Care of the Older Adults

Age- related neurological changes ability to learn new materials and meet
cognitive demands of independent living
Anatomy and Physiology
remains intact without the presence of
- Frontal lobe neurologic disease
o Language- Broca’s area - With aging there is neuronal death and
o Motor functions changes in the synapse between neurons
o Judgement o These changes are especially
o Problem solve pronounced in neurodegenerative
o Impulse control diseases such as Alzheimer’s disease
o Reasoning and memory (a progressive and irreversible
o Executive function- ability to plan disease causing dementia) or
and think abstractly Parkinson’s disease (a progressive
o MMSE can be used to measure these disease causing rigidity, tremor, and
- Temporal slowness of movement)
o Language- Wernicke’s area o Neurons in the synapse of the brain
o Memory decreases as well
o Hearing o Neurodegenerative diseases- a
o Perception and recognition progression off neurologic
- Occipital dysfunction
o Visual processing - Neuroendocrine changes also occur with
o Visual information aging. There is a mean increase in
- Parietal glucocorticoids with aging, which in effect
o Sensory information- taste, pain, and puts the body in chronic stress condition
temperature o An increase in glucocorticoids may
- Central brain influence the development of
o Amygdala- under the hippocampus depression and the development of
▪ Functions of emotions, T2DM, a common disease of the
recognizing and eliciting older adults
o Hippocampus- long term memory o Hypothalamic-adrenal axis
storage ▪ All connected leading to
▪ If this is affected the client will neuroendocrine changes
not be able to recall ▪ Glucocorticoids + cortisol =
- Factors that may result to this: chronic stress
o Decreased oxygenation and - The neurologic conditions of the central
nutrients nervous system fall into the categories of
o Neurochemical related memory, movement, seizure disorders, and
o Age stroke
- The conditions of the peripheral nervous
system fall into categories of motor, sensory,
Age-related neurological changes and autonomic disorders
o Fine motor skills, involuntary functions
- Myth: aging adult- cognitive decline
- Memory, attention, and executive function
do experience changes with aging, but the
3Ds in Geriatric Psychiatry
- Lola Pearl, 83-year-old female in a long term
care setting. Appears confused. Has been
crying and trying to leave the facility. She
has been needing more help to manage
personal care but sometimes refuses it
o Delirium
o Depression
o Dementia
- Modified barthel’s index to determine
whether an older person needs help in
activities of daily living
Delirium
- Altered consciousness has been regarded
as a core feature of delirium
o Client is awake and conscious but
there is alteration in the attention
o Client does not understand you or
client is not paying attention
because he/ she understand what is
Depression
happening
o GCS- assessment of the level of
arousal
- DSM-5 now operationalizes consciousness
as changes in attention. It should be
recognized that attention relates to content
of consciousness, but arousal corresponds to
the level of consciousness
- Manifestations of delirium (CCF)
o Disturbance of consciousness (ie
reduced clarity of awareness of
environment) occurs, with reduced
ability to focus, sustain, or shift
attention
o Changes in cognition (e.g. memory
deficit, disorientation, language,
disturbance, perceptual
disturbance) occurs that is not better
accounted for by preexisting,
established, or evolving dementia
o The disturbance develops over a
short period (usually hours to days)
and tends to fluctuate during the
course of day
o evidence from the history, physical
examination, or laboratory findings is
present that indicates the
disturbance is caused by a direct
physiologic consequence of a
general medical condition, an
intoxicating substance, medication
use, or more than one cause
- A common disorder occurring in 50% of
older persons admitted to acute care
settings
o Happens in an acute care setting
because you have removed them
from their care setting
o Reorient the client
- Unrecognized and undiagnosed,
misdiagnosed as depression
- It is a medical emergency
- Priority: safety and communication
- Underreported (masked by dementia, by
comorbidities, or stigma of aging)
o Depression is not a part or aging or
dementia
o A single entity
- DSM-5: the individual must be experiencing
five or more symptoms during the same 2-
week period and at least one of the
symptoms should be either (1) depressed
mood or (2) loss of interest or pleasure
- What to observe?
o MISCPAGE
o Depressed mood most of the day,
nearly everyday
o Markedly diminished interest or
pleasure in all, or most all, activities
most of the day, nearly everyday
o Recurrent thoughts of death,
recurrent suicidal ideation without a
