Gerontological Nursing A. B.

Gerontological
Nursing
A. Principles of Gerontology
B. Nutrition and Aging
• The terms are not interchangeable!
• Gerontology is concerned with the social, psychological,
and biological aspects of aging.
• Geriatrics is the study of disease in the elderly.
Gerontology and
Geriatrics
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• First proposed as a distinct specialty in 1909 by Dr.
Ignatz Nascher when he viewed aging as a physiological
process and not mere deterioration.
• Geriatrics is concerned with the decline of major body
systems in the elderly.
• A geriatric specialist treats disease in the elderly client
and attempts to decrease the effects of aging on the body.
Geriatrics
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• Developed into an organized field in the 1940s.
• Acknowledged that there exist experts in the elderly in
many fields and findings must be integrated.
• Studying the physical, mental and social changes in
people as they age
• Study of physical process of aging
• Study of the effects of the aging population on society
and the effects of society on the elderly
• Identification of appropriate treatment and management
of the elderly
Gerontology
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“You must not treat a young child as you would a grown
person, nor would you treat an old person as you would
one in the prime of life.”
…“Relation of old age to disease…” American Journal of
Nursing, 1904
History of Gerontological
Nursing
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• 1935: Federal Old Age Insurance Law
• 1961: ANA recommends formation of geriatric nursing
specialty
• 1966: Geriatric Nursing Division of ANA formed
• 1970: Publication of Standards for Geriatric Nursing
Practice
• 1975: Certification of first nurses in Gerontological
Nursing
Historical Influences
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• Aging is a natural process
• Various factors influence the aging process
• Nursing of the elderly requires unique information and
skills
• There are common needs shared by the elderly and all
ages
• Gerontological nursing’s goal is to promote optimum
levels of physical, psychological, social and spiritual
health
Principles of Gerontological
Nursing Practice
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• Holistic: incorporate physical, mental, emotional, and
spiritual well being
• Use every opportunity to offer suggestions for healthy
aging
• Include health promotion
in every plan of care of the
elderly patient
• Close the gap between “life span”
and “healthy life span”
Competent nursing of the
elderly patient
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Increased creativity and confidence
Increased coping ability
Increased gratitude and appreciation
Increased insight and acceptance
Benefits of healthy aging
• Responsible for defining scope and standards of nursing
practice
• Established the Division of Geriatric Nursing Practice in
1966 with the goal of creating standards for quality
nursing care for the elderly
• Changed the name to Division of Gerontological Nursing
Practice in 1976
Role of the ANA in
Gerontological Nursing Care
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• Persons older than 65 comprise 12% of the US population
• Increasing life expectancy
• 20% of the population will be older than 65 by 2020
The Aging Population
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• Young-old: 65 to 74 years
• Old: 75 to 84 years
• Old-old: 85 to 100 years
• Elite old: over 100 years
Subsets of the Elderly
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Born between 1946 and 1964
Most have children, but fewer in number
Best educated generation yet
Higher income
Favor more casual
dress
• Enjoy technology
• Less leisure time
• Interest in health
and fitness
The Baby Boomers
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• Adequate nutrition
• Maintaining safety
• Preserving body’s normal
functions
• Meeting and coping with
crises
• Adapting to change
• Learning new skills
Accomplishments of Old
Age
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• Promotes normalcy, independence and individuality
• Reduces risks associated with dependency, e.g., failure to
thrive
• Recognizes individual attributes of wisdom, experience
and competence
Recognizing Inner
Resources of the Elderly
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• In 2005, long term health care accounted for 12% of all
healthcare expenditure
• 70% of this figure was covered by Medicaid and
Medicare
• 18% was paid by patients and families
Associated Costs
and Funding
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“Old” means being sick
Older people cannot learn new information
Health promotion is wasted on older people
The elderly do not pull their own
weight
• It is too late to change bad habits
in the elderly
• Older people have no interest
in sex
Myths of Aging
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• Biocognitive Theory (Mario Martinez)
• Absence of envy
• Live in the present, being optimistic about the present and
the future
• No sense of aging, don’t tell their age (prevents being
“pegged”)
• Usually underweight, not obese
• Active
• No concept of retirement or middle age, no marker for
biology to follow
Common Characteristics of
Centenarians (1)
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• Rarely seek medical advice unless complaint is
significant
• Usually die by accident or in sleep…death is peaceful and
without lamenting
• Low protein, high complex carbohydrate diet
• Live in subcultures that revere the elderly
• Drink alcohol prudently, not addictively
• There are no atheists, a belief in a benign, not wrathful,
power
Common Characteristics of
Centenarians (2)
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Longevity in the family is not a requirement
Definite sense of humor
Forgive easily
They are negotiators
Have commitment to community, a sense of service
Fearless about life’s challenges
Believe they are loveable
Common Characteristics of
Centenarians (3)
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Insight into understanding the process of aging
Promote aging in a healthy fashion
Postpone or minimize negative effects
Emphasis is not on prolonging life
Goal is to
• Keep the client healthy
• Keep the client active
• Maximize quality of life
Value of Theories of Aging
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• Biological theories attempt to explain these variations:
• Rate of aging
varies between
individuals
• There is variation
in rates of aging
within one
individual
Biological Theories of
Aging
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• Premise: life expectancy is inherited due to a genetic program
• Cellular theory—senescence takes place at the cellular level
• Error theory—decline is caused
by genetic mutations within
each organ
• Failure of a growth substance
or excessive production of an
aging substance
Genetic Theories of Aging
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• These theories integrate an individual’s
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Mental capacities
Methods of behavior
Personal feelings
Coping mechanisms
Values, attitudes and beliefs
Psychosocial Theories of
Aging
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• Society and the individual mutually agree to withdraw
from one another
• The individual is free to become introspective
• Society enjoys the benefit of transferring power and
resources to the
young and continues
Is this a “win-win” on an ice floe?
