PAMANTASAN NG CABUYAO

BACHELOR OF SCIENCE IN NURSING

LEARN MAT - NCM114 Care of the Older Adult

VISION
A premier educational institution of higher learning, developing globally competitive and value-laden
professionals and leaders instrumental to community development and nation building.
MISSION
As an institution of higher learning, PnC is committed to equip individuals with knowledge, skills and values
that will enable them to achieve their professional goals and provide leadership and service for national
development.

COURSE TITLE: CARE OF THE OLDER ADULT

COURSE CODE: NCM 114
PRE-REQUISITE: None

COURSE OBJECTIVES:
At the end of this course, the students should be able to:
1. Apply knowledge of physical, social, natural and health sciences, and humanities in the care of the
older adult.
2. Apply guidelines and principles of evidence-based practice in the care of the older adult.
3. Adopt the nursing core values in the practice of gerontology nursing.

COURSE CONTENTS:

Module 1: Concepts, Principle and Theories in The Care of Older Adults

Module 2: Nursing Care of the Older Adults in Wellness
Module 3: Nursing Care of The Older Adult in Chronic Illness
Module 4: Core Elements of Evidence – Based Gerontological Nursing Practices
Module 5: Ethico-Legal Considerations in The Care of Older Adult
Module 6: Communicating with The Older Persons
Module 7: Guidelines for Effective Documentation
Module 8: Geriatric Health Care Team
Module 9: Research agenda on Aging
Module 10: Trends/ Issues and Challenges on the Care of Older Persons
Module 11: Advocacy Programs Relevant to The Care of Older Persons
Module 12: Entrepreneurial Opportunities

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LEARN MAT 1
Title: Concepts, Principle and Theories in The Care of Older Adults

Overview:
Aging and disease do not necessarily go hand in hand, and the nurse caring for older adults needs
to have clear understanding of the difference between age-related changes and those that may actually be
pathologic. Moreover, nurses must put in mind that scientists are still in the process of discovering what is
“normal” aging.
Integrating the psychologic aging theories into nursing practice becomes relatively essential as the
population continues to age. Present and future generations can learn from both age brackets. Older adults
should be encouraged to engage in a “life review process” which can be obtain by utilizing techniques e.g.
reminiscence, oral histories, and storytelling. Looking back over life’s accomplishments or failures are crucial
in assisting older adults to achieve developmental tasks (as in ego integrity), to promote positive self-esteem
and acknowledge that one “did not live in vain”.

Learning Objectives:
At the end of module 1, the student should be able to:
1. Integrate principles and concepts of physical, social, natural and health sciences and humanities in
the care of the older adults.
2. Apply appropriate nursing concepts and actions holistically and comprehensively.
3. Perform safe, appropriate and holistic care to older adults utilizing the nursing process.

Learning Coverage
A. Topic: Perspective of Aging
B. Topic: Demography of Aging and Implications for Health and Nursing Care
C. Topic: Impact of Aging Members in the Family
D. Topic: Theories of aging and its nursing implications
E. Topic: Physiologic changes in aging affecting various systems

TOPIC A
Topic Title: Perspective of Aging
Introduction:
Ageism is the terminology coined by Butler in 1969 to describe the deep and profound prejudice in
American Society against older adults. “Ageism reflects a deep-seated uneasiness on the part of the young
and middle-aged – a personal revulsion and distastes for growing old, disease, disability; and fear of
powerlessness, uselessness, and death”. In a society that highly values youth and vitality, it is no surprise
that ageism exists. Furthermore, it is seen as a process of systematic stereotyping of and discrimination
against people because they are old, just as racism and sexism accomplishes this with color and gender.”

Persons in advanced age are more vulnerable to the multiple losses typically associated with aging,
thus making them frailer. These frail older adults need more intensive care in all the health care settings in
which they are found. Coupled with the growth of life-extending therapies and the continuous development
of sophisticated treatment measures, the structure, services, financing of the current health care delivery
system are still not equipped to effectively managed the needs of this population segment.

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Topic Objectives:
At the end of the topic, the student should be able to:
1. Distinguish the factors responsible for the rapid growth of the older adult population.
2. Analyze the concept of ageism as related to the care of older adults in various settings.
3. Differentiate issues and trends influencing gerontologic nursing education.

Topic Content:

Any discussion of older adult nursing is complicated by the wide variety of terms used
interchangeably to describe the specialty. Some terms are used because of personal preference or because
they suggest a certain perspective. Still otherwise are avoided because of the negative inference they evoke.
The following are the commonly used terms and definitions:
1. Geriatrics – from the Greek word “geras”, meaning “old age”, geriatrics is a branch of medicine that
deals with the diseases and problems of old age. Viewed by many nurses as having limited
application to nursing because of its medical and disease orientation, the term geriatrics is generally
not used when describing the nursing of older adults.
2. Gerontology – from the Greek word “geron”. Which means “old man”. Gerontology is the scientific
study of the process of aging and the problems of aged persons, it includes biologic, sociologic,
psychologic and economic aspects.
3. Gerontologic nursing – this specialty of nursing involves assessing the health and functional status
of older adults, planning and implementing health care and services to meet the needs, and
evaluating the effectiveness of care. It is the term most often used by nurse specializing in this field
of nursing expertise.
4. Gerontic nursing – this term was developed by Gunter and Estes in 1979 is meant to be more
inclusive than geriatric or gerontologic nursing because it is not limited to disease or scientific
principles. It connotes to nursing the older persons – the art and practice of nurturing, caring, and
comforting. This term has not gained wide acceptance, but it is viewed by some more appropriate
description of the specialty.
These terms and their usage spark a great deal of interest and relevance for nurses who are practicing
care for the older persons, wherein field of specialization develops as years in earth have gained in number
[1].

Aging in Developmental Process

Humans have the longest life span of mammalian species and consume more energy over their life
span on a per weight basis. These two unique biological characteristics reflect an unusually slow innate rate
of aging of all physiological functions. Although much work in biogerontology involves studies on how humans
and other animals age, little research has been oriented toward obtaining an understanding of what
determines the longevity of humans and other animals. Consequently, a large gap exists in our knowledge
about the unique characteristics of human biology that might help explain why human aging processes arc
so extraordinarily slow.
Clearly, any insight into understanding why humans live as long as they do have the potential to
contribute importantly toward developing effective means to ensure a healthy, productive life span for more
individuals in our population and to provide new concepts for the development of treatments for the vast

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number of diseases initiated by aging processes affecting so many older citizens. The vast complexity of the
physiological aspects of aging impedes progress in understanding the biological mechanisms causing aging.
This is particularly true since we still are far from understanding the normal nonaging characteristics of human
biology.
Moreover, increased knowledge limited only to understanding the mechanism of aging could lead to
little increased insight as to how to develop more effective methods for treating age-related dysfunctions.
That is, knowing what is wrong (the causes of aging) does not necessarily lead most efficiently to the best
means of correcting the problem (decreasing aging rate). In contrast to this inherent difficulty in studying
aging mechanisms, a study of longevity rather than aging mechanisms may involve less complex biology and
lead more directly to possible useful methods in the treatment of dysfunctions caused by aging processes. It
is this latter approach to the problem of aging that has determined the direction of our research program [1].

References:
[1] Meiner, Sue Gerontologic Nursing, 2005.
[2] Cutler,Richard Antioxidants and Aging, American Journal of Clinical Nutrition, 2015.

Topic B
Title: Demography of Aging and Implications for Health and Nursing Care
Topic Objectives:
At the end of the topic, the student should be able to:
1. Distinguish at least three factors that influence the aging experience.
2. Differentiate health and wellness within the context of aging and chronic illness.
3. Relate the trends seen in global aging today.

