Gerontological Nursing

Certificate of Geriatric Care
(CGC)
CGC-02
Geriatric Care Nursing
Block –01
Introduction to Gerontological Nursing
UNIT :I Concept of Gerontological Nursing

UNIT :II Approach to an elderly patient
UNIT :III Levels of Geriatric Care and Role of Nurse
Expert Committee
Dr. Sadhu Charan Panda Dr. Prakash Chandra Panda
Associate Professor, Associate Professor,
Dept. of Community Medicine Dept. of Community Medicine
VIMSAR, Burla – Chairperson VIMSAR, Burla – Member
Dr. Ojaswini Patel Miss Sulochana Dash

Associate Professor Principal
Dept. of Obstetric Gynaecology School of Nursing
VIMSAR, Burla – Member VIMSAR, Burla – Member
Mrs. Lilarani Swain Ms. Prashansa Das

Tutor Academic Consultant
School of Nursing OSOU, Sambalpur – Convener
VIMSAR, Burla– Member
Course Writer Course Editor

Ms. T.Malathi Mr. Baba Vajrala
Asst. Professor, Prof. cum HOD
Smt. Vijayaluke College of Nursing Dept. of Mental Health
Vishakapatanam NRI College of Nursing Guntur, AP
Mrs. Jasmin Debora
Prof. cum HOD
Medical Surgical Department
NRI College of Nursing, Guntur, AP
Material Production
Dr. Jayanta Kar Sharma
Registrar
Odisha State Open University, Sambalpur
© OSOU, 2017. Geriatric Care Nursing is made available under a Creative
Commons Attribution-ShareAlike 4.0 http://creativecommons.org/licences/by-sa/4.0
Printed by : Sri Mandir Publication, Sahid Nagar, Bhubaneswar
UNIT – 1: CONCEPTS OF GERONTOLOGICAL NURSING
Structure
1.1 Introductions to gerontological nursing

1.2 History of gerontological nursing
1.3 Landmarks in the development of gerontological nursing
1.4 Attitude towards aging and older adults
1.5 Definitions of gerontological nursing
1.6 Concept and scope of gerontological nursing
1.8 Principles of gerontological nursing
1.9 Summary
1.10 Check Your Progress
1.11 Key Terms
1.12 References
1.1 INTRODUCTION TO GERONTOLOGICAL NURSING
Aging, 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.
Odisha State Open University, Sambalpur Page 1

1.2 HISTORY OF GERONTOLOGICAL NURSING
The history and development of gerontological nursing is rich in diversity and

experiences, as is the population it serves. There has never been a more opportune
time than now to be a gerontological nurse. No matter where nurses practice, they
will at some time in their career care for older adults. The health care movement is
constantly increasing life expectancy; therefore, nurses must expect to care for
relatively larger numbers of older people over the next decades. With the increasing
numbers of acute and chronic health conditions experienced by elders, nurses are in
key positions to provide disease prevention and health promotion, and to promote
positive aging.
The American Journal of Nursing, the American Nurses Association (ANA),

and the John A. Hartford Foundation Institute for Geriatric Nursing at New York
University contributed significantly to the development of the specialty of
gerontological nursing. The specialty was formally recognized in the early 1960s
when the ANA recommended a specialty group for geriatric nurses and the formation
of a geriatric nursing division, and convened the first national nursing meeting on
geriatric nursing practice. The growth of the specialty soared over the next three
decades. In the early 1970s, the ANA Standards for Geriatric Practice and the Journal
of Gerontological Nursing were first published (in 1970 and 1975, respectively).
Following the enactment of federal programs such as Medicare and Medicaid, rapid
growth in the health care industry for elders occurred. In the 1970s, the Veterans
Administration funded a number of Geriatric Research Education and Clinical
Centres (GRECCs) at VA medical centres across the United States.
Nurses were provided substantial educational opportunities to learn about the

care of older veterans through the development of GRECCs. The Kellogg Foundation
also funded numerous certificate nurse practitioner programs at colleges of nursing
for nurses to become geriatric nurse practitioners. These were not master‘s in
nursing–level programs, but provided needed nurses who were trained in geriatrics to
meet the growing needs of an aging population. Terminology used to describe nurses
caring for elders has included geriatric nurses, gerontic nurses, and gerontological
nurses. These terms all have various meanings; however, gerontological nursing
provides an encompassing view of the care of older adults. In 1976, the ANA
Geriatric Nursing Division changed its name to Gerontological Nursing Division and
published the Standards of Gerontological Nursing (Ebersole&Touhy, 2006;
Meiner&Lueckenotte, 2006). The decade of the 1980s saw a substantial growth in
gerontological nursing when the National Gerontological Nursing Association was
established, along with the ANA statement on the Scope and Standards of

Gerontological Nursing Practice. Increased numbers of nurses began to obtain
masters and doctoral preparation in gerontology, and higher education established
programs to prepare nurses as advanced practice nurses in the field (geriatric nurse
practitioners and gerontological clinical nurse specialists).
Thus, interest in theory to build nursing as a science grew and nurses were
beginning to consider gerontological nursing research as an area of study.
Implementation of five Robert Wood Johnson (RWJ) Foundation Teaching Nursing
Homes provided the opportunity for nursing faculty and nursing homes to collaborate
to enhance care to institutionalized elders. An additional eight community-based RWJ
grant–funded demonstration projects enabled older adults to remain in their homes
and fostered cooperation between social service and health care agencies to partner in
providing in-home care.
In the 1990s, the John A. Hartford Foundation Institute for Geriatric Nursing
was established at the NYU Division of Nursing. It provided unprecedented
momentum to improve nursing education and practice and increase nursing research
in the care of older adults. In addition, it focused on geriatric public policy and
consumer education. The Nurses Improving Care for Health system Elders (NICHE)
program gained a national reputation as the model of acute care for older adults. The
21st century has provided a resurgence in gerontological care, as older adults are
gaining full status and recognition by society. As the baby boomers enter the older
age group in 2011, this cadre of individuals will not only expect but demand
excellence in geriatric care. In 2003, the collaborative efforts of the John A. Hartford
Institute for Geriatric Nursing, the American Academy of Nursing, and the American
Association of Colleges of Nursing (AACN) led to the development of the Hartford
Geriatric Nursing Initiative (HGNI). This initiative substantially increased the number
of gerontological nurse scientists and the development of evidence-based
gerontological nursing practice. Today, there are multiple professional journals,
books, Web sites, and organizations dedicated to the nursing care of older adults. One
of the newest journals to emerge in 2008 was the Journal of Gerontological Nursing
Research.
The development of gerontological nursing as a specialty is attributed to a host

of nursing pioneers. The majority of these nurses were from the United States;
however, two key trailblazers were from England. Florence Nightingale and Doreen
Norton provided early insights into the ―care of the aged.‖ Nightingale was truly the
first geriatric nurse, because she accepted the nurse superintendent position in an
English institution comparable to our current nursing homes. She cared for wealthy
women‘s maids and helpers in an institution called the Care of Sick Gentlewomen in

Distressed Circumstances (Wykle& McDonald, 1997). Doreen Norton summarized
her thoughts on geriatric nursing in a 1956 speech at the annual conference of the
Student Nurses Association in London. She later focused her career on care of the
aged and wrote often about the unique and specific needs of elders and the nurses
caring for them. She identified the advantages of learning geriatric care in basic
nursing education as:
 Learning patience, tolerance, understanding, and basic nursing skills;

 Witnessing the terminal stages of disease and the importance of skilled
nursing care at that time;
 Preparing for the future, because no matter where one works in nursing the
aged will be a great part of the care;
 Recognizing the importance of appropriate rehabilitation, which calls upon all
the skill that nurses possess; and
 Being aware of the need to undertake research in geriatric nursing (norton,
1956).
1.3 Landmarks in the development of Gerontological Nursing
The following is a summary of significant landmarks in the development of

gerontological nursing as a specialty:
1902 American Journal of Nursing (AJN) publishes first geriatric article by an MD.
1904 AJN publishes first geriatric article by an RN.
1925 AJN considers geriatric nursing as a potential specialty Anonymous column
entitled ―Care of the Aged‖ appears in AJN.
1950 First geriatric nursing textbook, Geriatric Nursing (Newton), published First
master‘s thesis in geriatric nursing completed by Eleanor Pingrey Geriatrics becomes
a specialization in nursing.
1952 First geriatric nursing study published in Nursing Research.
1961 ANA recommends specialty group for geriatric nurses 1962 ANA holds first
National Nursing Meeting on Geriatric Nursing Practice.
1966 ANA forms a geriatric nursing division First Gerontological Clinical Nurse
Specialist master‘s program begins at Duke University 1968 First RN (Gunter)
presents at the International Congress of Gerontology.

1970 ANA creates the Standards of Practice for Geriatric Nursing.
1973 ANA offers the first generalist certification in gerontological nursing (74 nurses
certified).
1975 First nursing journal for the care of older adults published: Journal of
Gerontological Nursing by Slack, Inc. First nursing conference held at the
International Congress of Gerontology.
1976 ANA Geriatric Nursing Division changes name to Gerontological Nursing
Division ANA publishes Standards of Gerontological Nursing.
1977 Kellogg Foundation funds Geriatric Nurse Practitioner certificate education
First gerontological nursing track funded by the Division of Nursing at the University
of Kansas.
1979 First national conference on gerontological nursing sponsored by the Journal of
Gerontological Nursing.
1980 AJN publishes Geriatric Nursing journal Education for Gerontic Nurses by
Gunter and Estes suggests curricula for all levels of nursing education ANA
establishes Council of Long Term Care Nurses.
1980 First Robert Wood Johnson (RWJ) Foundation grants for health-impaired elders
given (eight in the United States).
1981 First International Conference on Gerontological Nursing sponsored by the
International Council of Nursing (Los Angeles, California) ANA Division of
Gerontological Nursing publishes statement on scope of practice John A. Hartford
Foundation‘s Hospital Outcomes Program for the Elderly (HOPE) using a geriatric
resource nurse (GRN) model developed at Yale University under the direction of
Terry Fulmer.
1982 Development of RWJF Teaching-Nursing Home Program (five programs in the
United States).
1983 First endowed university chair in gerontological nursing (Florence Cellar
Endowed Gerontological Nursing Chair) established at Case Western Reserve
University.

