Moral Development in Younger Adults

According to Kohlberg, your response to moral dilemmas reversals your

stage of moral development, as well as your level of CD
Kohlberg proposes a 3-level sequence, subdivided into 6 stages
1. Preconventional morality (external authority)
People who act in this level are doing it to please others or to avoid
punishment. Age varies, and some people might do things for selfinterest
Stage 1: obey rules to avoid punishment
Stage 2: obey rules to earn rewards
1. Conventional level
Stage 1: good behaviour pleases other people
Decisions and behaviour bases on concerns about the reactions of
others (external authority)
Ill do something because it will please you or because it is expected
Capable of empathy
Stage 2: integrates norm of larger reference groups
Obeys law because it is the law/respects authority (external authority)
Legal = right; illegal = wrong
Ill do it because it is the law and my duty
1. Postconventional level
Designing own principles for living
Stage 1: self-chosen principles (inner authority)
Social contract focus/orientation
Generally, adheres to social laws to ensure fairness
But laws can be ignored or changed as peoples needs change (e.g.,
will change practice based on new evidence) (relativistic view)
Goes beyond views about specific social order; designs universal
principles about justice, equality, and human rights
Ill do something because it is morally and legally right, even if it is
not popular with the group.
Upholding the law is important, but will break it when doing so serves
the common good (e.g., civil disobedience)
Stage 2:
Assumes personal responsibility based on fundamental and universal
ethical principles (inner authority)
Still operates in stage 1, but incorporates injustice, pain, and death as
integral parts of life
Ill do something because it is morally, ethically, and spiritually right,
even if it is illegal and I get punished and even if no one else
participates
Post-conventional reasoning is relatively rare
Causes and Consequences of Moral Development

The decline of egocentrism as people move through Piagets concrete

and formal operational stages is key in moral reasoning

E.g., greater ability to understand another persons view is linked to

higher moral reasoning
Also, the development of moral reasoning requires support from the
social environment (e.g., from parents). Ex, giving up seat to someone
who is pregnant or older, holding the door open for someone.
Consideration of others; being a moral agent, less egocentric
Kohlbergs findings based on Western cultures and largely from boys

Bronfenbrenner

1.
2.
3.
4.

5 moral orientations, based on a persons context (vs stages)

Person may move forward and backward, depending on
Culture
Exposure to different values
The situation/context
Self-orientated: personal needs take precedence
Authority-orientated: complies with authority or power
Peer-orientated: peers views affect choices of right or wrong
Collective-orientated: makes choices based on duty or obligation to
family, country, etc
5. Objectively-orientated: believes universal principles have a morality of
their own
Moral Development in Girls Giligan

Boys view morality in terms of broad principles (e.g., justice or

fairness)
Girls see it as responsibility toward others, willing to sacrifice self to
help others

Morality in Females a 3 Stage Process

Orientation to individual survival (best for self)

Goodness as self-sacrifice (deference to others)
Morality of nonviolence (hurting anyone, including self, is immoral)
(most sophisticated form of reasoning)

One of Tis research studies: when there was a crisis, the daughters did
everything for their mom. Once they got stressed, they started to only look
self. When coming to a sensible conclusion, they looked after both.
Self-Concept (SC)

1.
2.
3.
4.

Definition: thoughts, feelings, attitudes, and beliefs about self

4 aspects of holistic SC
Physical (e.g., body image)
Cognitive (e.g., identity)
Emotional (e.g., self-esteem)
Spiritual (e.g., link with higher purpose); what is fundamentally
important to you in life

Some Factors that may Influence SC

Social environment, e.g.,

Negative: poverty, dysfunctional parenting, loss of parent, lack of
education, parental literacy
Positive: stable home, sports, academic success, praise, support
Reactions of others that you internalize: there are so many social
factors telling us what to do, how we should act; but you are you, be
yourself
Self-expectations (Ellis irrational ideas)
Perceived abilities
Attitudes
Habits
Knowledge
Other characteristics

Body Image (BI)

The physical dimension of SC

How person perceives their physical self
BI includes the persons:
Surface, internal, and postural picture of body
Values, attitudes, emotions, and personality reactions in relation to
body
BI:
Shifts (constant revision)
May not reflect actual body structure
In adults, is a social creation

Factors that may affect BI

Sociocultural scripts (e.g., norms and media)

Your ideals
Parental reaction
Your interpretation of other peoples reactions
Physical characteristics and function, including hidden aspects
Motives
Dependency
Views of space and objects around body or attached to it
Activities body performs
Normality
Judged by appearance and use of body as prescribed by society (script)
Approval for normal and proper
In adults, there is a close interdependence between BI and personality,
SC, and identity

N2050 Middle Adulthood _

October 20, 2014

Cohort Effect

Born in a different historical era than younger adults

So have different formative experiences (shaped who you are) and
more past experiences
Through middle adulthood, views and insights broaden and deepen
and the attitudes and behaviour change

Adulthood involves thoughtful confrontation with self

Let go of idealized (desire to be perfect) and acknowledge real self
Acquires new beliefs about self and world
Resolves conflicts between past and present
Cognition in Middle Adulthood:

Use formal operations

Sometimes use concrete operations for practical reasons
Use post-formal thinking
Dialectical thinking
Seek intellectual stimulation, even crisis
Welcome contraindications and opposing views
Create new order
Discover what is missing
Struggle (e.g., with morality, ethics, philosophy, religion, politics)
Look at an experience from many perspectives (e.g., narratives)
Thus, knowledge is always changing
Intellectual Curiosity
Progressive integration
Analyze and judge info without being influenced by personal needs or
opinions of others

Two Types of Intelligence

Fluid intelligence (generally declines with age)

Reasoning, critical thinking, how you use it, storage & retrieval of
memories
Crystallized intelligence - (maintained and may improve)
Structural knowledge; skills in daily life and profession

More Specific Types of Intelligence

Some abilities begin to decline at age 25 and continue to decline. Ex,

of abilities; inductive reasoning, spatial orientation, perceptual speed
and verbal memory
Numeric ability increases until mid-40s, is lower at age 60, and then
maintained

Verbal ability, increases until around 40 years, and then stays fairly
steady

Strategies that Experts Use to Maintain High-Performance

Selective-optimization (concentrate on particular skills to compensate

for losses in others)
Rely on experience and intuition
Often;
Bend rules- to advocate for the client (vs. Beginners who: use formal
procedures and rules)
Process information automatically, without much thought (Tacit,
proceduralized)
Design better solutions and are more flexible in solving problems

Declarative intelligence: talking through procedures etc.

Procedural intelligence: going through procedure automatically
Memory

1.
2.
3.

3 sequential components
Sensory
Short-term (or working)
Long-term
Sensory and short-term are maintained in middle adulthood
Long-term declines for some people, due to less efficiency in
registering, storing, and retrieving information
But, memory, declines are relatively minor and most can be
compensated for

Benign Forgetfulness: harmless forgetfulness; Ex. Go into a room and forget

why you went in there etc. Sometimes due to multi-tasking
N2050 _
October 27, 2014
*red is added information- from her mouth directly*
Many Middle Aged adults use memory shortcuts, called schemas, to ease the
burden of remembering everything each day

Schema an organized body of information stored in memory

Package information together you redo your schemas every time you
get a new schedule
M-A people have schemas for
Particular individuals (e.g., mother, child)
Categories of people (e.g., RNs, engineers)
Behaviours or events (e.g., eating in a restaurant)

Schemas help people to

Organize their behaviour into coherent wholes/represent how their

world is organized.
Interpret social events/categorize and interpret new info
For example, how we are interpreting what happened in Ottawa
(shooting), we are trying to make sense of what happened.
Convey cultural information

Research about adult cognition

Most studies cross-sectional (vs. longitudinal)

Thus, many factors other than age have affected the results
Factors such as
Different experiences
Amount of education
Years since finishing school
Fixed attitudes: when we are younger attitudes tend to be more fixed
and as we get older they tend to be more flexible
Health status
Kind of test
Speed requirements of the test
Longitudinal studies: follow the same people as they age
Some risks: people might get familiar with the test. Example, doing a
drivers test every 2 years, you might begin to memorize the answers
instead of knowing them.
IQ tests may be irrelevant; instead, test how people identify problems
and use reason and intuition to solve them

Maturity

Not reached at any one age or for all time

Staying power is part of maturity
Characteristics of staying power
Integrity
Loyal to values, philosophy, beliefs
Holds to cause greater than self
Giving up something worthwhile vs. Worrying about present risks that
need attention
In adulthood, there is no one set of appropriate (somebody is the
judge telling you what is appropriate/normal) personality
characteristics
Mature person feels good about self; does not want to relive younger
years
They have a stable sense of self
They know who they are, what their values are, content with getting
older, do not morn for younger youth
They are very reflective

