Chapter 3-GERIA

MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

CHAPTER 3: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS
This chapter is divided into two (2) lessons. In the syllabus, there are three
lessons, however, we have already incorporated the care of an older adult with impaired
verbal communication with the two identified lessons. Overall, this chapter will consume
four (4) hours for lecture.
Lesson 1: Disturbance in Sensory Perception
Lesson 2: Chronic Confusion
LESSON 1: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS with DISTURBANCE
IN SENSORY PERCEPTION
Before we proceed with the disturbance in sensory perception, it is very important

to understand first the concept of chronic illness.
After completing this lesson, you must have:

1. Defined chronic illness and explain the differences between chronic illness and
acute illness.
2. Discussed the factors that influence the experience of chronic illness.
3. Identified competencies to improve care for chronic conditions.
4. Discussed models to enhance self-care management of chronic illness.
5. Discussed the assessment and treatment of diseases of the eye and ear that
may occur in older adults.
6. Described the importance of health education and screening for eye diseases
to prevent unnecessary vision loss in older adults.
7. Discussed nursing interventions to maximize wellness in the presence of
chronic illness.
Warm-up Activity:
Before you start officially with the learning inputs, watch this short video and
let’s see what will it make you feel.
• https://www.youtube.com/watch?v=uG1wtGbL0oA
1. What did you feel after watching the video?

2. What do you think is the need of older clients with chronic illness?
Presentation of Learning Inputs:
A. CHRONIC ILLNESS
- a medical condition or health problem with associated symptoms or disabilities
that require long-term management.
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CHARACTERISTICS OF ACUTE AND CHRONIC ILLNESS
ACUTE ILLNESS CHRONIC ILLNESS
Description Description
Disease that have a rapid onset and short Diseases that are prolonged, do not resolve
duration spontaneously and are rarely cured
Examples: colds, influenza, gastroenteririts completely
Characteristics Characteristics
• Usually self-limiting • Permanent impairments or
• Responds readily to treatment deviations from normal
• Complications are infrequent • Non-reversible pathologic changes
• After illness person returns to • Residual disability
previous level of functioning • Special rehabilitation required
• Need for long-term medical and/or
nursing management
b. Phases of the Chronic Illness Trajectory
The Corbin & Strauss Chronic Illness Trajectory Model
1. Pre-trajectory Phase
• Genetic factors or lifestyle behaviors that place a person or community
at risk for a chronic condition
2. Trajectory onset
• Appearance or onset of noticeable symptoms associated with a chronic
disorder
3. Stable Phase
• Illness course and symptoms are under control as symptoms
4. Unstable Phase
• Characterized by an exacerbation of illness symptoms, development of
complications, or reactivation of an illness in remission

5. Acute Phase
• Severe and unrelieved symptoms or the development of illness
complications necessitating hospitalization, bed rest, or interruption of
the person’s usual activities to bring illness course under control
6. Crisis Phase
• Critical or life-threatening situation requiring emergency treatment or
care and suspension of everyday life activities until the crisis has passed
7. Comeback Phase
• Gradual recovery after an acute period and learning to live with or to
overcome disabilities and return to an acceptable way of life within the
limitations imposed by the chronic condition or disability
8. Downward Phase
• Illness course characterized by rapid or gradual worsening of a
condition; physical decline accompanied by increasing disability or
difficulty in controlling symptoms
9. Dying Phase
• Final days or weeks before death; characterized by gradual or rapid
shutting down of body processes, biographical disengagement and
closure, and relinquishment of everyday life interests and activities
c. Seven Tasks of Persons with Chronic Illness

1. Preventing and Managing a Crisis
2. Carrying out prescribed treatment regimen
3. Controlling symptoms
4. Reordering time
5. Adjusting to changes in course of disease
6. Preventing social isolation
7. Attempting to normalize interactions with others
d. Prevention of Chronic Illness

1. Primary Prevention- refers to those measures such as proper diet, exercise
and immunization that prevent the occurrence of a specific disease.

2. Secondary prevention- refers to actions aimed at early detection of disease
that can lead to interventions to prevent disease progression.
e. Factors that Affect Adjustment to Chronic Illness

• Suddenness, extent, and duration of lifestyle changes necessitated by the
illness
• Family and individual resources for dealing with stress
• Stages of individual/family life cycle
• Previous experience with illness and crises
• Underlying personality characteristics
• Unresolved anger or grief from the past
f. Characteristics of Chronic Conditions

1. Managing chronic illness involves more than treating medical problems.
2. Chronic conditions usually involve many different phases over the course of
a person’s lifetime.
3. Keeping chronic conditions under control requires persistent adherence to
therapeutic regimens.
4. One chronic disease can lead to the development of other chronic
conditions.
5. Chronic illness affects the entire family.
6. The day-to-day management of illness is largely the responsibility of people
with chronic disorders and their families.
7. The management of chronic conditions is expensive.
8. Chronic conditions raise difficult ethical issues for patients, families, health
care professionals, and society.
9. Living with chronic illness means living with uncertainty.
g. Applying the Nursing Process Using the Phases of the Chronic Illness System
Step 1: Identifying Specific Problems and the Trajectory Phase
Step 2: Establishing and Prioritizing Goals
Step 3: Defining the Plan of Action to Achieve Desired Outcomes
Step 4: Implementing the Plan and Interventions
Step 5: Following Up and Evaluating Outcomes