1984 National Gerontological Nursing Association (NGNA) established ANA
Division on Gerontological Nursing Practice becomes Council on Gerontological
Nursing.
1986 National Association for Directors of Nursing Administration in Long Term
Care established ANA publishes Survey of Gerontological Nurses in Clinical
Practice.
1987 ANA revises Standards and Scope of Gerontological Nursing Practice.
1988 First PhD program in gerontological nursing established (Case Western Reserve
University) 1989 ANA certification established for Clinical Specialist in
1990 ANA establishes Division of Long Term Care within the Council of
1992 Nurses Improving Care for Healthsystem Elders (NICHE) established at New
York University (NYU) Division of Nursing based on the HOPE programs.
1996 John A. Hartford Foundation Institute for Geriatric Nursing established at NYU
Division of Nursing NICHE administered through the John A. Hartford Foundation
Institute for Geriatric Nursing 1998 ANA certification available for geriatric
advanced practice nurses as geriatric nurse practitioners or gerontological clinical
nurse specialists.
2000 American Academy of Nursing, the John A. Hartford Foundation, and the NYU
Division of Nursing develop the Building Academic Geriatric Nursing Capacity
(BAGNC) program.
2002 American Nurses Foundation (ANF) and ANA fund the Nurse Competence in
Aging (NCA) joint venture with the John A. Hartford Foundation Institute for
Geriatric Nursing.
2003 The John A. Hartford Foundation Institute for Geriatric Nursing, the American
Academy of Nursing, and the American Association of Colleges of Nursing (AACN)
combine efforts to develop the Hartford Geriatric Nursing Initiative (HGNI) John A.
Hartford Foundation Institute for Geriatric Nursing at NYU awards Specialty Nursing
Association Programs-in Geriatrics (SNAP-G) grants.

2004 American Nurses Credentialing Centre‘s first computerized generalist
certification exam is for the gerontological nurse.
2005 Journal of Gerontological Nursing celebrates 30 years.
2007 NICHE program at John A. Hartford Foundation Institute for Geriatric Nursing
at NYU receives additional funding from the Atlantic Philanthropies and U.S. Aging
Program.
2008 Geriatric Nursing journal celebrates 30 years Journal of Gerontological Nursing
Research emerges.
1.4 ATTITUDE TOWARDS AGING AND OLDER ADULTS
As a Geriatric care professional, you may have preconceived ideas about caring for
older adults. Such ideas are influenced by your observations of family members,
friends, neighbours, and the media, and your own experience with older adults.
Perhaps you have a close relationship with your grandparents or you have noticed the
aging of your own parents. For some of you, the aging process may have become
noticeable when you look at yourself in the mirror. But for all of us, this universal
phenomenon we call aging has some type of meaning, whether or not we have taken
the time to consciously think about it.
The way you view aging and older adults is often a product of your
environment and the experiences to which you have been exposed. Negative attitudes
toward aging or older adults (ageism) often arise in the same way—from negative
past experiences. Many of our attitudes and ideas about older adults may not be
grounded in fact. Some of you may have already been exposed to ageism, which is
often displayed in much the same way as sexism or racism—via attitudes and actions.
This is one reason for studying the aging process—to examine the myths and realities,
to separate fact from fiction, and to gain an appreciation for what older adults have to
offer.
Population statistics show that the majority of your careers as Geriatric health
professionals will include caring for older adults. As MathyMezey, director of the
John A. Hartford Foundation Institute for Geriatric Nursing at NYU, stated, ―The

population of older Americans is exploding. Geriatric patients are not one subgroup
of patients but rather the core business of health systems‖ (Mezey, 2005). Providing
high-quality care to elders requires knowledge of the intricacies of the aging process
as well as the unique syndromes and disease conditions that can accompany growing
older.
As you read and study this book, you are encouraged to examine your own
thoughts, values, feelings, and attitudes about growing older. Perhaps you already
have a positive attitude toward caring for older adults. Build on that value, and
consider devoting your time and efforts to the practice of gerontological nursing. If,
however, you are reading this chapter with the idea that gerontological nursing is a
less desirable field of nursing, or that only those professionals who cannot find jobs
elsewhere work in nursing homes, or that working with older people would be an
option of last resort, then you may need to re-examine these feelings. Armed with the
facts and some positive experiences with older adults, you may change your mind.
Advocates for older adults, such as Nobel laureate Elie Wiesel, feel that older
adults, as repositories of our collective memories, should be appreciated and
respected. As the 1997 American Psychological Association‘s keynote convention
speaker, Wiesel said, ― an old person represents wisdom and the promise of living a
full life . . . the worst curse is to make him or her feel worthless‖ (American
Psychological Association, 2008).
The older population is changing dramatically as the baby boomers (those

born from 1946–1964) reach retirement age (as of 2011). Because this phenomenon is
happening in many places around the globe , gerontology is the place to be! Caring
for the largest number of older adults in history will present enormous opportunities.
With the over-85 age group being the fastest growing, the complexity of caring for so
many people with multiple physical and psychosocial changes will present a
challenge for the most daring of nurses. Will you be ready?

The purpose of this chapter is to provide the essential information needed by
students of gerontological nursing to provide quality care to older adults. In your
study of this text, you will be presented with knowledge and insights from
experienced professionals with expertise in various areas of gerontological nursing
and geriatrics.
1.5 DEFINITIONS OF GERONTOLOGICAL NURSING
Gerontology is the broad term used to define the study of aging and/or the aged. This
includes the biopsychosocial aspects of aging. Under the umbrella of gerontology are
several subfields including geriatrics, social gerontology, geropsychology,
geropharmacology, financial gerontology, gerontological nursing, and gerontological
rehabilitation nursing.
Geriatrics is often used as a generic term relating to the aged, but specifically refers
to medical care of the aged. For this reason, many nursing journals and texts have
chosen to use the term gerontological nursing instead of geriatric nursing.
Social gerontology is concerned mainly with the social aspects of aging versus the
biological or psychological. ―Social gerontologists not only draw on research from all
the social sciences—sociology, psychology, economics, and political science—they
also seek to understand how the biological processes of aging influence the social
aspects of aging‖.
Geropsychology is a branch of psychology concerned with helping older persons and
their families maintain wellbeing, overcome problems, and achieve maximum
potential during later life.
Geropharmacology is the study of pharmacology as it relates to older adults. The
credential for a pharmacist certified in geropharmacology is CGP (certified geriatric
pharmacist).
Financial gerontology is another emerging subfield that combines knowledge of
financial planning and services with a special expertise in the needs of older adults.
Cutler (2004) defines financial gerontology as ―the intellectual intersection of two

fields, gerontology and finance, each of which has practitioner and academic
components‖.
Gerontological rehabilitation nursing combines expertise in gerontological nursing
with rehabilitation concepts and practice. Nurses working in gerontological
rehabilitation often care for older adults with chronic illnesses and long-term
functional limitations such as stroke, head injury, multiple sclerosis, Parkinson‘s
disease, spinal cord injury, arthritis, joint replacements, and amputations. The purpose
of gerontological rehabilitation nursing is to assist older adults to regain and maintain
the highest level of function and independence possible while preventing
complications and enhancing quality of life.
Gerontological nursing, then, falls within the discipline of nursing and the scope of
nursing practice. It involves nurses advocating for the health of older persons at all
levels of prevention. Gerontological nurses work with healthy elderly persons in their
communities, acutely ill elders requiring hospitalization and treatment, and
chronically ill or disabled elders in long-term care facilities, skilled care, home care,
and hospice. The scope of practice for gerontological nursing includes all older adults
from the time of ―old age‖ until death.
1.6 CONCEPT AND SCOPE OF GERONTOLOGICAL NURSING
Gerontological nursing draws on knowledge about complex factors that affect the
health of older adults. Older adults are more likely than younger adults to have one or
more chronic health conditions, such as diabetes, cardiovascular
disease, cancer, arthritis, hearing, impairment, or a form of dementia such
as Alzheimer's disease. As well, drug metabolism changes with aging, adding to the
complexity of health needs.
Gerontological nurses work in a variety of settings, including acute

carehospitals, rehabilitation, nursing homes (also known as long term care homes and
skilled nursing facilities), assisted living facilities, retirement homes, community
health agencies, and the patient's home. Depending on the conditions of the geriatric's
health determines what type of facility one should reside in. Assisted living facilities

are also known as a senior retirement home that provides care services depending on
health conditions. Skilled nursing otherwise known as a nursing home is a place
where they can reside and get provided with 24/7 cares.
Older adults have been referred to as "the core business of healthcare" by

gerontological nursing experts. Population aging and the complexity of health care
needs of some older adults means that older adults are more likely than younger
people to use health care services. In many settings, the majority of patients are older
adults. Thus, experts recommend that all nurses, not only those identified as
gerontological nurses, need specialized knowledge about older adults. This position
was endorsed by 55 US nursing specialty organizations.
1.7 PRINCIPLES OF GERONTOLOGICAL NURSING
According to Stanford School of Medicine- Ethno geriatrics, the principles of

geriatric care include,
Biopsychosocial approach: the integration of consideration of physical,

psychological, and social factors in providing health care
Use of multidisciplinary teams
Importance of chronic illnesses and geriatric syndromes
Importance of showing respect to older patients
Goal of maximizing function Awareness and sensitivity to sensory
changes
Age-appropriate dosing and avoidance of interactions of multiple
medications
Continuity of care through the different components of geriatric care
o Geriatric primary care
o Geriatric acute care
o Geriatric rehabilitation
o Geriatric long-term care
Community based

o Home care
o Adult day care/day health care
o Respite care
Residential Services
o Assisted living, board & care, adult care, or residential care
o Nursing homes
o Combinations of levels of care—Continuing care retirement
communities
Geriatric managed care: integration of primary, acute, and long term care
o Program of All-inclusive Care for the Elderly (PACE)
o U.S. Department of Veterans Affairs geriatric programs.
According to Emory, the basic principles of gerontological nursing are,
Principles Descriptions
 Aging occurs at different rates

1. Aging is not a disease
between individuals, within
individuals in different organ
systems.
 Aging alone does not generally
cause symptoms.
 Aging increases susceptibility to
many diseases and conditions
("homeostenosis").
 Aging people are heterogeneous -
some are very healthy, some are
very ill.
 Older individuals commonly suffer

2. Medical conditions in
multiple chronic conditions,
geriatric patients are
making management complex and
commonly chronic, multiple,

and multifactorial challenging.
 Acute illness are superimposed on

chronic conditions and their
management.
 Treatment for one chronic or acute
illness can influence the
management of other underlying
conditions.
 Multiple factors are generally
involved in the pathogenesis of
geriatric conditions.
 Older individuals, caregivers, and

3. Reversible and treatable
health professionals mistakenly
conditions are often
attribute symptoms to "old age".
under-diagnosed and under-
 Many conditions present atypically
treated in geriatric patients
in the geriatric population.
 Systematic screening for common
geriatric conditions can help avoid
undiagnosed, treatable conditions.
 Geriatric "syndromes" are
commonly undiagnosed and
therefore not managed optimally,
such as: delirium, gait, instability
and falls, urinary incontinence,
pain, and malnutrition.
 Functional capacity, in
4. Functional ability and quality
combination with social supports,
of life are critical outcomes in
is critical in determining living
the geriatric population
situation and overall quality of life.

