GERIATRIC

NURSING

1
 GERIATRIC NURSING

INTRODUCTION

Ageing the normal process of time related change, begins with birth and continues throughout
life. The older segment of the population is growing more rapidly than the rest of the
population: the U.S Census Bureau projects that by the year 2030, there will be more than 65
years of age than people younger than 18 years of age. As the older population increases, the
number of people who live to be very old will also increase. Health professionals will be
challenged to design strategies that address the higher prevalence of illness within this aging
population. Many chronic conditions commonly found among older people can be managed,
limited, and even prevented. Older people are more likely to maintain good health and
functional independence if appropriate community based support services are available.

HISTORY OF GEDIATRIC NURSING

The development of gerontological nursing came through the combined efforts of the
American Journal of Nursing, John A. Hartford Foundation Institute for Geriatric Nursing
and the American Nurses Association. However, it was the American Nursing Association
(ANA) that formed a specialized group for geriatric nurses in the 1960s and recognized it
over the next three decades. Programs were established to solidify the geriatric nursing
specialization and nurses were given substantial educational opportunities through the
development of Geriatric Research Education and Clinical Centre’s (GRECCs), allowing
them to provide quality care for older veterans. Later, certificate programs, baccalaureate
degrees, and master’s degrees were created to allow applicants to become geriatric nurses in
their respective states.

Caring for the aged is not a new concept in nursing; Florence Nightingale pioneered this
specialized field. She was renowned as the first geriatric nurse because of her nurse
superintendent position in an English institution, where she cared for helpers and maids of
wealthy women. Nowadays, gerontological care is recognized by society through the
collaboration of several organizations and hardworking individuals in the field of nursing. In
time, geriatric nurses trained for the job and an evidence-based geriatric nursing practice was
developed, which allowed the production of books, journals, websites and even organizations
dedicated to caring for older adults.

2
DEFINITION

Ageing

The process of growing old, is defined as the gradual biological impairment of normal
function, probably as a result of changes made to cells (mitotic cells, such as fibroblasts and
post-mitotic cells, such as neurons) and structural component.

Gerontology :

Gerontology it is a science that deals with study of ageing process

Geriatric care:

Geriatric care This is related to the disease process of old age and its aims at keeping old
person at the state of self-dependent as far as possible & to provide facilities to improve the
life

Geriatric nursing:

Geriatric nursing Geriatric nursing is the specialty that concerns itself with the provision of
nursing services to geriatric or aged individuals.

AGEING

Attitudes towards Aging

The way we care for aged individuals is influenced by our experiences with family, friends,
neighbourhood, school and even work. Aging is a normal process, and it is common to see
older people around in our community. However, derogatory attitudes toward older adults
often exist because of negative past experiences. Some of us may not have solid beliefs about
older adults, but separating myth from reality is a good way of appreciating older adults and
caring for them in the correct manner.

Demographics of Aging

In the latest census by the US Census Bureau, a whopping 39.6 million older adults reside in
America, which makes up 12.9% of the population of the country. By 2035, it is expected
that 1 out of 5 individuals will be 65 years or older. These seniors will be different from those
of past decades. They will enjoy better health, longer lives, and more active lifestyles because
of technology and new advancements in medical care.

3
However, the increased life expectancy has also caused the creation of three elderly sub-
populations, namely the young old (people aged 65 to 74), the old (people aged 74 to 84) and
the oldest-old (people aged 85+). The new retirees will require medical and Social Security
assistance to meet their needs. They will also need long-term care to maintain their health and
well-being throughout the remainder of their lives.

Economics of Aging

As more and more people are born, a growing number are also becoming elderly. The
growing population of the elderly is due to declining fertility rates and increased longevity.
According to the Centre’s older Disease Control and Prevention, the life expectancy of a
new-born today is nearly 78 years, which is more than twice as long as those born a thousand
years ago. In 1930, people were expected to live for 59.7 years; and in 1960, life expectancy
increased to 69.7 years. This dramatic increase in life expectancy is not an accident. It is the
result of public health initiatives, infectious disease control and new surgical and
rehabilitation techniques. In fact, there is a significant decrease in mortality rates, accounted
for in 2007, which showed a declining percentage of deaths from the 15 leading diseases like
stroke, diabetes, accidents, homicide, influenza, pneumonia and many others. Also, medical
breakthroughs are solving our problems with birth, early infancy disorders as well as
contagious diseases, thereby improving longevity and allowing people to live longer than in
past decades.

Housing Arrangements

Housing arrangements are one of the many things we have to consider when we get older.
Senior individuals have specific needs, and most have fragile bones and lifestyle diseases that
need long-term care. They may require specialized nursing services, but they also need better
housing conditions. Nowadays, there are a lot of accommodation options for elderly
individuals, including nursing homes, retirement communities and apartments designed for
older people. Some of these options may be suitable for a particular person, while others are
not. This is due to several considerations like physical and medical needs, home maintenance,
social and emotional needs as well as financial concerns. Elderly individuals or family
members with older people at home should always take into account their lifestyle, health and
finances. Housing arrangements should not affect the old person’s overall health and well-
being and ability to thrive and have a comfortable aging process. It should planned in a way
as to promote a better quality life, with less risk of injury and health issues.

4
Healthcare Provisions

The elderly population is vulnerable to a variety of health problems. Prevention and control
requires a multifaceted approach with collaboration of the social welfare, health, legal and
rural/urban development sectors. A geriatric healthcare program should contain a
comprehensive policy at the start. Any healthcare provision be supported by a strong political
will and social action to make the policies efficient and sustainable. Nevertheless, other
measures like improving healthcare knowledge, health insurance and promotion of a healthy
lifestyle are also the keys to better elderly care.

The provision of quality healthcare services to the elderly population imposes several
challenges. It is important to address the factors that hinder these services to develop a better
way of life for our seniors. Families with the elderly should take a significant role in ensuring
that their needs are adequately met. Failure to address their healthcare needs early on can
result in costly issues later. In fact, it can aggravate an existing condition that causes a major
meltdown within the family.