specific plan, or a suicide attempt or
a specific plan for committing
suicide
 o Diminished ability to think or
concentrate, or indecisiveness nearly
everyday
o A slowing down of thought and
reduction of physical movement
(observable by others, not merely
subjective feelings of restlessness or
being slowed down) psychomotor
agitation or retardation
o Significant weight loss when not
dieting or weight fain, or decrease or
increase in appetite nearly everyday
o Feelings of worthlessness or excessive
inappropriate guilt nearly everyday
o Fatigue or loss of energy nearly
everday
Dementia
- DSM-5: neurocognitive disorder. An umbrella
term for a number of neurological
conditions, of which the major symptom is
the decline in brain function due to physical
changes in the brain. It is distinct from
mental illness.
o Diagnosis: ruling out of mental illness
before diagnosing dementia
- Alzheimer’s type disease is the most
common type of dementia in the older
persons
o 60% of all dementias are the
Alzheimer’s type
- DSM-4: memory loss and one
o Aphasia- expressive receptive
▪ Fading of language or
comprehension of speech
▪ Expressive- cannot express
what he/she understands
▪ Receptive- the patient
cannot understand the
information
▪ Repeat what you have told
the client
o Apraxia
▪ Inability to carry out motor
activities
▪ Stop of action despite intact
sensory function
o Agnosia
▪ Inability to recognize or
identify objects despite intact
sensory function
o Executive dysfunction- higher order
decision making and planning
▪ SOAP (sequencing, ordering,
abstract thinking, and
planning)
▪ Sequencing/ ordering: spell
world or water backwards, or
count backwards
▪ Abstract- drawing of polygon
- DSM-5: difference between minor and major
neurocognitive disorders is based on the six
cognitive domains:
o Perceptual-motor-visual perception
(praxis)
o Complex attention
o Executive ability
o Learning and memory
o Language
o Social cognition
- DSM-5: Minor neurocognitive disorder: also
medically referred to as prodromal disease
or mild cognitive disorder (MCD)It is defined
by the following criteria:
o This evidence of modest cognitive
decline from a previous level of
performance in one or more of the
domains, based on the concerns of
the individual, a knowledgeable
informant or the clinician; And a
decline in neurocognitive
performance, typically involving test
performance in the range of 1 and 2
standard deviations below
appropriate norms (i.e. between the
third and the 16th percentiles) on
formal testing or equivalent clinical
evaluation
o The cognitive deficits are insufficient
to interfere with independence (for
example instrumental activities of
daily living such as complex tasks
 such as paying bills or managing o Not exclusively due to delirium
medications, are preserved), but - Alzheimer’s type of dementia has insidious
greater effort, compensatory onset and gradual progression
strategies, or accommodation may
be required to maintain
independence
3D geriatric psychiatry
o The cognitive deficits do not occur
exclusively in the context of a - Dementia
delirium o Insidious onset; months to weeks
o The cognitive deficits are not o Course: progressive
primarily attributable to another o Duration: months to years
mental disorder (for example major
- Delirium
depressive disorder and
o Rapid onset: minutes to days
schizophrenia)
o Course: fluctuating
- DSM-5: Major neurocognitive disorder
o Duration: hours to weeks
o There is evidence of substantial
cognitive decline from a previous - Depression
level of performance in one or more o Acute or insidious onset; weeks to
of the domains, based on the months
concerns of the individual, a o Course: maybe chronic
knowledgeable informant, for the o Duration: months to years
clinician; and a decline in
neurocognitive performance,
typically involving test performance Assessment tools
in the range of two or more standard
deviations below appropriate terms - CAM: confusion assessment method
(i.e. below the third percentile) on (delirium)
formal testing or equivalent clinical - MMSE: Mini mental status examination or
evaluation Mini-Cog (dementia)
o The cognitive deficits are sufficient to - CDT: Clock drawing test (dementia) to
interfere with independence (i.e. support MMSE
requiring minimal assistance with
- GDS: geriatric depression scale (depression)
instrumental activities of daily living)
o The cognitive deficits do not occur
exclusively in the context of a
delirium
o The cognitive deficits are not
primarily attributable to another
mental disorder (for example major
depressive disorder and
schizophrenia)
- DSM-5: Minor vs major neurocognitive
disorder
o Report by patient, informant,
clinician, and-
o NCD: minor 1-2 vs major >2
o Interference with independence in
IADLs, minor intact IADLs vs major
impaired IADLs
Confusion assessment method

