GERIATRIC CONSIDERATIONS IN NURSING

INTRODUCTION:-

Gerontological changes are important in nursing assessment and care because the changes can adversely affect health and functionality and require therapeutic strategies. These changes must be differentiated from pathological processes to allow development of appropriate interventions; predispose to disease, thus emphasizing the need for risk evaluation of the older adult; and can interact reciprocally with illness, resulting in altered disease presentation, response to treatment, and outcomes.

BASIC CONCEPTS OF GERONTOLOGICAL NURSING:-

The following terms are used in the study of ageing:-

1. Geriatrics:- from Greek gears ( old age) and iarike (medicine) is the branch of medicine concerned with medical problems and care of older people

2. Gerontology:- this is the scientific study of the process and problems of aging and focuses on the biological aspects of normal ageing.

3. Gerontologic nursing—this specialty of nursing involves assessing the health and functional statusof older adults.--it is the term often used by nurses specializing in the field.d)

4.  Gerontic nursing—this term was developed by Gunter and Estes in 1979 is meant to be more inclusivethan geriatric / gerontologic nursing because it is not limited to diseases/ scientific principles. this term has not gained wide acceptance , but is viewed by some as a more Appropriate description of the specialty.

5. Ageism---is a termed that was coined by Butler 1969 describe the deep & profound prejudice inamerican society against older adults.--age descrimination

6.  Gero Psychology –branch of psychology concern w/ helping older persons & their families tomaintain well being, over come problems, & achieved maximum during later life.

7.  Gero Pharmacology---study of pharmacology as relates to older adults.8.  Financial Gerontology---combines knowledge a financial planning & services w/

special expertisein the needs of older adults

HISTORY OF GERENTOLOGICAL NURSING: DEVELOPMENT OF A SPECILTY:-

Geriatric nursing, the first name given to the nursing specialty was replaced by gerontological nursing in 1976 to reflect nursing emphasis on health rather than disease. Historically, nurses have always been in the front lines caring for the aged. They have provided hands on care, supervision, administration, programme development, teaching, and research and are, to a great extent responsible for the rapid advance of gerontology as a profession. Nurses have been and continue to be, the mainstay of care of older adults.

The origin of gerontological nursing begin when Florence Nightingale, the founder of modern nursing, accepted a position as superintendent in an institution comparable to today’s nursing home, the institution for the care of Sick Gentle women in distressed circumstances.

Patients at this institution were primarily Governesses and ladies’ maids from the wealthy English families. Awareness of need for education in gerontological nursing, as well as the need for improvement in the care of institutionalised older adults, was first noted in the American nursing literature in the early 1900’s. The first book on gerontological nursing was written by Newton and Anderson in 1950, and in 1966, T he Division of Geriatric nursing practice was established within ANA, giving nursing care of the aged specialty status along with maternal/child, medical-surgical, psychiatric, and community health.

Considered nursing’s newest and youngest specialty, gerontological nursing emerged as a circumscribed area of practice only within the last 5 decades. Before 1950, gerontological nursing care was seen as the application of general principles of nursing care to the older adults with little recognition of this area of nursing as a specialty similar to other specialties.

ANA AND THE SCOPE AND STANDARDS OF GERONTOLOGICAL NURSING PRACTICE:-

To develop accurate and informed attitudes, gerontological nursing organizations have established standards, legitimized the specialty, upgraded the knowledge base, enhanced the image of gerontological nurses, and identified the benefits of working with the older adults. Nursing is the first of the professions to develop standards of gerontological care and the first to provide a certification mechanism to ensure specific professional expertise through credentialing. In 1973 the ANA first defined standards of geriatric care, and geriatric nursing was the first specialty to establish standards of practice within the ANA.

AGEING PROCESS:-

Ageing is a universal phenomenon old age is not in itself is a disease, but is a normal part of the human life span. Ageing is a normal, universal, progressive, irreversible process. It is an inevitable physiological phenomenon.

The human life span follows a recognised pattern from birth to death. A peak of human growth and development is reached in the twenties. Then there is a gradual deteriorisation in physical and mental abilities. As the ageing process progresses mental capabilities such as memory and physical abilities further deteriorate.

FACTORS WHICH INFLUENCE AGEING:-

1. Hereditary factors:-Some families live longer than others given the same environmental circumstances. This is elated with genetic factors. This gene is not only the ageing gene but could also be a cancer gene.