Impact of Aging Members in the Family

Many of our older individuals experience a decline in their physical and cognitive
functioning. This has made them lose the ability to live independently, forcing them to seek
long-term care services from institutions like long-stay hospitals, nursing homes, residential
care and assisted living facilities. Families with older people often carry the burden of caring
for these individuals, accumulating significant costs when they do. In less developed
countries where affordable long-term care facilities are not available, families with elderly
adults withdraw from their employment or school commitments just to care for these family
members and make ends meet. They may end up with significant debt due to their
hospitalization, medication maintenance, and home care adjustment costs.

The impact of having an aging family member often varies on how well they handle the
changes and demands of day- to-day living. Most families with a solid economic background
and strong financial support from the government seek long-term nursing services to care for
the elderly. Unfortunately, this may not apply to families with fewer resources and
unemployed family members. The demands of an elderly individual are often unpredictable
and changing. Thus, families should be prepared for this day to balance the situation and
ensure the provision of a safe retirement for their loved ones.

5
THEORIES OF AGING

There are several theories about the process of aging, yet they are mutually exclusive and
often contradict one another. Nowadays, the biological theories of aging have two main
categories:

1. The programmed theory; ageing has a biological timetable or internal biological clock

2. The damage or error theory. ; Ageing is a result of internal or external assaults that
damage cells or organs so they can no longer function properly.

Programmed theories or non-stochastic theories

 Programmed senescence theory

 Endocrine theory
 Immunology theory

Error theories

 Wear and tear theory

 Cross linking theory
 Free radical theory
 Error catastroph theory
 Somatic mutation theory

PROGRAMMED THEORIES OR NON-STOCHASTIC THEORIES

The programmed theory implies that aging has a biological timetable and is regulated by the
changes in gene expression affecting the systems responsible for our repair, maintenance and
defence responses.

Programmed senescence theory/hayflick limit theory

1950’s hayflick ina series of classic experiments demonstrated that culture skin fibroblasts
would reproduce or divide a finite number of times. From these observations rose the
programmed theory of cell death. In this theory, it is proposed that there is an impairment in
the ability of the cell to continue dividing.

The hay flicks limit theory indicates that there is a need to slow down the rate of cell division
if we want to live long lives. Cell division can be slowed, down by diet and lifestyle, etc., but
it is also surmised that cell division can be improved with many of the protocols of the other

6
ageing theories described herein. The use of ribonucleic acids improve cell repair process,
enhance cellular capacities and increase the maximum number of cell division in animals and
vitro tests.

Endocrine theory or neuroendocrine theory

First proposed by Professor Vladimir Dilman and Ward Dean MD, this theory elaborates on
wear and tear by focusing on the neuroendocrine system. This system is a complicated
network of biochemical that govern the release of hormones which are altered by the walnut
sized gland called the hypothalamus located in the brain. This theory proposes that aging
occurs because of functional decrements in neurons and associated hormones.

It suggests that neural and endocrine changes may be pacemaker for many cellular and
physiologic aspects of aging. This approach relates aging to the organism’s loss of
responsiveness of neuroendocrine tissues to various signals. In some cases, this is a result of a
loss of receptors, but in others, it is caused by changes in neurotransmission beyond the
receptors. An important focus of this theory is the functional changes of hypothalamic-
pituitary system. These changes are accompanied by a decline functional capacity in other
endocrine organs such as the adrenal and thyroid glands, ovaries and testes. The
hypothalamus controls various chain-reactions to, instruct other organs and glands to release
their hormones, etc. The hypothalamus also responds to the body hormone levels as a guide
to the overall hormonal activity. But as we grow older, the hypothalamus loses it precision
regulatory ability and the receptors which uptake individual hormones become less sensitive
to them. Accordingly; as we age the secretion of many hormones declines and their
effectiveness (compared unit to unit) is also reduced due to the receptors down grading.

Immunologic theory

It proposes declining functional capacity of immune system as the basic for the ageing
process. It suggests that ageing is not passive wearing out of systems but an active self-
destruction mediated by immune system.

This theory is based observing an age associated decline in T-cell functioning accompanied
by a decrease in resistance and increase in autoimmune disease with ageing. Some studies of
cell division suggest that cells of the immune system become more diversified with age and
demonstrate a progressive loss of self -regulatory patterns. The result is an autoimmune

7
phenomena in which cells normal to the body are mistaken as foreign and are attacked by the
persons own immune system.

ERROR THEORIES

Error theories emphasize the environmental impact that induces cumulative damage,
instigating the aging process. These two theories are based on evolutionary concepts wherein
aging is considered the result of an individual’s inability to combat the natural deterioration
processes and is a result of a biological program that allows decay and death to attain a direct
evolutionary benefit.

Wear and tear theory

 Early theory on ageing proposed that there is fixed store of energy available to the
body as time passes, the energy is depleted and because it cannot be restored, the
person dies
 Later, other theories emerged. The wear and tear theory stated that the body is like a
machine that wears out its parts with repeated use and comes to a grinding valt. This
is not widely accepted

Cross linked theory

 It postulates that over time and as a result of exposure to chemicals and radiation in
the environment. Cross-links have formed between lipids, proteins, and carbohydrates
as well as nucleic acid
 These cross-links result in decreased flexibility and elasticity and this increases
rigidity in tissues.
 Such changes in cell structure may explain the observable cosmetic changes
associated with ageing, such as wrinkles of skin and decreased dispensability of
arterial blood vessels.
 The cross-linking theory of aging is also referred to as the glycosylation theory of
aging. In this theory, it is the binding of glucose to protein, that causes various
problems
 once this binding has occurred, the protein becomes impaired and is unable to
perform as efficiently. Living a longer life is going to lead to the increased possibility
of oxygen meeting glucose and protein and known cross- linking disorders include
senile cataract and the appearance of tough, leathery, and yellow skin.

8
 Indeed, you can see cross-linked in action now. Simply cut an apple in half and watch
the oxygen in the air react with the glucose in the apple as it turns yellow and brown
as eventually becomes tough.