Clock drawing test

Mini mental status examination and Mini-cog

Geriatric depression scale
- DSM-5: difference between minor and major
neurocognitive disorder is based on the six
cognitive domains
- Cognitive domains: P-C-E-L-L-S
Management
- Pharmacologic- start low, go slow
- Non-pharmacologic
o CBT: cognitive behavior therapy
o Communication, consistency
o Safety and communication
Continuation of dementia
- Has 4 major types
o Alzheimer’s- most common type in
the elderly
o Dementia with lewy bodies- second
most common type of dementia in
the older adults and adults
o Frontotemporal dementia
o Vascular dementia
o Perceptual-motor-visual perception
(praxis)- significant difficulty with
using telephones, writing, fork and
spoon, driving or riding, problems
with tasks that he/she usually does
▪ Hippocampus is already
affected
o Complex attention- sustained
attention, divided, selective
attention, lack in speed in
information processing
▪ Check if patient has difficulty
or increase agitation if there
are multiply stimuli
▪ Difficulty in retaining
information
o Executive ability- involves planning,
responding to feedback, mental
flexibility
▪ Difficulty in performing
complex tasks
▪ Cannot remember steps in
tasks that he/she usually does
o Learning and memory- includes
immediate, long term, and recent
memory
▪ Repeatedly conversing
about the same topic
 ▪ Cannot keep track of a short
list of items
▪ Requires frequent reminder of
tasks, or places is a warning
sign
▪ Repetitive behaviors are also
signs
o Language- expressive language,
naming, grammar
▪ If client cannot explain what
he/she wants to say
▪ Problem identifying words or Parts and functions of the limbic system
things- agnosia
o Social cognition- emotions,
behaviors, and social
appropriateness
▪ Insensitivity with social
standards
▪ Patient has little insight and
becomes socially awkward,
withdrawn, and isolated

Percentages of each type of dementia

- Fronto-temporal dementia (5%)

o Damage to the frontal lobe and/or
temporal parts of the brain. - Hypothalamus
Behavior, emotional responses, and o Controls body temperature, hunger,
language skills are affected fatigue, and sleep
- Dementia with lewy bodies (DLB) (15%) - Basal ganglia
o Is a type of dementia that shares o Control of movements, hearing,
characteristics with both Alzheimer’s habit, cognition, and sensation
and Parkinson’s diseases—protein - Thalamus
deposits in the nerve cells o Regulation of sleep, consciousness,
- Alzheimer’s disease (60%) and alertness
o Is the most common cause of - Hippocampus
dementia- parts of the brain o Motivation, emotion, learning, and
become damaged memory
- Vascular dementia (20%) - Amygdala
o Problems in the supply off blood to o Memory, decision-making, and
the brain emotional responses