Disengagement Theory
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“I don’t want to!”
Disengagement theory
problems…
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• “Longevity through denial”
• Perpetuating the middle-age
lifestyle
• Maintaining an active life
while adjusting for biological
change
• Gradually substitute mental
activities for physical ones
Activity Theory
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• AKA Developmental
Theory
• “PNC”—people never
change
• Recognizes the unique
qualities of each
individual
• Those qualities guide
the individual through the
aging process and adaptation to
change
Continuity Theory
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• Specific tasks must be completed in each stage of life
before moving on successfully
• If successful, the person
finds meaning in each
stage and in life as a whole
Developmental Tasks
Theory
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• Coping with loss and change
• Establishing meaningful roles
• Exercising independence and
control
• Finding purpose and meaning
in life
Developmental Tasks
Throughout the Lifespan
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• Adjustment to infirmities
• Satisfaction with the life lived
• Preparation for death
Major Tasks of the Elderly
(Robert Butler and Myrna Lewis)
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• Ego differentiation vs role preoccupation
• Body transcendence vs body preoccupation
• Ego transcendence vs ego preoccupation
All contribute to the effectiveness of completing ego integrity vs despair
Specific Challenges of
the Elderly
(Robert Peck)
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• Nutritional needs change as the individual ages
• Failure to adjust nutrition accordingly can contribute to
the aging process
Nutrition and aging
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• Less lean body mass and
increased adipose tissue
• BMR declines 2% for each
decade of life
• Activity level
usually declines
with age
Reduced calorie need in
the older adult
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• Age related physical changes: decreased total body water
due to less lean body mass
• Reduced access to fluids
• Fear of incontinence and nocturia
• Increased insensitive fluid loss
Dehydration risk factors
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Reduced intracellular fluid with age
Reduced margin of safety
Minimum 1500 mL per day
Reduced thirst sensation
Fear of incontinence
Decreased availability of fluid
Physical impairment
Altered mood or cognition
GI distress
Specific threats to
Hydration
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• Patient may present with altered mental status, lethargy,
syncope
• Mild dehydration: decreased skin turgor, dry mucous
membranes, orthostatic hypotension
• Symptoms consistent with mild dehydration may exist in
patients who are
normally hydrated
Signs of early
Dehydration
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Dark urine with decreased output
Confusion, lethargy
Headache, light-headedness
Eyes sunken
Dry mucous membranes and
axillae
• Furrows in tongue
• Postural changes in vital signs
Advanced dehydration
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• Dark green vegetables, colorful vegetables, dried beans—
2 ½ cups every day
• Fresh, frozen, dried, canned fruits—
1 ½ cups every day
• Grains—6 ounces every day
• Protein foods—5 ounces every day
• Dairy—3 cups every day
Tufts University MyPlate
for older adults
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• Acknowledges the possible need for supplements
• Includes physical activity as part
of daily routine
• Water is included
• Recommendations for protein unchanged
Tufts additions to
traditional food guide
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• Sarcopenia—age related loss of muscle mass, strength,
and function
• Protein breakdown exceed
protein synthesis as the
body ages
• RDA is unchanged:
0.8g/kg body weight
Role of protein in the diet of
the elderly client
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• Some elderly clients take supplements for
nonconventional reasons
• Clotting is affected by fish oils, garlic, ginseng, ginko
biloba, baby aspirin
• Quality and content of many supplements are neither
regulated nor standardized
Dietary supplements—
nursing considerations
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• Weight—unintentional loss of 5% in 1 month or 10% in 6
months is significant
• Height
• Body mass index = (weight in pounds x 703)
(height in inches)2
Body measurements
(anthropometrics)
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• Use of Mini Nutritional Assessment (MNA)
• “Tell me what you ate yesterday.”
• Risk factors:
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Inability to feed oneself
Chewing, swallowing problems, mouth pain
Changes in taste
Leaves > 25% food uneaten at most meals
Nutritional history
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• Indigestion, food intolerance—client may chose to use
antacids or limit food intake
• Have several small meals instead of 3 large ones
• Avoid fried foods
• Remain in high Fowler’s position for at least
30 minutes
• Adequate fluid for motility promotion
Strategies to improve nutrition--1
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• Anorexia
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Identify the cause
High calorie diet
Referral to social programs
Psychological/psychiatric
referral
• Weight loss > 5% in 1 month
and >10% in 6 months is
significant
Strategies to
improve nutrition--2
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Polypharmacy
Pain
Dysphagia
Dependency
Cognitive impairment
Potential causes of
anorexia
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• Dysphagia
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Careful swallowing assessment
Sit in upright position
Allow sufficient time to eat
No residual food in mouth before
taking additional food
• Small portions
• Suction machine available
• Thickened liquids
Strategies to improve
nutrition--3
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• Constipation
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Fluids
Fruits, vegetables
Activity
Increase fiber intake cautiously
Consider laxatives only when other methods are
unsuccessful
Strategies to improve
nutrition--4
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• Imbalanced nutrition—more/less than body requirements
(also, “Risk for”)
• Impaired swallowing; Risk for aspiration
• Excess/deficient fluid volume
(also, “Risk for”)
• Failure to thrive (adult)
• Impaired skin integrity
(also, “Risk for”)
Nursing diagnoses-nutrition
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