 Small changes in functional
capability (e.g., the ability to
transfer) can make a critical
difference for quality of life of
older patients and their caregivers.
 Standard tools can be used to
measure basic and instrumental
activities of daily living and
overall quality of life.
 Understanding the patient's life

5. Social history, social support,
history and preferences for care are
and patient preferences are
critical (place of birth, education,
essential aspects of managing
occupation, family relationships,
geriatric patients
spirituality, resources, willingness
to take risks and utilize resources
for care, etc).
 Living circumstances are critical to
managing frail older patients.
 Caregiver availability, health, and
resources are critical determinants
of care planning for frail older
patients.
 Interdisciplinary respect,
6. Geriatric care is
collaboration, and communication
multidisciplinary
are essential in the care of geriatric
patients and their caregivers.
 Various disciplines play an
important role in geriatric care, e.g.
nursing, rehabilitation therapists,
dieticians, pharmacists, social

workers, etc.
 Aging is associated with changes

7. Cognitive and affective
in cognitive function.
disorders are prevalent and
 Common causes of cognitive
commonly undiagnosed at
impairment include delirium,
early stages
Alzheimer's Disease, and multi-
infarct dementia.
 Geriatric depression is often
undiagnosed.
 Screening tools for delirium,
dementia, and depression should
be used routinely.
 Polypharmacy, adverse drug

8. Iatrogenic illnesses are
reactions, drug-disease
common and many are
interactions, drug-drug
preventable
interactions, inappropriate
medications all common.
 Complications of hospitalization,
such as falls, immobility, and
deconditioning can be serious and
life-threatening.
 There are specific definitions and

9. Geriatric care is provided in
criteria for admission to different
a variety of settings ranging
types of care settings.
from the home to long-term

care institutions  Funding for care in different
settings varies and depends on
many factors.
 Transitions between care settings
must be coordinated in order to
avoid unnecessary duplication,
medical errors, and patient injuries.
 Integrated, multi-level systems
provide the most coordinated care
for complex geriatric patients.
 Ethical issues arise almost every

10. Ethical issues and end-of-
day in geriatric care.
life care are critical aspects
 Advance directives are critical for
of the practice of geriatrics
preventing some ethical dilemmas.
 Principles of palliative care and
end-of-life care are essential for
high quality geriatric care.
1.8 SUMMARY
The older adults enjoy, good health, in national surveys as many as 40% of
adults aged 65 and older report disability. Chronic diseases are the major reasons for
disability, and heart diseases, cancer and stroke continued to be the three most
significant causes of death in persons 65 years of age and older. Alzheimer‘s disease
accounted for almost 44,000 deaths in 1999 (National Centre for Health statistics,
2000). It is the duty of the health professionals to coordinate with the health team
members in providing care to the elderly and assist them for a better living.
1.9 CHECK YOUR PROGRESS
1.9.1 OBJECTIVE TYPE QUESTIONS
1. In humans, the time-related changes begins with birth and continues …………

2. …………….contributed to development of gerontological nursing.
3. Gerontological nursing was 1st recognized in ………..…..
4. ………………………is the study of aged.
5. …………………..refers to the study of medical care of aged.
6. Collaboration of …………………..is required for care of elderly.
7. Residential services for elderly include …………………………..and ……………
8. ……………….is the major chronic disease among aged population.
9. Gerontological nursing improves …………………….of elderly.
10. Aging is associated with changes in …………………. function.
1.9.2 SHORT ANSWER QUESTIONS
1. Scope and concept of gerontological nursing?

2. Explain how the attitude of people influences the care of elderly?
3. Elaborate about the history of gerontological nursing?
4. Discuss the various landmarks in the origination of gerontological nursing?
1.9.3 ESSAY TYPE QUESTIONS
1. Define gerontological nursing? Explain in detail the various principles of

gerontological nursing?
1.9.4 ANSWERS TO OBJECTIVE QUESTIONS
1. throughout life.
2. Hartford foundation institute for geriatric care
3. 1960s
4. Gerontology
5. Geriatrics
6. Health team members

7. Assisted living facilities and nursing homes.
8. Alzheimer‘s disease
9. Quality of life
10. Cognitive
1.10 KEY TERMS
1. Gerontology- is the broad term used to define the study of aging and/or the aged.
2.Geriatrics- is often used as a generic term relating to the aged, but specifically
refers to medical care of the aged.
3. Gerontological rehabilitation nursing- combines expertise in gerontological
nursing with rehabilitation concepts and practice.
4. Gerontological nursing, then, falls within the discipline of nursing and the scope
of nursing practice.
1.11 REFERENCES
1. http://medicine.emory.edu/geriatrics-gerontology/education/big-10.html
2. http://www.jblearning.com/samples/076375580X/55805_CH01_001_0025.pd
f
3. https://www.scribd.com/doc/6210848/Principles-of-Gerontology
4. https://geriatrics.stanford.edu/culturemed/overview/introduction/principles.ht
ml
5. https://en.wikipedia.org/wiki/Gerontological_nursing.
6. Suzanne C. Smeltzer (2004), textbook of medical surgical nursing, 12th edition,

Lippincott William and wilkins publishers, p185-210.
7. Lewis (2010), Textbook of medical surgical nursing, 9th edition, Elsevier

publishers, p120-138
8. Gerentological Nursing- Competencies of care by Kristen L. Mauk Jones &

Bartlett Publishers, 2010
UNIT II:- APPROACH TO AN ELDERLY PATIENT
Structure
2.1 Introduction
2.2 Assessment of an elderly patient
2.3 Approaches to an elderly patient
2.4 Summary
2.6 Key Terms
2.7 References
2.1 INTRODUCTION
Approach to the elderly for evaluation usually differs from a standard medical
evaluation. For elderly patients, especially those who are very old or frail, history-
taking and physical examination may have to be done at different times, and physical
examination may require 2 sessions because patients become fatigued.
The elderly also have different, often more complicated health care problems,
such as multiple disorders, which may require use of many drugs (sometimes called
polypharmacy) and thus greater likelihood of a high-risk drug being prescribed.
Diagnosis may be complicated, resulting in delayed, missed, or erroneous diagnoses
leading to inappropriate use of drugs.
Early detection of problems results in early intervention, which can prevent

deterioration and improve quality of life, often through relatively minor, inexpensive
interventions (eg, lifestyle changes). Thus, some elderly patients, particularly the frail
or chronically ill, are best evaluated using a comprehensive geriatric assessment,
which includes evaluation of function and quality of life, best administered by an
interdisciplinary team.
On average, elderly patients have 6 diagnosable disorders, and the primary

care physician is often unaware of some of them. A disorder in one organ system can
weaken another system, exacerbating the deterioration of both and leading to

disability, dependence, and, without intervention, death. Multiple disorders
complicate diagnosis and treatment, and effects of the disorders are magnified by
social disadvantage (eg, isolation) and poverty (as patients outlive their resources and
supportive peers) and by functional and financial problems.
Clinicians should also pay particular attention to certain common geriatric

symptoms (eg, delirium, dizziness, syncope, falling, mobility problems, weight or
appetite loss, urinary incontinence) because they may result from disorders of
multiple organ systems.
If patients have multiple disorders, treatments (eg, bed rest, surgery, drugs)
must be well-integrated; treating one disorder without treating associated disorders
may accelerate decline. Also, careful monitoring is needed to avoid iatrogenic
consequences. For example, with complete bed rest, elderly patients can lose 1 to 3%
of muscle mass and strength each day (causing sarcopenia), and effects of bed rest
alone can ultimately result in death.
Disorders that are common among the elderly are frequently missed, or the
diagnosis is delayed. Clinicians should use the history, physical examination, and
simple laboratory tests to actively screen elderly patients for disorders that occur only
or commonly in the elderly; when diagnosed early, these disorders can often be more
easily treated. Early diagnosis frequently depends on the clinician‘s familiarity with
the patient‘s behaviour and history, including mental status. Commonly, the first
signs of a physical disorder are behavioural, mental, or emotional. If clinicians are
unaware of this possibility and attribute these signs to dementia, diagnosis and
treatment can be delayed. The elderly people must be approached by the health
professionals at times of pain, cancer, psychological complications such as delirium,
dementia, Alzheimer‘s which is already discussed in the previous chapters. A careful
and detailed assessment of the elderly is required.
2.2 ASSESSMENT OF AN ELDERLY PATIENT
Often, more time is needed to interview and evaluate elderly patients, partly
because they may have characteristics that interfere with the evaluation. The
following should be considered:
 Sensory deficits: Dentures, eyeglasses, or hearing aids, if normally worn,
should be worn to facilitate communication during the interview. Adequate
lighting and elimination of visual or auditory distraction also helps.
 Underreporting of symptoms: Elderly patients may not report symptoms
that they consider part of normal aging (eg, dyspnoea, hearing or vision
deficits, memory problems, incontinence, gait disturbance, constipation,

dizziness, and falls). However, no symptom should be attributed to normal
aging unless a thorough evaluation is done and other possible causes have
been eliminated.
 Unusual manifestations of a disorder: In the elderly, typical manifestations
of a disorder may be absent. Instead, the elderly may present with nonspecific
symptoms (eg, fatigue, confusion, weight loss).
 Functional decline as the only manifestation: Disorders may manifest
solely as functional decline. In such cases, standard questions may not apply.
For example, when asked about joint symptoms, patients with severe arthritis
may not report pain, swelling, or stiffness, but if asked about changes in
activities, they may, for example, report that they no longer take walks or
volunteer at the hospital. Questions about duration of functional decline (eg,
―How long have you been unable to do your own shopping?‖) can elicit useful
information. Identifying people when they have just started to have difficulty
doing basic activities of daily living (BADLs) or instrumental activities of
daily living (IADLs) may provide more opportunities for interventions to
restore function or to prevent further decline and thus maintain independence.
 Difficulty recalling: Patients may not accurately remember past illnesses,
hospitalizations, operations, and drug use; clinicians may have to obtain these
data elsewhere (eg, from family members, a home health aide, or medical
records).
 Fear: The elderly may be reluctant to report symptoms because they fear
hospitalization, which they may associate with dying.
 Age-related disorders and problems: Depression (common among elderly
who are vulnerable and sick), the cumulative losses of old age, and discomfort
due to a disorder may make the elderly less apt to provide health-related
information to clinicians. Patients with impaired cognition may have difficulty
describing problems, impeding the physician‘s evaluation.
2.2.1 Interview
A clinician‘s knowledge of an elderly patient‘s everyday concerns, social
circumstances, mental function, emotional state, and sense of well-being helps orient
and guide the interview. Asking patients to describe a typical day elicits information
about their quality of life and mental and physical function. This approach is
especially useful during the first meeting. Patients should be given time to speak
about things of personal importance. Clinicians should also ask whether patients have
specific concerns, such as fear of falling. The resulting rapport can help the clinician
communicate better with patients and their family members.