Stress in Middle Adulthood

 3 major consequences of stress

1. Physiological: elevated BP, decreased immune function, increased
hormonal activity, psycho physiological
2. Harmful behaviours: increased use of nicotine, more use of booze,
younger girls are more into the coloured vodkas or the coloured drinks,
drug use, decreased nutrition, decreased sleep
3. Indirect health-related behaviours: not adhering to health care advice
(No, I am not going to do that), might not seek health care as quickly
as they should due to stress,
Sympathetic: When youre scared you are counting on your heart,
respiratory, blood pressure is going faster, pupils dilate,
Parasympathetic: body focus on digestion and normal day-to-day
things
Vagus nerve: will slow your pulse down, if you give too much digoxin
the pulse will slow way down and itll put the heart in failure.
Post-traumatic stress: adults who were in the military, people who have
lost family members, devastating consequences, ebola, RNs who
worked on units with children who have serious illness often change
their jobs, physician who is called down to examine someone who has
been in a car accident (only physician in town); only to find out it was
his son.
Coronary heart disease

Genetic disposition, and environment and lifestyle factors also sex

and age
Country-to-country variations in incidence
Behaviour (on a continuum)
Type A (tendency towards frustration and hostility, driven to
accomplish, engage in polyphasic (multi-tasking),easily angered, has
more stress, and excessive arousal) versus Type B (non-competitive,
more patient, lack aggression, have less sense of time urgency time
isnt as important to them, rarely hostile)
People are not usually one way or the other, they may be closer to one
end
Type A (versus Type B) men have 2x the rate of coronary heart disease,
more fatal heart attacks, and 5x as many heart problems
The key component that links Type A and heart disease is hostility.
Type A doesnt cause heart disease, but it is somehow linked to heart
disease
Type A wear-and-tear theory: it is hard on people

Personality Development
2 perspectives
1. Normative-crisis (e.g., Erik Erikson) Erikson says there are stages we
go through (the 8 stages of man)
Says that each stage is associated with a crisis
1. Life events: the timing of events shape our personality

All theorists agree that MA is a time of continuing and significant

psychological growth
Other perspectives:
Vaillant: keeping the meaning (vs. Rigidity)
Levinson: seasons of your life midlife transition (a time of
questioning) and midlife crisis (time of uncertainty, they may have
accomplished less than they thought)(yet, the evidence of universality
is lacking)

Stability versus change in personality:

1.
2.
3.
4.
5.

Erikson and Levinson say there is substantial change

Other research suggests stability and continuity
The big 5 personality traits
Neuroticism: degree to where we are anxious, moody,
Extroversion: are we extraverted or introverted
Openness: how curious are we?
Agreeableness: how easy going and helpful are we?
Conscientiousness: how organized and responsible are we?
Although there are some variations in specific traits (1-3 decline; 4&5
increase), the basic pattern is stability in these traits

Emotional development in MA

Self-assess and greater introspection

Appraise achievements against goals and values
Realizes
How past choices limited present choices
That time is finite

Development crisis (Erikson): generativity vs. Self-absorption and stagnation

Characteristics of generativity
Equal concern for others and self
Sense of parenthood and creativity
Guiding (e.g., the next generation, the arts, a profession)
Feels important to the welfare of humankind
Self seems less important
Service, love, and compassion gain new meaning and drive actions
Comfort in lifestyle
Gratification from job well done
Accepts self and body
Sincere, mature judgement; empathy
Stable values that spur reflection and caution

VERSUS

Characteristics of stagnation/self-absorption
Regressed behaviour

Hates aging body

Feels insecure, in-adept in handling self
Impaired/less socially organized intellectually skills and values
Intellectual skills fused by emotions
Seeks private self-absorption and vicarious immersion in problems of
others
These methods of coping may/not work

Moral Development in MA

Increases whenever we experience sustained responsibility for others

MA, if lived generativity, provides this experience
Consistent commitment to ethical application of higher principles
Level of cognitive development sets upper limits for moral
development, for example,
If stays in concrete operations of cognitive development, will unlikely
move beyond conventional level of moral development (law and order
reasoning), because post-conventional requires in-depth understanding
of events, along with critical reasoning ability

Factors that May Influence Body Image in MA

Physical change
Work
Illness or death of others
Concern about health
Fear of aging
Beliefs (e.g., youth is best)
Effects of cultural (e.g., media) values and expectations (e.g., about
youth, vigour, sexuality, gender, age, obsolescence)
Depression, irritability, and anxiety about femininity and masculinity
may result
If lacks self-confidence and cannot accept aging, may develop
compulsions (trapping of youth, e.g., cosmetics, surgery, hair, cars,
dating)

Work and Leisure in MA

Work is viewed differently by different middle-agers (e.g., older vs.

Younger)
New categories of workers
Free agents
Nomads: move from one geographical area to another
Globalists
Niche-finders: finding a new place, might spot new marks/merging
markets, build companies and capitalize them
Retreads: always up to date on current knowledge

Corporate leaders: incorporating new skills and ventures. Ex., RNs

going into working with architects to build Senior homes
The time spent in full-time work has increased over the past 20 years,
leading to a decrease in leisure and in private life
How we are connected to work
MA women working outside the home and thus in the middle
(sandwiched) in terms of demands on their time and energy

Marriage

More singles today

Coping mechanisms for successful marriages:
Realistic expectations of each other
Focus on the positive about the partner
Compromise (versus win-lose)
Partners discuss what is bother them
Why marriages unravel
Individualistic western culture
Divorce more socially acceptable
Fewer legal impediments
Wife less dependent on husband
Eroding love and excitement, more boredom
Stress
Infidelity
Fewer women (especially older women) than men remarry after divorce
Reason for the age difference: the marriage gradient

Empty-nest syndrome: sometimes when the kids leave the partners look at
each other and think, we dont actually know one another

Negatives
Benefits
Helicopter parents: they can interfere with their childrens notions at
work or school

Boomerang children: because of marriage failures or issues, children go back

home to live
Sandwich generation

Causes
Challenges: resentment, person getting the care might feel guilty of
being a burden
Benefits: can be rewarding, greater attachment, greater moral
development, greater understanding of one anothers weaknesses and
strengths

Grandparenting Styles

Involved: actively engaged with the grandchildren

Companionate: more detached, give support, like buddies to the
grandchildren, might visit and call frequently, might take grandchildren
on vacation or invite them to visit
Remote: more detached/distant, show little interest in grandchildren,
might criticize the grandchildrens behaviours

Family violence and domestic abuse (physical, psychological)

No segment of society is immune

Cycle of violence: economic concern, people who grew up in a family
that is violent have a better chance of being violent
Tension-building: batterer becomes upset and shows dissatisfaction
verbal abuse, may be physical behaviour like shoving, or grabbing
Acute bettering: shoved, kicked, stepped on, burned, forced to engage
in physical activity,
Loving contrition (remorse has no bearing on the possibility of future
violence): abuser seeks forgiveness, apologizes, person who was
abused may feel responsible for what had happened

Cultural Roots of Violence

Traditions in which violence is viewed as acceptable

Examine legal, political, educational, and economic roles of men and
women

Work and Careers

Younger adults interested in abstract and future orientated

concerns
MA interested in here-and-now qualities of work
Work-related challenges:
Burnout
Unemployment
Switching and starting careers

*REMEMBER THE ACRONYM OCEAN* Openness, Conscientiousness,

Extraversion, Agreeableness, Neuroticism
N2050
2014

November 03,

Perimenopause

Normal transition
Begins with first change in menstrual cycles
Ends after cessation of menses: after the periods stop

Menopause

Cessation of menses associated with declining ovarian function

After one year of amenorrhea
Starts gradually
Usually associated with changes in menstruation (e.g., flows increased, decreased,
irregular, or a combination)
Accompanied by:
Decline in secondary sexual characteristics
Decreases in:
Breast tissue
Body hair
Skin elasticity
Subcutaneous fat
Size of ovaries and uterus
Cervix and vagina become pale and friable
Vasomotor instability: not as reliable
Long-term consequences: changes in estragon = increased risk of osteoporosis, increased
risk of heart disease because estragon seems to give a protection for heart disease so after
menopause that barrier is gone.