Dementia in the limbic system of the brain

- Has different affected areas or lobes in the

brain
 o But it generally affects the
hippocampus and amygdala
o Cerebral cortex and limbic system
o Limbic system- hippocampus and
amygdala
o Hippocampus- encoding and
retrieval of information, damage
causes global retrograde amnesia
that is irreversible
o Amygdala- controls ability to feel
certain emotions and to perceive
them in other people
- At an early stage, difficulty remembering
- Two problems: formation of amyloid plaques
names of loved ones and recent events
and neurofibrillary proteins or tau proteins
o Demonstrate impaired judgement,
o Amyloid plaques combine then stops
disorientation, behavior, trouble in
transmission of neurotransmitters >
speaking, swallowing, and walking
neuron dies > (x) transmission of
- Once it damages the hippocampus, global
impulses > (x) memory, brain control,
retrograde amnesia occurs- cannot retain
function
newly acquired information
o Tau protein combine > cause
tangles > also hinder impulse
transmission > death of neuron
o Increase and accumulation >
damage cortical area which
controls motor, memory, and
executive
o Number of synapses decreases >
neuron deprived on nutrients >
death
- As people age amyloid and tau proteins
increase in number
- Function of beta amyloid and tau proteins
o There is already a lot of beta amyloid
in the synapse
o APP (amyloid precursor protein) if this
breaks down becomes beta amyloid
▪ This bridges impulses
(chemical and electrical)
from one neuron to the other
▪ If this metabolizes becomes
beta amyloid
▪ Half of Beta broken down
and metabolized and
eventually thrown away
▪ Half remains and forms
plaques in the hippocampus
 o Tau protein
▪ A normal protein existing in
every cell body (neurons) but
for some reasons these
proteins undergo a process
where phosphate molecules
target tau proteins > loses its
shape and then becomes
tangled > connects to the
microtubules of the neuron
and then it blocks the signal
of the chemical and
electrical signals from one
neuron to the other, thus,
degrading neurons leading
to death
- No cure for Alzheimer’s currently
o But can be prevented by balanced
diet (fasting diets) and exercising
Management
o Memory exercising
- Increasing sulcus spaces and increasing
ventricles is evident in Alzheimer’s
Stages
- Not easily diagnosed because the only
manifestation is memory loss
- Mild
o Begins with forgetfulness
o Progresses to disorientation and
confusion
o Personality changes
o Symptoms of depression/ manic
behaviors
- Moderate
o Need assistance with ADLs
o Unable to remember names
o Loss of short-term recall
o May display anxious, agitated,
delusional, or obsessive behavior
o May be physically or verbally
aggressive
o Poor personal hygiene
o Disturbed sleep
o Inability to carry on a conversation
o May use “word salad” (sentence
fragments)
o Posture may be altered
o Disoriented to time and place
o May asks questions repeatedly
- Severe
o Loss of verbal articulation
o Loss of ambulation
o Bowel and bladder incontinence
o Extended sleep patterns
o Unresponsive to most stimuli
- Cholinesterase inhibitors
o Blocks breakdown of Ach
o Acetylcholine, a neurotransmitter for
thinking and memory
o Side effects: nausea and diarrhea
o Donezepil, rivastigimine,
galantamine (mild to moderate)
o Memantine (moderate)
o Acetylcholine and glutamate are
important for transmitting information
o In Alzheimer’s acetylcholine is broken
down by cholinesterase inhibitor
- Nurse’s role
o Appropriate use of available
pharmacological and
nonpharmacological interventions
o Prompt treatment of all reversible
and irreversible conditions
o Coordination between care
providers and family members
- Goals
o Preserve self-esteem
o Retain self-care abilities
o Prevent complications
Additional notes
- Parkinson’s is considered as dementia
because it also causes shrinkage of the
brain
- Travels from the hippocampus to the right
area where it reaches the thalamic area
and the basal ganglia where dopamine is
created and stored
o Dopamine is responsible for
accuracy of movement
Parkinson’s disease (PD)
- A chronic, progressive neurologic disorder
- Symptoms are caused by the loss of nerve
cells in the pigmented substantia nigra pars
compacta and the locus coeruleus in the
midbrain
o Substantia nigra pars compacta- has
dopamine
- Lewy bodies are present in the basal
ganglia, brain stem, spinal cord, and
sympathetic ganglia
o Lewy body will be tangled in the
synapse of a neuron
o This will result to the motor deficits
- Considered an extrapyramidal syndrome-
chorea (involuntary twitching of the limbs or
facial muscles), and dystonia (involuntary
muscle contractions forcing unusual or
painful positions)
o EPS- because of its anatomical
structure
▪ Tremors
o Chorea and dystonia- both are