A mental status examination may be necessary early in the interview to
determine the patient‘s reliability; this examination should be conducted tactfully so
that the patient does not become embarrassed, offended, or defensive. Routine
screening for physical and psychologicdisorders should be done annually, beginning
at age 70.
Often, verbal and nonverbal clues (eg, the way the story is told, tempo of
speech, tone of voice, eye contact) can provide information, as for the following:
 Depression: Elderly patients may omit or deny symptoms of anxiety or

depression but betray them by a lowered voice, subdued enthusiasm, or even
tears.
 Physical and mental health: What patients say about sleep and appetite may
be revealing.
 Weight gain or loss: Clinicians should note any change in the fit of clothing
or dentures.
Unless mental status is impaired, a patient should be interviewed alone to

encourage the discussion of personal matters. Clinicians may also need to speak with
a relative or caregiver, who often gives a different perspective on function, mental
status, and emotional state. These interviews may be done with the patient absent or
present.
The clinician should ask the patient‘s permission before inviting a relative or
caregiver to be present and should explain that such interviews are routine. If the
caregiver is interviewed alone, the patient should be kept usefully occupied (eg,
filling out a standardized assessment questionnaire, being interviewed by another
member of the interdisciplinary team).
If indicated, clinicians should consider the possibility of drug abuse by the

patient and patient abuse by the caregiver.
2.2.2 Medical history

When asking patients about their past medical history, a clinician should ask
about disorders that used to be more common (eg, rheumatic fever, poliomyelitis) and
about outdated treatments (eg, pneumothorax therapy for TB, mercury for syphilis). A
history of immunizations (eg, tetanus, influenza, pneumococcal), adverse reactions to
immunizations, and skin test results for TB is needed. If patients recall having surgery
but do not remember the procedure or its purpose, surgical records should be obtained
if possible.

Clinicians should ask questions designed to systematically review each body
area or system (review of systems) to check for other disorders and common
problems that patients may have forgotten to mention.
2.2.3 Drug history

The drug history should be recorded, and a copy should be given to patients or
their caregiver. It should contain
 Drugs used
 Dose
 Dosing schedule
 Prescriber
 Reason for prescribing the drugs
 Precise nature of any drug allergies
All drugs used should be recorded, including
 Topical drugs (which may be absorbed systemically)

 OTC drugs (which can have serious consequences if overused and may
interact with prescription drugs)
 Dietary supplements
 Medicinal herb preparations (because many can interact adversely with
prescription and OTC drugs)
Patients or family members should be asked to bring in all of the above drugs
and supplements at the initial visit and periodically thereafter. Clinicians can make
sure patients have the prescribed drugs, but possession of these drugs does not
guarantee adherence. Counting the number of tablets in each vial during the first and
subsequent visits may be necessary. If someone other than a patient administers the
drugs, that person is interviewed.
Patients should be asked to demonstrate their ability to read labels (often

printed in small type), open containers (especially the child-resistant type), and
recognize drugs. Patients should be advised not to put their drugs into one container.
2.2.4 Alcohol, tobacco, and recreational drug use history

Patients who smoke should be counseled to stop and, if they continue, not to
smoke in bed because the elderly are more likely to fall asleep while doing so.
Patients should be checked for signs of alcohol use disorders, which are
underdiagnosed in the elderly. Such signs include confusion, anger, hostility, alcohol

odor on the breath, impaired balance and gait, tremors, peripheral neuropathy, and
nutritional deficiencies. Screening questionnaires and questions about quantity and
frequency of alcohol consumption can help. The 4 CAGE questions are quick and
straightforward, the clinician asks if the patient has ever felt.
 Need to Cut down drinking

 Annoyed by criticism about drinking
 Guilty about drinking
 Need for a morning "Eye-opener"
Two or more positive responses to the CAGE questions suggest the possibility
of alcohol abuse. Questions about use of other recreational drugs or substances of
abuse also are appropriate.
2.2.5 Nutrition history

Type, quantity, and frequency of food eaten are determined. Patients who
eat ≤ 2 meals a day are at risk of undernutrition. Clinicians should ask about the
following:
 Any special diets (eg, low-salt, low-carbohydrate) or self-prescribed fat diets

 Intake of dietary fiber and prescribed or OTC vitamins
 Weight loss and change of fit in clothing
 Amount of money patients have to spend on food
 Accessibility of food stores and suitable kitchen facilities
 Variety and freshness of foods
The ability to eat (e.g., to chew and swallow) is evaluated. It may be impaired
by xerostomia and/or dental problems, which are common among the elderly.
Decreased taste or smell may reduce the pleasure of eating, so patients may eat less.
Patients with decreased vision, arthritis, immobility, or tremors may have difficulty
preparing meals and may injure or burn themselves when cooking. Patients who are
worried about urinary incontinence may reduce their fluid intake; as a result, they
may eat less food.
2.2.6 Mental health history

Mental health problems may not be detected easily in elderly patients.
Symptoms that may indicate a mental health disorder in younger patients (eg,
insomnia, changes in sleep patterns, constipation, cognitive dysfunction, anorexia,
weight loss, fatigue, preoccupation with bodily functions, increased alcohol
consumption) may have another cause in the elderly. Sadness, hopelessness, and
crying episodes may indicate depression. Irritability may be the primary affective

symptom of depression, or patients may present with cognitive dysfunction.
Generalized anxiety is the most common mental disorder encountered in elderly
patients and often is accompanied by depression.
Patients should be asked about delusions and hallucinations, past mental

health care (including psychotherapy, institutionalization, and electroconvulsive
therapy), use of psychoactive drugs, and recent changes in circumstances. Many
circumstances (eg, recent loss of a loved one, hearing loss, a change in residence or
living situation, loss of independence) may contribute to depression.
Patients‘ spiritual and religious preferences, including their personal

interpretation of aging, declining health, and death, should be clarified.
2.2.7 Functional status

Whether patients can function independently, need some help with basic
activities of daily living (BADLs) or instrumental activities of daily living (IADLs),
or need total assistance is determined as part of comprehensive geriatric assessment.
Patients may be asked open-ended questions about their ability to do activities, or
they may be asked to fill out a standardized assessment instrument with questions
about specific ADLs and IADLs.
2.2.8 Social history

Clinicians should obtain information about patients‘ living arrangements,
particularly where and with whom they live (e.g., alone in an isolated house, in a busy
apartment building), accessibility of their residence (e.g., upstairs or a hill), and what
modes of transportation are available to them. Such factors affect the ability of the
elderly to obtain food, health care, and other important resources. A home visit,
although difficult to arrange, can provide critical information. For example, clinicians
can gain insight about nutrition from the refrigerator‘s contents and about multiple
ADLs from the bathroom‘s condition.
The number of rooms, number and type of phones, presence of smoke and
carbon monoxide detectors, and condition of plumbing and heating system are
determined, as is the availability of elevators, stairs, and air conditioning. Home
safety evaluations can identify home features that can lead to falls (e.g., poor lighting,
slippery bathtubs, unanchored rugs), and solutions can be suggested.
Having patients describe a typical day, including activities such as reading,

television viewing, work, exercise, hobbies, and interactions with other people,
provides valuable information.

Clinicians should ask about the following:
 Frequency and nature of social contacts (eg, friends, senior citizens‘ groups),
family visits, and religious or spiritual participation)
 Driving and availability of other forms of transportation
 Caregivers and support systems (eg, church, senior citizens‘ groups, friends,
neighbors) that are available to the patient
 The ability of family members to help the patient (eg, their employment
status, their health, traveling time to the patient‘s home)
 The patient‘s attitude toward family members and their attitude toward the
patient (including their level of interest in helping and willingness to help)
Marital status of patients is noted. Questions about sexual practices and

satisfaction must be sensitive and tactful but thorough. The number and sex of sex
partners are determined, and risk of sexually transmitted diseases (STDs) is
evaluated. Many sexually active elderly people are not aware of the increasing
incidence of STDs in the elderly and do not follow or even know about safe sex
practices.
Patients should be asked about educational level, jobs held, known exposures
to radioactivity or asbestos, and current and past hobbies. Economic difficulties due
to retirement, a fixed income, or death of a spouse or partner are discussed. Financial
or health problems may result in loss of a home, social status, or independence.
Patients should be asked about past relationships with physicians; a long-time
relationship with a physician may have been lost because the physician retired or died
or because the patient relocated.
2.2.8 Advance directives
Patient wishes regarding measures for prolonging life must be documented.

Patients are asked what provisions for surrogate decision making (advance directives)
have been made in case they become incapacitated, and if none have been made,
patients are encouraged to make them. Getting patients and their surrogates
accustomed to discussing goals of care is important; then when circumstances require
medical decisions and prior documentation is unavailable or not relevant to the
circumstance (which is very common), appropriate decisions can be made.

LAWTON INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE
Activity Description Score

Using the telephone Uses a telephone, including looking up and 1
dialling numbers.
Dials a few familiar numbers. 1

Answers the telephone but does not dial. 1
Does not use the telephone. 0
Shopping Does all the shopping without help. 1

Shops for small items without help. 0
Shops for small items without help. 0
Cannot do any shopping. 0
Preparing food Plans, prepares, and serves adequate meals 1
without help.
If given the ingredients, prepares adequate 0
meals.
Heat and serves prepared meals or prepares 0
meals but ones that are nutritionally
inadequate.
Needs someone to prepare and serve meals. 0
Doing household Does household tasks without help or 1

tasks occasionally with help for physically
demanding tasks (eg, washing windows).
Does light housework (eg, dish washing, 1

dusting).
Does light housework but does not keep the 1
house adequately clean.
Needs help with all household tasks. 1
Does not do any household tasks. 0
Doing laundry Does laundry without help. 1

Washes small items (e.g., stockings). 1
Needs someone to do all laundry. 0
Traveling other than Uses public transportation without help or 1

by walking drives a car.
Calls for taxis but does not use other public 1
transportation.
Uses public transportation if accompanied 1
by someone to help.
Travels only by taxi or car and only if 0
helped by someone.
Does not travel. 0
Taking prescription Takes the correct doses of prescribed drugs 1

drugs as directed. at the correct time without help.
Takes prescribed drugs if they are prepared 0
in advance in separate dosage.
Cannot dispense the prescribed drugs. 0
Managing money. Manages finances (eg, making a budget, 1
writing checks, paying rent, keeping track of
income) without help.
Buys small items needed on a daily basis but 1
requires help with banking and major
purchases.
Cannot manage money. 0