Postmenopause

Time after menopause

When menopause happens:
Ranges from 44 to 55 years, average is 51 years
Causes of earlier menopause includes:
Illness
Removal of uterus or both ovaries
Adverse effects of radiation therapy or chemo
Drugs
Age at which menopause occurs is not affected by (myths)
Age at menarche: meaning when you first start to get your periods
Physical characteristics
Number of pregnancies
Date of last pregnancy
Use of oral contraceptive
Earlier menopause is associated with
Genetic factors
Autoimmune conditions: means the body for some reason is attacking itself. It thinks
itself is a foreign thing and it attacks itself.
Cigarette smoking
Racial or ethnic factors

Events that result in menopause are started by changes in ovary

Regression of follicles in each ovary start with puberty and accelerates after age 35
With increasing age, fewer and fewer follicles respond to FSH (follicle stimulating
hormone - in the ovary)

FSH stimulates dominant follicle to secrete estrogen

When follicles no longer respond to FSH, ovarian production of estrogen and
progesterone declines
Perimenopausal (peri- around: around menopause) women can get pregnant until
menopause has occurred
Decreased ovarian function leads to decreased levels of estrogen and a gradual increase
in FSH and LH (a negative feedback process)
By menopause, a 10-to-20-fold increase in FSH
The increased FSH may take several years to return to premenopause level
Reduced estrogen causes a decrease in frequency of ovulation and results in changes in
reproductive organs and tissues (e.g., atrophy of vaginal tissue)

Clinical manifestations of perimenopause

Irregular menses (irregular vaginal bleeding could indicate cancer)

Occasional vasomotor symptoms (hot flashes, night sweats) vessels dilate and you
perspire
Atrophy of genitourinary tissue with decreased support
Stress and urge incontinence
Osteoporosis
Mood changes

Perimenopause

A time of erratic hormone fluctuation

Signs and symptoms of diminished estrogen

Vasomotor
Hot flashes, night sweats
Genitourinary
Atrophic vaginitis (changes in the vagina), dyspareunia- pain on intercourse (secondary
to poor lubrication), incontinence
Psychological
Emotional lability (means the mood is up and down happy/sad) someone with a
stroke could have lability, someone with BP that is up and down, changes in sleep,
decreased REM sleep
Skeletal
Increased fracture rate (especially vertebral bodies, but also humerus, distal radius, upper
femur)
Cardiovascular
Decreased high-density lipoproteins (HDLs), increased low-density lipoproteins (LDLs)
Dermatological
Reduced collagen content, changes in breast tissue

Loss of estrogen

A significant contributor to age-related changes

Critical changes

Greater risk for coronary artery disease and osteoporosis

Other changes
Redistribution of fat
Easier weight gain
Muscle and joint pain
Reduced skin elasticity
Changes in hair (amount, distribution)
Atrophy of external genitalia and breast tissue

Hallmarks of perimenopause include

Vasomotor instability (hot flashes) and irregular menses

Hot flash:
Warmth in upper chest, neck and face, then
Profuse perspiration
Lasts several seconds to 5 minutes
Occurs mostly at night disturbs sleep
Causes not clearly understood (perhaps temperature regulators in brain are close to where
gonadotropin- releasing hormone (GnRH) is released)
Lowered estrogen is associated with dilation of cutaneous vessels leading to hot flashes
and sweating
Sudden withdrawal of estrogen (e.g., removal of ovaries) leads to greater severity of
symptoms
Symptoms subside over time, with or without HRT (hormone replacement therapy)
Triggers for hot flashes whatever affects body temperature, e.g., hot meal, hot weather,
alcohol, stress, warm clothes

Atrophic changes associated with reduced estrogen include

Vagina
Thinner mucosa, disappearance of rugae (folds), secretions reduced and more alkaline
Greater risk for:
Trauma and infection (e.g., HIV if exposed)
Dyspareunia
Water soluble lubricants
If needed, hormonal creams or systemic HRT
Lower urinary tract
Reduced
Bladder capacity
Tone in bladder and urethra (may cause symptoms that mimic infection [e.g., dysuria
painful urination, urgency, frequency) when no infection is present
Frequency caused by decrease in maturation. Takes longer for the signal to get to them
that they need to go, therefore frequency can be normal.
Unclear whether or not reduced estrogen causes psychological changes associated with
perimenopause
Depression, irritability, and cognitive problems may result from life stressors or sleep
deprivation from flashes

Clinical manifestations of Postmenopause (after menopause)

Cessation of menses (menstruation stops)

Vasomotor instability (hot flashes, night sweats)
Atrophy of GU tissue (e.g., vaginal epithelium)
Stress and urge incontinence
Breast tenderness

Diagnosis of Perimenopause

Make only after other causes of womens symptoms have been ruled out
Other causes may be
Depression
Thyroid challenges
Anemia (low blood cells when you stand up, you might get dizzy or might have a short
of breath)
Anxiety
Get accurate history of menstrual patterns

Drug therapy

Hormone replacement therapy (HRT) was once standard in Canada for menopause
symptoms
HRT includes:
Estrogen for women without ovaries
Estrogen and progesterone for women without uterus
However, findings from Womens Health Initiative (2002) changes that practice
Women who took estrogen plus progestin had
Greater risk for breast cancer, stroke, heart disease, emboli
Less risk of hip fractures, colorectal cancer
Women who took only estrogen (Premarin) had
Greater risk for stroke and emboli
Less risk of fractures
No increased risk for heart disease or breast or colorectal cancer
Neither estrogen plus progestin nor estrogen alone affected the risk of death

If women wish to take HRT for short-term (4-5 years) help with menopause symptoms,

Risks and benefits need to be considered carefully

The decision to take HRT and which ones to take need to be thoroughly discussed
between woman and HCP
The lowest effective dose should be used

Age of starting HRT may determine risk of heart disease (risks seems to increase the further a
woman moves away from menopause)

Some adverse effects of estrogen:

Nausea

Fluid retention
Headache
Breast enlargement
Some adverse effects of progesterone:
Greater appetite
Weight gain
Irritability
Depression
Spotting
Breast tenderness

A commonly used estrogen preparation

0.625 mg of conjugated estrogen (Premarin) daily

May need higher dose for symptom relief

To receive the protective benefit of progesterone

5 to 10 mg of medroxyprogesterone (Provera) is indicated for 12 days of each month on a

cyclical regimen, or
2.5 mg if on a continuous regimen

If estrogen is to be increased for symptom relief, the progesterone should also be increased
Other forms of progesterone:

Norethindrone (Brevicon, Synphasic)

Micronized progesterone creams, dermal patches, gels, and lotions
Rings placed around the cervix
Subcutaneous pellets

Vaginal creams are useful for urogenital symptoms (e.g., dryness)

Transdermal (skin patch) estrogen has the advantage of bypassing the liver but the disadvantage
of causing skin irritation
Antidepressants:

Known as selective serotonin reuptake inhibitors (SSRIs) are an effective alternative to

HRT in reducing hot flashes
E.g., Paxil, Prozac
Hot flashes also may be relieved by an antihypertensive drug (clonidine) or by an
antiseizure drug (Neurontin)

Selective estrogen receptor modulators (SERMs) e.g., raloxifene (Evista)

Also used for menopause problems

Have some positive effects of estrogen (e.g., preventing bone loss) without negative
effects of estrogen (e.g., endometrial hyperplasia increased growth of cells on the
endometrial layer)

Raloxifene competes with estrogen for estrogen receptor sites

It decreased bone loss and cholesterol but has minimal effects on breast and uterine tissue
We are socialized to over prescribing I have a health problem, give me a drug for it

Biphohonates (e.g., aldenronate, risedronate)

Used to decrease risk of osteoporosis in PM women

Alternative Therapies for Menopausal Symptoms

For hot flashes:

Measures to decrease heat production and increase heat loss
E.g., cool environment, limit caffeine and alcohol, behaviour changes (e.g., relaxation),
increased air circulation at night, avoid bedding that traps heat, loose-fitting clothes, cool
cloths, vitamin E
For anxiety and depression:
Good nutrition, exercise, sleep
For sleep avoid alcohol, stress reduction
For bone loss and weight gain:
Regular exercise, which also modifies the risk for coronary artery disease in the
myocardium of the heart (e.g., stress, obesity, inactivity, and hypertension)

Nutrition

To decrease cardiovascular disease, osteoporosis, and vasomotor symptoms

Daily intake of about 30 kcal/kg of body weight
Adequate intake of calcium and vitamin D to maintain bones
PM women not taking supplemental estrogen need at least 1500 mg of calcium daily
Those taking estrogen need at least 1000 mg/day
Calcium supplements are best absorber with meals
Either dietary calcium or calcium supplements may be used

Diet high in

Complex carbohydrates
Vitamin B complex (especially B6)

Phytoestrogens (e.g., soy, tofu, chickpeas, sunflower seeds) may reduce menopausal symptoms

With soy, consult HCP if have history of breast, ovarian, or uterine cancer or
endometriosis
Soy may interact with warfarin
Herbs (e.g., black cohosh)
Please remember that many herbs cause serious adverse effects

Culturally Competent Care

Menopause is a universal phase in a womans life

However

The perception of this change varies by culture

E.g.,
Hindu women may look forward to it
When elders are revered, menopause is a transition to being a wise woman
NA culture negative about aging and high value on youth therefore, menopausal
symptoms viewed as troublesome and need to be treated (medicalization)
Thus, menopause is a milestone embedded in each womans personality and culture

OLDER ADULTS

Age is an issue of mind over matter, If you dont mind, it does not matter - Mark Twain
Our socially constructed society....
Chronological age is a convenient way to group phenomena, but it does illuminate the
dynamic processes that contribute to aging and influence it

OAs are more diverse than any other generation

Their era, roots, cohorts, history, and experiences who the ebb and flow of ideas and...
the fragility of truth
Todays absolutes may be unreliable over time
Long-held truths are often built on repetitious but questionable information

Life transitions and story

Growing older is not easy

Various changes (often simultaneous) demand multiple adjustments that require stamina,
ability, and flexibility
E.g., changes in technology, society, cost-of-living, labor, as well as retirement, reduced
income, housing, loss of significant others, reduced function
Ageism
Changes in family roles and relationships
Parenting
Grandparenting
Loss of spouse
Retirement
Loss of work role
Reduced income
Changes in health and functioning