Free radical theory

 It was proposed in 1956 by Harman

 A free radical is highly reactive atom or molecule that carries an unpaired electron
and thus seeks to combine with another molecule, causing an oxidative process
 This process, also called oxidative stress, can ultimately disrupt cell membrane and
alter DNA and protein synthesis
 Common diseases such as atherosclerosis and cancer are associated with oxidative
stress
 Cellular integrity, function and regeneration mechanisms are injured
 Free radicals are natural by products of many normal cellular processes and are also
created by such environmental factors as smog, tobacco smoke and radiation.
 There are numerous natural protective mechanisms in place to prevent oxidative
damage
 Recent researches focused on roles of various antioxidants, including vitamin-c and E,
beta-carotene and selenium, to slow down the oxidative process and ultimately aging
processes.
 The term free radical describes any molecule that has a free electron, and this property
makes it react with healthy molecules in a destructive way
 Because the free radical molecule has an extra electron, it creates an extra negative
charge. This unbalanced energy makes the free radical bind itself to another balanced
molecule as it tries to steal electrons. In so doing, the balanced molecule becomes
unbalanced and thus a free radical itself. Perhaps a bit like bumper-cars crashing into
each other at the fair.
 It is known that diet, lifestyle, drugs and radiation etc , are accelerators of free radicals
production within the body
 However there is also natural production of free radicals within the body. This is the
result of the production of energy. Particularly from the mitochondria. The simple
process of eating, drinking and breathing form free radicals from the energy
production cycles, as the body produces the universal energy molecule ATP

9
  Free radicles are known to attack the structure of cell membranes, which then create
metabolic waste products. Such toxic accumulation interfere with cell
communication, disturb DNA,RNA and protein synthesis, lower energy levels and
generally impede vital chemical processes
 Free radicals can however be transformed by free radical scavengers(antioxidants)
particular antioxidants will bind to particular free radicals and help to stabilize them
 Free radicals come in a hierarchy with the hydroxyl radical and the superoxide radical
at the top of the list. It is therefore necessary to take a cross section of anti-oxidants in
order for the process of elimination of the free radicals to occur, otherwise higher
damaged free radicals may be converted into a greater number of lower damaged free
radicals.
 Such a broad cross section of anti-oxidants includes substances such as beta-carotene,
vitamin C, grape seed extract, vitamin E and possibly also stronger substances such as
hydergine, melatonin and vinpocetine

Error and fidelity theory

An error is a mistake and fidelity refers to being faithful, so knowing that we can discuss this
theory. Also remember that this occurs over a lifetime.

 Normally, we constantly or faithfully produce cells throughout our bodies using our
same correct DNA map to do so time & time again. This theory is saying that over
time an error or mistake occurs in our DNA map (protein)and it begins to produce
cells that are not correct-it’s like going from producing a high quality product to
producing a lesser quality product. This deterioration results in aging and eventually
over a lifetime, death
 The somatic mutation and intrinsic mutagenesis theories postulate that aging is a
result of lifelong genetic damage which may include the progressive accumulation of
faulty copying in dividing cells or accumulation of errors in information containing
molecules

Somatic theory or gene mutation theory

Scientists investigated the role of mutations in aging, radiation not only increased animal
mutation but it also accelerated their aging process as well.

10
FUNCTIONS OF GERONTOLOGICAL NURSING

The functions of geronotological nurse are mentioned on the basis of spelling of the word:

G (guiding): Giving guidance to people of all ages regarding ageing process.

E (elimination): eliminating ageism, or considering old age as disease.

R (respecting): respecting the rights of older people,

O (observing): observing the facilities provided to old people & improving them.
N (noticing): noticing health hazards that may happen in old age & try to reduce them.
T (teaching): teaching how to take care of old people, for those who are caring for them
O (opening channels): opening the channels of development activities for the care of the
aged.
L (listening): listening attentively to the problems of old people & giving due importance to
them.
O (offering): offering positivism presenting different possibilities of life.
G (generating): generating energy for participation in the care of aged & researches for new
supporting techniques.
I (implementing): implementing activities for rehabilitation & readjustment.

C (coordinating): coordinating different services related to the care of the aged.

A (assessing): Assessing the needs & health of the old people.
L (linking): linking, contacting services according to need.
N (nurturing): prepare future nurses for the care of the aged.
U (understanding): understanding every old person as an invaluable asset of the society.
R (recognizing): recognizing the moral & religious aspects of old age & giving them
recognition.
S (supporting): supporting the old people in accepting realities & preparing them mentally for
impending death.

E (education & encouraging): educating & encouraging old people for self-care.

11
PHYSIOLOGICAL CHANGES DUE TO AGING

Physiologic Changes in the Integumentary System

Skin changes are the most visible signs of aging. As we age, our skin becomes wrinkled and
prone to injury. This is due to the fact that pigment-containing cells decrease, and connective
tissues as well as the blood vessel function deteriorates. An elderly individual usually
experiences a change in their skin’s elasticity and strength. The sebaceous glands will generate
a lower production of oil and the dermis becomes fragile. As a result, most elderly men and
women have problems with insulation or a reduced ability to maintain body temperature. The
subcutaneous fat layer thins and it loses its protective layer. The skin is less able to feel touch,
vibration, pressure, heat and cold.

Aging skin has a reduced ability to repair itself. Elderly individuals often experience a delayed
wound healing, thereby making pressure ulcers and infections worse. Skin disorders among
older people are often related to conditions like arteriosclerosis, liver disease, heart disease,
nutritional deficiencies, diabetes, obesity, stress and allergies. These skin changes can be
alleviated through adequate nutrition and proper hydration. Older people are prone to injuries
and nutritional deficiencies. This is why they have to be mindful of what they eat and the
lifestyle they choose.

Physiologic Changes in the Musculoskeletal System

Physiologic changes in the musculoskeletal system of men and women usually start at the age
of 30. The density of bones starts to diminish at this age, especially for women nearing the
menopausal stage. As a result, bones are becoming fragile and are likely to break.