Topic Contents:
Global Aging
Demography is the statistical science dealing with the distribution, density, and vital statistics of
human populations. The rate and intensity of aging is highly variable and individual which occurs gradually
and in no predictable sequence [1].
Before the year 2050, the number of persons 60 years of age and older worldwide is likely to exceed
those younger than 15 years for the first time in recorded history, most notably in developing or low-income
countries (National Institute on Aging, National Institutes of Health, 2007). This occurred in Europe in 1995
but will not occur in North America until 2015. Those older than 60 years of age will not surpass children until
2040 in Asia, Latin American, and the Caribbean (United Nations [UN], 2007a). However, in 2007, Japan
already had the highest percentage of persons 60 years of age and older at 27.9% (UN, 2007b). These
changes pose major challenges in meeting the needs of the aging global community as the number of
younger adults providing care and financial support diminishes. Although the number of the very old remains
small, the relative number of centenarians in the world’s population is growing dramatically in the United
States alone.
In view of this, the U.N. estimates that a worldwide population of 270,000 centenarians will grow to
2.3 million by the year 2050 (Kinsella & He, 2009, p. 28). Among centenarians, women are between four and
five times more numerous than men (UN, 2007b, p. xxviii). Africa stands out as the only major region where

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the population is still relatively young and the number of elderlies, although increasing, will still be far below
the number of those 0 to 59 years of age in 2050. Those between 15 and 59 years of age in Africa is projected
to rise from half a billion in 2005 to more than 1.2 billion in 2050 (UN, 2007a), while those older than 60 will
only increase from 0.05 billion to 0.2 billion in the same period.
All people over age 18 are considered adults, but there is a large difference between a person aged
21 and a person who is 45. More specific breakdowns, such as “young adult” and “middle-aged adult,” are
helpful. In the same way, groupings are helpful in understanding the elderly. The elderly is often lumped
together, grouping everyone over the age of 65. But a 65-year-old’s experience of life is much different than
a 90-year-olds.
The older adult population can be divided into three life-stage subgroups: the young-old
(approximately 65–74), the middle-old (ages 75–84), and the old-old (over age 85). Today’s young-old age
group is generally happier, healthier, and financially better off than the young-old of previous generations. In
North America, people are better able to prepare for aging because resources are more widely available.
Subsequently, many people are making proactive quality-of-life decisions about their old age while
they are still young. In the past, family members made care decisions when an elderly person reached a
health crisis, often leaving the elderly person with little choice about what would happen. The elderly is now
able to choose housing, for example, that allows them some independence while still providing care when it
is needed. Living wills, retirement planning, and medical powers of attorney are other concerns that are
increasingly handled in advance.

Nursing is a vital aspect of the health care of older people, and the practice of gerontological nursing
provides a unique vantage point from which to make an impact on it. Nurses attracted to this specialized field
recognize that expertise in caring for older adults can make a significant difference in the quality of life of the
persons served. In times of illness and rehabilitation and end-of-life care, outcomes for the older person most
often depend on the nursing care received. Through research, gerontological nurses have made substantial
contributions to the body of knowledge of best practices in the care of elders, and they are recognized as
leaders in aging care. Gerontological nurses have opportunities to provide care across the continuum of
aging services, caring for everyone from the most ill and frail elders to those who are active and independent.
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 As stated by Mezey and Fulmer (2002), the commitment of gerontological nurses to “tackle difficult
but exceptionally meaningful issues that impact profoundly on the health and quality of life for older adults,
the opportunities for decision making, independent action, innovation, and the significant contribution of
geriatric nursing research to improved patient outcomes and health policy position the specialty for continued
growth, recognition, contribution and value to society” (Mezey & Fulmer, 2002, p. 440). Gerontological nursing
may be the most needed specialty in nursing, both now and in the future (Ebersole & Touhy, 2006).
It is the responsibility of the nurse to assist elders to achieve the highest level of wellness in relation
to whatever situation exists. The nurse can, through knowledge and affirmation, empower, enhance, and
support the person’s movement toward the highest level of wellness and quality of life possible. The nurse
assesses and helps explore the underlying situation that may be interfering with the achievement of wellness,
and work with the person and significant others to develop affirming and appropriate plans of care. The nurse
can utilize the resources available, such as Healthy People 2020 and the Clinical Preventive Services
Guidelines to maximize the potential for health (see Table 1-1). The nurse and the elder collaboratively
implement interventions to achieve individual goals and evaluate their effectiveness. The goals of the nurse
are to care and comfort always, to cure sometimes, and to prevent that which can be prevented.

Nurses in all practice settings play a key role in improving care for older people across the continuum.
New roles for nursing are emerging in the era of health care reform and heightened attention to improved

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patient outcomes. Most nurses work in only one setting and are not familiar with the requirements of other
settings or the needs of patients in those settings. As a result, there are often significant misunderstandings
and criticisms of care in the different settings across the continuum. We can stop the finger pointing and start
working together through the common transitions patients endure in our health care system. This will be a
win-win situation for patients and providers alike (Resnick, 2008).
It is essential that educational programs prepare students for competent care of older adults in a
variety of health care settings, including acute, long-term, home, and community-based care. Nurses in all
settings need to increase awareness of the roles and responsibilities of nursing practice across the continuum
and work collaboratively to improve care outcomes, particularly during times of transition. We can no longer
work in our individual “silos” and not be concerned with what happens after the patient is out of our particular
unit or institution. Nurses are well positioned “to create services and environments that embrace values that
are at the core of this profession—patient/caregiver centered care, communication and collaboration, and
continuity (Naylor, 2002).
Moreover, health in later life is often thought of in terms of functional ability (i.e., the ability to do what
is important to a given person) rather than the absence of disease (Dunn, 1961). This may mean the person’s
ability to live independently or the ability to enjoy greatgrandchildren when they visit at the nursing home, but
it is always individually determined. Well-being for those older than 60 years of age is strongly related to
functional status but is affected also by socioeconomic factors, degree of social interaction, marital status,
and aspects of one’s living situation and environment.
Approaching aging from a viewpoint of health even if the person has an illness emphasizes strengths,
resilience, resources, and capabilities rather than focusing on existing pathological conditions. A wellness
perspective is based on the belief that every person has an optimal level of health independent of his or her
situation or functional ability or ability to manage day-to-day activities. Movement toward higher wellness is
possible if the emphasis of care is placed on the promotion of well-being in the least restrictive environment,
with support and encouragement for the person to find meaning in the situation, whatever it is.
The effects of population aging on individuals, societies and governments are still largely unknown.
Nonetheless, experts, governments and global organizations express alarm about the pressures that aging
exerts on two critical policy areas, namely, the pension systems and health services. Pension can help
caution the impact of reduced income in late life, while the demand of the elderly for healthcare could
compromise the health needs of younger age groups. Research in these areas is just beginning to emerge,
showing, for example, how some countries in the developed world are revising their established pension and
health policies toward aging- friendly societies.
As health care improves and life expectancy increases across the world, elder care will be an
emerging issue. Wienclaw (2009) suggests that with fewer working-age citizens available to provide home
care and long-term assisted care to the elderly, the costs of elder care will increase.
Worldwide, the expectation governing the amount and type of elder care varies from culture to
culture. For example, in Asia the responsibility for elder care lies firmly on the family (Yap, Thang, and
Traphagan 2005). This is different from the approach in most Western countries, where the elderly are
considered independent and are expected to tend to their own care. It is not uncommon for family members
to intervene only if the elderly relative requires assistance, often due to poor health. Even then, caring for the
elderly is considered voluntary. In North America, decisions to care for an elderly relative are often
conditionally based on the promise of future returns, such as inheritance or, in some cases, the amount of
support the elderly provided to the caregiver in the past (Hashimoto 1996).

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 These differences are based on cultural attitudes toward aging. In China, several studies have noted
the attitude of filial piety (deference and respect to one’s parents and ancestors in all things) as defining all
other virtues (Hamilton 1990; Hsu 1971). Cultural attitudes in Japan prior to approximately 1986 supported
the idea that the elderly deserve assistance (Ogawa and Retherford 1993). However, seismic shifts in major
social institutions (like family and economy) have created an increased demand for community and
government care. For example, the increase in women working outside the home has made it more difficult
to provide in-home care to aging parents, leading to an increase in the need for government-supported
institutions (Raikhola and Kuroki 2009).
In North America, by contrast, many people view caring for the elderly as a burden. Even when there
is a family member able and willing to provide for an elderly family member, 60 percent of family caregivers
are employed outside the home and are unable to provide the needed support. At the same time, however,
many middle-class families are unable to bear the financial burden of “outsourcing” professional health care,
resulting in gaps in care (Bookman and Kimbrel 2011). Chinese Canadians, for example, are thought to have
a higher sense of filial responsibility and to perceive providing family assistance for the elderly as a more
normal aspect of life than Caucasian Canadians (Funk, Chappell, and Liu 2013).
It is important to note that even within a country, not all demographic groups treat aging the same
way. While most Americans are reluctant to place their elderly members into out-of-home assisted care,
demographically speaking, the groups least likely to do so are Latinos, African Americans, and Asians
(Bookman and Kimbrel 2011).
In 2002, the Second World Assembly on Aging was held in Madrid, Spain, resulting in the Madrid
Plan, an internationally coordinated effort to create comprehensive social policies to address the needs of
the worldwide aging population. The plan identifies three themes to guide international policy on aging: 1)
publically acknowledging the global challenges caused by, and the global opportunities created by, a rising
global population; 2) empowering the elderly; and 3) linking international policies on aging to international
policies on development (Zelenev 2008).
The Madrid Plan has not yet been successful in achieving all its aims. However, it has increased
awareness of the various issues associated with a global aging population, as well as raising the international
consciousness to the way that the factors influencing the vulnerability of the elderly (social exclusion,
prejudice and discrimination, and a lack of socio-legal protection) overlap with other developmental issues
(basic human rights, empowerment, and participation), leading to an increase in legal protections (Zelenev
2008).