B. DISABILITY
- Disabilityis an umbrella term for impairments, activity limitations, participation
restrictions, and environmental factors. (WHO, 2001)
- Impairment is a loss or abnormality in body structure or physiologic function,
including mental function.
The Americans With Disabilities Act of 1990 (ADA) defines a person with a
disability as one who:
(1) has a physical or mental impairment that substantially limits one or more
major life activities,
(2) has a record of such an impairment, or
(3) is regarded as having such an impairment.
Lutz and Bowers (2005) defines Disability as a multifaceted, complex

experience that is integrated into the lives of people with disabilities. The degree of
the integration is influenced by three disability-related factors:
(1) the effects of the disabling condition,
(2) others’ perceptions of disability, and
(3) the need for and use of resources by the person with a disability.
Age-related Disabilities
-occur in the elderly population and are thought to be due to the aging process.
Examples of age-related disabilities include osteoarthritis, osteoporosis, and hearing
loss.
a. Types of Disability
1. Sensory Disabilities- affect hearing or vision
2. Learning disabilities - affect the ability to learn, remember, or concentrate;
3. Disabilities that affect the ability to speak or communicate
b. Guide to Interacting and Communicating with People Who have Disabilities
General Considerations
• Do not be afraid to make a mistake when interacting and communicating with
someone with a disability or chronic medical condition.
• Treat adults as adults. Address people with disabilities by their first names only
if extending the same familiarity to all others present.
• Relax. If you do not know what to do, allow the person who has a disability to
identify how you may be of assistance and to put you at ease.
• If you offer assistance and the person declines, do not insist. If your offer is
accepted, ask how you can best help, and follow directions. Do not take over.
• If someone with a disability is accompanied by another individual, address the
person with a disability directly rather than speaking through the
accompanying companion.
• Be considerate of the extra time it might take for a person with a disability to
get things done or said. Let the person set the pace.

• Do not be embarrassed to use common expressions such as, “See you later,” or
“Got to be running,” that seem to relate to the person’s disability.
• Use person-first language: refer to “a person with a disability” rather than “a
disabled person,” and avoid referring to people by the disability or disorder
they have (eg, “the diabetic”).
C. DISTURBANCE IN SENSORY PERCEPTION

a. Vision
1. Diseases of the Eye
i. Glaucoma
Etiology: variable and often unknown. However, when the natural

fluids of the eye are blocked by ciliary muscle rigidity and
the buildup of pressure, damage to the optic nerve occurs.
Signs & Symptoms:

- Headaches
- Poor vision in dim lighting
- increased sensitivity to glare
- “tired eyes”
- impaired peripheral vision
- a fixed and dilated pupil
- frequent changes in prescriptions for corrective lenses.
Treatment:
- Beta blockers
- laser surgery treatments (trabeculoplasty) may be

recommended for some types of glaucoma.
ii. Cataract
▪ are a prevalent disorder among older adults caused by oxidative
damage to lens protein and fatty deposits (lipofuscin) in the ocular
lens.
▪ Cataracts are categorized according to their location within the lens
and are usually bilateral.
Signs and Symptoms:

- clouding of the ordinarily clear ocular lens
- the red reflex may be absent or may appear as a black
area.
- The cardinal sign of cataracts is the appearance of
halos around objects as light is diffused
- Blurring of vision

- Decreased perception of light and color (giving a yellow
tint to most things)
- sensitivity to glare.
Risk factors:
- most common causes of cataracts are heredity and
advancing age
- occur more frequently and at earlier ages in individuals
who have been exposed to excessive sunlight, have
poor dietary habits, diabetes, hypertension, kidney
disease, eye trauma, or history of alcohol intake and
tobacco use.
- high dietary intake of lutein and zeaxanthin,
compounds found in yellow or dark leafy vegetables, as
well as intake of vitamin E from food and supplements,
appears to lower the risk of cataracts in women.
Management:
- Surgery
o When visual acuity decreases to 20/50 and the
cataract affects safety or quality of life, surgery
is recommended.
o involves removal of the lens and placement of a
plastic intraocular lens (IOL).
o performed with local anesthesia on an
outpatient basis, and the procedure has greatly
improved with advances in surgical techniques.
iii. Diabetic Retinopathy

▪ is a disease of the retinal microvasculature characterized by
increased vessel permeability. Blood and lipid leakage leads to
macular edema and hard exudates (composed of lipids). In
advanced disease, new fragile blood vessels form that
hemorrhage easily. Because of the vascular and cellular
changes accompanying diabetes, there is often rapid
worsening of other pathologic vision conditions as well.
Signs and Symptoms:

- There is little to no evidence of retinopathy until 3 to 5
years or more after the onset of diabetes.
- Early signs are seen in the funduscopic examination
and include microaneurysms, flame-shaped
hemorrhages, cotton wool spots, hard exudates, and
dilated capillaries.