2. Environmental factors:- Bourlier in 1973 has given 3 factors.a. Abiotic factors:-

These are the physical and chemical components of the environment such as – climatic influences, pollutants and radiation.

b. Biotic factors:-These result from the influence of the thousands of living organisms which share man’s environment. Ageing processes are affected by such things as pathogens, parasites and quality and availability of food products.

c. Socio-economic factors:-Adverse living and working conditions can increase the wear and tear of tissues to which the individual is exposed. Stressful living conditions are likely to accelerate the process of ageing. Stress factors are more prevalent in modern industrialised society. Income, poverty and chronic health problems also affects ageing.

3. Disabilities of old people:-

Inability to performas expected in the socio-economic and cultural context, e.g. poor self care, improper family role and social role, vocational incompetence, improper interpersonal relationship, bad money management. All these causes a burden to the family. So the care had to be planned accordingly such as

i. Individualised needsii. Family needsiii. Available resources and facilities

These are termed as

a. Residential in the home selfb. In hospitalsc. In half way homesd. In day care centrese. In long stay care homes with lumpsum deposits or monthly payments or inf. Professional care centres with better facilities

So, we have to identify the needs of the particular person, his financial condition and set an objective and take action and implement it. The main goal is helping the aged to reach and maintain their best level of functioning, reduction or maintenance of disability or to remove the problems faced as a result of illness.

The effect of ageing causes gradual reduction in the normally functioning cells and cause dysfunctional abilities and social activities. It is a sum total of these functions, that determine the individual’s response of ageing.

A. Changes in posture and appearance:- As ageing progresses lean body mass in muscle tissue is lost, whereas the

proportion of the fat increases. This decline in muscle mass and increase in fat is known as “SARCOPENIA”.

There is a loss of elasticity and flexibility in muscle is due to increase in fibre, decrease in muscle mass after the age of 50. In order to reduce such loss or prevent it, vigorous exercise may help.

Changes in the body composition are due to the result of their diet and life style. Older people need less calories and more protein, calcium and vitamin D.

The wrinkled, dried and tougher skin surfaces of old people is due to the ultraviolet from the sun which damages the elastic fibres and this is known as photo ageing or extrinsic ageing.

Outer epidermis in adult and young goes on replenishing itself by shedded dead cells and replacing them with new cells. Then the dermis, the second layer becomes thin and less elastic, making it longer to spring back into shape. All these causes the wrinkling and sagging of the skin. Women experiences this earlier as they have less oil in their sebaceous glands. This can also depend upon lifestyles and heredity. Deeper layers loses fat and the sebaceous and sweat glands deteriorate. There is a reduction in circulation in the skin causing skin temperature regulation mechanism less functioning, as a result older people are more sensitive to hot or cold temperatures.

Due to less circulation wound healing is delayed. When the body temperature rises, as they cannot be lessened by sweating,

due to less number of sweat glands, the temperature rises causing heat exhaustion, heat stroke, heat failure and stroke. This heat increase may cause nausea, vomiting, dizziness, dry skin, cramps, fainting and confusion.

In older people, the texture of the hair. The hair becomes fine, limp and scanty or bald. As we age, more hair are lost than replaced. Grey hair is a result of loss of pigments which are gradually reduced so the hair become white or grey. But due to hereditary factor, some may never lose the pigment production and can keep their hair black.

Usually the height reduces by three inches with age in both body and extremities. This is due to the lessening in production of estrogens and testosterone which causes a lot of mineral bone density, causing the bone to become brittle, so that easy bending occurs and easy fractures in older people. So the spine becomes more curved and discs in the vertebra

becomes compacted causing spondylitis and also osteoporosis – which makes the bone porous – hence fractures.

Thus their posture becomes stooped forward with flexed knees, hips and elbows and head is titled back.

B. Changes in musculoskeletal system

Older people suffer from arthritis, paralytic stroke in addition to the osteoporosis problems. This produces stiffening of the joints making them difficult for easy movement such as getting up from a chair, to turn their neck and to keep an erect posture.

Also their shoulder width is reduced due to bone loss and also weakening muscles and loss of tone and elasticity causes stooping. The same way the collapsing of vertebra causes a hunched back or kyphosis in addition to spondlytis. This occurs as the spongy cartilages decreases and break down causing no or less lubrication between the vertebra.

Unless the older people resort to a regular exercise programme, their strength and stamina deteriorates.

C. Changes in central nervous system

Because of the changes in the central nervous system older people develop decreased ability to orient their bodies in space to detect externally induced changes in body position.