Aging in the Philippines

Living independently from children is the ideal set-up in late life, alone or with spouses and regardless
of economic condition as long as possible. Longevity, poverty, frailty, choice and family values transform the
nuclear family into a household because “larger households [are] more likely to be caring for an extended
family member”. This is in contrary to the unfounded view that modernity leads to smaller families (Go, 1994).
The three- to four-generational household provides a sense of integration that becomes more important in
late life because of loneliness due to poor health, isolation from loved ones and widowhood. In contrast,
ethnohistorical and ethnographic evidence show that in cultures where the nuclear family is the rule, the poor
elderly lives alone, too old to fend and care for themselves, and they die malnourished and abandoned by
their children.

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 It is a truism that a culture that encourages aging produces elderly populations in society. However,
the idea that a culture that promotes filial piety in the young produces filiation among them needs
reconsideration. How “utang na loob” operates, alone or in relation to “gaba and hiya”, is still poorly
understood and needs to be examined further. One needs to look into the role of consciousness of filial piety
and volunteerism, the economic status of the children, the decision-making involved and how filial piety and
voluntarism prevent depression that caregivers for frail elderly suffer in order to understand more deeply how
debt of gratitude plays out in care for the elderly.
Friendship, membership in organizations, volunteerism and paid work are independent from familial
relations. They are important aspects of sociality that contribute to satisfaction in life. Friendship remains the
core relationship, and it serves as an anchor to other modes of connectedness and social network building.
Volunteerism remain constant even upon widowhood, while poor, healthy and active widows show interest
in paid work that suits their abilities. It would be interesting to look into the positive effects of widowhood in
relation to sense of freedom and interest with paid work.
Belief in God, immortality and in good and evil does not seem as important as activity and
commitment in fostering a sense of community and integration with co-religionists. Belief in a gracious God
intensifies with crises. Life itself is a manifestation of the experience of a gracious God. The less poor are
more candid about their belief than the poor: they owe everything to God―longevity, health, the success of
children, etc. If one’s status is an attestation to God’s grace, then the poor have less to declare about this,
which is not to say that they are less satisfied with life or are less religious. Rather, belief is not something
that they resort to even in difficult times. Besides, other indicators, such as the role of doctrine and
membership in church organizations, may play vital roles in the religious life of individuals.

References:
Ebersole and Hess, Gerontological Nursing and Healthy Aging, 2014
Rolando C. Esteban (2015) Thinking about Aging: Experience, Identity and Meaning among an Elderly
Population in the Philippines, Advances in Aging Research,04,133-153. doi: 10.4236/aar.2015.45015
Introduction to Sociology, First Canadian edition

TOPIC C
Topic Title: Impact of Aging Members in the Family
Introduction:
Most of us live our entire lives in the context of a family. Our family provides us with the important
resources we need to help us learn independence as children and remain independent as older adults.
Throughout our lives we exchange help and support within the family. These exchanges can involve providing
emotional and physical care, as well as financial support.
As we faced many new issues as our society ages, it was revealed that ever in the history of America
or the world has the population had more older adults than children. Researches where conducted to delved
on some issues that happen as a result of having a greater number of older adults than children. It also
creates an overview at the roles of the family and intergenerational relationships supporting our aging society.
In effect, there are some reflective thoughts on how will the smaller workforce cope with providing
for a larger retired community? What is the role of the family in caring for more than one generation of elders?

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Not to mention, how will modern families decide to distribute and share resources with aging parents and
stepparents?
These are just a handful of foreseeable scenarios which was brought about by the influx of aging
population and preparing them to live life to the fullest with dignity and quality of life as they pass through in
their twilight years.

Topic Objectives:
At the end of the topic, the student should be able to:
1. Relate cohort and generation from one another in identifying family relationships in this new era.
2. Critique current and relevant concepts on how the family structure is changing through the years.
3. Examine the major types of intergenerational relations and support for the elderly within the family.

Topic Contents:
The family becomes more and more important for the elderly as the need for support increases. Yet
we must remember that the aging person and the family are all part of a larger society. Society impacts the
resources and services available to older adults and their families.
Two terms, generation and cohort, are frequently used when discussing aging. These terms help
explain family and societal aspects of aging. We use the term generation to better understand the impact of
aging on the family. A generation is a group of people at the same step in the line of the family. In a family,
children, parents, grandparents, and great-grandparents reflect different generations. People in the same
generation often have common roles, responsibilities, and expectations. For example, those in the “parent
generation” are responsible for raising their children, caring for their parents and/or grandparents, and taking
care of their own personal responsibilities. This is why they have been called the “sandwich generation.”
Family members from different generations often have different ideas about life in the family and what it
should be like.
We use the term cohort when we are talking about society instead of the family. A cohort defines a
group of people who were born during the same time in history. People in the same cohort were born around
the same time, which means they have lived through time and history together. They may share common
experiences and often common beliefs. For example, the “baby boomers” (born between 1946 and 1964) are
a cohort. They experienced the years of the "traditional family" (e.g., mom, dad, and children), and the
Vietnam era. The cohort born in the early part of the 19th century shared two World Wars as well as the
Great Depression.
Having these common experiences molds a cohort's expectations of aging. Clashes between cohorts
occur when people from different cohorts fail to recognize the differences in their experiences.

Changes in the Structure of the Family

In the 1900s, families in the United States commonly had many children. Also, grandparents usually
died before their grandchildren reached adulthood. This meant the family structure looked like a pyramid with
a large number of children and parents and very few grandparents.

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 Figure 1

In the 2000s, however, the family model is more like a lopsided rectangle. More generations are alive
at the same point in time than in past eras. Families have fewer children, but grandparents and great-
grandparents are living longer.

Figure 2
By 2030 the boomers will be grandparents and great-grandparents. This means the top of the
pyramid will be quite broad, and there will be fewer parents and children.

Figure 3
Understanding the impact of these changes is important for families and society. More members in
the older generation may help families raise children. But older members may require care and support.
Policy makers must consider these changes as they plan for schools and health care.

Intergenerational Relations
We have all seen the ideal image of the family often portrayed by the media. On television, family
members rarely argue. And, when they do, the problems are solved before the program ends. In real life,
family members often disagree. Sometimes they may decide to leave the family entirely. Frequently, the
disagreements are between people from different generations.
Relationships between children and their parents, parents and grandparents, or children and their
grandparents are called intergenerational relationships. Along with this, generations interact differently in

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different families. Some are emotionally close, while others are emotionally distant. Some families spend a
great deal of time together, while others rarely see one another.
Based on research, there are three dimensions of intergenerational interactions to better understand
families:
1) emotional closeness, 2) frequency of contact, and 3) social support.
Using these three dimensions, five types of intergenerational relations in families where identified:
• Tight-Knit: Families are emotionally close and have frequent contact with one another. If they live
close together, they see each other often. If they live farther apart, they remain close emotionally
with frequent phone calls, emails, or letters. These families take care of one another across
generations.
• Sociable: Families are emotionally close across generations and have frequent contact with one
another. They are less likely to provide care for one another.
• Intimate: Families describe themselves as emotionally close but don't visit frequently and may live
far away from one another. They rely on others to provide care for family members.
• Obligatory: Families see one another frequently and provide support across generations. These
families don't feel especially close emotionally but provide care and support if necessary.
• Detached: Families are not close emotionally, don't see one another often, and do not provide
support or care for one another.

Social Support
Older people often rely on family members for help. They may need help with the demands of
everyday life because of a chronic illness or during a crisis. Adult children may have a strong sense of
responsibility and commitment toward their aging parents. Many adult children provide caregiving in spite of
time, distance, or competing responsibilities. The help provided to older adults is called social support.
Family members provide four basic types of social support:
• Instrumental: Housework, transportation, shopping and personal care.
• Emotional: Confiding, comforting, reassuring, and listening to problems.
• Informational: Advice in seeking medical treatment, referrals to agencies, sharing family news.
• Financial and Housing: Help paying bills, sharing a home.
We know that families provide most of the help for frail and disabled elderly who live in the
community. Family members and the elderly often prefer it that way.