involuntary due to the imbalance of
acetylcholine (excitatory
neurotransmitter) and dopamine
(inhibitory neurotransmitter)
o In Parkinson’s there is decrease of
the dopamine resulting to
involuntary movements
- Increases with age; more common in men
than women
o Parkinson’s disease is prevalent in 1-2
persons/ 1,000 people increases 2%
above 65 years old
- Unknown cause
o Idiopathic symptoms will appear
even without other symptoms
- Loss of the dopaminergic cells situated
deep in the midbrain in the substantia nigra
(the black substance so named because of
the melanin seen in those neurons). With the
depletion of dopamine, which inhibits
neurotransmitters, an abnormal movement
syndrome characterized by rigidity and
tremor can occur
- Aside from the dopaminergic activity,
exposure to environmental toxins that results
to genetic predisposition can lead to this
disease
o Toxins > becomes neurotoxins >
inflammation of the brain >
especially in the blood vessels >
decrease in nutrients especially in
the substantia nigra > decreasing
dopamine release or production
- Will worsen without treatment
- Also a neurodegenerative disorder
- Patients with this disease may also present
cognitive impairment
- May happen to first degree relatives of older
people who had Parkinson’s
- Currently, no exact diagnostic test, but is
assessed and tested through PET scans,
MRIs, dopamine tests
- For confirmatory test, autopsy is done
Pathology of PD
- Loss or decline in dopamine cells >
depletion > abnormal movement syndrome
> rigidity, tremor occur d/t the decline of
dopamine in the synapse needed for
transmission at the nerve terminals which is
necessary to create movement
- Therapy to correct dopamine deficiency >
pharmacological administration (levodopa,
a synthetic dopamine) is done
- Metabolic precursor of dopamine, this also
presents bradykinesia
- Message passed to end of axon > sacs
containing dopamine is stimulated to be
released in the synapse > crosses to bind to
dopamine receptors > opening >
transmitting the message to the receptor
cells > dopamine goes back to the synapse
> reabsorbed in the axon
- There are enzymes that destroys dopamine
if it is not reabsorbed, MAO-B (Monoamine
Oxidase Type B) enzymes, cleans the
synapse so it is ready for the next message
- Destruction of the dopamine neuronal cell
in the substantia nigra of the basal ganglia >
decrease/ depletion of dopamine stores >
imbalance of the excitatory and inhibitory
neurotransmitters
- Excitation occurs (because acetylcholine is
higher) > no restriction in the movement >
occurs in the corpus striatum, where EPS
tract is located controlling the complex
body movements
- With severity of PD depletion of dopamine
leads to other changes > affect other
neurotransmitters like glutamate, GABA, and
serotonin
- GABA and glutamate are excitatory
neurotransmitters
- Serotonin – mood stabilizer
- That is why you see PD a mask-like
expression
Four cardinal manifestation
- Two of the four of the cardinal
manifestations may help you diagnose that
a patient has PD
- May manifest cognitive impairments during
the course of the disease
- Tremor
o Begins in the hands
o Often occurring in one side and then
as it progresses it will also occur in
the other side
o Resting tremor
o When a client is at rest the hands are
shaking
o Disappear with purposeful
movement
o Rhythmic, slow turning motion,
pronation, supination of the hands,
or the forearm
o Pill-rolling tremor
- Rigidity
o Stiff movements
o Resistance to passive limb
movement
o Involuntary stiffness to passive
movement of extremities
 o Early in the disease, a patient may o Parkinson’s with dementia with
st
complain of shoulder rigidity (1 sign) dysphagia has a high rate of
o Jerky movements- lead pipe or mortality
cogwheel movement - Loss of balance can cause falls that result in
o Stiffness of the arm but on one side serious injuries or death
of the body
o Bells’ palsy and trigeminal neuralgia-
twitching which is different from
stiffness
o No difference in male and female
PD manifestations
- Akinesia
o No movement
o Sudden arrest of movement
- Bradykinesia
o Slowness of active movements
o Peristalsis will still be normal because
this is involuntary, but the problem
will be in the chewing, eating,
swallowing because this are
voluntary > high risk for aspiration,
may present dysphagia (inability to Mid stage
swallow) in progressive stages
- Urinary and bladder problems are presented
- Postural
here
o Stoop posture
o Shuffling gait- prone to falls because Advanced
patient does not lift feet when
- Can no longer walk or stand without
walking
assistance
o They shuffle because they have lost
- Not able to do activities of daily living
their balance
- There are present cognitive manifestations
- Priority
already
o Safety o client