There is progressive loss of nervous and sensory systems as ageing progresses. There is delayed reaction and responses in elderly. There is a reduction in the efficiency of sensory perception due to degenerative changes in the elderly, which effects vision, hearing, gustatory, tactile and olfactory senses.

Atrophy of the brain, decreased blood flow and affection of peripheral nerves like deep tendon reflexes, decrease in dopamine level, occurs in persons suffering with parkinsons.

D. Sense of touch

Sense of touch deteriorates with age especially in finger tips and palms and in lower extremities. This also causes less levels of painful stimuli. But they may complain of pain and it is due to depression.

So, we have to have adaptations to change their life. That is there may be poor lighting, uneven stairs and floors, high shelves and cupboards, slippery floors especially in bathroom all these had to be modified, to prevent falls. Make hand rails, rough floors in the bathroom, good lighting everywhere especially stairs. Keep all things (only need things ) within reach of the person. Remove all unnecessary furniture.

E. Changes in respiratory system

With ageing the inspiratory and expiratory muscle strength is reused, the lung loose elasticity so that efficiency in breathing is reduced. This restricted ventilation causes decreased vital capacity causing decline in oxygen consumption. Intercoastals and scalene accessory muscles and diaphragms used more for expiration. In erect posture, posterior thoracic curve resulting in kyphosis which restricts breathing. Breathing may become more difficult after strenuous exercise or after climbing up several flights of stairs, but it does not necessarily impair the persons daily functions, but he had to move slowly, suffer from fuel pollutants and infections. So older people can avoid many problems by being active in their life.

Adaptation to the environment:-

As the environment changes continuously the older people takes from it what he needs, controls what can be manipulated and adjusts to conditions that cannot be changed.

Adaptation thus includes a process in which the individual

F. Changes in immune systemG. Changes in cardio vascular systemH. Changes in urinary systemI. Changes in gastrointestinal systemJ. Changes in endocrine systemK. Changes in reproductive systemL. Changes in nervous systemM. Changes in sleep patternN. Changes in sensory functionsO. Changes in visionP. Changes in hearingQ. Changes in taste and smellR. Other changes

PSYCHOSOCIAL THEORIES OF AGEING:-

Sociological theories of ageing:-

Activity theory Disengagement theory Subculture theory Continuity theory Age stratification theory Person-environment-fit theory Gerotranscendence theory

Psychological theories:-

Human needs theory Theory of individualism

Stages of personality development theory Life course (life span development) paradigm Selective optimisation with compensation theory

BIOLOGICAL THEORIES OF AGEING:-

Stochastic theories or statistical perspective1. Free radical theory2. Orgel / error theory3. Wear and tear theory4. Connective tissue theory

The Non - Stochastic theories1. Programmed theory2. Gene / biologic clock theory3. Neuro-endocrine theory4. Immunologic / autoimmune theory

NURSING THEORIES OF AGEING:-

Functional consequences theory Theory of thriving

PSYCHOSOCIAL THEORIES OF AGEING:-

The earliest theories on ageing came from the psychosocial disciplines. Psychosocial theories attempts to explain ageing in terms of behaviour, personality and attitude changes. Development is considered as a lifelong process characterised by transitions. Psychological theories are concerned with personality or ego development and the accompanying challenges associated with various life stages. How mental processes, emotions, attitudes, motivation and personality influence adaptation to the physical and social demands are central issues.

Sociological theorists consider how changing roles, relationships, and status within a culture or society impact the older adult’s ability to adapt. Societal norms can affect how individuals envision their role and function within that society, and thus impact role choices as well as how roles are enacted.

It is hard to disentangle the social from the psychosocial aspects of theories of ageing and they are usually considered together under the term ‘psychosocial’ moreover it should be appreciated that there are number of theories of psychosocial ageing, there is little evidence to support any systematic change in the psychology of people as they become older. This is indicated by the contradictory nature of the two theories of psychosocial ageing: disengagement theory and activity theory.

Sociological theories of ageing:-

Activity theory:-Sociological theorists have attempted to explain older adult behaviour in

relationship to society with such concepts as disengagement, activity and continuity. One of the earliest theories addressing the ageing process was begun by Havighurst and Albrecht in 1953 when they discussed the concept of activity engagement and positive adaptation to ageing. From studying a sample of adults, they concluded that society expects retired older adults to remain active contributors. Activity theory was conceived as an actual theory in 1963 and purports that remaining occupied and involved is a necessary ingredient to satisfying late-life. They suggest activity as a means to prolong middle age and delay the negative effects of old age. An assumption of this theory is that inactivity negatively impacts one’s self concept and perceived quality of life and hastens ageing.