There are two ways of understanding how older adults get assistance:
1. Principle of Substitution
2. Task-Specific Model
The Principle of Substitution describes the order in which older adults choose their care providers.
Married older adults prefer to receive help from their spouses. If a spouse is not available or unable to help,
they turn next to their children and other relatives. Friends and neighbors help by driving, picking up groceries
and medicines, and checking on the older person. Older adults turn to professionals as a last resort.
The Task-Specific Model states that different tasks require the help of different people. For
example, spouses and close family members provide the kind of help that requires a great deal of time and
energy. They also perform personal tasks such as bathing. Friends and neighbors help with errands, provide

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transportation, and offer leisure activities. Professionals are called only when the tasks of social support
become too time-consuming, too technical, or too difficult.
If the time comes when continued professional help is needed, the family may have to consider
institutionalization, such as a nursing home. That choice is only made when the people identified in
the Principle of Substitution are no longer able to continue managing in-home care.
Family, religion, community, and history are important reference points for self-worth and identity for
persons from any ethnic group. Familial supports vary among groups, social classes, and subcultures, yet
the nuclear or extended family is the chief avenue of transmitting cultural values, beliefs, customs, and
practices.
In some groups, elders are considered repositories of cultural knowledge. The elder and extended
family provides orientation, stability, and often, sanctuary. In gross generalizations, we must consider the
possibility that persons of Asian descent value familial piety; Hispanics, the extended family; African
Americans, extended or fictive kin (family “members” due to emotional bond) supports; Native Americans, a
system of kinship and line of descent; and persons of northern European descent, the desire for
independence and autonomy above all other things (Purnell & Paulanka, 2008).
Changes are threatening the historical role of the older adult in the traditional family. Economic
independence and mobility of the younger members of the family are chipping away at the insulation afforded
by the community (Jett, 2006). Intergenerational discontinuities created by assimilation produce a
communication gap between the young and the old. This may cause isolation and estrangement between
the oldest and youngest generations.
Nurses can take an active role in facilitating self-actualization by facilitating expression of the
uniqueness of the individual, by attending to the elder’s spiritual and cultural needs, and by taking the lead
in optimizing the health and abilities of those who seek our care.

References:
Family Relationships in an Aging Society (http://edis.ifas.ufl.edu/fy625), Martie Gillen, PhD, Terry Mills,
PhD, and Jenny Jump, M.S.
US Census Bureau. 2010. “The Older Population in the United States: 2010 to 2050.” Accessed October
2012. http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/DOCS/p25-1138.pdf.
Ebersole and Hess, Gerontological Nursing and Healthy Aging, 2014

TOPIC D
Topic Title: Theories of Aging and Its Nursing Implications
Introduction:
Human aging is influenced by a composite of biologic, psychologic, social, functional and spiritual
factors. Aging may be viewed as a continuum of events that occur from conception to death (Ignatavicius
and Workman, 2005). Biologic, social and psychologic theories of aging attempt to explain and explore the
prominent theories of aging as a guide for developing a holistic gerontologic nursing theory for practice
application. No single gerontologic nursing theory has been accepted by this specialty, which requires the
nurses to use eclectic approach from other disciplines as the basis of clinical decision making (Comfort,
1970).

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 In this effect, inculcating the application of holistic approach to the care of older adults, nurses can
view this ever-dynamic portion of the population more comprehensively. Nurses have the ability to synthesize
various aspects of the different aging theories, and they visualize older adults interfacing with their total
environment, including physical, mental/emotional, social and spiritual aspects. Thus, concretizing the
thought that eclectic approach provides a strong foundation when planning high-quality care for older adults.
Various basic concepts and assumptions have been accepted over the years as guiding research
and clinical practice related to aging. Human aging is viewed as a total process that begins at conception.
Because individuals have unique genetic, social, psychologic and economic factors intertwined in their lives,
the course of aging varies from one individual to another. Senescence, which is defined as a change in the
behavior of the organism with age, leading to a decreased power of survival and adjustment, occurs as well.
The recognition of the universal truth is what we attempt to discover through the theories of aging.

Topic Objectives:
At the end of the topic, the student should be able to:
1. Differentiate normal age-related changes from those that are potentially pathological.
2. Analyze several nursing implications for each of the major biologic, sociologic and psychologic theories of
aging.
3. Develop a plan of care for the older adult that targets prevention and health promotion.

Topic Contents:
Aging comprises a series of complex changes and occurs in all living organisms. Most of these
changes are intrinsic, coming from within; others are a result of extrinsic, environmental factors, such as
exposure to smoke or other pollutants. Some changes are beneficial (e.g., learned experiences, resistance
to some infections), others are to one’s disadvantage (e.g., slowed reaction time) and others are neutral (e.g.,
graying of hair). Just why the changes occur has been of interest to scientists for decades as they have
unceasingly searched for the mythical “fountain of youth,” yet it is now well accepted that the maximum
possible age in the human is about 120 years (Walston, 2010).
It is known that the triggers of aging are greatly influenced by genetics and by injury to or abuse of
the body earlier in life. Later life is a time of challenge and opportunity. Among the challenges are physical
changes which occur to many or most persons as they accumulate years. Other challenges are the result of
pathological conditions, many of which are the manifestations of lifestyle choices made at younger ages,
such as smoking and obesity. Some indications of pathological conditions are mistakenly considered an
expected part of the aging process.

Biological Theories of Aging

A theory is an explanation of some phenomenon that makes sense to us. Theories remain
reasonable explanations until someone finds them to be incorrect. Most theories can neither be proved nor
disproved, but they are useful as points of reference. Each theory in its own right provides a clue to the aging
process. However, many unanswered questions remain. The biological theories of aging today have evolved
from the early study of changes over the life span of the organism.
Two related theoretical views form the foundation of biological theories: error (stochastic) theories
and predetermined aging (nonstochastic) theories. Although they differ, both viewpoints agree that, in the
end, the cells in the body become disorganized or chaotic and are no longer able to replicate, and cells die.

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When enough cells die, so does the organism. In recent years, research on the biological theories of aging
has emphasized the cells, the genes, and other components within the cell. The physical traits that identify
one as older (e.g., gray hair, wrinkled skin) are referred to as the aging phenotype, that is, an outward
expression of one’s individual genetic makeup (Carnes, Staats, Sonntag, 2008).

Neuroendocrine Control or Pacemaker Theory

The neuroendocrine system regulates many essential activities related to an organism’s growth and
development. The neuroendocrine (or pacemaker) theory focuses on the changes in these systems over
time. It may be that common neurons in the higher brain centers act as pacemakers that regulate the
biological clock during development and aging, and slow down and eventually “shut off” at the predetermined
time. Much of the current research in this area is on the examination of the influence of hormones on
neuroendocrine functioning over time, especially dehydroepiandrosterone (DHEA) and melatonin.

Genetic Research
As the human genome is being mapped, scientists continue to examine the roles that genetics, and
RNA in particular, has in both random and programmed aging and may eventually be able to explain
senescence. Among the findings are that telomeres, which serve to cap the ends of the chromosomes,
shorten with each cellular reproduction until a time when the telomere disappears, and the cell can no longer
reproduce and dies. Abnormal cells such as cancer cells produce an enzyme called telomerase, which
actually lengthens the telomeres, enabling the cells to continue to reproduce. Learning to manipulate
telomerase may have significant implications for controlling both cellular reproduction and aging.

Progerin and Telomeres

Some of the latest research in this field has found an association between telomeres which cap either end of
chromosomes and a toxic protein call progerin. As long as a telomere is securely bound to the chromosome,
the cell is able to replicate and in essence live forever. However, the telomeres actually wear away with aging
at the same time the cell produces more and more progerin. The progerin, a mutated version of normal cell
protein, interferes with the stability of the telomeres and ultimately the length of the cell’s life. (From Cao K,
Faddah DA, Kieckhaefer JE, et al: Progerin and telomere dysfunction collaborate to trigger cellular
senescence in normal fibroblasts, J Clin Invest 121(7): 2833–2844, 2011.)

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Error (Stochastic) Theories
Error theories explain aging as the result of an accumulation of errors in the synthesis of cellular
DNA and RNA, the basic building blocks of the cell (Short et al., 2005). With each replication, more errors
occur, until the cell is no longer able to function. The visible signs of aging, such as gray hair, are thought to
be the result of the accumulation of these cellular errors. Three of the most common theories of error are
wear-and-tear, cross-linkage, and free radical.