2.3 APPROACHES TO AN ELDERLY PATIENT
2.3.1 Preliminary Steps (Before you walk into the room)
 Acuity increases with age, so beware of the under-triaged older adult based on
o Atypical presentations of common complaints
o Stoicism or minimization of problem.
 Review medical records (if available)
o Does the patient have a history of dementia, delirium or other
cognitive deficit? If so, verify (corroborate) any history
o Is there a pattern of ED(Emergency Department) visits to suggest
unmet social needs (e.g. caregiver fatigue; unsafe home environment;
poor access to care)
o Are there patterns of injuries to raise suspicion of elder abuse?
 Code status and goals of care.
o If unclear, ask for this information and find out sooner than later.
2.3.2 Recommended Approach and Assessment
2.3.2.1 Subjective Assessment:

 Older adults may minimize complaints, conditions, and symptoms.
 Over 40% of older adults in ED have a cognitive deficit which may affect
history-taking (37% dementia; 5% delirium), corroborate history with
family/caregiver/companion whenever feasible to not miss anything.
 Atypical chief complaints are common.
 ―Confusion‖ – Is it dementia, delirium or an intracranial lesion?
o If they have dementia, how is this episode DIFFERENT FROM
BASELINE?
o A ―new‖ psychiatric problem (e.g. ―psychosis‖ or ―mania‖ or
―aggressive behaviour‖ is RARELY a de novo psychiatric problem –
think medical (organic) etiology first, then think medications, then
think something else OTHER than.
o Common medical problems can cause change in mutation: UTI; AMI;
pain; thyroid dysfunction.
2.3.2.2 Objective Assessment:
 Mental Status or “Confusion” – Is it dementia, delirium or an intracranial
lesion?
o Not everyone needs a head CT: anyone on anticoagulants MUST get
a head CT, EVERYTIME

o If they have dementia, how is this episode DIFFERENT FROM
BASELINE?
 If you suspect undocumented dementia, the Short Blessed Test
is a good cognitive function screen for ED use that is most
sensitive/specific
o A “new” psychiatric problem (e.g. “psychosis” or “mania” or
“aggressive behaviour” is RARELY a de novo psychiatric
problem – think medical (organic) etiology first, then think
medications, then think something else OTHER than psychiatric
o Delirium
 Richmond Agitation Sedation Scale (RASS) is a quick delirium
screen for ED use with very good sensitivity/specificity; RASS
>+1 or <-1 is nearly diagnostic
o Intracranial
 Older adults, particularly those on anticoagulants, may be at
higher risk for delayed bleeds. However, there is NO widely
accepted consensus guidelines on screening for delayed bleeds
if the initial CT is negative.
 A compromise strategy may be to screen (e.g. by telephone
follow-up for signs/symptoms within 24 hours) to decide need
for repeat head CT within 24 hours of a negative study; if
follow-up cannot be guaranteed, admission for observation
may be necessary.
o Dizziness
 15% of older adults presenting to ED for dizziness have serious
etiologies; 4-6% are stroke-related and sensitivity of CT for
identifying stroke or intracranial lesion in dizziness is poor
(16%), so if CNS etiology suspected, seek neuro consult or
MRI (83% sensitivity).
o Skeletal Injury
 C-spine injuries may result from seemingly benign
trauma/falls.
 Compression fractures of vertebral column can result from
relatively little trauma.
 Given high prevalence of osteopenia/osteoporosis, X-ray
imaging can have reduced sensitivity, consider CT studies
for fractures, especially vertebral fractures
 Knee pain? May be referred pain from occult hip fracture
o Cardiopulmonary

 AMI presents with atypical complaints in older adults (e.g.,
―indigestion‖, ―dizziness‖, ―tired‖)
 The HEART score assigns maximal points to
anyone >65y (2 points) but the mean age (+SD) of
participants used to derive and validate the HEART
score was 61 +15y, thus unclear how valid the score is
for the very old.
 Heart failure (HF): ~70% of patients >65y with HF
have normal EF of >50%(18), and BNP (B-type Natriuretic
Peptide)underestimates degree of decompensation due to
thicker heart (thicker heart, less stretch, smaller rise in BNP);
consider BNP difference from last hospital discharge to help
determine severity and disposition.
o Abdominal pain
 Visceral pain is modified in older adult; exam can
underestimate severity.
 Constipation and urinary retention are common but often
overlooked causes of abdominal pain.
 Risk of ischemic bowel is higher in older adults.
 Acute abdominal series provides quick screen for perforation
or SBO (Small Bowel Obstruction) and balances benefit of CT
against higher risk of contrast-induced nephropathy in older
adults.
o Falls
 Rule-out medical/surgical or medication-related reasons for the
fall; check orthostatic vital signs
 One mechanical fall in a given year –no unequivocal need for
further ED testing unless clinical suspicion
 Two falls in a given year is a red flag and requires a
comprehensive evaluation (in the outpatient setting; ideally by
a geriatrician).

2.3.3 Clinical Decision Making and ED Management:
 Screening for geriatric syndromes is critical
o polypharmacy
o delirium/dementia
o fall risk
o function (independence) and mobility
o abuse and neglect
 Geriatric syndromes are individually associated with ED returns and adverse
outcomes (e.g. hospitalization, death at 30 days) and must be addressed, not
necessarily in the ED if prompt and reliable outpatient follow-up with their
PCP(Primary Care Physician) can be arranged
 Beware that screening for adverse outcomes is complicated by scarcity of
reliable instruments (results vary across populations)
 Managing the agitated older adult
o Try to avoid use of restraints (if patient has dementia or is delirious,
restraints worsen the situation)
o Is agitation related to pain? Agitation is often secondary to pain: Start
with low dose opioid, and titrate up (start low and go slow) – why?
You can reverse it
o Avoid benzodiazepines with delirium, they can paradoxically worsen
it – UNLESS patient is on chronic benzodiazepines (make sure it‘s for
a good reason), then consider use as it could be benzo withdrawal
o Avoid Haldol – Haldol can lead to fatal reactions in Parkinson‘s
disease and prolonged QT interval; if neither condition is present (once
you‘re sure), then use a LOW dose. AVOID Haldol 5mg in anyone
over 55. Use magnesium sulphate to treat long QT interval

o Antipsychotics help manage the behaviour but will NOT treat the
underlying cause – you still need to evaluate for the medical cause(s)
of the agitation
 After any diagnostic study with IV contrast, give fluids
o Older adults are at higher risk of contrast-induced nephropathy; IV
saline is recommended.
 IV fluid resuscitation
o Unless patient is in shock, steady IV infusion is preferred over a
rapid bolus, particularly if heart failure present
 Medications
 Do not assume what is listed in the computer accurately reflects the patient‘s
medication regimen
 Always confirm medication regimen with patient, family, or pharmacy/home
health if patient/family not able to tell
 Potentially Inappropriate Medications (PIM). Older adults have greater
susceptibility to adverse effects of particular medications.
 New symptoms may be due to a medication side effect.
 New medications for common complaints could be a source of adverse
outcomes.
 PIMs may be indicated and necessary in specific ED situations (e.g.
diphenhydramine for acute allergic reactions) but be cautious regarding
duration/course when prescribing for post-discharge use.
2.3.3.1 Disposition:
 Precautionary steps at time of discharge
o Ability to understand and follow discharge instructions (consider
degree of patient and caregiver health literacy, low vision, cognitive
impairment, logistics of clinician follow-up)
 If all work-ups are negative but clinical suspicion persists
o Pursue rapid (24-48 hours) outpatient follow-up with PCP (if available
and if patient logistically can go to PCP)
o Consider the 48-hour ED return
 CAUTION: Hospitalization worsens function, mobility, and
morbiditywhich in turn lead to ED returns and hospitalization.
o Hospitalize only if clinically indicated (ideally)
o If social issues exist – can ED social worker or case manager find a
sufficiently safe disposition for patient and avoid hospitalization?
o If social needs cannot be met, or if safety is a concern, then admit to
hospital but ensure that inpatient service understands the problem (and
document this need for transitions of care)

2.3.3.2 Pitfalls
 Look for atypical presentations of common medical conditions.
 Avoid admitting to hospital simply because of their age, as unwarranted
hospitalization can be harmful to the patient‘s subsequent function, mobility,
and quality of life.
o Know your own biases: older adults are a source of stress in EPs;
>75% recognize the need to improve quality of care.
o 22% of ED admits are potentially avoidable.
o 50% of ED admits are for non-clinical reasons.
 Address unmet social needs as these are highly responsible for ED returns–
ask ED social worker or case manager for help.
 Screen for geriatric syndromes to identify older adults at high risk for adverse
events
o Delirium (abnormal RASS score) predicts increased mortality at 6
months.
o Dementia is unrecognized in the ED up to 70% of the time.
o Elder abuse and neglect may have subtle signs/symptoms.
o Two mechanical falls in a given year indicates an increased risk of
adverse events.
o Declines in mobility (e.g. walking speed) are associated with
increased hospitalization or mortality.
 Potentially Inappropriate Medications (PIMs)
2.4 SUMMARY
Assessment can have the following benefits:

 Improved care and clinical outcomes
 Greater diagnostic accuracy
 Improved functional and mental status
 Reduced mortality
 Decreased use of nursing homes and acute care hospitals
 Greater satisfaction with care
If elderly patients are relatively healthy, a standard medical evaluation may be

appropriate. Comprehensive geriatric assessment and the necessary approach is most
successful when done by a geriatric interdisciplinary team (typically, a geriatrician,
nurse, social worker, and pharmacist). Usually, assessments are done in an outpatient
setting. However, patients with physical or mental impairments and chronically ill
patients may require inpatient assessment.


1.Approach to the elderly for evaluation usually depends on ………………….
2. Early detection of problems results in …………………………….
3. Disorders may manifest solely as …………………………
4. Older adults, particularly those on anticoagulants, may be at higher risk for
…………………
5. Risk of …………………..is higher in older adults.
2.5.2 SHORT ANSWER QUESTIONS
1. Geriatric assessment?
2. Management of falls in elderly?
3. Effect of medications on elderly?
2.5.3 ESSAY QUESTION
1. Define geriatric assessment? Explain in detail about the various approaches for
assessment of the elderly?
2.5.4 KEY FOR OBJECTIVE TYPE QUESTIONS

1. Medical evaluation
2. Early intervention
3. Functional decline
4. Delayed bleeds
5. Ischemic bowel
2.6 KEY TERMS
1. Delirium- an acutely disturbed state of mind characterized by restlessness,

illusions, and incoherence, occurring in intoxication, fever, and other disorders.
2. Sensory deficit- a defect in the function of one or more of the senses.
3. Pit falls- a hidden or unsuspected danger or difficulty.
4. Dizziness- a sensation of spinning around and losing one's balance.
5. Advanced directives- a living will which gives durable power of attorney to a
surrogate decision-maker, remaining in effect during the incompetency of the
person making it.