Management:
- Constant, strict control of blood glucose, cholesterol,
and blood pressure and laser photocoagulation
treatments can halt progression of the disease.
- Laser treatment can reduce vision loss in 50% of
patients, and recent evidence suggests that treatment
with various drugs may deliver a better outcome
(USDHHS, 2012).
- Annual dilated funduscopic examination of the eye is
recommended beginning 5 years after diagnosis of
diabetes type 1 and at the time of diagnosis of diabetes
type 2.
iv. Macular Degeneration

▪ a degenerative eye disease that affects the macula, the
central part of the eye responsible for clear central vision. The
disease causes the progressive loss of central vision, leaving
only peripheral vision intact
Etiology:
- results from systemic changes in circulation,
accumulation of cellular waste products, tissue
atrophy, and growth of abnormal blood vessels in the
choroid layer beneath the retina. Fibrous scarring
disrupts nourishment of photoreceptor cells, causing
their death and loss of central vision.
Signs and symptoms:
- Early signs: blurred vision, difficulty reading and
driving, increased need for bright light, colors that
appear dim or gray, and an awareness of a blurry spot
in the middle of vision.
Management:
- Amsler grid is used to determine clarity of central
vision
- Individuals over 40 years of age should have a dilated
eye examination at least every 2 years.
- high-dose formulation of antioxidants and zinc
significantly reduces the risk of advanced AMD and
associated vision loss
Implications for Gerontological Nurses and Healthy Aging

Vision impairment is common among older adults in connectionwith aging
changes and eye diseases and can significantlyaffect communication, functional
ability, safety,and quality of life. The issues of concern to nurses who carefor
older adults are appropriate assessment; adapting theenvironment to enhance
8 | P a g e vision and safety; communicatingappropriately;
NCM 114-A and providing appropriate
MMSU-CHS-DEPARTMENT OF NURSING
health teachingand referrals for prevention and treatment.
Strategies for Communicating with Elders with Visual Impairment
• Make sure you have the person’s attention before you start talking.
• Always speak promptly and clearly identify yourself and others with you.
State when you are leaving to make sure the person is aware of your
departure.
• Get down to the person’s level and face them when speaking.
• Speak normally but not from a distance; do not raise or lower your voice
and continue to use gestures if that is natural to your communication.
• When others are present, address the visually impaired person by
prefacing remarks with his or her name or a light touch on the arm.
• Use the analogy of a clock face to help locate objects (e.g., describe
positions of food on a plate in relation to clock positions such as meat at 3
o’clock, dessert at 6 o’clock).
• Ensure adequate lighting on your face and eliminate glare.
• Select colors for paint, furniture, pictures with rich intensity (red, orange).
• Use large, dark, evenly spaced printing.
• Use contrast in printed material (e.g., black marker on white paper).
• Do not change the room arrangement or the arrangement of personal
items without explanation.
• Use some means to identify patients who are visually impaired, and
include visual impairment in the plan of care
• Screen for vision loss, and recommend annual eye exams for older
people.
• If the person is institutionalized, label glasses and have a spare pair if
possible.
• Be aware of low-vision assistive devices such as talking watches, talking
books, and facilitate access to these resources.
• If the person is blind, offer your arm while walking. Pause before stairs or
curbs and alert the person. When seating the person, place his or her
hand on the back of the chair. Always let the person know his or her
position in relation to objects.
• Never play with or distract a seeing-eye dog.
b. Hearing Impairment
Hearing loss diminishes quality of life and is associated with multiple negative
outcomes including decreased function, miscommunication, depression, falls, loss of
self-esteem, safety risks, and cognitive decline (Wallhagen& Pettengill, 2008). Hearing
impairment increases feelings of isolation and may cause older adults to become
suspicious or distrustful or to display feelings of paranoia. Because older persons with
a hearing loss may not understand or respond appropriately to conversation, they may

be inappropriately diagnosed with dementia. Older people may be initially unaware of
hearing loss because of the gradual manner in which it develops.
1. Types of Hearing Loss
i. Sensorineural hearing loss

▪ results from damage to any part of the inner ear or the neural
pathways to the brain.
Presbycusis
- is a form of sensorineural hearing loss that is related to
aging. It is the most common form of hearing loss in
the United States. Presbycusis is a bilateral and
symmetrical sensorineural hearing loss that also affects
the ability to understand speech.
- have difficulty filtering out background noise and often
complain of difficulty understanding women’s and
children’s speech and conversations in large groups.
ii. Conductive hearing loss

▪ usually involves abnormalities of the external and middle ear
that reduce the ability of sound to be transmitted to the
middle ear. Otosclerosis, infection, perforated eardrum, fluid
in the middle ear, or cerumen accumulations cause
conductive hearing loss.
2. Tinnitus
It is defined as the perception of sound in one or both ears or in the
head when no external sound is present. It is often referred to as “ringing in
the ears” but may also manifest as buzzing, hissing, whistling, cricket
chirping, bells, roaring, clicking, pulsating, humming, or swishing sounds. The
sounds may be constant or intermittent and are more acute at night or in
quiet surroundings.