Will I die of PD?

Pharmacological treatment for PD
- You will not die because of PD but you will
die with it and its symptoms
- Later diagnosis, earlier death
o Early diagnosis will lead to better
prognosis
- Parkinson’s disease is not considered fatal,
however people with PD have a shorter life
expectancy
- In advanced cases, difficulty swallowing
can cause PD patients to aspirate food into
the lungs, leading to pneumonia or other
pulmonary conditions
- In the synaptic junction there is dopa
decarboxylase > destroys dopamine
- There are two factors that complicate the
mechanism of action of levodopa
o Med must past through BBB dopa
decarboxylse is also in the intestinal
mucosa
o Only 30-40% of the medication
crosses the BBB
o Most of it is lost before it enters the
gen circulation and BBB
o New drug- levodopa + DDC inhibitor
> destroys dopa decarboxulase
▪ Carbidopa + levodopa
(sinemet) can be divided into
4 nigra > restores the balance
▪ Added to maximize
absorption and facilitate
crossing of the BBB
▪ Should be taken in an empty
stomach
▪ At least 1 hour before meals
or 2 hours after meals
▪ Potential side effect nausea
and vomiting, postural
hypotension
▪ Teach strategies to avoid
falling
▪ How to sit and how to stand,
hold on unto something
▪ Do not give food high in
vitamin B or pyridoxine or
vitamin B complex because
vitamin B facilitates
breakdown of levodopa,
increases action of dopa
decarboxylase
▪ Older person may develop
drug induced tolerance
▪ Drug becomes ineffective at
this time hyperactive
movements will show, take
note of the time when
levodopa is administered
o Amantadine
▪ Combined with levodopa
and carbidopa or cholinergic
▪ Potentiated release of
dopamine (remaining
dopamine in the substantia
nigra)
▪ This is transitory, does not
happen all the time this is
why It is combined
▪ Also a prophylaxis in viral
infections
o Dopamine agonists
▪ Directly stimulates dopamine
receptors > increase
dopamine in the substantia
between inhibitory and
excitatory neurotransmitters
▪ Initiated in the early stages of
PD before starting with
levodopa
▪ Used in combination with
levodopa throughout the
progression of PD
▪ Bromocriptine
▪ Pramipexole
▪ Ropinorole (requip)
▪ Patients should be monitored
for sleepiness and drowsiness
o MAO-B inhibitors
▪ Normally we have this in the
synapses, it destroys
dopamine that is not
reabsorb signal transmission
▪ Inhibits breakdown of
dopamine
o COMT inhibitors (peripheral)
▪ Catechol-O-
methyltransferase
▪ Reduces motor fluctuations in
PD and increases duration of
levodopa and carbidopa by
decreasing its
biotransformation in the
peripheral tissues
▪ Synergistic drugs
 ▪ May cause dizziness
(tacapone) and turn urine
orange or brown in color
▪ Make sure avoids alcohol,
this will potentiate risk of liver
failure
o COMT inhibitor (central)
▪ Anticholinergic
▪ Used for symptomatic
treatment
▪ Relieves tremors and rigidity
▪ Blocks action of
Acetylcholine and corrects
imbalance
▪ WOF: dry mouth,
constipation, blurred vision
(not given to client w
glaucoma) urinary retention
▪ Do not give if the client has
urinary retention because it
could complicate an
enlarged prostate
Nursing diagnosis
- Impaired physical mobility related to muscle
Nursing care
rigidity and motor weakness
o Tremors during eating may result to
aspiration and falling when bathing
- Self-care deficit related to tremor and motor
disturbances
o Falls may result to fractures: hip and
wrist fracture are the most common
fractures
▪ For partial hip replacement-
neck or acetabulum only is
fixed
▪ Complete- both the neck of
the femur and acetabulum
- Constipation related to medication and
reduced activity
o Movement is needed to stimulate
peristalsis to move bowel, due to
slowness of movement, patient may
experience constipation due to slow
peristalsis
- Imbalanced nutrition: less than body
o Tremors while eating affect the
appetite
o Slowness of eating affect the
intestinal movement
o >45 mins-1hr eating the body will not
anymore recognize that you are
eating, it will recognize it as resting
already which will slow down
peristalsis leading to decrease in
appetite
o Difficulty eating/ swallowing
- Impaired verbal communication related to
decrease speech volume, slowness of
speech, and inability to move facial muscles
o Due to the rigidity of the facial
muscles, the client will not be able to
interpret expressions
o Speech problems- slurred speech,
client will not easily be understood
- Ineffective coping related to depression
and dysfunction due to disease progression
- Risk for falls/risk for injury related to rigidity
and motor weakness
- Priority NDx- risk for falls and self-care deficit
- The goal of treatment is to control the
symptoms and maintain functional
dependence
o Do you have leg or arm stiffness?
o Have you experienced any irregular
jerking of your arms and legs?
o Do you notice yourself grimacing or
making faces or chewing
movements?
o Does your mouth water excessively?
 - Assess fall risk by using the functional reach
test