Wear-and-Tear Theory
One of the earliest theories of aging is known as “wear and-tear.” According to this theory, cell errors
are the result of “wearing out” over time because of continued use and trauma. Internal and external stressors
increase the numbers of errors and the speed with which they occur (e.g., in shoulder joints of pitchers or
knees of runners). These errors may cause a progressive decline in cellular function.

Cross-Link Theory
Cross-link theory explains aging in terms of the accumulation of errors by cross-linking, or the
stiffening of proteins in the cell. Proteins link with glucose and other sugars in the presence of oxygen and
become stiff and thick (MarinGarcia, 2008). Because collagens are the most plentiful proteins in the body,
this is where the cross-linking is most easily seen. Skin that was once smooth, silky, firm, and soft becomes
drier and less elastic with age. Collagen is also a key component of the lungs, the arteries, and the tendons,
and similar changes can be seen there, such as in stiffened joints.

Oxidative Stress Theory (Free Radical Theory)

The oxidative stress theory, otherwise known as the free radical theory of aging, is among those
most understood and accepted (Jang & Van Remmen, 2009). Free radicals are natural by-products of cellular
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activity and are always present to some extent. It is believed that cellular errors are the result of random
damage from molecules in the cells called free radicals. It is known that exposure to environmental pollutants
increases the production of free radicals and increases the rate of damage. The best-known pollutants include
smog and ozone, pesticides, and radiation (Abdollahi et al., 2004; Lodovici & Bigagli, 2011). Other
environmental sources thought to cause increases in free radicals are gasoline, by-products from the plastic
industry, and drying linseed oil paints.
There is also new evidence that chronic exposure to racial discrimination increases evidence of
oxidative stress. This may provide some explanation for a number of the disparities in incidence and
prevalence of several diseases that are associated with free radicals, such as heart disease (Pashkow, 2011).
In youth, naturally occurring vitamins, hormones, enzymes, and antioxidents neutralize the free radicals as
needed (Valko et al., 2005). However, with aging, the damage caused by free radicals occurs faster than the
cells can repair themselves, and cell death occurs (Hornsby, 2009; Marin-Garcia, 2008).

Programmed Aging (Nonstochastic Theories)

The nonstochastic theories attribute the changes of aging to a process that is thought to be
predetermined or “programmed” at the cellular level. This means that each cell has a natural life expectancy.
As more and more cells cease to replicate, the signs of aging appear, and ultimately the person dies at a
“predetermined” age. These theories evolved from the groundbreaking work of Hayflick and Moorehead
(1981). They referred to this process as the inner biological clock. In other words, each cell is “born” with a
limited number of replications and then it dies.

Neuroendocrine-Immunological Theory
Closely tied to both programmed and free radical theory is the immunity theory of aging. It is based
on changes in the integrated neuorendocrine and immune systems. In this case, the emphasis is on the
programmed deaths of the immune cells from damage caused by the increase of free radicals as aging
progresses (Effros et al., 2005; Marin-Garcia, 2008). The immune system in the human body is a complex
network of cells, tissues, and organs that function separately and together to protect the body from
substances from the outside, such as bacteria. It is highly dependent on the release of hormones. In the
simplest terms, the specialized B lymphocytes (humoral) and the T lymphocytes (cellular) protect the body
against invasion by infection or other matter that is considered foreign, such as tissue or organ transplants.
The results of animal studies have demonstrated that the cells of the immune system become
progressively more diversified with age and in a somewhat predictable fashion lose some of their ability to
self-regulate. The T lymphocytes show more signs of “aging” than do the B lymphocytes. The reduced T cells
are thought to be responsible for hastening the age-related changes caused by autoimmune reactions as the
body battles itself; healthy cells are mistaken for foreign substances and are attacked.
It is important for the nurse to understand that the exact cause of aging is unknown; there is
considerable variation in the aging process. Not only is there variation between persons but also between
the systems of any one person. Aging is a wholly unique and individual experience.

Sociological Theories of Aging

Sociological theories of aging attempt to explain and predict the changes in roles and relationships
in middle and late life with an emphasis on adjustment. Many of the basic theories were developed in the
1960s and 1970s and must be viewed within the context of the historical period from which they emerged.

17
Some of the theories continue to generate interest and thought, such as modernization and social exchange
theories, and others such as disengagement theory, are no longer considered relevant.

Disengagement Theory
The disengagement theory states that “aging is an inevitable, mutual withdrawal or disengagement,
resulting in decreased interaction between the aging person and others in the social system he belongs to”
(Cummimg & Henry, 1961, p. 2). This means that withdrawal from one’s society and community is natural
and acceptable for the older adult and his or her society. The measures of disengagement are based on age,
work, and decreased interest or investment in societal concerns. The theory is seen as universal and
applicable to older people in all cultures, although there are expected variations in timing and style.

Activity Theory
The activity theory is based on the belief that remaining as active as possible in the pursuits of middle
age is the ideal in later life. Because of improved general health and wealth, this is more possible than it was
40 years ago when Maddox (1963) proposed this theory. The activity theory may make sense when
individuals live in a stable society, have access to positive influences and significant others, and have
opportunities to participate meaningfully in the broader society if they continue to desire to do so. Attempts
at clarifying activity theory as a general concept of satisfactory aging have not been supported.

Continuity Theory
The continuity theory, proposed by Havighurst and co-workers (1968), explains that life satisfaction
with engagement or disengagement depends on personality traits. Three ideas about personality (Neugarten
et al., 1968) are important to understanding continuity theory:
• In the normal progression of aging, personality traits remain quite stable.
• Personality influences role activity and one’s level of interest in particular roles.
• Personality influences life satisfaction regardless of role activity.

Age-Stratification Theory
Age-stratification theory is a newer approach to understanding the role, the reactions, and the
adaptations of older adults. Like continuity theory, it specifically challenges activity theory and disengagement
theory. Age-stratification theory goes beyond the individual to the age structure of society (Marshall, 1996).
The structuring of different ages can take a number of different forms, including the conceptualization of
“young,”“middle-aged,” and “old.” With the increasing life expectancy and compressed morbidity, age
categories are changing. Readers have probably heard that “60 is the new 40.” In the future, 60 to 80 years
of age may be considered “young old,” 80 to 100 years of age “middle-old,” and 100 years of age and over,
“oldest-old.” Historical context is a key component of age-stratification theory.
Elders can be understood as members of cohorts along with others who have shared similar
historical periods in their lives, with age-graded systems of expectations and rewards. They have been
exposed to similar events and conditions and common global, environmental, and political circumstances
(e.g., World Wars, Great Depression, Viet Nam, civil rights movement) (Riley et al., 1972). Hooks (2000)
reminds us that race must be considered when understanding cohort effects. This theory may be particularly
useful to examine aging within a global context. The definitions of age strata usually encompass social and
cultural expressions of aging as well as who is placed in a given stratum and when. The cohort effect can be

18
used as a powerful tool for understanding the potential life experiences of people from not only different
cultures, but also different parts of the world.

Social Exchange Theory

Challenging both activity theory and disengagement theory, social exchange theory is based on the
consideration of the cost-benefit model of social participation (Dowd, 1980). It explains that withdrawal or
social isolation is the result of an imbalance in the exchanges between older persons and younger members
of society and that the balance is what determines one’s personal satisfaction and social support at any point
in time. Older adults are often viewed as unequal partners in the exchange and may need to depend on
metaphorical reserves of contributions to the pool of reciprocity. This may be seen in the expectation of
elderly African Americans for care as “pay-back” for their providing care to others earlier in their lives (Jett,
2006).
Other elders care for younger grandchildren so that their adult children can work. For this they may
receive total support (i.e., room, board, income). Although this exchange may appear uneven, it can also be
viewed from the more holistic perspective of a lifetime of exchanges and contributions. Hooyman and Kiyak
(2011) noted that “although older individuals may have fewer economic and material resources, they often
have nonmaterial resources such as respect, approval, love, wisdom, and time for civic engagement and
giving back to society. Intergenerational programs are an example of the value of social exchange between
generations.

Psychological Theories of Aging

Psychological theories presuppose that aging is one of many developmental processes experienced
between birth and death. Life, then, is a dynamic process. Although these are widely accepted because of
their face validity, like the sociological theories, they are not well suited to testing or measurement and do
not address the influence of culture, gender, and ethnicity.