Hearing impairment is common among older adults andsignificantly
affects communication, function, safety, andquality of life. Inadequate
communication with older adultswith hearing impairment can also lead to
misdiagnosis andaffect adherence to a medical regimen. The
gerontologicalnurse must be able to assess hearing ability and use
10 | P a g e appropriatecommunication skillsNCM 114-A
and MMSU-CHS-DEPARTMENT
devices to help OFolderNURSING
adultsminimize or even avoid problems.
Communication Strategies for Elders with Hearing Impairment

• Never assume hearing loss is from age until other causes are ruled out
(infection, cerumen buildup).
• Inappropriate responses, inattentiveness, and apathy may be symptoms
of a hearing loss.
• Face the individual, and stand or sit on the same level; don’t turn away
while speaking (e.g., face a computer).
• Gain the individual’s attention before beginning to speak. Look directly at
the person at eye level before starting to speak
• Determine if hearing is better in one ear than another, and position
yourself appropriately.
• If hearing aid is used, make sure it is in place and batteries are
functioning.
• Ask patient or family what helps the person to hear best.
• Keep hands away from your mouth and project voice by controlled
diaphragmatic breathing.
• Avoid conversations in which the speaker’s face is in glare or darkness;
orient the light on the speaker’s face.
• Careful articulation and moderate speed of speech are helpful.
• Lower your tone of voice, use a moderate speed of speech, and articulate
clearly.
• Label the chart, note on the intercom button, and inform all caregivers
that the patient has a hearing impairment.
• Use nonverbal approaches: gestures, demonstrations, visual aids, and
written materials.
• Pause between sentences or phrases to confirm understanding.
• Restate with different words when you are not understood.
• When changing topics, preface the change by stating the topic.
• Reduce background noise (e.g., turn off television, close door).
• Utilize assistive listening devices such as pocket talker.
• Verify that the information being given has been clearly understood. Be
aware that the person may agree to everything and appear to understand
what you have said even when they did not hear you (listener bluffing).
• Share resources for the hearing-impaired and refer as appropriate.
Activity 1. Analyze the case study related to a patient with visual impairment. After that,
understand the nursing process applied to the given scenario.
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Case Study: A Patient With Visual Impairment

Mrs. Owen is a 78-year-old woman who has any other falls her mother may have had, but
just been admitted to the hospital’s has noticednumerous bumps and bruises on her
rehabilitation unit. She is recovering from an mother’s arms andlegs within the past few
open reduction with internal fixation of her months. Mrs. Owen denies this,saying, “Oh, I
right hip. She fractured her hip 5 days ago at bruise easily. I always have. It’s worse sinceI’m
home when she fell getting up to go to the taking an aspirin every day.” Additional
bathroom in the middle of the night. The medicationsinclude atenolol for hypertension,
circumstances of the fall were not imipramine for depression,and pilocarpine
documented because she lives alone, but Mrs. eyedrops for glaucoma.Mrs. Owen has a regular
Owen states, “I got my feet all tangled up in an primary care provider, but hasnot seen her eye
electrical cord I was using to run the fan doctor for several years. She states, “Oh,he
because it was so hot in my room. I just didn’t never does a thing for me. Heonly tests the
see it.” Mrs. Owen has a daughter who lives in pressure inmy eyes and says OK, you’re good.”
a nearby town. The daughter states she is
unaware
Applying of
the Nursing Process
1. Assessment
2. Diagnoses
3. Expected Outcomes
4. Planning and Implementation
5. Evaluation
Wrap-up Activity
Chronic illnesses and the consequences of treatment can affect an older adult’s ability to
fulfill basic physiological needs without assistance or adaptation. Nursing interventions are
directed at enhancing self-care abilities as well as providing care to ensure that basic
needs can be met with as much independence as possible. Chronic illnesses and disabilities
may impair physical function, but a sense of safety, security, belonging, self-esteem, and
self-actualization can still be attained. Maintaining integrity and achieving one’s maximal
potential despite functional limitations and illness may be one of the greater
accomplishments of many older people. Our care must support the potential for wellness
at all stages in life.
Hearing and vision impairments can contribute to challenges at all levels of the hierarchy
from meeting biological integrity needs, such as activity, safety, and security needs to the
higher-level needs such as a sense of belonging, feeling of self-esteem, and self-
actualization. The consequences of these impairments severely affect quality of life and
predispose the individual to potential negative health and quality-of-life outcomes.

Whatever the age or the impairments experienced, continued growth and development
toward self-actualization, the task of aging, requires interactions and environments in
which the older adult is assured that basic needs are met, compensations are made for
losses, and meaningful and satisfying experiences continue to be a part of life.
General Conclusions Based from

• Declines in mortality, a growing older adult population, increasing medical
expertise, and sophisticated technological developments have resulted in a great
increase in the survival of the very old with multiple chronic disorders.
• The effects of chronic illness range from mild to life-limiting, with each person
responding to unique circumstances in a highly individualized manner.
• The Chronic Illness Trajectory and the Shifting Perspectives Model of Chronic Illness
offer useful frameworks to understand chronic illness and design nursing
interventions.
• People with chronic illnesses can achieve wellness, and the role of the nurse is
critical in the promotion of wellness.
• The goals of healthy aging include minimizing risk for disease, encouraging health
promotion, and in the presence of disease, alleviating symptoms, delaying or
avoiding the development of complications, and maximizing function and quality of
life.
• Vision and hearing impairment can significantly affect functional ability, safety, and
quality of life among older adults.
• Vision loss from eye disease is a global concern and preventive interventions, early
detection, and treatment of eye diseases is an important priority for nurses and
other health care professionals.
• The major diseases affecting vision are glaucoma, cataracts, macular degeneration,
and diabetic retinopathy. Many of these diseases can be identified and
appropriately treated through proper screening. All adults over 65 years of age
should have annual eye examinations.
• Ear damage and hearing impairment are increasing due to the aging of the
population and increased exposure to loud noises such as blast exposure in combat
situations among military personnel. The two types of hearing impairment are
sensorineural and conductive.
• Tinnitus is a common condition among older people and can interfere with hearing,
as well as become extremely irritating. It is characterized by ringing in the ear and
may also manifest as buzzing, hissing, whistling, clicking, pulsating, or swishing
sounds.
Post Assessment:A quiz will be given after the discussion and will be uploaded at mVLE.
References:

