriatric Giants
 Common problems that have been identified as warranting special attention in elderly
1. Cognitive Disorders:(Dementia/Delirium)
2. Polypharmacy
3. Falls/Gait Instability
4. Urinary Incontinence
5. Depression
6. Malnutrition
Assessment Steps per domain
1. History.
2. Examination.
3. Assessment tool
4. Referral