Jung’s Theories of Personality

Psychologist Carl Jung (1971), a contemporary of Freud, proposed a theory of the development of
a personality throughout life, from childhood to old age. He was one of the first psychologists to define the
last half of life as having a purpose of its own, quite apart from species survival. The last half of life is often a
time of inner discovery, quite different from the biological and social issues that demand a great deal of
outward attention during the first half of life. The last half of life, ideally, is less intensely demanding and
allows more time for inner growth, self-awareness, and reflective activity.
According to this theory, a personality is either extroverted and oriented toward the external world or
introverted and oriented toward the subjective inner world of the individual. Jung suggested that aging results
in the movement from extraversion to introversion. Beginning perhaps at midlife, individuals begin to question
their own dreams, values, and priorities. The potentially resulting crisis or emotional upheaval is a step in the
process of personality development. With chronological age and personality development, Jung proposed
that the person is able to move from a focus on outward achievement to one of acceptance of the self and to
the awareness that both the accomplishments and challenges of a lifetime can be found within oneself.
The development of the psyche and the inner person is accomplished by a search for personal
meaning and the spiritual self. This personality of late life can easily be compared to Erikson’s ego integrity,
Maslow’s self-actualization, and Tornstam’s gerotranscendence.

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Developmental Theories
Psychologist Eric Erikson is well known for articulating the developmental stages and tasks of life,
from early childhood to later “elderhood.” Most students have studied Erikson’s eight-stage or task model.
Erikson (1963) theorized a predetermined order of development and specific tasks that were associated with
specific periods in one’s life course. He proposed that one needed to successfully accomplish one task before
complete mastery of the next was possible and originally articulated these in “either/or “language.
He proposed that all persons would return again and again to a task that had been poorly resolved
in the past. Erikson’s task of middle age is generativity. If successful in this task, one establishes oneself and
contributes in meaningful ways for the future and future generations. Failure to accomplish this task results
in stagnation. Erikson saw the last stage of life as a vantage point from which one could look back with ego
integrity or despair on one’s life. Ego integrity implies a sense of completeness and cohesion of the self. In
achieving this final task, individuals can look back over their lives, at the joys and the sorrows, the mistakes
and the successes, and feel satisfied with the way they lived.
Another developmental theory related to aging is based on the theory of Robert Peck (1968). He
expanded on the original work of Erikson with the identification of specific tasks of old age that must be
addressed to establish ego integrity. Peck’s tasks represent the process or movement toward Erikson’s final
stage. Peck’s tasks are as follows:
• Ego differentiation versus work role preoccupation. The individual is no longer defined by
his or her work.
• Body transcendence versus body preoccupation. The body is cared for but does not
consume the interest and attention of the individual.
• Ego transcendence versus ego preoccupation. The self becomes less central, and one feels
a part of the mass of humanity, sharing their struggles and their destiny.
To achieve ego integrity, according to Peck’s theoretical model, one must develop the ability to
redefine the self, to let go of occupational identity, to rise above bodily discomforts, and to establish meanings
that go beyond the scope of self-centeredness. Although these are admirable and idealistic goals, they place
a considerable burden on the older person. Not everyone may have the courage or the energy to laugh in
the face of adversity or surmount all of the assaults of old age. The wisdom of old age involves a crisis of
understanding in which the ordinary structures are shaken and the meaning of life is reexamined. It may or
may not include the wisdom of questioning assumptions in the search for meaning in the last stage of life.
Robert Havighurst (1971) is another developmental theorist who has proposed specific tasks to be
accomplished in middle age and later maturity. Havighurst’s developmental tasks are determined as:
Middle Age
• Assisting teenage children to become responsible and happy adults
• Achieving adult social and civic responsibility
• Reaching and maintaining satisfactory performance in one’s occupational career
• Developing adult leisure-time activities
• Relating to one’s spouse as a person
• Accepting and adjusting to the physiological changes of middle age
• Adjusting to aging parents
Later Maturity
• Adjusting to decreasing physical strength and health
• Adjusting to retirement and reduced income

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 • Adjusting to death of a spouse
• Establishing an explicit affiliation with one’s age group
• Adopting and adapting social roles in a flexible way
• Establishing satisfactory living arrangements

Theory of Gerotranscendence
Lars Tornstam (1994, 1996, 2005), a Swedish sociologist, proposed the theory of
gerotranscendence. According to Tornstam, human aging brings about a general potential for what he terms
gerotranscendence, a shift in perspective from the material world to the cosmic and, concurrent with that, an
increasing life satisfaction.
Gerotranscendence is thought to be a gradual and ongoing shift that is generated by the normal
processes of living, sometimes hastened by serious personal disruptions. An understanding of
transcendence and the unique characteristics of this transformation in older people is important to the
continued growth and development of older people. It is associated with wisdom and spiritual growth, similar
to Erikson’s concept of integrity and Maslow’s self-actualization. Characteristics of gerotranscendence are
identified as:
• A high degree of life satisfaction
• Midlife patterns and ideals are no longer prime motivators
• Complex and active coping patterns
• A greater need for solitary philosophizing, meditation, and solitude
• Social activities are not essential to well-being
• Satisfaction with self-selected social activities
• Less concern with body image and material possessions
• Decreased fear of death
• Affinity with past and future generations
• Decreased self-centeredness and increased altruism
Knowledge about the process of life span development and the various ways people experience
aging assists nurses in understanding the meaning of healthy aging for each individual and provides the
foundation for nursing interventions that enhance lifelong growth, development, health, and well-being. A rich
and stimulating environment should be available to all older adults in all settings so that they can thrive, not
merely survive, in old age.
Relatively, future generations of older adults will redefine what we now consider the “norms” for
aging. People can expect to spend 30 or more years in “late life,” and there are still many important tasks to
be accomplished during this period. Concerns of the young are to become established as adults; middle-
aged persons are overwhelmed with the requirements of success and survival. Focusing on the reason for
being and the meaning of life is the concern of elders.

TOPIC E
Topic Title: Physiologic changes in aging affecting various systems
Introduction:
The physical changes that accompany aging affect every body systems, and the theories of why they
occur are many. Although there are numerous ways nurses can promote healthy aging in the presence of

21
these changes, when nurses are able to begin to differentiate these normal changes from signs and
symptoms of potential health problems, the positive effect of the nurse’s interventions is multiplied.
Many of the normal changes with aging may be misinterpreted as being pathological, and some
pathological conditions may be mistaken for normal changes of aging. With this, careful assessment of
individual aging changes, lifestyle, and desires is fundamental to caring and the promotion of health in later
life. The nurse cannot rely on the “typical” signs of infection in the older adults associated with aging process
but must use a more holistic approach to determine the health compromising problems.

Topic Objectives:
At the end of the topic, the student should be able to:
1. Differentiate the physical changes that are associated with normal aging.
2. Interpret at least one age-related change for each body system and how it affects the aging process.
3. Distinguish plan of care for older adults that corresponds to each changes in the body sytem.

22
 Figure 1

Based on the current biological theories of aging, with support of clinical evidence, it can be
concluded that complex functions of the body decline before simple body processes; that coordinated activity,
which relies on interacting systems such as nerves, muscles, and glands, has a greater decremental loss
than single-system activity; and that a uniform and predictable loss of cell function occurs in all vital organs.
Yet many older adults are able to function effectively within the physical dictates of their body and continue
to live to a healthy old age, capable of wisdom, judgment, and satisfaction.
Although there are numerous ways nurses can promote healthy aging in the presence of these
changes, when nurses are able to begin to differentiate these normal changes from signs and symptoms of
potential health problems, the positive effect of the nurse’s interventions is multiplied in order to provide the
23
quality of life among older persons as they go along the challenges of every day’s gift from God of spending
the most of it here on Earth.