Kane, R. L., Ouslander, J. G., &Abrass, I. B. (2013). Essentials of clinical geriatrics. New York:
McGraw-Hill, Health Professions Division.
Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing &
healthy aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby.
Fitzwater, C. 2011.Look Close See Me, Aging & Communications: Engaging Older People.
University of Cincinnati College of Nursing
LESSON 2: NURSING CARE OF THE OLDER ADULT IN CHRONIC ILLNESS with CHRONIC
CONFUSION
Acute confusion
Chronic confusion
After completing this lesson, you must have:
1. Differentiated between dementia, delirium, and depression.

2. Discussed the different types of dementia and appropriate diagnosis.
3. Described nursing models of care for persons with dementia.
4. Discussed common concerns in care of persons with dementia and nursing
responses.
5. Developed a nursing care plan for an individual with delirium.
6. Developed a nursing care plan for an individual with dementia.
7. Applied appropriate methods of communication to persons with impaired
verbal communications.
Warm-up Activity:
Before you proceed with the learning inputs, can differentiate delirium and
dementia?
Learning Inputs:
Cognitive impairment
14 | P a g e - is a term that describesNCM a range
114-A ofMMSU-CHS-DEPARTMENT
disturbances in cognitive
OF NURSING
functioning, including disturbances in memory, orientation,
attention, and concentration. Other disturbances of cognition may
affect intelligence, judgment, learning ability, perception, problem
DIFFERENCE BETWEEN DELIRIUM & DEMENTIA

Characteristic Delirium Dementia
Onset Sudden, abrupt Insidious, slow, over years and
often unrecognized until
deficits are obvious
Course over 24 hr Fluctuating, often worse Fairly stable, may see changes
at night with stress
Consciousness Reduced Clear
Alertness Increased, decreased, or Generally normal
variable
Psychomotor activity Increased, decreased, or Normal, may have apraxia or
mixed agnosia
Sometimes increased, other
times decreased
Duration Hours to weeks Years
Attention Disordered, fluctuates Generally normal but may have
trouble focusing
Orientation Usually impaired, fluctuates Often impaired, may make up
answers or answer close to the
right thing or may confabulate
but tries to answer
Speech Often incoherent, slow Difficulty finding word,
or rapid, may call out perseveration
repeatedly or repeat
the same phrase
Affect Variable but may look Slowed response, may be labile
disturbed, frightened
a. Delirium
Etiology:
▪ result of complex interactionsamong multiple causes.
▪ results from theinteraction of predisposing factors (e.g., vulnerability
onthe part of the individual due to predisposing conditions,such as
cognitive impairment, severe illness, and sensoryimpairment) and
precipitating factors/insults (e.g., medications,procedures, restraints,
iatrogenic events).

▪ Delirium is thought to be related to disturbances in the
neurotransmitters in the brain that modulate the control of cognitive
function, behavior, and mood.
▪ The causes of delirium are potentially reversible; therefore accurate
assessment and diagnosis are critical.
▪ Delirium is given many labels: acute confusional state, acute brain
syndrome, confusion, reversible dementia, metabolic
encephalopathy, and toxic psychosis. The correct terminology is
delirium.
Incidence & Prevalence:

▪ a prevalent and serious disorder that occurs in elders across the
continuum of care.
▪ Older patients with dementia are three to five times more likely to
develop delirium, and it is less likely to be recognized and treated
than is delirium without dementia
Risk Factors:
▪ Predictive causes: immobility, functional deficits, use of restraints or
catheters, medications, acute illness, infections, alcohol or drug
abuse, sensory impairments, malnutrition, dehydration, respiratory
insufficiency, surgery, and cognitive impairment.
▪ Unrelieved or inadequately treated pain significantly increases the risk
of delirium
▪ Medications account for 22% to 39% of all delirium, and all
medications, particularly those with anticholinergic effects and any
new medications, should be considered suspect.
▪ Invasive equipment, such as nasogastric tubes, intravenous (IV) lines,
catheters, and restraints, also contribute to delirium by interfering
with normal feedback mechanisms of the body
CLINICAL SUBTYPES OF DELIRIUM

Hypoactive Hyperactive Mixed
• Quiet or pleasantly • Excessive alertness • Unpredictable
confused • Easy distractibility fluctuations between
• Reduced activity • Increased hypoactivity and
• Lack of facial psychomotor activity hyperactivity
expression • Hallucinations,
• Passive demeanor delusions
• Lethargy • Agitation and
• Inactivity aggressive actions
• Withdrawn and • Fast or loud speech

sluggish state • Wandering,
• Limited, slow, and nonpurposeful
wavering repetitive movement
vocalizations • Verbal behaviors
(yelling, calling out)
• Removing tubes
• Attempting to get out
of bed
Consequences:
▪ Results in significant distress for the patient, his or her family and
significant others, and nurses.
▪ associated with increased length of hospital stay and hospital
readmissions, increased services after discharge, and increased
morbidity, mortality, and institutionalization, independent of age,
coexisting illnesses, or illness severity
▪ also associated with lasting cognitive impairment and psychiatric
problems that may persist after discharge and interfere with the
ability to manage chronic conditions