We often do not notice these musculoskeletal changes of our body as we grow older, but time
and time again, the joints are affected by the changes in our connective tissue and cartilage.
The cartilage becomes thinner and its components altered, making it less resilient and therefore
susceptible to damage. Some people find their joints a bit different than they used to be, and
experience a condition called osteoarthritis. In osteoarthritis, joints become stiffer and the
tendons brittle and rigid. Individuals with this condition often have a limited range of motion.
They often cannot perform their daily routine because of the pain and inflammation
experienced in the joints.

12
Furthermore, muscle mass also deteriorates in aging. The size of muscle fibers and the amount
of muscle tissue gradually decreases throughout life. This will result in a loss of muscle strength
which stresses the joints and predisposes them to be arthritic as well. Fortunately, muscle mass
and muscle strength can be preserved through regular exercise. This will significantly delay
the changes in our musculoskeletal system and allow us to maximize the functioning of our
muscles.

Physiologic Changes in the Respiratory System

The effects of aging on the respiratory system are similar to other organs. Through time, the
maximum function of our lungs will gradually decline. It will decrease its gas exchange, peak
flow and vital capacity. Respiratory muscles will also weaken as well as their effectiveness in
creating a barrier against bacteria, viruses, and other harmful organisms. However, the age-
related changes in the respiratory system do not often lead to symptoms in healthy individuals.
This will only reduce the ability to perform intense aerobic exercises like biking, running and
mountain climbing. Thus, older people have limited capacity to perform certain activities.

Individuals who have existing medical problems such as heart disease and obesity may have a
limited lung function as well. They are at a higher risk of viral and bacterial infections like
pneumonia and lung cancer. Hence, older people often acquire diseases faster than young
adults.

Physiologic Changes in the Cardiovascular System

Physiologic changes in the cardiovascular system typically occur as we age. The heart is a
natural pacemaker that regulates the heartbeat, but through time, some of its pathways will
develop fat deposits and fibrous tissue. This may result in a slower heart rate and a slight
increase in its size, especially the left ventricle. Older people often experience an abnormal
rhythm like atrial fibrillation and a heart murmur, caused by stiffness of the valves. Receptors
in the cardiovascular system often monitor the blood pressure whenever a person performs
certain activities and changes positions. But as we age, these receptors become less sensitive,
which is why many older people experience orthostatic hypotension. The capillary walls of the
heart will also thicken and the main aorta artery becomes stiffer, thicker and less flexible.

13
Normal aging can cause a reduction of total body water (TBW). Blood volume decreases and
there is less fluid in the bloodstream. Red blood cells, which respond to stress and any kind of
illness, are fewer in number while the white blood cells remain at the same levels, though their
ability to ward off bacteria and other sorts of infection.

Physiologic Changes in the Hematopoietic and Lymphatic System

The main role of the hematopoietic and lymphatic system is to protect the body against
infection and illness. With advancing age, this system becomes less effective. The T and B
cells, the primary cells involved in attacking specific invaders, become less responsive. The T
cells are responsible for cellular immunity, and they often respond to infection and invasion of
a pathogen. The B cells, on the other hand, are responsible for producing antibodies. However,
they become less responsive over time, making the body more susceptible to bacterial and viral
infections.

Vaccinations for viruses are strongly recommended for older people because their lymphatic
system is not working as well as when they were younger. Moreover, the increased occurrence
of cancer in older individuals is due to the declining ability of the lymphatic system to eliminate
tumor cells efficiently. This is also caused by nutritional deficiency, common in older adults.

Physiologic Changes in Gastrointestinal System

Aging is often a factor in different gastrointestinal disorders. With age, the strength of the
esophageal contractions, as well as the tension of the upper esophageal sphincter, will decrease;
but this does not affect or impair the movement of food. A peptic ulcer is common in older
people because of the decreasing capacity of the stomach lining to resist any damage,
particularly in those using aspirin and NSAID’s as maintenance. Aging can even affect the
ability of the stomach to accommodate more food because of its decreasing elasticity and
capacity to empty food into the small intestines. This is why most older adults have a decreased
appetite for food.

Other parts of the gastrointestinal system are also affected by aging. For instance, the small
intestines will have a decreasing lactase level, which leads to the intolerance of milk and dairy
products. There will be an excessive growth of bacteria which can lead to bloating, pain and
weight loss. The pancreas, gallbladder, and liver usually decrease in weight as we age. Some

14
of the tissues are replaced by scaring and a number of structural as well as microscopic changes
occur, making these organs prone to injury and illness.

Physiologic Changes in the Urinary System

There is a slow and steady decline in kidneys weight as we age. At the age of 30 to 40, two-
thirds of the kidneys’ function of filtering blood undergoes a gradual decline. The arteries that
supply the kidneys become narrower, which makes even healthy kidneys decrease in size. Also,
the small arteries that flow to the glomeruli thicken over time, reducing their capacity to
function. This declining ability will have an impact on the nephrons that excrete waste
products. That is why several drugs are not filtered and removed properly as we age. However,
sufficient kidney function can be preserved to the meet the body’s needs. The changes that
occur in our kidneys may or may not cause disease, but this can reduce the degree of reserve
kidney function. This means that both kidneys have to work to their full capacity to perform
the normal kidney function.

Ureters do not undergo a lot of changes compared to the bladder and urethra. The volume of
urine that a bladder holds decreases with time, as well as the ability to delay urination after
feeling the need to urinate. There is also a decreasing rate of urine outflow to the urethra and
the sporadic contractions of the bladder wall muscles are not blocked by the brain, resulting in
urinary incontinence. In women, there is a shortening of the urethra and a thinning of its lining.
These changes will decrease the urinary sphincter’s ability to close tightly, placing a person at
risk for urinary incontinence. In men, the prostate gland tends to enlarge and blocks the flow
of urine. This blockage can cause urinary retention and kidney damage if left untreated.