- Goal of nursing care is to address and

- Improve functional mobility
recognize symptoms of the client and help
- Maintain independence in activities of daily
gain independence through providing
living
safety
- Achieve adequate bowel movement
- Observe degree of disability and functional
- Attain and maintain acceptable nutritional
changes such as responses to medications
status
- Quality speech, facial expressions, tremors,
- Achieve effective communication
posture rigidity, mental slowness, and
- Develop positive coping mechanisms
confusion should be observed and
managed if client experiences this Functional mobility
- Nursing care should be directed to help the
- Encourage exercise for joint mobility and
older adult by developing programs that will
joint flexibility (e.g. stationary bike, walking
promote mobility, prevent falls, assist in
and range-of-motion exercises)
preventing dysphagia, and independence
o A physical therapist may be needed
- Symptoms
o Special walking techniques should
o Mild- only one side if affected,
be done to counteract falling and
inconvenient but not disabling yet
leaning forward
▪ Change in walking and
o Water therapy will help with gait,
posture
posture, balance, and mobility
o Moderate- difficulty rising from bed,
o Program daily exercises to prevent
wheelchair, chair, and assumes
muscle rigidity and muscle
flexed position, difficulty in initiating
contractures
walking
o Postural exercises to avoid stooping
▪ Older adults lean forward to
forward
get started, small shuffling
o If client does not move or exercise
steps may be observed,
he/ she may experience sarcopenia
unsteady gait especially
or muscle atrophy
when turning, and difficulty in
- Teach patient to walk erect, watch the
stooping
horizon, use a wide-based gait, swing arms
▪ Do not let them pickup
with walking, walk heel-toe, and practice
objects from the ground
marching to music
because they may fall
 - Encourage breathing exercises while Factors of falls
walking and frequent rest periods to prevent
- Intrinsic factors
fatigue and frustrations
o Unique characteristics of individuals
- This are all done in combination with the
that may lead to falls such as
medications prescribed to the patient
reduced vision, hearing problems,
- Nursing evaluation after we provide this: the
cognitive impairment, unsteady gait,
client is participating active in exercise
and effect medications
program
o Environmental- bathtubs, toilet bowls
o Client must have a routine
o Make sure bathroom has handrails
- If the client is walking provide a wide-base
o If toilet is too low, elevate it or setup
gait to support balance
a make-shift commode
o Exaggerate the movement of arms
o Height of the bed (as low as
when walking to aid in balance
possible)
Falls o Condition the floors- should be
contrasting in color and not slippery
o Lighting
o Assistive devices

- Falls are a significant public health problem.

Worldwide, falls are the second leading
cause of accidental or unintentional injury
or deaths
o Most common cause for hospital Algorithm for fall prevention
admission of the older adult
- This is how you will assess the client
- The presence of dementia increases risk for
- Assessment and interventions are important
falls two fold, and individuals with dementia
in preventing falling
are also at increased risk of major injuries
(fractures) related to falls Self-care
- Psychological manifestation after fall:
- Environmental modifications are necessary
fallophobia- fear of falling
to compensate for functional disabilities
o This leads to an older person
- A hospital bed at home with bedside rails,
choosing not move because he/she
an overhead frame with a trapeze, or a
is afraid to fall
rope tied to the foot of the bed can help
provide assistance in pulling up without help
- Enlist assistance of an occupational
therapist as indicated
Additional notes:

- When client takes antipsychotic

medications and EPD manifests, tell the
doctor to decrease the dose of the
antipsychotic and not to give an
antiparkinsonian drug because this will not
solve the problem > will only cause drug
toxicity to the client
- If a patient has impaired physical mobility
related to bradykinesia the nurse should
suggest that the patient rock from side to
side to initiate leg movement and facilitate
balance