2.7 REFERENCES

Lippincott William and wilkins publishers, p185-210.
3.https://www.gmjournal.co.uk/psychotherapeutic_approaches_to_the_elderly_25769
815462.aspx
4. http://www.emdocs.net/em-approach-to-geriatric-patient-pearls-pitfalls/
5.http://www.merckmanuals.com/professional/geriatrics/approach-to-the-geriatric
patient/evaluation-of-the-elderly-patient

UNIT -III: LEVELS OF GERIATRIC CARE AND ROLE OF NURSE
Structure
3.1 Introduction to geriatric care

3.2 Definitions of geriatric care
3.3 Overview of geriatric care
3.4 Health Care settings for providing geriatric care
3.5 Principles of geriatric care
3.6 Services of geriatric care
3.7 Geriatric Interdisciplinary Team
3.8 Levels of geriatric care
3.8 Role of a nurse in geriatric care
3.9 Summary
3.11 Key Terms
3.12 References
3.1 INTRODUCTION TO GERIATRIC CARE
Gerontology (from the Greek geron, "old man" and logia, "study of"; coined
by IlyaIlyichMechnikov in 1903) is the study of
the social, cultural, psychological, cognitive, and biological aspects of aging. It is
distinguished from geriatrics, which is the branch of medicine that specializes in the
treatment of existing disease in older adults. Gerontologists include researchers and
practitioners in the fields of biology, nursing, medicine, criminology, dentistry, social
work, physical and occupational therapy, psychology, psychiatry, sociology,
economics, political science, architecture, geography, pharmacy, public health,
housing, and anthropology.
Gerontology encompasses the following:
 Studying physical, mental, and social changes in people as they age
 Investigating the biological aging process itself including aging's causes, effects
and mechanisms (bio gerontology)

 Investigating the social and psycho-social impacts of aging (sociogerontology)
 Investigating the psychological effects on aging (psycho gerontology)
 Investigating the interface of biological aging with aging-related
diseases (geroscience)
 Investigating the effects of an ageing population on society (demography)
 Exploring the relationship between the aging and their environment
(environmental gerontology)
 Applying this knowledge to policies and programs, including the macroscopic
(for example, government planning) and microscopic (for example, running a
nursing home) perspectives.
The multidisciplinary nature of gerontology means that there are a number of sub-
fields, as well as associated fields such as physiology, anthropology, social work,
public health, psychology and sociology that overlap with gerontology.
Geriatric care management (also known as "elder care management", "senior

health care management" and "professional care management") is the process of
planning and coordinating care of the elderly and others with physical and/or mental
impairments to meet their long term careneeds, improve their quality of life, and
maintain their independence for as long as possible. It entails working with persons
of old age and their families in managing, rendering and referringvarious types of
health and social care services. Geriatric care managers accomplish this by combining
a working knowledge of health and psychology, human development, family
dynamics, public and private resources and funding sources, while advocating for
their clients throughout the continuum of care. For example, they may assist families
of older adults and others with chronic needs such as those suffering
from Alzheimer's disease or other dementia.
3.2 DEFINITIONS OF GERIATRIC CARE
Elderly care, or simply elder care (also known in parts of the English speaking
world as aged care), is the fulfilment of the special needs and requirements that are
unique to senior citizens. This broad term encompasses such services as assisted
living, adult day care, long term care, nursing homes (often referred to as residential
care), hospice care, and home care.
Geriatrics is the branch of medicine that focuses on health care of the elderly.
It aims to promote health and to prevent and treat diseases and disabilities in older
adults.

Gerontological nursing is the specialty of nursing pertaining to older
adults. Gerontological nurses work in collaboration with older adults, their families,
and communities to support healthy aging, maximum functioning, and quality of
life. The term gerontological nursing, which replaced the term geriatric nursing in the
1970s, is seen as being more consistent with the specialty's broader focus
on healthand wellness, in addition to illness.
3.3 OVERVIEW OF GERIATRIC CARE
Geriatric care management integrates health care and psychological care with
other needed services such as: housing, home care services, nutritional services,
assistance with activities of daily living, socialization programs, as well as financial
and legal planning (e.g. banking, trusts). A care plan tailored for specific
circumstances is prepared after a comprehensive assessment has taken place, and is
continuously monitored and modified as needed. A comprehensive geriatric care
assessment is thorough and can take anywhere from 2 to 5 hours in length, this of
course is broken down into 2 or 3 assessment visits with the patient/family members.
The comprehensive assessment is really a compilation of smaller individual
assessments with the first one being a primary intake assessment which includes
demographic type data as well as a health history, social history, and legal/financial
history. From there, a medication profile assessment is included, as well as an
assessment of ADLs (Activities of Daily Living) and IADLs (Instrumental Activities
of Daily Living). In addition other assessments may include; Falls risk assessment,
Home safety assessment, Nutritional assessment, Depression assessment, Pain
assessment, Mini Mental State Exam (MMSE), MiniCog Clock Drawing Exam
(Cognitive Assessment), Balance assessment, and Gait assessment (ability to walk). If
the comprehensive geriatric care management assessment is being conducted by a
Registered Health Care Proffessional, then a physical assessment can be included
such as vital signs recording temperature, pulse, respirations, blood pressure, oxygen
saturation, and sometimes FBS or RBS (Fasting or Random Blood Sugar) checks for
diabetics. In addition, physical assessments in areas such as cardiopulmonary,
gastrointestinal, musculoskeletal, genitourinary, eyes/ears/nose/throat, integumentary
(skin), lower extremities inspection, as well as a modified neuro assessment and
medication compliance assessment.
Because older adults tend to have multiple disorders and may have social or
functional problems, they use a disproportionately large amount of health care
resources. In the US, people ≥ 65 account for,

 > 40% of acute hospital bed days
 > 30% of prescription and OTC drug purchases
 $329 billion or almost 44% of the national health budget
 > 75% of the federal health budget
The elderly are likely to see several health care practitioners and to move from
one health care setting to another. Providing consistent, integrated care across specific
care settings, sometimes called continuity of care, is thus particularly important for
elderly patients. Communication among primary care physicians, specialists, other
health care practitioners, and patients and their family members, particularly when
patients are transferred between settings, is critical to ensuring that patients receive
appropriate care in all settings. Electronic health records may help facilitate
communication.
3.4 HEALTH CARE SETTINGS FOR PROVIDING GERIATRIC CARE
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 (see Home Health 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: These facilities include assisted-living facilities,
board-and-care facilities, nursing homes, and life-care communities. Whether
patients require care in a long-term care facility depends partly on the
patient‘s wishes and needs and on the family‘s ability to meet the patient‘s
needs.
 Day care facilities: 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.
 Hospice: 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 neighborhoods or towns (consider Sun City, the nation‘s ―first and

finest‖ senior community) that are limited to people of a minimum age. They
are designed for active seniors and have a variety of social clubs such as golf,
arts and crafts and cards. While some senior communities offer additional
levels of care, many are not equipped for individuals who require assistance
with ADLs. Some senior communities require the resident move on, should
they require this level of care.
 Continuing Care: Continuing care communities are sometimes called ―step
care‖ or ―progressive‖ care facilities. They offer a wide range of options, all
the way from independent living to special care. Residents are usually
admitted when they live independently. As their needs increase, they are
guaranteed vacancies in the lower level of care. An entry fee is often required,
making this option quite expensive.
 Assisted Living: Assisted living offers the elderly a place to live outside of
their own home, where they can receive basic assistance in one or more of the
following areas: housekeeping, meal preparation, 24/7 monitoring, shower
assistance, toileting, medication assistance or reminders, transportation,
eating, dressing, activities or socialization. In assisted living, your loved one
will likely have their own apartment, unless you or your loved one consents to
sharing a room with someone. A private bathroom is most often in the
apartment to allow for privacy and dignity. Most facilities will have a
kitchenette in the apartment with a sink, microwave, refrigerator, and
cupboard space. Each apartment will likely be climate controlled individually.
There will be access to common areas such as a TV room, an activity room,
dining room, library, and communal sitting areas. Assisted living facilities are
designed for people who need help with complex ADLs on a daily basis.
Basic ADLs include eating, bathing, dressing and hygiene. More complex
ADLs include cooking, shopping and money management. Assisted living
aims to be the mid- point between independent living and long-term care.
Most assisted living facilities have a dining room decorated like a restaurant
as well as a variety of activities. Most assisted living facilities are not licensed
to administer IVs, requiring patients who need IVs to temporarily relocate to a
skilled nursing facility.
 Board and Care: Board and care is similar to assisted living in terms of care,
although some group homes work with lower functionality seniors than those
found in assisted living. This is usually a single-family dwelling which has
been converted into a residence for elderly and disabled residents. The
monthly rent paid commonly includes room, three meals a day, laundry
services, and some transportation – in addition to a 24-hour staff person.
While basic medical care can be attended to, residents who have serious
medical conditions will be expected to move into a more suitable facility.

 Skilled Nursing: Skilled nursing (also called SNF or ―sniff‖) is the first level
of care that is licensed to administer medical treatment with nurses. In fact,
there are strict regulations that require nurses to be on duty and to regulation
the nurse-patient ration. As the name denotes, such a facility offers extensive
nursing services for the residents. Admission must be initiated by a person‘s
physician, who recommends that a patient enter either ‗rehab care‘ or a
‗special care‘ facility.
 Rehab care: Located in hospitals or nursing homes, rehab care programs
are sometimes called ―Level 1‖ or transitional care. They provide intensive
medical care for patients who are expected to regain functional capacity
and return home in a relatively short time.
 Special care: There are two types of special care facilities: those involved
with unique medical issues (sometimes called ―Level 2‖ care), and those
which manage behavioural problems that may arise from dementia.
( not appropriately framed)Many patients are admitted to skilled nursing to

address an acute condition such as rehabilitating a broken hip, or treating an infection
with IV antibiotics. Many skilled nursing facilities have a portion of their residents
who are long- term care patients. These are patients who require the treatment
capabilities of a SNF, yet their condition requires that level of care permanently.
Long-term care includes nursing supervision, but it is custodial in nature – focused on
maintenance as opposed to curative care. Here the condition is not expected to
improve, and the nursing activities are focused on keeping the person healthy and
safe.
3.5 PRINCIPLES OF GERIATRIC CARE
Clinical judgement should be used to determine which level of care would be

most appropriate based on the criteria below.
Although a lower level of care will usually require a lower nurse to patient
ratio or reduced critical care support, this may not apply in all circumstances
and the aim should be to be flexible in the provision of staff resources to meet
the needs of the patient. The level of care assigned to a patient will influence,
but not determine, staffing requirements.
The location of patients does not determine their level of care.
Patients who have „not for resuscitation‟ orders written or who are receiving
palliative care may also fulfill the criteria listed below. It may be appropriate
to modify the actual level of critical care delivered to these patients whilst
enhancing their palliative care.