Physiologic Changes in the Nervous System

The brain is the primary organ of the nervous system. During childhood, its ability to think and
function steadily increases, allowing a child to acquire complex skills. Its abilities is relatively
stable in early adulthood and will decline after a certain age. Although brain functioning as we
age varies from person to person, it usually affects short-term memory, verbal abilities and
intellectual performance. Older people often have a slower reaction time and brain performance
compared to young people. The effects of aging on brain functioning have an influence on
certain disorders like stroke, an underactive thyroid gland and degenerative brain disorders like
Alzheimer’s disease. However, this varies from person to person.

15
The spinal cord and the peripheral nerves will also change as people age. The disks located in
the backbones become brittle and hard, losing its capacity to cushion it and start to place
pressure on the spinal cord and the nerves emerging from it. Peripheral nerves, on the contrary,
may conduct impulses slowly, resulting in a decrease of sensation, clumsiness and slower
reflexes. Degeneration is common among older people. The blood flow decreases and the
ability of the nervous system to self-repair becomes slower and incomplete. This makes them
vulnerable to injuries and various diseases.

Physiologic Changes in the Endocrine System

Despite the changes caused by aging, the endocrine system functions well in older people. The
changes that occur are due to the external factors and genetically programmed changes of the
cells. They may affect hormonal production and secretion, hormonal metabolism, rhythms in
the body, and target cell’s response to hormones and hormone levels that circulate in the blood.
For instance, the development of Type II Diabetes is thought to be related to increasing age,
especially in those individuals at greater risk of the disorder. This affects the size of the pituitary
gland that regulates the production of hormones. Decreased levels of hormones can also affect
heart function and cause lean muscles and osteoporosis.

Physiologic Changes in the Reproductive and Genitourinary System

Aging affects woman’s ovaries, resulting in menopause. This usually happens between the age
of 45 and 65 at which time the ovaries stop producing estrogen and progesterone and cease
storing egg cells. When this happens, the menstrual period stops and a woman cannot bear
children anymore. But before menopause takes place, there are perimenopause signs that every
woman experiences. These symptoms include more frequent periods at first and occasional
missed periods in the following months. This accompanies a change in the menstrual flow and
periods that are either shorter or longer.

Menopause is a normal part of a woman’s aging process. It declines hormone levels, affecting
other parts of the genitourinary system. Vaginal walls become drier, thinner and less elastic,
making sex more painful and placing a woman at greater risk for vaginal yeast infections.
Meanwhile, men do not have a major or rapid change in fertility as they grow older. Aging can
only affect the testicular tissue, erectile function, and sperm production. Although it varies from
person to person, most men experience an enlargement of the prostate gland, which causes a

16
condition called benign prostatic hypertrophy. Erectile dysfunction and infertility occur when
there is a gradual decrease in the production of testosterone, a male hormone found in the testes.

FACTORS AFFECTING HEALTH PROMOTION IN ELDERLY

Health promotion in the elderly is sometimes challenging. Several factors can affect the
planning and preparation of meals, for example, as some people are not able to obtain the
necessary nutrients for optimum physical and psychological well-being. The good news is that
a lot of these factors can be controlled and their negative impact can be minimized.

Decreased taste and smell

Older adults have fewer taste buds compared to younger people. According to Medline Plus,
the number of taste buds starts to decrease at the age of 40 to 50 in women and 50 to 60 in men.
Some of them atrophy, leading to a reduced taste sensation and loss of appetite. Elderly adults
often do not eat well and have a lesser food consumption than younger adults. This is also due
to their diminished sense of smell caused by a loss of the nerve endings in the nose.

Loss of appetite

A lot of people have a lesser appetite as they age. According to the Academy of Nutrition and
Dietetics, around 5 to 10% of adults over 45 years old experience iron deficiency anemia caused
by difficulty in chewing and loss of appetite. The inability to obtain the right nutrients can
affect the overall nutrition of an elderly; thus, it is recommended to supplement with vitamins
and eat small and frequent meals. Food can be made more appetizing by adding or using spices
and preparing different kinds of meals every day.

Lack of mobility and financial issues

Seniors with a disability often have problems buying nutritious foods and meals. These
individuals have limited access to the supermarket because of their physical condition, but
programs such as delivery meal services are now offered to make nutritious foods accessible.
Nevertheless, financial issues like a small fixed income among the elderly population impose
a great problem for health promotion. This limits food selection in older people, especially
those with special dietary needs.

17
Nutrient absorption

Most older adults may not be able to absorb the essential nutrients from food and other sources
of nutrition because of age-related changes in metabolism. They often experience a Vitamin
B12 deficiency because their digestive tract is unable to absorb the vitamin well, making them
at risk for depression and dementia. A blood test can assess this deficiency and vitamin B12
shots may be necessary to supplement the loss.

Reproductive system problems

Women lose 3 to 5 percent of their bone mass as their estrogen production declines. This
menopausal stage can lead to a greater risk for osteoporosis, as calcium production decreases
over time. Men on the other hand, experience prostate problems which can block the urinary
system and cause difficulty with urination and bowel movement. Unfortunately, these
reproductive system problems can limit an elderly person’s compliance with health promotion.

Religion

Older adults have different views on life. Bound by faith, these seniors believe that aging is a
normal process and compliance with health promotion is an added cost. Therefore, they tend
to isolate themselves and wait for their time of death.

Risk for heart disease

The risk for heart disease increases after we reach 50. For older adults, developing heart disease
is common. They cannot easily perform certain tasks because of unstable blood pressure. Some
elderly even limit their food selection because of the possibility of aggravating the disease.

Depression and isolation

Older adults who live alone are vulnerable to social isolation. They are prone to depression
which can lead to poor nutrition and disease complications. Nowadays, a lot of senior centers
and elderly care programs are reaching out to these individuals to minimize depression and
promote optimum health and well-being.