Several instruments can be used to assess the presence andseverity of
delirium. To detect changes, it is very importantto determine the person’s
usual mental status. If the personcannot tell you this, family members or
other caregiverswho are with the patient can be asked to provide this
information.If the patient is alone, the responsible party orthe institution
transferring the patient can provide thisinformation by phone. Do not assume
the person’s currentmental status represents his or her usual state, and do
notattribute altered mental status to age alone or assume thatdementia is
present. All older patients, regardless of theircurrent cognitive function,
should have a formal assessmentto identify possible delirium when admitted
to thehospital.
Communicating with a Person Experiencing Delirium

• Know the person’s past patterns.
• Look at nonverbal signs, such as tone of voice, facial expressions, gestures.
• Speak slowly.
• Be calm and patient.
• Face the person and keep eye contact—get to the level of the person rather than
standing over him or her.
• Explain all actions.
• Smile.

• Use simple, familiar words.
• Allow adequate time for response.
• Repeat if needed.
• Tell the person what you want him or her to do rather than what you don’t want him
or her to do.
• Give one-step directions; use gestures and demonstration to augment words.
• Reassure of safety
• Keep caregivers consistent.
• Assume that communication and behavior are meaningful and an attempt to tell us
something or express needs.
• Do not assume the person is unable to understand or is demented.
Interventions
1) Nonpharmacological
▪ Help promote sleep and rest by reducing noise and distraction.
▪ Reassure the patient and help them understand the environment.
▪ Explain to the patient what is happening.
▪ Bring familiar objects from home (for example, photos, a blanket, a
bedside clock) to help make the patient more comfortable in an
unfamiliar environment. Soothing music may be helpful, as well.
▪ Feed the patient and give him or her drinks, if appropriate,
throughout the day.
▪ Encourage the patient to get out of bed, if it’s safe to do so.
▪ Keep the patient oriented. Talk about current events and family news,
as this provides mental stimulation. Reading out loud to the patient
can be helpful.
▪ Make sure the patient has nutritional food and stays hydrated.
▪ Keep the patient awake during the day and exposed to sunlight. Avoid
naps.
▪ Try to ensure that the patient gets maximum uninterrupted sleep at
night.
2) Pharmacological
Pharmacological interventions to treat the symptoms of delirium may
be necessary if patients are in danger of harming themselves or others, or
if nonpharmacological interventions are not effective.
a) antipsychotic drugs
- to treat agitation and hallucinations and to improve sensory
problems).

- These include: Haloperidol (Haldol®), Risperidone (Risperdal®),
Olanzapine (Zyprexa®), and Quetiapine (Seroquel®).
b) Benzodiazepines
b. Dementia
- It is an acquired, persistent impairment of intellectual function with
compromise in multiple spheres of mental activity
- Sufficiently severe to cause social or occupational disability
- is an irreversible state that progresses over years and causes memory
impairment and loss of other intellectual abilities severe enough to cause
interference with daily life.
Criteria for Dementia

1. Cognitive loss in 2 or more domains
a. Memory
b. Language
c. Calculation
d. Orientation
e. Judgment
f. Executive functions
2. Sufficiently severe to cause social or occupational disability
Warning signs of dementia

1. Memory loss
2. Difficulty performing familiar tasks
3. Problems with language
4. Disorientation with time and place
5. Poor or decrease judgment
6. Problems with abstract thinking (balancing a checkbook/understanding
new concepts)
7. Misplacing things
8. Changes in mood or behavior
9. Changes in personality (becoming extremely confused, suspicious,
fearful or dependent)
10. Loss of initiative
Incidence and Prevalence

▪ one of the most disabling and burdensome of chronic health conditions.
▪ The cost of care for someone with dementia is three times more than for
those who do not have the disease

▪ Worldwide, around 50 million people have dementia, with nearly 60%
living in low- and middle-income countries. Every year, there are nearly
10 million new cases.
Types of Dementia
1. Alzheimer’s disease
➢ 50 -80% of all dementias
➢ Memory problem is the earliest sign
➢ Other cognitive functions are affected as the disease progresses
➢ Brain scans may be normal or show atrophy
➢ Diagnosis is made in the absence of any other disease that may
explain the dementia
2. Vascular dementia
➢ 15% of all dementia
➢ Dementia after stroke
➢ Must be confirmed by brain scan
➢ Clinical course is not the same as Alzheimer’s disease as long as
there are no further strokes
➢ May improve or remain the same
➢ Respond o medications for Alzheimer’s disease
3. Mixed Alzheimer’s disease and vascular dementia

➢ 10-15% of all dementias
➢ Common in elderly patients with beginning Alzheimer’s disease
with a sudden stroke
4. Frontotemporal dementia
➢ 5-10% of all dementias
➢ Starts with personality changes: depression, disinhibition, poor
judgment
➢ Memory decline later
Diagnostics
1. Brain CT scan or MRI
2. Serum electrolytes
3. Hepatic, renal, thyroid function tests
4. Vitamin B12 levels
5. Serum VDRL/RPR (syphilis screening)
6. EEG

Treatment Goals
1. Slow the progressive deterioration
2. Maintain current capabilities
3. Delay nursing home placement or total dependence