The cumulative effects of life transitions

Shrinking social world

Awareness of mortality

Responding to life transitions

Life review and life story

Self-reflection (journals, letters, emails, art)

Strengthening inner resources

Research: incidence of acute MI greater within 24 hours of death of a significant other
and grief over the death was associated with an acutely increased risk of MI in the
subsequent days (heart attack greater risk)

Apocalyptic Demography

We should neither underemphasize nor overemphasize the social importance of

population aging
Yet, some people try to overemphasize it via a discourse/ideology called Apocalyptic (or
voodoo) demography
Defined: it is used to characterize the oversimplified notion that a demographic trendpopulation aging will be catastrophic for our society

5 interrelated themes of apocalyptic discourse:

Aging is a social problem that needs fixing

Homogenizes OAs (stereotypes)
Blames OAs for overusing social programs and, thus, for government debts/deficits
Intergenerational injustice and conflict OAs are getting more than their fair share of
societys resources
Intertwine social policy and population aging, e.g.,
Make deep cuts to accommodate the growing numbers of OAs
Dismantle the welfare state to counteract the social burden of an aging population (e.g.,
privatize pensions, eliminate Old Age Security, reduce health care spending [privatize])

Meanwhile, increases in health-care costs due to simple aging are estimated to be 1% of total
health care cost

One factor that increases costs is inappropriate prescribing of drugs for OAs
It may be that 19% of hospital admissions result from inadequate or inappropriate
drug prescriptions

Ageism

Prejudice and discrimination against OAs

Manifestations

Causes

Words bed lockers (locking the beds in hospitals), over the hill, confused,
incontinent, non-compliant (judgemental I know what is right for you and you
are not doing it)
Attitudes (OAs viewed negatively on traits, especially are competence and
attractiveness)
The heart has no wrinkles
Interpret identical behaviour in OAs and YAs differently

Reverence for youth in many modern western societies (e.g., media dying hair,
plastic surgery, Botox, etc.)
Meanwhile, in colonial USA, and today in Asia and in Native societies, OAs held
in high esteem
Misinformation about OAs and aging (e.g., myths/ageist stereotypes)

Consequences

How OAs are treated (e.g., prejudice)

Psychological distress negative attitudes

Systematic bias against OAs harms them, e.g.,

5 key dimensions of ageist bias in healthcare (how it fails OAs):

HCPs lack education about proper care for many OAs

OAs (vs YAs) less likely to receive preventative care
OAs (vs YAs) less likely screened/tested for diseases and other health challenges
Proven medical interventions for OAs often ignored, leading to inappropriate or
incomplete care
OAs are consistently excluded from clinical trials, even though they are the
largest users of approved drugs

Age is not a neutral platform it is

A hot seat of bias

Political

Not taking action against ageism

Suppresses the politics of age in the social dialogue

Perpetuates harm for OAs

Current and future HCPs lack of education/knowledge about

Aging
OAs, including their needs, and
Responsive care

Many authors identify this issue, most recently

Special Senate Committee on Aging, April 2009

Sinha report, Living Longer, Living Well, January 2013 LOOK THIS OVER

Insufficient gerontological content and coursework in health professional education is a

form of ageism and discrimination
Senate Committee on Aging:

That report was dedicated to OAs because they have inadvertently [been]
shunted...to the sidelines

ADVERSE EVENTS IN HOSPITAL

Baker et al (2004). The Canadian adverse events study: The incidence of adverse
events among hospital patients in Canada. Canada Medical Association Journal,
170 (11), 1678-1686
Adverse Events (AE) defined:
Unintended injuries or complications that result in death, disability, or prolonged
hospital stay and arise from health care management
Four hospitals in each of 5 provinces (BC, Alberta, Ontario, Quebec, Nova
Scotia); random chart reviews for the year 2000
Results:
Incidence: AE rate 7.5/100 hospital admissions
Events judged to be preventable 36.9%
Death in 20.8 %
Estimate: 1521 additional hospital days were associated with AEs
Patients with AEs were significantly older
The incidence suggests that of the almost 2.5 million annual hospital admissions
similar to the type studied, about 185,000 are associated with an AE and close to
70,000 of those are potentially preventable

Canadian Patient Safety Institute

Government created in 2002

Many health care organizations have initiated efforts to improve patient safety

In 1976, Illich introduced the concept of iatrogenic illness

Clinical iatrogenesis HCPs, treatments, and hospitals are the pathogens or sickening
agents, e.g.,

Addictions to, and side effects of, prescribed drugs

Diethylstilbestrol (DES)
Unnecessary hysterectomies: the whole uterus is removed unnecessarily
Silicone breast implants
Spread of HIV/AIDS and hepatitis C through blood
March 2008, nearly 400 women with breast cancer received inaccurate tests
results (Nfld/Labrador)
October 21, 2014 Infection outbreak at private Toronto pain clinic

Thus, we are organizing and delivering health care in the most

Proposed Solutions
Recommendations in Canadas aging population: Seizing the opportunity, Special Senate
Committee on Aging, Final Report, April 2009

Counter ageism
Integrate care (continuum for aging in place)
Comparable access to services across the country
Age-friendly cities and communities
Eliminate poverty
Support the voluntary sector
Health and social care workforce *
Incorporate research and new technology
Federal population groups leading by example (e.g., veterans, First Nations and
Inuit)

Recommendations in Living Longer, living well Seniors Strategy for Ontario, Sinha
(2013)

Promote health and wellness

Strengthen/enhance
Primary care for OAs
Home and community care
Acute care for OAs (e.g., senior friendly hospitals, seamless transitions)
LTC (e.g., staff education)
Why are they left with no call bell?
Address:
Specialized needs of OAs
Ageism and elder abuse
The unique needs of older Aboriginal persons
Medications and OAs (e.g., better prescribing)
Care for caregivers
Develop elder-friendly communities
Ready all future HCPs core educational programs, including relevant content
and clinical opportunities
Establish the mandate, implement the strategy (e.g., leadership, governance
structure, funding)

Factors That Fuel the Complexity of OAs Care

OAs diversity/uniqueness
Many factors (e.g., poverty, social isolation) may affect their health and wellbeing
Interrelationships between
NACs
Effects of disease and other abnormal conditions and drugs and other treatments
Many OAs have chronic conditions that uniquely affect
Acute illnesses
Reactions to treatments
Quality of life
Causes of illness are more variable
Frequently, presentations of physical disease overlaps with presentation of
psychological disease

Many OAs underreport: in relation to pain, because they think something is

normal, or I didnt want to bother you
Manifestations of illness, even acute, tend to be subtler/muted and less predictable
in OAs, e.g.,
Physical disturbances or adverse drug effects may present as changes in level of
function
OAs with infection are more likely to have mental changes vs an elevated
temperature
Painless MI or ulcer
Pneumonia without a cough
Many conditions can coexist and muddy the ability to
Chart the course of one disease
Identify the cause/s of symptoms
The risk of complications is high
OAs may have many complaints due to many coexisting diseases

A manifestation of illness in an OA will usually have at least 3 possible explanations,

e.g.,

A change in function is usually related to a combination of several of the

following:
Acute illness
Psychosocial factors
Environmental conditions
Normal aging changes
A new chronic illness
An existing chronic illness
An adverse effect of medication(s) or other treatments
(Note: Medications may be prescribed, self-prescribed, complementary,
alternative, etc., thus, the potential for interactions, e.g.,
Drug-person, drug-drug, drug-food, drug-herb, drug-disease
Often, diagnoses do not tell the whole story; so, it is helpful to think in terms of
presenting problems (*but the problem may not give a clue about the cause/s)
Common problems in OAs include (a list of Is):
Immobility
Instability
Incontinence
Intellectual impairment
Infection
Impaired vision, hearing
Irritable colon: causes cancer, etc
Isolation (depression): cause drugs, illnesses, external events
Inanition (malnutrition)
Impecunity
Iatrogenesis (inappropriate prescribing, harmful labels) unintentially cause harm
Insomnia

Immune deficiency: cause normal aging changes, underlying viruses, protein

deficiency
Impotence: cause underlying conditions, diabetes, drugs, athrosclerosis
Assessment of physiologic illness becomes even more difficult when OAs are
Depressed
Cognitively impaired, or
Otherwise psychosocially compromised
Conditions may be
Missed
Underdiagnosed
Incorrectly diagnosed
By the time illness is identified and treated, it may have advanced, with more
complications
Consequences of illness (greater burden of harm)
Are more far reaching (greater impact on the OA)
May combine with other factors to reduce function and quality of life
May include serious psychosocial consequences
Due to all these factors, assessment of OAs
May require a detective-like approach
Is time-consuming and puzzle-solving
If shortened, can harm the OA
Gerontological nurses have a key role in advocating (e.g., for structures, systems,
policies, and practices) that recognize and respond to the complexity of OAs
needs and care
OAs conditions can cut across many clinical specialities; thus, RNS needs broad
knowledge
O-A care requires effective
Structures (e.g., positive ideologies about OAs and their care; immense
knowledge; broader models for care; shared goals amongst gerontologically
prepared HCPs; expectations for care)
Systems (e.g., communication, coordination and continuity of care, staffing
numbers and ratios, interdisciplinary care)
Resources (e.g., to support ongoing learning)