18
TYPES OF NON VERBAL COMMUNICATION

Good communication is the core foundation of a successful relationship. In caring for the
elderly, it is essential to recognize and be familiar with non-verbal communication – like
facial expressions, eye contact, gestures, tone of voice and posture. These signals have a huge
impact, because it is often the starting point of conversation, especially when it comes to
providing quality healthcare. Most older adults have varying special needs. Their interaction
with others is quite limited compared to young people because of their age and disability. If
we do not recognize the nonverbal cues displayed in an older adult, we cannot become an
effective healthcare provider

Facial expressions

There are several types of nonverbal communication signs, and facial expressions are some of
them. The human face is expressive, and it can convey many emotions without ever saying a
word. Unlike other forms of non-verbal communication, facial expressions are universal. We
can express happiness, anger, sadness, fear, and disgust similarly regardless of one’s culture.
However, subtle cues alter the balance. Thus, it is important to get to know the particuilar
older adult you are caring for to know what they are trying to communicate, even without
words.

Body movement and posture

Our perception towards other people is affected by how they stand, sit, walk and hold their
head. The way we carry ourselves says a lot about us. Nonverbal communication includes
posture, stance, bearing and subtle movements.

Gestures

Gestures are part of our daily lives. We use our hands when we speak or argue and express
ourselves by waving, pointing or beckoning. However, it is important to take note that
gestures have a different meaning in different cultures. Even simple things like nodding,
patting someone on the head or showing your feet can have an entirely different meaning,
depending on where you come from. They might be easily misinterpreted if not done
properly.

19
Eye contact

Eye contact is an important type of nonverbal communication tool. For the elderly, this may
not be applicable at all times, but for someone who has clear vision and perception, it can
imply various emotions. It can mean interest, affection, attraction or even hostility.

Touch

Touch is also a form of interpersonal communication. A handshake, a warm hug, a reassuring

tap on the back, a patronizing pat on the head or a controlling grip on the arm are all forms of
communicating a message, but they provide different meanings. If you are unsure about the
other person’s reaction, it is best to use touch and body contact moderately so as not to offend
anyone.

Space

Some elderly require a lot of space to feel comfortable. This type of nonverbal
communication should be observed because personal space needs vary widely. It usually
depends on the culture, situation, and closeness of the relationship. If the older adult sits close
to you, it may indicate feelings of comfort, closeness or affection. But, it can also mean that
they come from a culture where less personal space is the norm, and they have no other
alternate feelings attached to it.

Voice

The tone of the voice and how you say something can convey a very different meaning.
Communicating with an elderly person requires a particular tone and pace of voice. When
communicating with someone who is older, try not to speak too fast or use unnecessary slang.
Talk at a clear and slow pace, without sounding condescending or patronizing. It is important
to understand this kind of nonverbal communication to promote understanding and convey
the right message.

MORBIDITY IN OLD AGE

Nearly half of the older people have one or more chronic diseases. Further nearly 40% of
them have one or more disability. Common are

 Hypertension
 Cataract
 Osteoarthritis

20
  COPD
 Ischemic heart disease
 Diabetes
 Dyspepsia
 Constipation
 Depression

MORTALITY IN OLD AGE

Mortality on old age the common causes of death in rural india are the following

 Ischemic heart disease

 Stroke
 Lung cancer
 Tuberculosis

NUTRITION AND AGEING

Healthy eating should be part of every elder’s diet plan. Food intake provides energy and
sufficient nutrients when done properly. However, without proper nutrition, the aging process
can affect several organs and cause various health complications, which in some extreme
cases may lead to an irreversible disability. Proper nutrition should be followed to promote
quality of life among elderly adults the ingestion of essential nutrients should be taken into
consideration

Vitamin D and calcium

Elderly individuals require more vitamin and calcium to keep their bones strong and healthy.
Foods rich in calcium include fat free or low fat milk and dairy products, yogurt, fortified
cereals, dark green leafy vegetables, fruit juices and canned fish with soft bones. Elderly
adults need at least three servings of vitamin d and calcium every day. If calcium
supplements or multivitamins are taken as a replacement, make sure to choose one containing
vitamin D.

21
Fiber

Fiber is essential in every elderly dirt to keep the bowel functions normal and promote a
healthy heart. It gives one a feeling of fullness which in return minimizes a feeling of hunger.
Older men and women should consume at least 30 grams of fiber each day from healthy food
sources like vegetables, fruit, and whole grains. There are also other grocery products with
fiber content, but choose those with at least three grams of dietary fiber per serving

Potassium

Like any other nutrient potassium is also important to maintain and promote healthy living
among older adults increasing potassium intake and decreasing sodium consumption may
lower the risk of high blood pressure and cardiovascular diseases. Foods rich in potassium
intake green leafy vegetables, fruit, yogurt, and low fat milk. Try to avoid foods with a high
sodium content. Rather then using salt in dishes, replace it with herbs and spices to lessen the
sodium intake.

Healthy fats

For overall health and weight control, fat caloric consumption should be at least 20 to 35
percent of the diet. Most of the fat intake should comes from heart friendly unsaturated fat
sources like extra virgin olive oil, walnuts, canola oil, and almonds. Healthy older adults
without heart disease should limit the consumption of saturated fats to 10 percentile, while
those with a high cholesterol history should limit it to 7 percent of their daily food intake.
Red meat, fried foods and even full fat diary products should be used minimally or in some
cases even avoided.

Making calorie count

Older individuals cannot eat the way they did in the 20s if they want to maintain their weight.
It is sad fact that as we age, tend to less active, lose muscle mass and gain fact. These changes
cause the metabolism to slow down and require an individual to keep it up his or her entire
lifespan.

The number of calories needed to consume everyday on the persons age, gender, and level of
activity. For older adults with a sedentary lifestyle , atleast 2000 calorie should be consumed
daily while for those with a moderately active lifestyle, calorie consumption should be atleast
2200 to 2400 per day. Moreover an active older adult should consume at least 2400 to 2800

22
calories per day. This should be balanced with physical activity to keep up the metabolism,
build muscle and increase energy.