3.6 SERVICES OF GERIATRIC CARE
 Home health
 Services must be ordered by a doctor.
 Services may include nurse, home health aide, therapies (ot, speech, pt).
 Services are provided in the patient‘s place of residence.
 Services may include assistance with all or some of ADLs
 Services may be long or short term.
 Patient may be dependent, semi-independent, and have acute or chronic
health status.
 Services are on an intermittent basis, not 24 hours a day
 Patient participates in a plan of care developed by a RN.
 Personal care services (ADLs) provided according to R432-700-30, which
include dressing, eating, grooming, bathing, toileting, ambulation,
transferring, and self-administration of medications.
 Assisted living facility type I
 Resident lives in a licensed facility that provides safe and clean living
accommodations and three meals a day.
 Resident may require minimal assistance with ADLs, including significant
assistance with up to two ADLs.
 Resident must be able to evacuate the facility under his own power (be
mobile).
 Resident must have stable health and free from any communicable
disease.
 Resident may receive assistance with medications or have medications
administered by a nurse.
 Resident may receive home health services through individual contract
with home health agency.
 Resident receives 24-hour general monitoring, 7 days a week.
 Resident may receive general nursing care according to facility policy.
 Resident participates in developing a service plan
 Assisted living facility type II
 Resident lives in a licensed facility, permits aging in place.
 Resident may receive full assistance with ADLs.
 Resident may be semi-independent and may require the assist of one
person for transfers or to evacuate the facility.
 Resident may receive assistance with medication or have medications
administered by a nurse.
 Resident receives general nursing care from facility staff.

 Resident must be free of communicable diseases that could be transmitted
to others through the normal course of activities.
 Resident receives 24 hour individualized personal and health-related
services, 7 days a week.
 Resident may receive home health services through individual contract
with a home health agency.
 Resident participates in developing a service plan
 Small health care facility - type n - (limited to three persons)
 Resident lives in a licensed home occupied by the owner or operator.
 Resident receives supervised nursing care on a daily basis from a written
plan of care.
 Resident receives assistance with medications or receives medication
administration by a nurse.
 Resident must be free of communicable diseases and does not require 24
hour nursing care or inpatient
 Hospital care
 Resident may be dependent.
 Resident may receive total assist with ADLs.
 Resident receives 24 hour direct care staff for monitoring and assistance.
 Resident may receive rehabilitative services through individual contract
with a home health agency.
 Intermediate care facilities/nursing facilities
 Resident lives in a licensed facility that provides 24 hour inpatient care to
residents who need licensed
 Nursing supervision and supportive care, but do not require continuous
nursing care.
 Resident may be semi-independent or dependent.
 Resident may receive full assist with ADL.
 Resident may receive full assist with transfers.
 Resident receives medications from a nurse following a doctor‘s order.
 Resident may receive outpatient rehab services.
 Facility provides licensed nursing coverage 8 hours a day for facilities
with less than 35 beds and 16
 Hours for facilities with 35 or more beds. Facilities have run as consultant.
 Resident receives periodic assessments by a licensed practitioner.
 Skilled nursing facility
 Resident lives in a licensed facility that provides 24 hour licensed nursing
services, eight hour of which is rn coverage.
 Resident may be dependent and require total assistance with ADLS

 Resident receives medications by a nurse according to a licensed
practitioners order.
 Resident receives required rehab services by the facility.
 Hospital
 Patient is admitted to a licensed facility for a short term for a condition
that requires treatment.
 Patient receives 24 hour RN care.
 Patient may receive rehab services either inpatient or outpatient.
 Patient may be dependent and require full assist with ADLs.
 Patient receives medications by an RN according to licensed practitioner‘s
orders.
 Hospice
 The hospice program is a health care agency or facility that offers
palliative and supportive services providing physical, psychological, social
and spiritual care for dying persons and their families.
 Patient may receive services in their place of residence or an inpatient
setting.
 Family and patient participates in a plan of care developed by an
interdisciplinary team which includes at least the patient and the patient‘s
family or primary care giver, nurse, social worker, volunteer, and clergy.
 Services must be ordered by a physician.
 Services may include nurse, social worker, clergy, volunteer, physical
therapy, occupational therapy,
 Speech therapy, nutritional therapy, and home health aides.
3.7 GERIATRIC INTERDISCIPLINARY TEAM
Geriatric interdisciplinary teams consist of practitioners from different

disciplines who provide coordinated, integrated care with collectively set goals and
shared resources and responsibilities. Not all elderly patients need a formal geriatric
interdisciplinary team. However, if patients have complex medical, psychologic, and
social needs, such teams are more effective in assessing patient needs and creating an
effective care plan than are practitioners working alone. If interdisciplinary care is not
available, an alternative is management by a geriatrician or a primary care physician
with experience and interest in geriatric medicine.
Interdisciplinary teams aim to ensure the following:
 That patients move safely and easily from one care setting to another and from
one practitioner to another
 That the most qualified practitioner provides care for each problem

 That care is not duplicated
To create, monitor, or revise the care plan, interdisciplinary teams must
communicate openly, freely, and regularly. Core team members must collaborate,
with trust and respect for the contributions of others, and coordinate the care plan (eg,
by delegating, sharing accountability, jointly implementing it). Team members may
work together at the same site, making communication informal and expeditious.
A team typically includes physicians, nurses, pharmacists, social workers, and

sometimes a dietitian, physical and occupational therapists, an ethicist, or a hospice
physician. Team members should have knowledge of geriatric medicine, familiarity
with the patient, dedication to the team process, and good communication skills.
To function effectively, teams need a formal structure. Teams should set

deadlines for reaching their goals, have regular meetings (to discuss team structure,
process, and communication), and continuously monitor their progress (using quality
improvement measures). In general, team leadership should rotate, depending on the
needs of the patient; the key provider of care reports on the patient‘s progress. For
example, if the main concern is the patient‘s medical condition, a physician leads the
meeting and introduces the team to the patient and family members. The physician
determines what medical conditions a patient has, informs the team (including
differential diagnoses), and explains how these conditions affect care. The team‘s
input is incorporated into medical orders. The physician must write medical orders
agreed on through the team process and discusses team decisions with the patient,
family members, and caregivers.
If a formally structured interdisciplinary team is not available or practical, a

virtual team can be used. Such teams are usually led by the primary care physician
but can be organized and managed by an advanced practice nurse, a care coordinator,
or a case manager. The virtual team uses information technologies (eg, handheld
devices, email, video conferencing, teleconferencing) to communicate and collaborate
with team members in the community or within a health care system.
3.7.1 Patient and caregiver participation
Practitioner team members must treat patients and caregivers as active

members of the team in the following ways:
 Patients and caregivers should be included in team meetings when
appropriate.
 Patients should be asked to help the team set goals (eg, advance directives,
end-of-life care).

 Patients and caregivers should be included in discussions of drug treatment,
rehabilitation, dietary plans, and other therapies.
 Patients should be asked what their ideas and preferences are; thus, if patients
will not take a particular drug or change certain dietary habits, care can be
modified accordingly.
Patients and practitioners must communicate honestly to prevent patients from

suppressing an opinion and agreeing to every suggestion. Cognitively impaired
patients should be included in decision making provided that practitioners adjust their
communication to a level that patients can understand. Capacity to make health care
decisions is specific to each particular decision; patients who are not capable of
making complex decisions may still be able to decide less complicated issues.
Caregivers, including family members, can help by identifying realistic and

unrealistic expectations based on the patient‘s habits and lifestyle. Caregivers should
also indicate what kind of support they can provide.
Geriatric care managers typically have prior training in nursing, social

work, gerontology or other health service areas. They are expected to have extensive
knowledge about the costs, quality, and availability of services in their communities.
In some countries and jurisdictions, they may obtain certification from various
professional associations, such as the National Association of Professional Geriatric
Care Managers in the United States.
Professional care managers help individuals, families and

other caregivers adjust and cope with the challenges of aging or disability by:
 Conducting care-planning assessments to identify needs, problems and eligibility

for assistance;
 Screening, arranging, and monitoring in-home help and other services;
 Reviewing financial, legal, or medical issues;
 Offering referrals to specialists to avoid future problems and to conserve assets;
 Providing crisis intervention;
 Acting as a liaison to families at a distance;
 Making sure things are going well and alerting families of problems;
 Assisting with moving their clients to or from a retirement complex, assisted
living facility, rehabilitation facility or nursing home;
 Providing client and family education and advocacy
 Offering counselling and support.

Depending on the country and health care organization, professional fees for
the services of geriatric care managers may be billed privately on a fee-for-
service basis. In the United States, they are not covered by Medicaid, Medicare nor
by most private health insurance policies. However, clients may be able to bill some
services to long term care insurance, depending on the history of the individual case.
3.8 LEVELS OF GERIATRIC CARE
LEVEL EXAMPLE
LEVEL 0: Requires hospitalization. o Intravenous therapy.
Needs can be met through normal ward o Observations required less
care. frequently than 4 hourly.
LEVEL 1:
Patients recently discharged from a o Patients requiring a minimum of 4
higher level of care. hourly observations.
Patients in need of additional o Requiring a minimum of 4 hourly

monitoring/clinical interventions, observation on the basis of clinical
clinical input or advice. need.
o Requiring continuous oxygen
therapy.
o Boluses of intravenous fluid (need
not determined by CVP).
o Epidural analgesia or Patient
Controlled Analgesia in use.
o Parenteral nutrition.
o Postoperative surgical patients
who are still requiring 4 hourly
observations.
o Requiring administration of bolus
intravenous drugs through a
Central Venous Catheter.
o With a tracheostomy.
o With a chest drain in situ.
o Requiring a minimum of 4 hourly
GCS assessment.
o With diabetes receiving a
continuous infusion of insulin.
o Who are at risk of aspiration
pneumonia?

o On established intermittent renal
support.
o Requiring respiratory
physiotherapy to treat or prevent
respiratory failure.
o Requiring frequent (> 2x day)
Patients requiring critical care Peak Expiratory Flow rate
Outreach service support. measurement for clinical reasons.
o Abnormal vital signs but not

requiring a higher level of critical
care.
o Risk of clinical deterioration and
potential need to step up to level 2
care.
LEVEL 2:
Patients needing pre-operative o Cardiovascular, renal or
optimization. respiratory optimization required
prior to surgery.
o (Invasive monitoring inserted to
assist optimization (arterial line,
and CVP as a minimum).
Patients needing extended o Immediate care following major

postoperative care elective surgery.
o Emergency surgery in unstable or
high risk patients.
Patients stepping down to Level 2 care o Where there is a risk of

from Level 3. postoperative complications or a
need for enhanced interventions
and monitoring.
o Requiring a minimum of hourly
observations.
o
requiring level 3 care again.
Patients receiving Basic Respiratory
Support. Indicated by one or more of the
following:
o Mask / hood CPAP or mask /

hood Bi-level positive airway
pressure (non-invasive ventilation)
o Patients who are Intubated to
protect the airway but needing no
ventilator support
o CPAP via a tracheostomy
o More than 50% oxygen delivered
by face mask. (Note, more than
50% has been chosen to identify
the more seriously ill patients in a
hospital). Short-term increases in
FiO2 to facilitate procedures such
as transfers or physiotherapy do
not qualify.
o Close observation due to the
potential for acute deterioration to
the point of needing advanced
respiratory support. (e.g. severely
compromised airway or
deteriorating respiratory muscle
function).
o Physiotherapy or suction to clear

secretions at least two hourly,
whether via tracheostomy,
minitracheostomy, or in the
absence of an artificial airway.
Patients receiving Advanced o Patients who are recently (within
Cardiovascular Support. 24 hours) extubated after a period
(greater than 24 hours) of
mechanical ventilation via an
endotracheal tube.
Indicated by one or more of the

following:
o Use of a CVP line for monitoring
of central venous pressure and /or
provision of central venous access
to deliver titrated fluids to treat
hypovolemia.