References:
Ebersole and Hess, Gerontological Nursing and Healthy Aging, 2014
https://www.slideshare.net/MartinMaphanga/the-biology-of-ageing

MODULE 2
Module Title: Nursing Care of the Older Adults in Wellness

Overview:
Nurses have many opportunities to promote wellness for older adults through actions that are integral
to holistic nursing care. A major focus of a “wellness approach” to older adult health care is addressing the
body–mind–spirit interconnectedness of each older adult as a unique and respected individual. This requires
that nurses assess each older adult in the full context of his or her personal history and current situation.
Based on this holistic assessment, nurses identify realistic wellness outcomes and plan interventions directed
toward improved health, functioning, and quality of life. This approach may seem challenging—or even
impossible—for older adults who are seriously or terminally ill or for those who have overwhelming chronic
conditions. Even when there are serious physical challenges, however, nurses need to recognize that they
can implement interventions directed toward improved physical comfort and psychological and spiritual
growth. Some nursing management that promote wellness for older adults are as follows:
• Addressing the body–mind–spirit interrelatedness of each older adult.
• Identifying and challenging ageist attitudes (including their own), especially those that interfere with
optimal health care.
• Assessing each older adult from a whole-person perspective.
• Incorporating wellness nursing diagnoses as a routine part of care.
• Planning for wellness outcomes, which are directed toward improved health, functioning, and quality
of life.
• Using nursing interventions to address the factors that interfere with optimal functioning (including
lack of accurate information about aging).
• Recognizing each older adult’s potential for improved health and functioning as well as psychological
and spiritual growth.
• Teaching about self-care behaviors to improve health and functioning (or teaching caregivers of
dependent older adults).
• Promoting wellness for caregivers and other people who provide care for older adults (including self-
care for nurses).
Subsequently, barriers to promoting wellness in older adults include older adults’ negative attitudes
about being able to improve, the existence of more serious or pressing health concerns, the focus of health
care environments on dis-ease treatment rather than prevention or health promotion, the false attribution of
symptoms of pathologic conditions to normal aging processes, and the belief that older adults are not capable
of learning and implementing health-promoting behaviors inherent in wellness-oriented care.

24
Module Objectives:
At the end of module 2, the student should be able to:
1. Assess with the older adult client his/her status/competence.
2. Formulate with the client a plan of care to address the identified health conditions, needs problems
and issues based on priorities.
3. Implement safe and evidenced-based quality interventions to address health needs, problems and
issues.

Module Coverage
A. Topic: Assessment
B. Topic: Planning for Health Promotion, Health Maintenance and Health Considerations
C. Topic: Implementation

TOPIC A
Topic Title: Assessment
Introduction:
Nurses conduct skilled and detailed assessments of and with the persons who entrust themselves
to their care. While many of the skills used in the physical assessment of younger and older adults are the
same, the overall process of working with persons later in life is strikingly different if for no reason other than
their medical, psychological, and social complexity. Older adults vary greatly in their health and function, from
active and independent to medically fragile and dependent. Along with this, the comprehensive assessment
is more complex, more detailed, and takes much longer to complete. More often, partial or problem-oriented
assessments are done. If a more thorough assessment is needed, this is usually performed by a nurse led
interdisciplinary health care team. The assessment is not complete until it is documented. Nursing
documentation is an age-old practice of making a permanent record of the conditions of our patients, our
actions, and the patients’ responses to our actions or those of others. There is probably not a nurse alive
who does not know the mantra, “If you didn’t document it—you didn’t do it!”
Furthermore, assessment of the older adult requires special abilities: to listen patiently, to allow for
pauses, to ask questions that are not often asked and to obtain data from all available sources, and to
understand that not all positive findings will require interventions. The nurse must be able to recognize normal
changes of aging and atypical presentations in order to appropriately and effectively conduct the assessment
and interpret the findings. The assessment must be paced according to the stamina of both the person and
the nurse. If the elder is physically frail, cognitively impaired, is unable to speak or does not speak the same
language as the nurse, the health assessment becomes particularly difficult but even more important. Thus,
the quality and speed of the assessment are a reflection of experience.
In that effect, novice nurses should neither be expected to nor expect themselves to do this
proficiently but should expect to see their skills, the amount of information obtained, and the speed at which
it is obtained, increase over time. According to Benner (1984), assessment is a task for the expert. However,
an expert is not always available. It is by following some basic guidelines and learning how to use the wide
range of assessment tools and resources now available, the quality of data collected by all nurses can be
improved.

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Topic Objectives:
At the end of the topic, the student should be able to:
1. Develop the skills needed to select an evidence-based and appropriate tool for a specific situation and use
it correctly.
2. Analyze the impact of common normal changes with aging on the assessment.
3. Differentiate the reasons for accurate and thorough documentation in gerontological nursing.

Topic Content:

Subjective Data
The initial verbalization of the health history marks the beginning of the nurse-client relationship and
the assessment process. It begins with a review of what the person reports as a problem, known as the “chief
complaint.” This is considered subjective data that is documented in the patient’s own words. In an older
adult this is much more likely to be vague and less straightforward. For example, it is not unusual for the
person to say “I just don’t feel well.” The health history is best collected either verbally in a face-to-face
interview or using the interview to review a written history completed by the patient or patient’s proxy
beforehand. Although longer for the patient, written formats are usually much faster than the verbal for the
nurse.
Moreover, the written document should never be used if the person has limited vision, questionable
reading level, the person has limited health fluency or written in a language or at a level in which the patient
does not have reading ability. Written histories provide reliable information only when the person is able to
adequately complete the documents alone or with some assistance. If collecting the history verbally or when
reviewing a previously written health references, the nurse uses techniques which optimize communication.
For instant, if the elder has limited language proficiency, a trained medical interpreter is needed and the
interview will generally take about twice as long. If the person has limited health fluency, special attention will
need to be paid to wording of questions and answers to the patient’s questions. If the person is cognitively
impaired, he or she should be included to the extent possible with additional information obtained from the
significant others. Any health history form or interview should include a patient profile, a past medical history,
a review of systems, a medication history, nutritional history and include any other factors which influence
the person’s quality of life.
With this, the nurse should be aware that in an older adult the traditional review of systems may be
quite lengthy due to the number of years the person has had the opportunity to have had problems. It may
be easier and more appropriate to begin with reviewing the symptoms the person is currently having and
gear the system review accordingly. In the oldest older adult, family history in and of itself becomes less
important as the person ages, and it is replaced with the increasing importance of the social history. The
social history, an essential part of the history, includes current living arrangements, economic resources to
meet current health-related or food expenses, amount of family and friend support, and community resources
available if needed.

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Objective Data
Comprehensive Physical Assessment of the Frail and Medically Complex Elder
FANCAPES is a model for a comprehensive yet prioritized, primarily physical assessment that is
especially useful for the frail elder (Resnick & Mitty, 2009). It emphasizes the determination of very basic
needs and the individual’s functional ability to meet these needs independently; these are the needs that
form even the most basic levels of Maslow’s Hierarchy. The acronym FANCAPES represents Fluids,
Aeration, Nutrition, Communication, Activity, Pain, Elimination, and Socialization. It can be used in all settings,
may be used in part or whole depending on the need, and is easily adaptable to functional pattern grouping
if nursing diagnoses are used. The nurse obtains comprehensive information in each section, guided by the
questions provided in the following text.
F—Fluids What is the current state of hydration? Does the person have the functional capacity to consume
adequate fluids to maintain optimal health? This includes the abilities to sense thirst, mechanically obtain the
needed fluids, swallow them, and excrete them.
A—Aeration Is the person’s oxygen exchange adequate for full respiratory functioning? This means the ability
to maintain an oxygen saturation of at least 96% in most situations. Is supplemental oxygen required, and if
so, is the person able to obtain it? What is the respiratory rate and depth at rest and during activity, talking,
walking, exercising, and while performing activities of daily living? What sounds are auscultated, palpated,
and percussed, and what do they suggest? For the older person, it is particularly important to carefully assess
lateral and apical lung fields.
N—Nutrition What mechanical and psychological factors affect the person’s ability to obtain and benefit from
adequate nutrition? What is the type and amount of food consumed? Does the person have the abilities to
bite, chew, and swallow? What is the oral health status and what is the impact of periodontal disease if
present? For edentulous persons, do their dentures fit properly and are they worn? Does the person
understand the need for special diets? Has this diet been designed so that it is consistent with the person’s
eating and cultural patterns? Can the person afford the special foods needed? If the person is at risk for
aspiration, including those who are tube fed, have preventive strategies been taught, including the need for
meticulous oral hygiene?
C—Communication Is the person able to communicate his or her needs adequately? Do the persons who
provide care understand the patient’s form of communication? What is the person’s ability to hear in various
environments? Are there any environmental situations in which understanding of the spoken word is
inadequate? If the person depends on lipreading, is his or her vision adequate? Is the person able to clearly
articulate words that are understandable to others? Does the person have either expressive or receptive
aphasia, and if so, has a speech therapist been made available to the person and significant others? What
is the person’s reading and comprehension levels?
A—Activity Is the person able to participate in the activities necessary to meet basic needs such as toileting,
grooming, and meal preparation? How much assistance is needed, if any, and is someone available to
provide this if needed? Is the person able to participate in activities that meet higher levels of needs such as
belonging (e.g., church attendance) or finding meaning in life? What are the person’s abilities to feed, toilet,
dress, and groom; to prepare meals; to dial the telephone; and to voluntarily move about with or without
assistive devices? Does the person have coordination, balance, ambulatory skills, finger dexterity, grip
strength, and other capacities that are necessary to participate fully in day-to-day life?