10 leading chronic conditions affecting OAs 65+ years

Arthritis
Hypertension
Hearing impairments
Heart conditions
Visual impairments
Deformities or orthopaedic impairments
Diabetes
Chronic sinusitis
Hay fever and allergic rhinitis
Varicose veins

Leading causes of death for OAs 65+ years

Heart disease
Cancer
Chronic lower respiratory disease
Stroke
Alzheimers
Diabetes
Influenza and pneumonia
Nephritis, nephrotic syndrome, nephrosis
Accidents
Septicemia (blood poisoning)

Acute Hospital Care for Frail OAs

At issue the provision of effective care for frail OAs

Frail OAs at high risk for adverse clinical outcomes (e.g., death and
institutionalization)
Frailty linked to key clinical syndromes:
Loss of mobility
Falls
Confusion
Incontinence
Polypharmacy
How hospitals may contribute to adverse outcomes
Rapid pace
Technological focus of medicine
Attitudes about OAs
Inappropriate prescribing
Skill mix of HCPs

OAs need comprehensive geriatric assessment (CGA)

Multidisciplinary and multidimensional assessment of health, rehab, and social

care needs)

Assessment then informs treatment and management in

Dedicated inpatient units

Recommendations to referring HCP/s
Patients home or other ambulatory care setting
Dedicated units: benefit function and mortality. Examples,
Stroke and hip units
Nurse-led units
Geriatric assessment and Acute Care for Elders (ACE)
Units

One issue in managing frail OAs is high incidence of delirium and its adverse outcomes

Key features (and examples) of ACE-unit strategies to prevent delirium:

Physical environment
Admission processes: try to identify early screening on admission,
Assessment incorporating CGA
Avoid unnecessary stress
Discharge (seamless care)
Frail OAs, often acutely ill were misclassified as sub-acute (the acuity of their
illness was missed, resulting in missed disease presentations)
Often, OAs have many interacting problems that are miss as

From OHara, T. (2013). Geriatric syndromes and their implications for nursing. Nursing
2013, 43(1), 1-3...
5 conditions most commonly considered geriatric syndromes
(They dont fit into specific disease categories)

Pressure ulcers
Incontinence
Falls
Functional decline
Delirium

Also classed as syndrome

Malnutrition
Challenges with eating
Problems with sleeping
Dizziness and syncope
Self-neglect

N2050 _
November 17, 2014
Hospital Care for Seniors: 48/6 Model of Care (2012), addresses six areas of functioning
for OAs 70 + years, plus individualized care plan and a discharge and/or transition plan

Bladder and bowel: working with the patient to maintain their usual bowel and
bladder function, intervening where necessary with additional interventions
Cognitive function: refers to the mental processes including memory, thinking,
judgement, calculation, and visuospatial skills. Attention must be paid to the
possibility of delirium, depression, dementia, and mild cognitive impairment.
Functional mobility: a persons ability to stand, walk, and transfer from bed to a
chair. Bed rest inhibits a persons capability to perform these functions as it
contributes to muscle atrophy and reduced endurance
Medication management: reviewing each persons medication list, dosages (dose
and dose interval), potential medication interactions and balancing the benefits
versus the risks of medications.

Nutrition and hydration: ensuring adequate amount and type(s) of food and liquid
consumed, assessing for any swallowing difficulties and/or food allergies, and
supplementing intake, where necessary.
Pain: refers to the use of medications and other interventions (such as massage,
exercise, or physiotherapy) to prevent, reduce, or stop acute or chronic pain

In Canada, over 50% acute-care beds occupied by OAs each day

30% of those OAs will be discharged with significantly reduced function
Most will never recover their previous independence (p. 3)
OAs IN THE EMERGENCY DEPARTMENT

Often have atypical S & S and may comorbidities that complicate diagnosis and
treatment
Greater risk for ED return visits, hospitalization, and death
Outcomes may be related in part to
Functional status
Comorbidity scores
Age
Social supports
Polypharmacy
Cognitive impairments
Depression

Conditions frequently encountered in ED:

Neuropsychiatric disorders (del, dem, dep)

Falls
Coronary disease
Polypharmacy and adverse drug effects (medication reconciliation)
Alcohol and substance abuse
Abdominal pain
Infections
Social cases (perhaps, but search for hidden illness)
Abuse and neglect

Tools:

Identification of Seniors at Risk tool (p. 266)

If high risk, more thorough geriatric evaluation in ED (e.g., mood, cognition,
function, and referral to geriatric specialist)

Functional Decline/Deconditioning in Hospitalized OAs

Disability from immobilization one of 10 preventable health problems

Functional decline can occur as early as day 2 in hospital
Cascade to dependency (Creditor)

Syndrome of dysfunction (Palmer)

Costs of functional decline

Greater
Risk of illness and death
Dependence
Diminished
Quality of life (end up dying or going into long-term care)
Autonomy
Institutionalization
Longer stays
Readmission/recidivism

Thus, RNs must look for risks and intervene

Complex contributors to functional decline

Aging and the hospital

Both illness and hospital environment, e.g.,
Environment designed for caregivers (vs. Patients)
Myopic models for care: Often care focuses on treating acute illness; physical and
cognitive function are overlooked
Aging and immobility
Aging and CV system
Cardiac output and stroke volume affected by changes in body position
Aging and pulmonary system
Frailty
Illness and iatrogenic events: could be caused by not washing hands properly
Best rest and immobility
Impaired cognition

Assessment of function ongoing (& please see 2250 notes)

Interventions

Make ambulation a focus

Prescribed hallway walking/walking routines
Resources to support ambulation programs
Safe areas, railings, distance markers, chairs in halls for rest
Few orders for bed rest
Patient and family teaching
Walking for fitness programs in hospital
Acute Care for Elders Units
Hospital Elder Life Program (HELP)
Nurses Improving Care for Health System Elders (NICHE)
More intensive home care

Resources:

Boltz et al. (2012). Evidence-based geriatric nursing protocols for best practice
(4 ed.)
John A Hartford Foundation Institute for Geriatric Nursing. Best Nursing
Practices in Care for Older Adults (a curriculum guide)
Hartford Institute for Geriatric Nursing Website
Advancing Care Excellence for Seniors
National Institute on Aging
Advocacy Centre for the Elderly
Canadian Gerontological Nurses Association (and Canadian Nurses Association
specialization in geriatric nursing)
Broader Strategies to Support Aging
City of Thunder Bay Age Friendly Action Plan 2014-2018
September 2010, the Local Health Integration Networks (LHINs) Senior
Friendly Hospital Strategy for Ontario
Senior Friendly Hospital Care: Evolving the Care of Older Adults
th

CONFUSION

The major causes of confusion in OAs are delirium and dementia

Delirium (can kill you quickly) superimposed on dementia is a risk for functional
decline and death
Misdiagnosis and inappropriate treatment of confusion can cause substantial
Morbidity
Hardship to families
Health-care costs
Issues with language:
Some definitions of confusion are too broad/imprecise
Use of cognitive impairment with careful documentation of timing and nature of
specific abnormalities is more precise and clinically useful
Documentation is best accomplished by screening and a thorough mental status
exam (if indicated)

Mental status examination

Several components essential in diagnosing delirium, dementia, or other

syndromes
State of consciousness
General appearance and behaviour
Orientation
Memory (short, long)
Language
Visuospatial functions
Executive control functions
Other cognitive functions (e.g., calculation, proverb interpretation)
Insight and judgement

Thought content
Mood and affect
Focus on each component systematically
Record observations to evaluate changes over time
Several tests can help to diagnose and to monitor
But many factors may influence performance and interpretation of mental status
tests, e.g.,
Education
First language
Sensory challenges
Poor baseline intellect
Implications of health challenges
Stress from being examined
Thus, scores on tests should not replace a comprehensive examination

Differential Diagnosis of Confusion

There may be several causes, including

Disorders of the brain

Systemic illness presenting atypically
Sensory impairment (e.g., reduced hearing)
Adverse effects of drugs or alcohol

Like many other disorders in OAs, confusion often caused by many interacting processes
Disorders causing confusion broadly categorized into 3 groups:

Acute disorders
More slowly progressive impairment
Impairments associated with affective disorders and psychoses

Potent labels and risks of premature closure

Remember, older age does not impair cognition enough to cause dysfunction
3 questions may inform accurate diagnosis of cause(s) of confusion:

Was onset acute (e.g., hours or a few days)

Might physical factors (e.g., illness, sensory challenges, and drugs) be
contributing to the abnormalities?
Are psychological factors (e.g., dep, psychoses) causing or complicating
impairment?