o Use of an arterial line for
monitoring the arterial pressure
and/or sampling of arterial blood.
o Single intravenous vasoactive
Patients receiving Renal Support. drug used to support or control
arterial pressure, cardiac output or
organ perfusion.
o Single/multiple intravenous
rhythm controlling drug(s) to
support or control cardiac
arrhythmias

following:
o Multiple intravenous vasoactive
and/or rhythm controlling drugs
when used simultaneously to
support or control arterial
pressure, cardiac output or organ /
tissue perfusion, (e.g. inotropes,
amiodarone, nitrates). To qualify
for advanced support status, at
least one drug needs to be
vasoactive.
o Continuous observation of cardiac
output and derived indices (e.g.
pulmonary artery catheter, lithium
dilution, pulse contour analyses,
esophageal Doppler, impedance
and conductance methods).
o Intra-aortic balloon pumping and
other assist devices.
o Insertion of a temporary cardiac
pacemaker (criteria valid for each
Patients receiving Neurological Support. day of therapeutic connection to a
functioning external pacemaker
unit).
Indicated by:
o Acute renal replacement therapy
(e.g.haemodialysis, hemofiltration

etc.) or
o Provision of renal replacement
therapy to a chronic renal failure
patient who is requiring other
acute organ support in a critical
care bed.

following:
o Central nervous system depression
sufficient to prejudice the airway
Patients receiving Dermatological and protective reflexes, excluding
Support that caused by sedation prescribed
to facilitate mechanical ventilation
or poisoning (e.g. deliberate or
accidental overdose, alcohol,
drugs etc.).
o Invasive neurological monitoring
or treatment e.g. ICP, jugular bulb
sampling, external ventricular
drain.
o Continuous intravenous
medication to control seizures and
/ or continuous cerebral
monitoring.
o Therapeutic hypothermia using
cooling protocols or devices.
Indicated by one or more of the following

o Patients with major skin rashes,
exfoliation or burns. (e.g. greater
than 30% body surface area
affected).
o Use of complex dressings (e.g.
large skin area greater than 30%
of body surface area, open
abdomen, vacuum dressings or,
large trauma such as multiple limb
or limb and head dressings).

LEVEL 3:
Patients receiving Advanced Respiratory Indicated by one of the following:
Support alone. o Invasive mechanical ventilator
support applied via a trans-
laryngeal tracheal tube or applied
via a tracheostomy.
o Bi-level positive airway pressure
applied via a trans-laryngeal
tracheal tube or applied via a
tracheostomy
o CPAP via a trans-laryngeal
tracheal tube.
o Extracorporeal respiratory
support.
3.8 ROLE OF A NURSE IN GERIATRIC CARE
Nursing interventions are aimed at maintaining the patient‘s 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 pattern disturbances.,
and supporting and educating family care givers. Research has demonstrated that
when the nurse can provide such support, older adults are able to maintain higher
levels of perceived and actual health.
3.8.1Supporting 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 and ques help to minimize confusion and
disorientation and give the patient a sense of security. Prominently displayed clocks
and calendars 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.
3.8.2 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 medications 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 gently persuading or
distracting the patient. Restraints are avoided because they may increase agitation.
Doors leading from the house must be secured. Outside the home, all activities must
be supervised to protect the patient, and the patient should wear an identification
bracelet or neck chain in case he or she becomes separated from the care giver.
3.8.3 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 reinforces 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 be the patient‘s only way of expressing an inability to cope with the
environment. When this occurs it is important to remain and unhurried. Measures
such as listening to music, stroking, rocking or distraction may quite the patient.
Frequently, the patient forgets what triggered the reaction. Structuring of activities is
also helpful. Becoming familiar with the patient‘s predicted responses to certain
stressors helps care givers to avoid similar situations.
By the time older persons with dementia have progressed to the late stage of
the disease, they typically reside in nursing homes and are predominantly cared for by
nurse‘s aids. Dementia education for care givers is imperative to minimize patient
agitation and is very effectively taught by advanced practice nurse specialists.
3.8.4 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 because
patients frequently forget the meaning of words or have difficulty 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.

3.8.5 Providing for socialization and intimacy needs: Because socialization with
friends and family can be comforting, visits, letters and phone calls 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 activities. 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.
Elderly with their spouses can continue their sexual activity. They must be
encouraged to talk regarding any sexual concerns. Simple expressions of love such as
holding, touching are often meaningful.
3.8.6 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,
serve one dish at a time. Food is cut into small pieces to avoid choking. Liquids may
be easier to swallow if they are converted to gelatine. Hot foods and beverages are
served warm to prevent burns.
3.8.7 Promoting balanced activity and rest: Many people complain with sleep
disturbances and wandering behaviours that may be 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 these are not corrected. During the day
time physical activity can be encouraged and long durations of sleep during the day
time are discouraged.
3.8.8 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
3.9 SUMMARY
The older adults being more 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 other 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.
1. Gerontology is the study of social, ……….,….and biological aspects of aging.

2. Environmental gerontology is relationship between ………………. and …………
3. ADL refers to ………………………………………..
4. Skilled nursing facilities is a ………………… care facility.
5. Day care facilities provide ……….. , ………….. And ………………….. Services.
6. Hospice care refers to providing care to ………………… patients.
7. Physical activities must be encouraged as they promote ………………………
8. Serve …………….. And ……………… food to avoid rejection.
9. Reduce ……………………. to avoid miscommunication.
10. …………….. Promotes comfort among older adults.
3.10.2 SHORT ANSWERS QUESTIONS
1. Outline the various health care settings for providing geriatric care?
2. Principles of geriatric care?
3. Services of geriatric care?
4. List the various team members in a geriatric care setting?
3.10.3 ESSAY QUESTIONS
1. Define geriatric care? Explain in detail the various levels of geriatric care with
examples?
3.10.4 ANSWERS TO OBJECTIVE QUESTIONS

1. Psychological and cognitive

2. Aging, environment
3. Instrumental activities of daily living.
4. Long term
5. Cognitive
6. Dying
7. Independence.
8. Appetizing and tasty
9. Distractions
10. Socialization
3.11 KEY TERMS
1. Geriatric care- is a specialty that focuses on health care of elderly people

2. Socialization- the process of learning to behave in a way that is acceptable to
society.
3. Self-independence- Not relying on others for support, cares, or funds; self-
supporting.
4. Self-esteem- confidence in one's own worth or abilities; self-respect.
5. Self-image- the idea one has of one's abilities, appearance, and personality.
6. Agitation- a state of anxiety or nervous excitement.
7. Distractions- a thing that prevents someone from concentrating on something else.
3.12 REFERENCES

Lippincott William and Wilkins publishers, p185-210.
3. http://www.insideeldercare.com/assisted-living/a-guide-to-different-levels-of-
elder-care/
4. http://health.utah.gov/hflcra/facinfo/HFLevelsOfCare.PDF
5.http://www.merckmanuals.com/professional/geriatrics/provision-of-care-to-the-
elderly/overview-of-geriatric-care
6. https://alvitacare.com/about-us/homecare-benefits/identifying-different-levels-of-
senior-care/


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Certificate of Geriatric Care

UNIT :I Concept of Gerontological Nursing

Dr. Ojaswini Patel Miss Sulochana Dash

Mrs. Lilarani Swain Ms. Prashansa Das

Course Writer Course Editor

1.1 Introductions to gerontological nursing

1.1 INTRODUCTION TO GERONTOLOGICAL NURSING

Odisha State Open University, Sambalpur Page 1

The history and development of gerontological nursing is rich in diversity and

The American Journal of Nursing, the American Nurses Association (ANA),

Nurses were provided substantial educational opportunities to learn about the

Odisha State Open University, Sambalpur Page 2

The development of gerontological nursing as a specialty is attributed to a host

Odisha State Open University, Sambalpur Page 3

 Learning patience, tolerance, understanding, and basic nursing skills;

1.3 Landmarks in the development of Gerontological Nursing

The following is a summary of significant landmarks in the development of

Odisha State Open University, Sambalpur Page 4

Odisha State Open University, Sambalpur Page 5

Odisha State Open University, Sambalpur Page 6

1.4 ATTITUDE TOWARDS AGING AND OLDER ADULTS

Odisha State Open University, Sambalpur Page 7

The older population is changing dramatically as the baby boomers (those

Odisha State Open University, Sambalpur Page 8

1.5 DEFINITIONS OF GERONTOLOGICAL NURSING

Odisha State Open University, Sambalpur Page 9

1.6 CONCEPT AND SCOPE OF GERONTOLOGICAL NURSING

Gerontological nurses work in a variety of settings, including acute

Odisha State Open University, Sambalpur Page 10

Older adults have been referred to as "the core business of healthcare" by

1.7 PRINCIPLES OF GERONTOLOGICAL NURSING

According to Stanford School of Medicine- Ethno geriatrics, the principles of

Biopsychosocial approach: the integration of consideration of physical,

Odisha State Open University, Sambalpur Page 11

According to Emory, the basic principles of gerontological nursing are,

 Aging occurs at different rates

 Older individuals commonly suffer

Odisha State Open University, Sambalpur Page 12

 Acute illness are superimposed on

 Older individuals, caregivers, and

Odisha State Open University, Sambalpur Page 13

 Understanding the patient's life

Odisha State Open University, Sambalpur Page 14

 Aging is associated with changes

 Polypharmacy, adverse drug

 There are specific definitions and

Odisha State Open University, Sambalpur Page 15

 Ethical issues arise almost every

1.9 CHECK YOUR PROGRESS

1.9.1 OBJECTIVE TYPE QUESTIONS

Odisha State Open University, Sambalpur Page 16

3. Gerontological nursing was 1st recognized in ………..…..

4. ………………………is the study of aged.

5. …………………..refers to the study of medical care of aged.

6. Collaboration of …………………..is required for care of elderly.

7. Residential services for elderly include …………………………..and ……………

8. ……………….is the major chronic disease among aged population.

9. Gerontological nursing improves …………………….of elderly.

10. Aging is associated with changes in …………………. function.