Nurses provide direct care for people with dementia in thecommunity,
hospitals, and long-term care facilities. Theyalso work with families and staff,
teaching best practiceapproaches to care and providing education and
support.With the rising incidence of dementia, nurses will playan even larger
role in the design and implementationof evidence-based practice and provision
of education,counseling, and supportive services to individuals withdementia
and their caregivers
Communicating Effectively with Persons with Dementia

Envision a tennis game: the caregiver is like the tennis coach, and whenever the
coach plays the ball, he or she seems to be able to put the ball where the person on the
other side of the net can return it. The coach also returns the ball in such a way as to keep
the rally going; he or she does not return it to score a point or win the match, but rather
returns the ball so that the other player is able to reach it and, with encouragement, hit it
back over the net again. Similarly, in our communication with people with dementia, our
conversation and words must be put into play in a way such that the person can respond
effectively and share thoughts and feelings.
Pharmacologic
➢ Medicines to slow the progression of dementia
➢ Medicines for behavioral problems/aggression
1. Acetylcholinesterase Inhibitors
a. Tacrine (Cognex)
b. Donepezil (Aricept)
c. Rivastigmine (Exelon)
d. Galantamine (Reminyl)
2. NMDA receptor antagonist
a. Memantine (Abixa)
Non-pharmacologic
1. Education, support and counseling
a. Educate the family on realistic expectations
b. Long-term planning needed
c. Daily management strategies
d. Support groups for family and caregivers

e. Behavioral strategies
2. Maintaining physical health
a. Physical and occupational therapy
b. Daily relevant exercise
c. Updated immunizations
d. Basic self-care and hygiene
3. Resources in your area
a. Neurologist, psychiatrist, geriatrician, internist
4. Support groups
General Nursing Interventions in Care of Persons with Dementia
• Address safety.
• Structure daily living to maximize remaining abilities.
• Monitor general health and impact of dementia on management
of other medical conditions.
• Support advance care planning and advanced directives.
• Educate caregivers in the areas of problem-solving, resources
access, long range planning, emotional support, and respite.
Four Useful Strategies for Communicating with Individuals Experiencing Cognitive

Impairment
1. Simplification Strategies (Useful with ADLs)
2. Facilitation Strategies (Useful in Encouraging Expression of Thoughts and Feelings)
3. Comprehension Strategies (Useful in Assisting with Understanding of Communication)
4. Supportive Strategies (Useful in Encouraging Continued Communication and

Supporting Personhood)
Activity 1. Analyze the case study related to a patient with chronic confusion. After that,
understand the nursing process applied to the given scenario.
Case Study: A Patient With a Chronic Confusion

Mr. Dalton is a 75-year-old man who has been admitted tothe hospital. He fell in
his home and suffered a fracturedleft hip and had an open reduction with
internal fixationthis morning. When Mr. Dalton first arrived, he was quietand
pleasant but now he is agitated, attempting to getout of bed, yelling, and
22 | P a g ethrowing his sheets on the floor.TheNCMnurse attempts
114-A to reason with him
MMSU-CHS-DEPARTMENT and
OF NURSING
reassure him,but he is not responding.
Applying the Nursing Process

1. Assessment
A complete assessment of each of these factors using standardized assessment

instruments is indicated while the older person is protected from injury.
2. Diagnosis
3. Expected Outcomes
4. Planning and Implementation
5. Evaluation
Central Activities (Formative Assessment):

There will be a a quiz on MvLE. Please wait for the instruction and schedule from
your instructor.
Wrap-up Activity
Chronic illnesses and the consequences of treatment can affect an older adult’s ability to
fulfill basic physiological needs without assistance or adaptation. Nursing interventions are
directed at enhancing self-care abilities as well as providing care to ensure that basic
needs can be met with as much independence as possible. Chronic illnesses and disabilities
may impair physical function, but a sense of safety, security, belonging, self-esteem, and
self-actualization can still be attained. Maintaining integrity and achieving one’s maximal
potential despite functional limitations and illness may be one of the greater
accomplishments of many older people. Our care must support the potential for wellness
at all stages in life.
Hearing and vision impairments can contribute to challenges at all levels of the hierarchy
from meeting biological integrity needs, such as activity, safety, and security needs to the
higher-level needs such as a sense of belonging, feeling of self-esteem, and self-
actualization. The consequences of these impairments severely affect quality of life and
predispose the individual to potential negative health and quality-of-life outcomes.
Whatever the age or the impairments experienced, continued growth and development
toward self-actualization, the task of aging, requires interactions and environments in

which the older adult is assured that basic needs are met, compensations are made for
losses, and meaningful and satisfying experiences continue to be a part of life.
Care and communication that respect and value the dignity and worth of every person
nursed, including those with cognitive impairment, and use of research-based
communication techniques, will enhance communication and personhood.
“Gerontological nurses who are sensitive to communication and interaction patterns can
assist both formal and informal caregivers in using more personalverbal and nonverbal
communication strategies that are humanizing and show respect for the person. Similarly,
they can monitor and try to change object-oriented communication approaches, which are
not only insensitive and dehumanizing, but also often lead to diminished self-image and
angry, agitated responses on the part of the patient with cognitive impairment
General Conclusions Based from