Arguments against this point of view are that it fails to consider that activity choices are often constrained by physical, economic, and social resources. Furthermore roles assumed by the older adults are highly influenced by the societal expectations. Maddox suggests, however , that leisure time presents new opportunities for activities and roles such as community service that may be more consistent with these limitations. A second criticism of activity theory is the unproven assertion that continued activity delays onset of the negative effects of ageing.

Despite these criticisms, Disengagement theory Subculture theory Continuity theory Age stratification theory Person-environment-fit theory Gerotranscendence theory

Psychological theories:-

Human needs theory Theory of individualism Stages of personality development theory Life course (life span development) paradigm Selective optimisation with compensation theory

Disengagement, activity and continuity theories:-

Disengagement theory describes a process whereby people gradually disengage from life as they become older. For example, a person may retire from employment and thereby have less involvement with the lives of the people who were also employed in the same company. On the other hand, activity theory describes a process whereby, while people do disengage from certain activities as they become older, they replace these with others as they are able physically and economically to do. For example, there are those who retire from work who take up new hobbies and interests and , indeed become more active in old age than they were in younger years.

Lying somewhere between these two theories is continuity theory, which describe a process whereby people, as they age, struggle to retain as many of the activities of their younger life as possible.

Erickson’s theory of life span:-

One theory that attempts to describe the process of ageing from cradle to grave is erikson’s theory of life span in which eight stages to the life process are described. This is in contrast to the above theories which really only consider old age are not developmental. Erikson’s theory incorporates adjustment to the process of ageing and further psychological development as people age.

Each stage represents a choice or conflict, and the way in which that conflict is resolved will affect all subsequent stages. It also affects the development of personality and success in adapting to the world. The internal conflicts in old age are integrity versus despair. Integrity is concerned with a sense of wholeness, uniqueness and worthwhileness, a feeling that one’s life has been of value. The ultimate stage of Erikson’s theory sees the older person reflecting on life and evaluating whether or not it has been a worthwhile and positive experience. If the answer is affirmative then they can die peacefully, but if it is negative, then they experience despair before death.

BIOLOGICAL THEORIES OF AGEING:-

Biological ageing or senescence, is an indisputable fact with plenty of supporting evidence. There are many classic signs of ageing, some of which become evident even in relatively young people. For example, the loss of hair colour and thinning of hair, loss of elasticity of skin leading to wrinkling and reduced joint flexibility are all signs of ageing which are universally displayed, albeit to different extents in people as they age. There are many theories of biological ageing and they can be grouped under three headings

i. Hereditary theories of ageingii. Physiological theories of ageing iii. Cellular theories of ageing

1. Hereditary theories of ageingThese are genetic in nature and propose that we are programmed at birth to age and die. Clearly these are true for all humans and may be true for individuals also in terms of rate of ageing and life span. Environmental aspects may play their part by acting on the genetics of the individuals; for example, some people may be more prone to some diseases but may or may not be exposed to them depending on how and where they live. The hereditary theories, in addition to explaining how we age, also offer some explanation in evolutionary terms of why we age and eventually die. Physiological theories:-

There are a number of physiological theories of ageing.

The notion of ‘wear and tear’ which leads, at different rates between systems and between individuals, to the organs of the body gradually deteriorating as we age and losing capacity to undertake their physiological functions.

Another physiological theory is based on a decreased ability to maintain homeostasis as the body ages and this leads to a decreased ability to withstand physiological stresses such as dehydration, changes in temperature and other disturbances to the homeostatic balance of the body caused by disease.

The cross linkage theory is based on accumulation of metabolic waste products with age that leads to a chemical change in the collagen in the body. This change is a chemical reaction leading to cross-linking between amino acids in the collagen and therefore loss of flexibility. This is observable in the skin and in the joints, as mentioned above.

The immune system has been implicated in ageing because as we age it becomes less capable of fighting infection and may even begin to attack cells of the body- a condition known as autoimmunity. There is evidences for reduced numbers of immune system cells, and autoimmunity has been implicated in

BIOLOGICAL THEORIES OF AGEING:-

A THEORY IS AN EXPLANATION of a phenomenon that makes sense to us. Theories remain reasonable explanations until someone finds them to be incorrect.