These questions help to find treatable causes

Once diagnoses and treated, cognition might improve
DELIRIUM

Prevalence: might be 15% on admission; might be coming in with delirium, in

hospital 1/3 might be delirious ; 22% community living people with dementia ;
15-70% in LTC residents ; 80% or more in ICU
Predisposing factors:
Impaired sense
Sensory deprivation
Sleep deprivation
Immobilization
Transfer to unfamiliar environment
Number of meds
Dementia
Functional dependency
Key features of delirium
Disturbances of consciousness
Changes in cognition not better accounted for by dementia
Acute onset (hours to days)
Fluctuating cognitive status (signs and symptoms)
Evidence that is caused by physiological consequences of a medical condition
The major features that distinguish delirium from other causes of impaired
cognitive function
Characteristics of delirium
Difficulty sustaining attention
Sensory misperceptions (e.g., illusions)
Fragmented or disordered thinking
Disturbed psychomotor activity (hyper or hypo)
Emotional disturbances
Neurological signs are uncommon
Major features that distinguish delirium from other causes of impaired function
are :
o disturbances of consciousness
o acute onset
o fluctuating cog. status
Factors associated with development of delirium in hospital:
Over 80 years
Men
Pre-existing dementia
Fracture
Infection
Malnutrition
3 or more drugs
Neuroleptics and narcotics
Restraints
Bladder catheters
Rapid identification of delirium is critical because
Is often related to reversible conditions

Is a poor prognostic sign for adverse outcomes (e.g., nursing home placement,
death)
Therefore, identify and treat all causes quickly.

Confusion Assessment Method (CAM)

A validated tool to identify delirium
Requires the presence of
Acute onset and fluctuating course and
Inattention and
Disorganized thinking or
Altered consciousness
FAM-CAM (reports from family and informal caregivers)
Short Portable Mental Status Questionnaire
Mini-mental Status
Mini-cog
Montreal Cognitive Assessment
Zung Self-rating Depression Scale
Differentiating delirium from dementia is crucial because

Dementia is not immediately life-threatening

Wrongly labelling a delirious patient as demented may delay diagnosis of serious
and treatable underlying conditions
The diagnosis of dementia must await the treatment of all potentially reversible
causes of delirium
(People can have depression from one or more causes, delirium from one or more
causes, and dementia from one or more causes, all at the same time)

Remember, older age does not impair cog. enough to cause dysfunction

Common causes of delirium in OAs:

Metabolic disorders
Hypoxia: low oxygen
Hypercarbia: increased carbon dioxide;
Hypo- or hyperglycemia: low or high sugars
Hyponatremia: low sodium
Azotemia: waste products in the blood
Disturbances in fluids and lytes
Infections
Decreased cardiac output
Dehydration
Acute blood loss
Acute myocardial infarction
Congestive heart failure
Stroke (small cortical)
Drugs

Intoxication (alcohol, other)

Hypo- or hyperthermia
Acute psychoses

People can have:

dep from one or more causes

del from one or more causes
dem from one or more causes
all at the same time = COMPLEX

Dementia
Key features

gradual progressing course (months, years)

no disturbance of consciousness

Two broad categories

reversible or partly reversible

nonreversible

Reversible causes of dementia-like signs/characteristics

crucial to rule out treatable potentially reversible causes

finding and treating reversible causes does not guarantee that dem will improve

Causes of potentially reversible dementias:

Neoplasms
Metabolic disorders (and endocrine disorders ex. thyroid problems, low blood
sugar)
Trauma (subdural hematoma)
Toxins
o Alcohol, heavy metals, organic poisons
o Infections (meningitis, encephalitis)
Viral, including HIV
Autoimmune disorders
o central nervous system vasculitis, temporal arteritis
o lupus
o multiple sclerosis
Endocrine challenges
Drugs
Nutritional Disorders
Psychiatric Disorders
Depression
Other disorders (ex normal pressure hydrocephalus)

Depression and dementia may co-exist

Non reversible dementias\:
4 categories
1. Degenerative diseases of CNS
1. AD
2. Dem with Lewy bodies (DLB)
3. Parkinson disease
4. Pick disease (a type of frontotemporal dementia)
5. Huntington disease
6. Progressive nuclear palsy
b. Vascular dementias
1. Multi-infarct dementia (MID)
2. Binswanger disease
3. Cerebral embolism
4. Arteritis
5. Anoxia secondary to cardiac arrest, cardiac failure of carbon monoxide
intoxication
b. Traumatic Dementia
1. craniocerebral injury
2. dementia pugilistica
b. Infections
1. HIV
2. Opportunistic infections
3. Creutzfeldt-Jakob disease (Human form of mad cow disease)
4. Postencephalitic dementia
AD (gradually progressive) and MID (stuttering or episodic, with step-wise deterioration)
frequently coexist

Crucial to differentiate vascular dem from other dem because vascular dem may
benefit from aggressive treatment of hypertension and other CV risks.

Dem with Lewy bodies (DLB) may overlap with Alz. and Parkinson dementias
In addition to characteristic patho signs, DLB includes

Detailed visual hallucinations

Parkinsonian signs
Altered alertness and attention

Evaluation of Patients suspected of Having Dementia:

Recognize that Dem may be present:

Mini-Cog assessment - useful tool to identify patient who need more assessment
Symptoms that suggest further evaluation:

o
o
o
o
o
o

Trouble learning, retaining (Are they repeating themselves? Are they

frequently misplacing things? Are they just stressed out?)
Trouble completing complex tasks (Are they having trouble balancing a
cheque book? Cooking a meal?)
Trouble reasoning/problem solving (Do they know what to do in an
emergency situation? Are they behaving in unusual ways?)
Trouble with spatial ability, orientation. (Are they having trouble
finding their way in familiar places?)
Language. (Are they having trouble following conversation? Leaving
sentences unfinished?)
Behaviour (Is there a change in their personality?)

If suspected of having dem:

a. History - Physical illnesses, complaints ; Drugs (prescription and nonprescription, including alcohol) ; Nature and severity of symptoms and signs
(deficits, onset, rate of progress, irregular stepwise vs. gradual loss, neuro signs or
not, dementia and then suddenly worse) ; Associated psychological symptoms
(depression, anxiety, agitation, paranoid, psychotic) ; Helpful in differentiating
dem, dep, or mixed ; Ask about common problems (wandering, driving,
behaviour, delusions or hallucinations, insomnia, poor hygiene, malnutrition,
incontinence)
b. Social Situation - Living arrangements, supports, relatives and caregivers
(including their employment, health) ; functional status
c. Physical exam - Focus particularly on CV (ex hypertension) and neuro (ex
unilateral weakness or sensory deficit) assessment (may include MID) ; Impaired
stereognosis or graphesthesia ; Gait disorder ; Abnormalities on cerebellar
testing ; Parkinsonian signs (ex tremor, bradykinesia, muscle rigidity) may mean
dem associated with Lewy bodies or frank Park. disease
d. Comprehensive Mental Status Exam and Standardized Mental Status Test - ex
Mini-Cod for screening ; Mini-Mental State Exam and Time and Change Test to
get objective score re cog. function ; Neuropsychological testing (ex to differ dep
and dem)
Diagnostic Studies to rule out reversible dementias:

Blood
o

CBC, glucose, urea nitrogen, lytes, calcium, phosphorous, liver function,

thyroid, vitamin B12 and folate, syphilis, HIV
Radiographic studies
CT or MRI of head
Consider drugs that may be causes
Neuropsychological testing

Treatment of Dementia:

Complete cure is not available for most dementias but optimal management can
improve function and well being of patients, families, caregivers

Treat all causes of reversible or potentially reversible dem (ex prevent more
strokes by controlling BP).

Drug treatment of Dementia:

Three Approaches:
1. Enhance cognition and function
2. Treat coexisting depression
3. Treat complications (Paranoia, delusions, agitation)
Drugs for depression may benefit
Primary drug approach to AD is cholinesterase inhibitors
Effectiveness is controversial; carefully weigh potential benefits vs risks and costs)

Optimize holistic function through physical activity and mind plasticity

o Treat underlying medical and other conditions
o Avoid drugs with CNS side effects (unless needed for psychological or
behavioural disturbances)
o Environmental assessment and alterations
o Physical, mental activity
o Avoid stressing intellectual abilities (use memory aids)
o Prepare patient for change in location
o Nutrition
Identify, manage behaviour complications
o Provide ongoing care
o Reassess to identify reversible causes or deteriorating function

Give information to patient and family about:

Nature, extent, prognosis

Behavioural challenges, approaches
Social services, support groups, respite, LTC
POA, advance directives
Counselling (for family conflicts, anger, guilt, decisions, legal and ethical issues)

Multidisciplinary care
Special care units (in nursing homes, assisted-living)
Pharmacokinetics
How body processes the drug (what body does to drug)
Four components:
1. Absorption

Nov 30

2. Distribution
3. Metabolism (biotransformation)
4. Excretion
Pharmacodynamics
What drug does to the body (how drug affects body)
Absorption - Factors that affect rate:

Administration route
Food, fluids given with drug
Dosage formulation
Status of absorptive surface
Rate of blood flow to small intestine
Acidity of stomach
Status of GI motility

First Pass Routes (goes through the liver):

Oral
Hepatic artery ??
Portal vein
Rectal - could be both first pass and non first pass

Non - First Pass:

Ear
Buccal (cheek)
Inhalation
Intraarterial
Intramuscular
Intranasal
Intravaginally
IV
Subcutaneous
Sublingual (under the tongue)
Transdermal

Pharmaceutics:
Drug dosage forms can determine rate at which drug dissolution and thus absorption
occurs
Dissolution - a process- how solid forms of drugs disintegrate, become soluble, get
absorbed into blood
Examples of drug preparations and rate of absorption (fastest to slowest):

Liquids, elixirs, syrups

Fastest

Suspension solutions
Powders
Capsules
Tablets
Coated tablets
Enteric-coated tablets

Slowest

Dosage forms that exist:

Enteral (GI - ex tablets, capsules, pills sublingual, buccal, elixirs, suspensions,

emulsions)
Parenteral (most commonly means injection - ex solutions, suspensions,
emulsions, powders for reconstitution, may include IV, subcutaneous,
intramuscular, intrathecally, intraarticular)
Topical (ex aerosols, ointments, creams, paste, powder, solutions, foams, gels,
transdermal patches, inhalers)

The specific characteristics of the dosages forms affect and how and to what extent drug
is absorbed

Oral - relies of gastric enzymes, pH

Topical - may work immediately once put on skin, for some drugs the skin is a
barrier that the drug has to work through
Parenteral - you can damage a vessel if the drug is too corrosive so the drug must
be as similar to the median of the blood as possible

Distribution
Transport of drug by blood to site of action
Drug can be distributed to extravascular tissue only if it is not bound to protein
Three primary proteins that bind to and carry drugs:

Albumin
Alpha-acid glycoprotein
Corticosteroid-bindings globulin

The most important is albumin

Drugs that are highly protein bound compete for binding sites on proteins leaving either

less of both drugs bound or

less of one of the drugs bound
That results in
more free, unbound drug and
possibility of drug-drug interaction (one drug causes a greater or lesser response
of the other drug)

Drug is distributed first to areas most extensively supplied with blood (ex heart,
liver, kidneys, brain)
Areas of slower distribution: muscle, skin, fat
Usually, highly water-soluble drugs have small volume of distribution and high
blood concentrations
Fat-soluble drugs have large volume of distribution and low blood concentrations
Drugs that are water soluble and highly protein bound are less likely to be
absorbed into tissues; thus, their distribution and onset of action can be slow
Drugs that are highly fat soluble and poorly bound to protein are easily taken into
tissues
In some sites: may be difficult to distribute drug due either to poor blood supply
(ex bone) or barriers (ex blood-brain barrier)

Metabolism
Transform drug into:

Inactive metabolite
More soluble compound
More potent metabolite

Liver is most responsible

Other tissues and organs that aid: skeletal muscle, kidneys, lungs, plasma, intestinal
mucosa
Hepatic biotransformation involves cytochrome P-450 enzymes (control chemical
reactions that aid in biotransformation)

These enzymes targeted lipid-soluble non-polar (no charge) drugs that are
typically difficult to eliminate (includes most drugs)

Mechanisms of liver biotransformation

Chemical reactions:

Oxidation
Reduction

Hydrolysis

Conjugation
Result:

Greater polarity of chemical, and thus more water soluble and more easily
secreted
Often results in loss of pharmacological activity

Comon P-450 enzymes and drug substrates/targets

Drugs with water soluble (polar) molecules may be more easily metabolized by simpler
metabolic reactions such as hydrolysis (metabolism by water molecules)
Excretion
Primary organ is kidney
Liver and bowel play important role
Due to biotransformation, most drugs that reach kidneys have been metabolized; only
small fraction of original drug is excreted as original compound

Once metabolized, drugs are more polar and water soluble which eases
elimination by kidney

Some drugs circumvent metabolism and reach kidneys in original form

Excretion in kidneys:

Glomerular filtration
Active tubular reabsorption
Tubular secretion

Excretion by intestines (biliary excretion)

Taken up by liver, released into bile, eliminated in feces

Other routes of elimination:

Lungs and glands (sweat, salivary, mammary)

Important consideration in determining effects of age on renal function and drug

elimination:

Wide inter-individual differences in rate of decline in renal function with

increasing age, so applying average declines to individual OAs could result in
over or under-dosing
Muscle mass declines with age; thus, daily endogenous creatinine production
declines (thus, serum creatinine may look normal when renal function is

reduced - serum creatinine does not reflect renal function (GFR) as accurately in
OAs as it does in YAs)
Many factors (ex state of hydration, cardiac output, renal disease) can affect renal
clearance of drugs and are often at least as important as NACs

A formula to estimate renal function in relation to age: Cockcroft Gault Formula

The result is about 15% less in females

It is useful when only data on serum creatinine are available and in initial
estimations of creatinine clearance for the purpose of drug dosing in OAs

When using drugs with narrow therapeutic-to-toxic ratios, use

actual measurements of creatinine clearance and drug blood levels

Characteristics of OAs relative to drug disposition and responses:

Reduced:

renal function
serum albumin and increased alpha 1 - acid glycoprotein levels
lean body mass and total body water
liver metabolizing capacity
cardiac reserve
baroreceptor sensitivity

Relative increases in body fat

Effects of drug - altered sensitivity
Concurrent illnesses
Multiple drugs
Large inter-individual variation
Practice Pearls:
1. Dont rely on BUN (blood urea nitrogen) as an indicator of renal function in OA:
BUN is affected by muscle mass, hydration, anemia, dietary intake of protein.
Calculating the creatinine clearance using formula gives more accurate
assessment of how drug will be metabolized and cleared by kidneys.
2. If patient receiving 2 or more drugs that are highly protein bound, watch for
interactions and variations in responses to each drug.
3. Rule of thumb for prescribing for OAs: Start low; go slow. Drug should be
prescribed at about recommended adult dose. Prescriber should wait 2x as long
as recommended in literature before increasing the dose. This rule helps prevent
toxic side effects.
Drugs that should be used with caution in OAs:

New to market
CNS effects
Highly protein bound
Eliminated by kidneys
High first pass effect
Low therapeutic-to-toxicity ratio

Prescription Drug Use and OAs

Epidemiology of drug use:

General pop versus OAs (OAs are prescribed more drugs)

Income
Gender differences (females tend to be prescribed more drugs than men)

Drug expenditures responsible for increasing proportion of health costs

OAs at greater risk of adverse drug-related events
Appropriateness of Prescription Drug Use:
4 Criteria:
1. Match between need and treatment - overuse and underuse
2. Appropriateness - Prescribing errors account for estimated 5 to 23 % of drugrelated hospital admissions. OAs (vs MA adults) more likely to receive potentially
inappropriate medication.
3. Cost effective - Prescribing of new drugs exceeds expected incidence of health
problems for which such drugs indicated.
4. Adherence - For many patients, adherence is far from ideal. In OAs, 11.4% of
hospital admissions attributed to adherence problems.
Potential effects of drug treatment compromised by:

Under and over-use of prescribed medication for certain conditions

Errors in drug, dose, duration
Suboptimal adherence

Drug-related illness - 6th leading cause of death in USA

Incidence of adverse drug reaction (ADRs) remained stable for last 30 years
Adverse drug related events more common in OAs:
o Primarily because they are more likely to be using more drugs and
possible because OAs are more likely to receive potentially inappropriate
medication

Unjustified expenditures on drugs erode ability to expand or even to maintain health

services that may be key to protecting OAs independence.
Many factors affect drug use in Canada ex:

1. Socio-demog characteristics of users: more prescribing for OAs, women, less

education, lower family income
2. Social characteristic of physicians: Number of physicians, Style of practice (ex
solo vs group, forms and effectiveness of regulation), Level of education, Amount
of continuing education, Significant lack of knowledge about drugs; Tend to use
drug adv., sales people for info (often incomplete disclosure, influences
prescribing), CPS for info (inadequate in many ways); size of practice, more
visits=more prescriptions, reimbursement; frequent over prescribing; direct to
consumer advertising - patient demands drugs and gets them; social (as well as
medical) causes for drug use - drugs for stress, lack family support, sleep, anxiety,
pain, BP, stomach; physicians tendency to medicalization/medical intervention
3. Pharmacists and pharmaceutical industry:
1. Cost (sell price not always related to prod. cost - if no price competition,
can max profits)
2. Drug comp many use discount pricing to entice pharmacy to sell its brand
of drug.
3. If prescriber doesnt say no substitute, pharmacy can dispense any
comps brand of that drug
4. Availability
5. Promotion and advertising - They may recommend drug for everyday,
normal concerns; May recommend the drug for beyond what the drug is
approved for; aggressive advertising to physicians and consumers; drug
industry provides only select info to doctors, public about effectiveness
etc; drugs that were previously prescribed is not over the counter which is
expected to boost sales; Offers financial incentives/gifts; Industry power
vs government power re how drugs are regulated, brought onto market etc
4) Drug payment schemes - government, private, individual
5) HCS