FACTORS AFFECTING NUTRITIONAL STATUS OF ELDERLY

 Changes in normal physiology

 Dental problems
 Changes in taste and smell
 Ability to digest and absorb nutrients can affect both the quality and quantity of food
consumed and overall suboptimal nutritional status

Increased prevalence of chronic diseases

 Obesity
 Accidents and trauma
 Heart disease
 Cancer
 Arthritis
 Osteoporosis
 Diabetes
 Senile dementia
 The use of prescription drugs can result
 Physician ordered changes in the diet
 Decrease in strength and ability to shop or cook
 Disturbances in the ability of the body to utilize nutrients normally

Socioeconomic, psychological and cultural factors

 Low income
 Beliefs and superstitions regarding food and dietary habits
 Social isolation
 Depression and loneliness from loss of spouse
 Family members and friends can decrease the quantity and quality of the diet
 Alcoholism and use of therapeutic drugs, when alcohol is substituted for nutritious
foods, it may interfere with absorption of some nutrients, notably folic acid. Long-
term use of certain therapeutic drugs that interfere with absorption and metabolism of
nutrients is an important cause of malnutrition in the elderly.

23
Other factors

 Loss of taste
 Loss of interest in food
 Depression due to loss of independence or bereavement, or simply eating alone can
reduce appetite.
 Poor appetite
 Difficulty in chewing
 Constipation

Drugs nutrient interaction:

Drugs nutrient interaction it has been estimated that 76% - 92% of elderly use at least one
prescription or non-prescription drug daily. With increasing age, the body’s ability to
metabolize medications decreases, therefore making it difficult for older adults to excrete
multiple medications. Older people take various medications for: heart disease, and to treat
respiratory problems, gastrointestinal disorders and arthritis.

Drugs that alter nutrient intake:

Drugs that alter nutrient intake, Drugs either prescribed or over the counter may contribute
undesirable side effects that can cause a reduction in food intake and thus nutrients entering
the body.

Drugs that can alter nutrient excretion

Drugs have been found to alter re-absorption in the kidneys or displace nutrients from their
plasma protein carriers. Diuretics such as Frusemide increase renal loss of potassium,
calcium, sodium, Magnesium and thiamine, Gentamicin, ithramycin and Actinomycin D
increase the excretion of calcium. Corticosteroids may cause sodium retention.

Increased magnesium urinary loss is due to mediations such as, Thiazides and Frusemide,
alcohol, Cyclosporine, and gentamycin

24
NATIONAL POLICY FOR OLD AGE

The National policy for old age was announced by govt. of India in January 1999. The
principle area of intervention and action strategies were suggested in the policy sector include
the following:

 Financial security for older persons working in the formal sector as well as working in
the informal sector.
 Health care & nutrition to enable older person to cope with the health associated with
ageing with particular emphasis on prevention.
 Shelter/ housing keeping in view the lifestyle of older person. Emphasis upon
education, training & information needs for older adults.
 Priority attention to vulnerable groups such as the destitute, widows, & disable older
person Protection of life & property of older person. Concessions rebate & discounts
to older person. Participation of NGOs in the care of aged. Strengthening the family &
reinforcing inter-generational relationship between children & older person.
 Formation of self-support group of older person.
 Development of the manpower for the caring of aged.
 Development of self support group of older person
 Creative use of media in the sector care of old person
Establishment of a specific bureau for older person in the ministry
reviewing the policy every three years.
Establishment of a national association of older person.
 Establishment of a national council for older person.
 Use of social justice committee & experts of public administration to coordinate &
monitor the implementation of the policy.

RESPONSIBILITEIS OF GERONTOLOGICAL NURSE

The main objective of gerontological nursing is to improve the quality of life of old people.
The nurse has the following role in gerontological nursing:

 Care giver & Health educator Coordinator of health services.

Counsellor & guardian

25
  Health assessment: In health assessment of old person,
 Daily activities of living.
 Activities related to use of equipment or procedure (telephone, bank account, food
preparation)
 Health screening
 Promoting good nutrition Promoting activity & exercise.
 Preventive care of elderly: In case of elderly, their physical & mental safety is very
important.

Gerontological nurse & care giver should pay special attention to the following safety
measures:

 Protection from unhealthy environment.

 Protection from mental tensions.
 Special care of personal health.
 Protection from physical & mental injuries, threats & fatigue.
 Providing rehabilitation services.
 Providing psychological support.

Spirituality & ageing

Spirituality is the power of the mind, it is the ability to look up to life, it is the attitude that we
adopt to make our lives better. Spirituality teaches us to follow morals, rights and obligations
thus making our lives fruitful and successful. Spirituality and old age go in tandem because
this is the time people get free to relax and enjoy the fruits of their hard work. Spirituality is
the cord that binds the mind, body and soul together.

spirituality and religious participation are highly correlated with positive successful ageing.
As much as diet, exercise, self-efficacy & social connectedness stimulating an interest in
understanding of why spirituality has such a positive effect on the quality of life & end of
life. Older adults who are more religious tend to demonstrate greater wellbeing than those
who are not. Spirituality tends to an important & adaptive role in ageing that seems to lead to
a better quality of life & life satisfaction as well as longevity.

Importance of spirituality: It has 3 major areas of importance: Mortality, Coping , and

Recovery .

26
Geriatric care may be delivered in the following settings:

Physician's office: The most common reasons for visits are routine diagnosis and
management of acute and chronic problems, health promotion and disease prevention, and
pre surgical or postsurgical evaluation.

Patient’s home: home care is most commonly used after hospital discharge, but
hospitalization is not a prerequisite. Also, a small but growing number of health care
practitioners deliver care for acute and chronic problems and sometimes end of life care in a
patient's home.

Long term care facilities: include assisted living facilities, board and care facilities, nursing
homes, and life care communities. Whether patients require care in a long term we facility
depends partly on the patient‘s wishes and needs and on the family‘s ability to meet the
patient‘s needs.

Day care facility; These facilities provide medical, rehabilitative, cognitive, and social
services several hours a day for several days a week.

Hospitals: Only seriously ill elderly patients should be hospitalized. Hospitalization itself
poses risks to elderly patients because of confinement, immobility, diagnostic testing, and
treatments.

Hospices: provide care for the dying. The goal is to alleviate symptoms and keep people
comfortable rather than to cure a disorder. Hospice care can be provided in the home, a
nursing home, or an inpatient facility.