• Declines in mortality, a growing older adult population, increasing medical
expertise, and sophisticated technological developments have resulted in a great
increase in the survival of the very old with multiple chronic disorders.
• The effects of chronic illness range from mild to life-limiting, with each person
responding to unique circumstances in a highly individualized manner.
• The Chronic Illness Trajectory and the Shifting Perspectives Model of Chronic Illness
offer useful frameworks to understand chronic illness and design nursing
interventions.
• People with chronic illnesses can achieve wellness, and the role of the nurse is
critical in the promotion of wellness.
• The goals of healthy aging include minimizing risk for disease, encouraging health
promotion, and in the presence of disease, alleviating symptoms, delaying or
avoiding the development of complications, and maximizing function and quality of
life.
• Vision and hearing impairment can significantly affect functional ability, safety, and
quality of life among older adults.
• Vision loss from eye disease is a global concern and preventive interventions, early
detection, and treatment of eye diseases is an important priority for nurses and
other health care professionals.
• The major diseases affecting vision are glaucoma, cataracts, macular degeneration,
and diabetic retinopathy. Many of these diseases can be identified and
appropriately treated through proper screening. All adults over 65 years of age
should have annual eye examinations.
• Ear damage and hearing impairment are increasing due to the aging of the
population and increased exposure to loud noises such as blast exposure in combat
situations among military personnel. The two types of hearing impairment are
sensorineural and conductive.
• Tinnitus is a common condition among older people and can interfere with hearing,

as well as become extremely irritating. It is characterized by ringing in the ear and
may also manifest as buzzing, hissing, whistling, clicking, pulsating, or swishing
sounds.
• Nurses must advocate for thorough assessment of any elder who appears to be
experiencing cognitive decline and inability to function in important aspects of life.
• Delirium sometimes is the result of physiological imbalances and may be caused by
a variety of biological disturbances. Delirium is characterized by fluctuating levels
of consciousness, sometimes in a diurnal pattern, and frequent misperceptions and
illusions. It often goes unrecognized and is attributed to age or dementia.
• People with dementia are more susceptible to delirium. Knowledge of risk factors,
preventive measures, and treatment of underlying medical problems is essential to
prevent serious consequences.
• Medications and pain are frequently the causes of delirious states in older people.
• Individuals with cognitive impairment respond best to calmness and patience,
adaptations of communication techniques, and environments and relationships
that enhance function, support limitations, ensure safety, and provide
opportunities for a meaningful quality of life. Because cognitively impaired persons
may be unable to express their feelings and needs in ways that are easily
understood, the gerontological nurse must always try to understand the world
from their perspective.
• Families provide most of the care for persons with dementia, and while many gain
satisfaction from this, they experience more adverse consequences than caregivers
of other older adults. Comprehensive interventions for both the person with
dementia and the caregiver should begin early in the disease and continue
throughout the trajectory.
Post-assessment:
There will be a long exam on MvLE. Please wait for the instruction and schedule from
your instructor.
References:
Tabloski,Patricia A. 2010 . Gerontological Nursing. 2nd ed. New Jersey. USA: Pearson
Education, Inc.
Touhy, T. A., Jett, K. F., & Ebersole, P. (2014). Ebersole and Hess' gerontological nursing &
healthy aging. 4th ed. St. Louis, Mo.: Elsevier/Mosby.

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MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

Before we proceed with the disturbance in sensory perception, it is very important

After completing this lesson, you must have:

1. What did you feel after watching the video?

Presentation of Learning Inputs:

1|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

b. Phases of the Chronic Illness Trajectory

The Corbin & Strauss Chronic Illness Trajectory Model

2|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

c. Seven Tasks of Persons with Chronic Illness

d. Prevention of Chronic Illness

3|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

e. Factors that Affect Adjustment to Chronic Illness

f. Characteristics of Chronic Conditions

Step 1: Identifying Specific Problems and the Trajectory Phase

Step 2: Establishing and Prioritizing Goals

Step 3: Defining the Plan of Action to Achieve Desired Outcomes

Step 4: Implementing the Plan and Interventions

Step 5: Following Up and Evaluating Outcomes

4|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

Lutz and Bowers (2005) defines Disability as a multifaceted, complex

b. Guide to Interacting and Communicating with People Who have Disabilities

5|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

C. DISTURBANCE IN SENSORY PERCEPTION

Etiology: variable and often unknown. However, when the natural

Signs & Symptoms:

- laser surgery treatments (trabeculoplasty) may be

Signs and Symptoms:

6|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

iii. Diabetic Retinopathy

Signs and Symptoms:

7|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

iv. Macular Degeneration

Implications for Gerontological Nurses and Healthy Aging

9|P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

1. Types of Hearing Loss

i. Sensorineural hearing loss

ii. Conductive hearing loss

Implications for Gerontological Nurses and Healthy Aging

Communication Strategies for Elders with Hearing Impairment

11 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

Case Study: A Patient With Visual Impairment

4. Planning and Implementation

12 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

General Conclusions Based from

13 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

After completing this lesson, you must have:

1. Differentiated between dementia, delirium, and depression.

DIFFERENCE BETWEEN DELIRIUM & DEMENTIA

15 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

Incidence & Prevalence:

CLINICAL SUBTYPES OF DELIRIUM

16 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

Implications for Gerontological Nurses and Healthy Aging

Communicating with a Person Experiencing Delirium

17 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

18 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

Criteria for Dementia

Warning signs of dementia

Incidence and Prevalence

19 | P a g e NCM 114-A MMSU-CHS-DEPARTMENT OF NURSING

3. Mixed Alzheimer’s disease and vascular dementia