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P—Pain Is the person experiencing physical, psychological, or spiritual pain? Is the person able to express
pain and the desire for relief? Are there cultural barriers between the nurse and the patient that make the
assessment of or expression of pain difficult? How does the person customarily attain pain relief?
E—Elimination Is the person having difficulty with bladder or bowel elimination? Is there a lack of control?
Does the environment interfere with elimination and related personal hygiene; for example, are toileting
facilities adequate and accessible? Are any assistive devices used, such as a high-rise toilet seat or bedside
commode, and if so, are they available and functioning? If there are problems, how are they affecting the
person’s social functioning?
S—Socialization and Social Skills Is the person able to negotiate relationships in society, to give and receive
love and friendship, and to feel self-worth ?

Mental Status Assessment

As persons enter their eighties and nineties their risk for impaired cognitive abilities increases
(Snowdon, 2002). With increases in age there is an increased rate of dementing illnesses, such as
Alzheimer’s and Lewy body dementia. Cognitive ability is also easily threatened by any disturbance in
physical health. Indeed, altered or impaired mental status may be the first sign of anything from a heart attack
to a urinary tract infection. The gerontological nurse must be aware of the need to conduct an assessment of
mental status, especially cognitive abilities and mood whenever there is a change in an elder’s condition or
safety.
Cognitive Measures Conducted Among Older Adults:
Mini-Mental State Examination. The Mini-Mental State Examination (MMSE) by Folstein and colleagues
(1975) is a 30-item instrument that has been used to screen for cognitive difficulties and is one of the tools
often used in the determination of a diagnosis of dementia or delirium. It tests orientation, short-term memory
and attention, calculation ability, language, and construction. It cannot be given to persons who cannot see
or write or who are not proficient in English. It has not been tested extensively in cultures other than those of
northern European descent and so culture bias must always be considered. A score of 30 suggests no
impairment, and a score below 24 suggests potential dementia; however, adjustments are needed for
educational level (Osterweil et al., 2000). In the long-term care setting, the MMSE is administered by either
the nurse or the social worker as part of a required periodic assessment. It is used in primary care but not
usually in the acute care setting.
Clock Drawing Test. The Clock Drawing Test has been used since 1992 (Mendez et al., 1992; Tuokko et
al., 1992) as a tool to help identify those with cognitive impairment and is used as a measure of severity. It
requires some manual dexterity to complete. It would not be appropriate to use with individuals with any
limitations in the use of their dominant hand. A person is presented with a blank piece of paper. He or she is
asked to draw a circle and the face of a clock so that it says 2:40 or some other time. Scoring is based on
both the position of the numbers and the position of the hands on the clock. This tool does not establish
criteria for dementia, but if performance on the clock drawing is impaired, it suggests the need for further
investigation and analysis. It has also been found very useful for assessing delirium in the hospitalized patient
(Moylan & Lin, 2004). Another evidence-based version of this measure is Royall’s CLOX (Kennedy, 2007).
The Mini-Cog. The Mini-Cog was developed as a tool that could establish cognitive status more quickly than
the MMSE and without the limitations of educational adjustments. It is the evidence-based tool now
recommended (Doerflinger & Carolan, 2007). It combines one aspect of the MMSE (short-term memory
recall) with the test of executive function of the Clock Drawing Test. It has been found to be highly sensitive

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to diagnosing dementia (Borson et al., 2000) and as a predictor of delirium in older hospitalized persons
(Brodaty et al., 2006; Alagiakrishnan et al., 2007).
The Global Deterioration Scale. The Global Deterioration Scale (Reisberg et al., 1982) is a classic measure
of the levels of cognitive changes as one passes through the process of dementia. It is useful to both the
nurse and the family to develop appropriate interventions to help the person to optimize his or her health and
anticipate future needs and changes.

Activities of Daily Living

The Katz Index (Katz et al., 1963) developed in 1963, has served as a basic framework for most of
the measures of ADLs since that time. There are several versions of the Katz Index; one is based on a 4-
point scale and allows one to score performance abilities as independent, assistive, dependent, or unable to
perform. Another version of the tool assigns 1 point to each ADL that can be completed independently and a
zero (0) if unable to perform these activities. Scores will range from a maximum of 6 (totally independent) to
0 (totally dependent) (Wallace & Shelkey, 2007). A score of 4 indicates moderate impairment, whereas 2 or
less indicates severe impairment (Table 7-2). This scoring puts equal weight on all activities, and the
determination of a cutoff score is completely subjective. Despite these limitations, the tool is useful because
it creates a common language about patient function for all caregivers involved in planning overall care.

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Functional Assessment
A determination of functional status is part of the usual gerontological assessment. If the person is
healthy and active, a simple statement documenting that effect may be all that is needed, such as “Patient is
active and independent; denies functional difficulties.” However, if any potential problems exist, such as for
the person with Parkinson’s disease or a recent fall, a more detailed functional assessment is conducted. A
thorough functional assessment will help the gerontological nurse promote healthy aging by doing the
following:
• Identifying the specific areas in which help is needed or not needed
• Identifying changes in abilities from one period to another
• Assisting in the determination of the need for specific service(s)
• Providing information that may be useful in determining the safety of a particular living situation
Functional abilities have been divided between those associated with the individual’s ability to
perform the tasks needed for self-care (i.e., those needed to maintain one’s health) that is, activities of daily
living (ADLs) and those tasks needed for independent living or instrumental activities of daily living (IADLs).
ADLs are most often identified as eating, toileting, ambulation, bathing, dressing, and grooming. Three of
these tasks (grooming, dressing, and bathing) entail higher cognitive function than the others. The IADLs
such as cleaning, yard work, shopping, and money management are considered to be more complex
activities necessitating higher physical and cognitive functioning than the ADLs. For persons with dementia,
the progressive loss of abilities begins with IADLs and progresses to the ADLs. The nurse must keep in mind

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that the willingness and skill to perform specific ADLs and IADLs are influenced by the sociocultural factors
unique to the person.

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Documentation for Quality Care
Clinical documentation chronicles, supports, and communicates the results of the assessment. Good
documentation will help the nurse identify, monitor, and evaluate treatment or interventions. The recorded
assessment provides the data needed for the careful development of the individualized plan of care and the
evaluation of patient outcomes.
Furthermore, documentation also provides the communication needed to ensure that a person
continues to receive continuity of care—from one shift to another and one caregiver to another and across
settings. The nurse who provides care to a patient for whom the previous nurse did not document knows well
the potential errors that can be made and the added risk to the patient. At the same time, documentation is
the major means for the nurse to demonstrate the quality of care he or she provides. In any setting,
documentation is a means to more quickly identify iatrogenic problems and hospital acquired conditions
(HACs) that frequently complicate recovery in seriously ill patients.
Health care documentation contains highly personal and confidential information relating to clients,
patients, or residents, whether it is written or electronic. For many years the confidentiality of health and
medical information was protected through professional codes of ethics. The expectation has always been
that the nurse and other health care providers will only access information that relates to a specific individual
on a “need to know” basis. Nursing students are taught to avoid talking about patients in hallways, elevators,
and lunch rooms or with persons outside their clinical groups, such as friends and family members. The nurse
who notes that a neighbor has been admitted to the unit is expected to not review the chart unless he or she
is the nurse assigned to provide the care.
However, we have not been as respectful of people’s privacy as we should be. This, coupled with
the electronic exchange of personal health information, has significantly increased the risk for breaches of
confidentiality. In 1996 the Health Insurance Portability and Accountability Act (HIPAA) was passed,
legislating the strict protection of the privacy of medical records. The Department of Health and Human
Services has the responsibility to ensure this protection. Patients may expect that reasonable steps are taken
to ensure that their verbal communications are confidential and that they have complete control as to who
has access to their information. It is expected that nursing actions to protect privacy include closing the
patient’s or resident’s door before having health-related conversations or staff ’s not discussing patient or
residents’ needs or condition in a location where it could be overheard, for example in hallways or some
nurses’ stations.

References:
Miller, Carol “Nursing for Wellness in Older Adults” sixth edition, 2012
Ebersole and Hess, Gerontological Nursing and Healthy Aging, 2014

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