Senior Communities; Senior housing is designed for high functioning elders, defined as
those not requiring assistance with ADLs. Senior communities are usually neighbourhoods or
towns

ROLE OF NURSE IN GERIATRIC CARE

Nursing interventions are aimed at maintaining the patient‘, physical safety. reducing anxiety
and agitation, improving communication, promoting independence in self-care activities..
providing for the patient‘s needs for socialization. self esteem, and intimacy.. maintaining
adequate nutrition. managing sleep mm disturbances" and supporting and educating family
care givers. Research has demonstrated that w the nurse can provide such support. older
adults are able to maintain higher levels of perceived and actual health.

27
Supporting cognitive function: As the patient‘s cognitive ability declines, the nurse
provides a calm predictable environment that helps the person interpret his or her
surroundings and activities. Environmental stimuli are limited and a regular routine is
followed. A quite. Pleasant manner of speaking, clear and simple explanations and use of
memory aids will help to minimize confusion and disorientation and give the patient a sense
of security.

Prominently displayed clocks and calendar: may enhance orientation to time. Colour
coding the door may help the patient who has difficulty locating his or her room. Active
participation may help the patient to maintain cognitive, functional and social interaction
abilities for a longer period. Physical activity and communication have also been
demonstrated to slow some of the cognitive decline.

Promoting physical safety: A safe environment allows the patient to move about as freely as
possible and relieves the family of constant worry about safety. To prevent falls and other
injuries. All obvious hazards are removed. Nightlights are helpful. The patient‘s intake of
medication and food is monitored .smoking is allowed only with supervision. A hazard free
environment allows the patient maximum independence and a Sense of autonomy. Because
of a short attention span and forgetfulness, wondering Behaviour can often be reduced by
gentle persuading or distracting the patient. Restraints are avoided because they may increase
agitation. Doors leading from the house must be secured. Outside the home, all activities
must be supervised to protect and the patient should wear an Identification bracelet or neck
chain in case he or she becomes separated from the Care giver.

Reducing anxiety and agitation: Despite profound cognitive losses, the patient will, at
times, be aware of his or her rapidly diminishing abilities. The patient still need constant
emotional support that reinforce a positive self-image. When losses of skills occur, goals are
adjusted to fit the patient‘s declining ability. The environment should be kept uncluttered,
familiar, and noise free. Excitement and confusion can be upsetting and may Precipitate and
combative, agitated state known as a catastrophic reaction (over reaction to excessive
stimulation). During such a reaction the patient responds. by screaming, crying or becoming
abusive (physically or verbally). This may the patient‘s only way of expressing an inability to
cope with the environment. When this occurs it is to remain and unhurried. Measures such as
listening to music, stroking, rocking may quite patient. Frequently the patient forgets what
triggered the reaction. Structuring of activities is also helpful. Becoming familiar with the

28
patient‘s predicted responses to certain stressors helps care givers to avoid similar situations
the time older persons with dementia have progressed to the late stage of the disease, they
typically in nursing homes and are predominantly cared for by nurse‘s aids.

Improving communication: To promote the patient‘s interpretation of messages, the nurse

should remain unhurried and reduce noises and distractions. Use of clear, easy to understand
sentences to convey messages is essential patients frequently forget the meaning of words or
have difficulty in organizing and expressing thoughts.

In the early stage, lists and simple written instructions may be helpful. In the later stage, the
patient may be able to point out at objects or use non-verbal language to communicate.
Tactile stimuli such as hugs and hand pats are usually interpreted as signs of affection,
concern and security.

Providing for socialization and intimacy needs: Because socialization with friends and
family can be comforting, Idlers and phone mils are encouraged. Visits should be brief and
non-stressful; limiting visitors to one or two at a time helps reduce overstimulation.
Recreation is important, and people are encouraged to participate in simple. Realistic goals
for activities that provide satisfaction are appropriate. Hobbies and activities such as walking,
exercising and socializing can improve quality of life. The non-Judgemental friendliness of a
pet can stimulate comfort and provide contentment Care of plants and pets can be satisfying
and an outlet for energy. Simple expressions of love as holding, touching are often
meaningful..

Providing adequate nutrition: mealtime can be pleasant social occasion or a time of upset
and distress, and it should be kept simple, calm without confrontations. People prefer foods
that are appetizing and tastes good. To avoid playing with food, one dish at a time. Food is
cut into small pieces to avoid choking. Liquids may be easier to swallow if they converted to
to gelatine. Hot foods and beverages are served warm to prevent bums.

Promoting balanced activity and rest: Many people complain with sleep disturbances and
wandering behaviours that inappropriate. These behaviours are most likely to occur when
there are unmet physical or psychological needs. Caregivers must identify the needs of the
patient who are exhibiting these behaviours because further health decline may occur if they
are not corrected. During the day time physical activity can be encouraged and long durations
of sleep during the day time are discouraged.

29
Supporting home and community based care: The emotional burden on the families of
elderly are enormous. The physical health is often stable and mental degeneration is gradual.
Family members may be faced with difficult decisions. Anger and agitation exhibited by the
older adults are often misunderstood by the family members. Abuse and neglect of the older
adults must be avoided and they have to be constantly supervised on the minor and major
ailments for immediate medical help is mandatory.

SUMMARY

The older adults being vulnerable to many health issues constitute the higher vulnerable
group. They must be constantly supervised and taken care of the minor ailments and
approach immediately for medical help in cases of emergency. The nurses must coordinate
with the older health team members to provide comprehensive and holistic care considering
all the needs and domains of a human being. Assisting in their daily activities and encourage
them to perform minimum physical activity as tolerated which improves self esteem and
enhances self image of the older adult.

BIBLIOGRAPHY

1. Shabeer.k.basheer ,text book of advance nursing practice

2. Brunner& suddarths,text book of medical surgical nursing\
3. www.geriatric nursing.org
4. www.scribd.com/geriatric nursing
5. www.slideshare.com/geriatric nursing

30