GERIATRIC ASSESSMENT:-

Geriatric assessments, which are tests performed on elderly patients, often include evaluations for depression or psychological disturbances. Geriatric mental health testing may be performed at clinics or by a private physician. Elderly patients with dementia often undergo short-term memory tests. A physician may also perform geriatric assessments on a patient as part of routine medical care. Examples of routine geriatric assessments include hearing and eye examinations, as well as testing for heart-related problems.

Elderly patients with medical conditions or mental health issues may require geriatric assessments that are targeted for his particular case. These assessments differ from the comprehensive routine examinations given to patients on a regular basis. For instance, a patient with urinary incontinence may require an assessment to determine the cause and treatment.

Geriatric assessments for patients with diabetes may help doctors understand how the disease impacts various functions in the elderly. The goal is to find solutions to provide a better quality of life for elderly diabetes patients.

Psychological assessments are a major part of geriatric evaluations. Clinical trials and studies in nursing homes may be conducted as part of this process. Studies can determine how depression or lack of social interaction may influence an elderly individual's overall health.

It is not uncommon for the elderly to undergo geriatric assessments for in-home care. These evaluations can help provide better management for seniors who wish to remain independent while living alone. Recommendations may also be offered to elderly people regarding home safety.

Many elderly people are at risk of suffering serious injuries due to accidents in the home. Accidents from falls cause more life-threatening injuries to the elderly than any other in-home accident. Many of these accidents are preventable, though a professional evaluation may be recommended in some cases. Geriatric assessments for falls can determine if someone is at risk. Caregivers can then implement strategies to prevent such an occurrence.

Dental problems in the elderly are fairly common. Assessments for oral hygiene can determine if an elderly person is able to maintain proper oral health. In addition to various questions, the patient or caretaker may be asked to complete an oral health status report. The report will record the frequency of tooth brushing and flossing, as well as dental implements used. As part of the assessment, difficulties in maintaining oral care will be noted.

Lack of proper nutrition can be a concern for many elderly people. Nutritional geriatric assessments also provide the tools necessary to maintain proper nutrition. These assessments can pinpoint nutritional deficiencies impacting a patient's health. An evaluation may also provide caregivers with an understanding of the patient's nutritional needs.

MAIN CONCERNS IN GERONTOLOGICAL NURSING:-

As people age, their health often becomes fragile, so doctors who treat geriatric patients must deal with a host of concerns about the elderly. One of the major concerns in geriatric health is dementia, which can seriously impact a patient's cognitive abilities. Learning how to manage dementia at the onset can help improve an elderly person's quality of life. An increased risk for type II diabetes is another geriatric health concern. Serious injury due to falls is a common occurrence in the elderly and a major concern in geriatric health.

Maintaining geriatric health is vital as one advance in age. Health issues and concerns may vary with the individual, although many elderly individuals share one common complaint: arthritis. Inflammatory conditions of the joints can be extremely painful and debilitating. Coping with arthritis is especially difficult for the elderly, as it can threaten their independence and quality of life.

Geriatric health care often involves treating patients with cardiovascular disease. The risk of coronary heart disease increases with age. Factors such as poor diet and obesity in elderly patients may contribute to heart-related issues.Impaired vision is another other main concern in geriatric health. Vision problems or even blindness may result as a complication from diabetes. The elderly are more likely to develop these complications if diabetes is not properly managed.

The effects of aging can also contribute to hearing loss. This is why it is more common for the elderly to rely on the use of hearing aids. Other treatment options, such as cochlear implants may help elderly patients with hearing loss.

Addressing mental health issues may be a fundamental part of geriatric care. Many elderly individuals suffer from depression, primarily due to lack of social interaction. Feelings of isolation may occur when an elderly person is housebound. In extreme cases of depression, suicide among the elderly is a concern.

Other mental health concerns in geriatric medicine are memory loss and dementia. Cognitive reasoning may be compromised as a result of dementia due to aging. Advanced dementia may cause symptoms such as delusions and hysteria. Alzheimer's disease may be mild to advanced, and generally requires treatment such as medication and cognitive therapy.Nutrition is a chief concern for many elderly individuals. In many cases, an elderly person who lives alone or is housebound may not receive adequate nutrition. Lack of proper nutrition may also be due to the inability to cook for him. Providing home care for an elderly individual who cannot look after himself may be a solution.