Issues in drug regulation

Lack good, systematic knowledge about drug efficacy, safety
Impoverished research about drugs
No routine, ongoing monitoring of drug effects on person or pop in Canada
(Health Canada lacks record of drug withdrawn due to safety and why)
Close ties b/t regulation body of government and international drug industry and
Pharmaceutical Manufacturing Association of Canada
Changes to drug approval value quick evaluation of new drugs over safety

3 Components of Comprehensive Medication Assessment

1. Drug History: ALL prescription, over the counter, from family/friends, topical,
taken and stopped within a month, illegal, remedies, alcohol/tobacco/caffeine; for
each medication ask about dose, schedule, regularity of use, reason, knowledge of
drug
2. Assess client: Medical Hx, Nutritional Hx, Fluid intake and status, Cognition,
Sensory function, Overall function, Opinions of medications and taking it, Pain,

BP (lying, sitting, standing), Temp, Pulses, Respirations, Elimination (bowel and

bladder) patterns
3. Drug assessment/appropriateness of regimen: reason/diagnosis for each drug,
non-drug methods considered, effectiveness of each drug, drugs used to treat side
effects of other drugs, doses adjusted to age/weight/NACs, potential/actual
troublesome side effects, drug interactions, drugs with defined therapeutic
windows monitored (by serum drug concentrations), regimen can be simplified,
drugs not generally recommended for OAs
Factors that affect how people take medication
1. Client factors: Culture/beliefs, attitude toward HCP, memory, comprehension,
perceptions, symptoms, functional abilities
2. Treatment factors: complexity of regimen, number of drugs, side effects,
mechanical difficulties, availability of medications, cost
Blood Pressure In Older Adults:
Heart and Stroke Foundation warns a perfect storm of heart disease is looming

GO OVER STEPS OF TAKING BP

ausculatory gap

Hypertension: usually defined as BP greater than or equal to 140/90 mm Hg or BP that

requires treatment with antihypertensives
BP even at high end of normal is risk for:

stroke
myocardial infarction
sudden cardiac death
coronary heart disease
congestive heart failure
renal disease

Recent studies confirmed importance of treating both diastolic and systolic BP when
elevated
Systolic (higher than 140) HTN is:

most common type of HTN in OAs

strongly associated with organ damage
greater risk of CV disease and mortality

Risks for HTN:

obesity
age
genetics

sleep apnea
stress
lower education, socioeconomic status
diet (higher fats, sodium, alcohol - lower potassium)

Healthy OAs will not have any significant change in CV performance because of age
changes alone
Increases in BP associated with risks ex lifestyle, sociocultural factors, diseases
And risks may be reduced by lifestyle and medical interventions
Regulation of arterial pressure:

Normal pressure maintained by negative mechanism: baroreceptor reflex (KNOW

ABOUT BARORECEPTORS)
Decrease in BP (ex on standing) activates SNS, increasing cardiac output (heart
rate, venoconstriction for venous return, and cardiac contractility) and increasing
peripheral resistance to trap blood in arteries, and restores arterial BP
Increase in BP leads to increase in baro stimulation of PNS leads to decreased HR
and BP

Baroreflex Mechanisms:

Regulate BP by increasing or decreasing HR and peripheral vascular resistance to

compensate for transient changes in arterial pressure
Age related changes that alter baroreflex mechanisms include: Arterial stiffening,
Reduced CV responsiveness to adrenergic stimulation
These changes blunt the compensatory response to hypertensive and to
hypotensive stimuli in OAs (so heart rate does not increase or decrease as
effectively as in YAs)

Types of HTN:

Primary - cant pinpoint the cause of it ; about 90% of those with HTN have this
type (Essential HTN, :Idiopathic)
Secondary - can usually find a cause - might be due to kidney/neurological/vessel
etc issues, could be drug/food related
White coat
Isolated systolic (systolic over 140 but diastolic under 90)
Resistant

Isolated Systolic:

Systolic BP is 140 mmHg or higher; diastolic BP is less than 90

Possible causes: increased cardiac output; atherosclerosis-induced changes in
blood vessel compliance (or both)

Causes of secondary HTN

Renal: ex Renal parenchymal disease, renal artery stenosis, renin-producing

tumors
Endocrine: ex acromegaly, hypothyroidism, hyperthyroidism, adrenal disorders
Neurologic: ex increased intracranial pressure, sleep apnea, autonomic dysreflexia
Drugs: ex some herbal, illegal, oral contraceptives

Pathologic conditions affecting CV wellness in OAs:

orthostatic hypotension
postprandial (after you eat) hypotension
these conditions are often overlooked, frequently affect CV function in OAs, due
to combination of age related changes (ex decreased baroreflex sensitivity) and
risks
Important to identify both HTN and hypotension in OAs

Orthostatic (postural) hypotension:

Reduction in systolic BP and diastolic BP of at least 20 mmHg or 10 mmHg,

respectively, within 3 minutes of standing, after being recumbent for at least 5
minutes
Prevalence: From 6% in healthy OAs to 68% in hospitalized OAs
Risks for ortho hypo:
o HTN, including ISH
o Parkinson disease
o Cerebrovascular disorders
o Diabetes
o Anemia
o Autonomic dysfunction
o Arrhythmias
o Volume depletion (dehydration)
o Electrolyte imbalance
o Drugs
o Alcohol
May be asymptomatic or accompanied by symptoms such as fatigue,
lightheadedness, blurred vision, syncope, cognitive difficulties
Serious negative functional consequences: greater risk of falls and CV
disease (ex CHF)

Assessment:

Keep arm in same position (either parallel or perpendicular to torso) during supine
and standing positions
Obtain BP reading after sitting or lying for at least 5 min
Second BP reading after standing for 1 to 3 min

Postprandial Hypotension:

Systolic BP reduction of 20 mmHg or more within 2 hours of eating a meal

Risks for it:

o Pathologic processes - Systolic HTN, Diabetes mellitus, parkinson
disease, multisystem atrophy
o Drugs - diuretics, antihypertensive drugs ingested before meals
Physiologic cause: Impaired autonomic function
Contributing factors: GI vasoactive peptides, impaired glucose metabolism
Assess in OAs, even those in bed, to reduce falls, syncope, stroke etc.
Assessment: Initial BP before meal, second and third reading at 15 minute
intervals after meal completed

Goals for assessing BP in OAs:

Detect HTN, orthostatic hypotension, postprandial hypotension

Normal findings:

difference between lying/sitting and standing

systolic is 20 mmHg or less after standing for 1 min
diastolic is 10 mmHg or less after standing for 1 min

Reasons why may be more difficult to assess BP accurately in OAs:

Increased variability of BP (greater tendency to fluctuate in response to postural

changes as other factors)
Post-prandial drop in BP may occur
Uncomfortably full bladder will increase BP
Many diseases, therapies influence BP and cause postural hypotension
Auscultatory gaps may be more common
Consistent differences in BP between arms may be more common in OAs
Incidence of arrhythmias increases with age
pseudohypertension occurs predominantly in OAs
self measurement of BP may be difficult

Target organ damage - examples

Cerebrovascular: Stroke (ischemic stroke and transient ischemic attack,

intracerebral hemorrhage, aneurysmal subarachnoid hemorrhage); Dementia
(vascular dementia, mixed vascular dementia and dementia of the Alz type);
hypertensive retinopathy; left ventricular dysfunction (left ventricular
hypertrophy); coronary artery disease (myocardial infarction, angina pectoris,
congestive heart failure); Renal (chronic kidney disease, albuminuria); Peripheral
artery (intermittent claudication)

Absolute risk for all types of CV morbidity and mortality is higher among persons with
(vs without) target organ damage
Assessment:

Physical exam: vital signs and weight, look at fundus on eye for retinal hypertension
damage (any signs of hemorrhage, exudate, papilledema etc.), examine neck vessels for
bruits, look for jugular vein distension, look for enlarged thyroid, auscultate the heart,
check for increased heart rate, abnormal rhythms, enlargement etc, check for precordial
impulses, listen for murmurs, listen for S3 and S4 heart sounds; Examine abdomen to
abdominal aortic artery for any bruits, examine abdomen for enlarged kidneys, assess all
extremities for symmetry
In order to take an accurate blood pressure, I would begin by gathering my equipment
and selecting an appropriate cuff size for my patient. I would position the patient so that
his/her arm is level to their heart and put the cuff on so that the artery marker is pointing
towards the brachial artery. I would palpate at the antecubical fossa for the strongest
pulse and auscultate with my stethoscope. I would then pump up the cuff 30-40 mmHg
higher than their normal BP (or 160-180 mmHg if a normal reading is not available) and
listen for the first rhythmic sound which is the systolic BP, and the last rhythmic sound
which is the diastolic BP.
Lab Tests for investigation:

Complete blood cell count

Urinalysis
Electrolyte levels
Fasting blood glucose
Blood urea nitrogen (BUN)
ECG
Chest Xray