8

Ca re of Older Adults
Principles of geriatrics and gerontology
Gerontology
- Is multidisciplinary Is a multidisciplinary
concerned with physical, mental, and social
aspects, and implications of aging.
- Is concerned with the biological, psychological,
economic, and social study of aging.
- A holistic study of aging and how environment
and aging affects a person.
o Inside the hospital older clients may
regress, these facilities fa cilities gets the
older person back to their normal stature
and is and disposition and be more
independent.
- Rehabilitation hospitals
o Strengthens systems of older clients.
- Community based home care
Principle and goal

- Health promotion, health protection, disease

Geriatrics
- Is a medical specialty focused on care and
treatment of older persons.
- Study and management of diseases of the
elderly.
Although gerontology and geriatrics have differing
emphases, they both have the goal of understanding
aging so that people can maximize their functioning
and achieve a high quality of life.
prevention, and treatment of disease with
emphasis on the evidence-based best
practices and current clinical practice
guidelines.
- The goal for nurses who provide health care to
older people is not only to improve the length of
life, but to improve the quality of life.
o Quality of life is achieved by dignity,
respect, and advocacy.

Subdivision
Areas
- Aging happens at the beginning of conception
- Skilled nursing facilities
and continues to the remainder of life.
o Like a small hospital where they can get
- These are subdivided to determine life
nursing care.
expectancy
- Retirement communities
- Life expectancy- number of years from the birth
o Where nurses create group activities
the individual can expect to live.
and tasks.
- Young old- 60-74 years old
- Adult day care
- Middle old- 75-84 years old
o Create plans on how to make the day of
- Old old- 85-90 years old
an olde r person worthwhile.
- Centenarians- Centennarians- 100 and above
- Residential care facilities
- Ages 70-79- septogerarians
o Like a house
- Ages 80-89- octogerarians
o When families cannot take care of their
old folks anymore they transfer them
here.
AGEISM
- Transitional care units
- Stereotyping or discrimination agai nst individuals or resources Paid employment is not the
groups base on their age only measure of value and
- Negative feedback towards aging and the elderly productivity and older people
continue to make
MYTH VS. FACT contributions to society into
MYTH FACT advanced old age and many
continue working,
Being old means Fewer than 5% of people over volunteering and mentoring
being sick the age of 65 are frail enough others ling after formal
to require care in a skilled retirement
nursing facility
Older people Many older people join clubs
Many older adults have are isolated and and do volunteer work to stay
chronic diseases but still lonely active and connected
function quite well
There are many ways to
Most older Older people can learn new maintain contact with pe ople
people are set in things and should be and healthy older adults have
their ways and challenged to stay mentally a variety of great options for
cannot learn active staying connected with others
new things or
Healthy older adults find Older people Although sexual activity does
take up new
hobbies that they can enjoy have no interest decrease in some older
activities
to give life meaning and in sex people, there are tremendous
pleasure differences. Most often, the
human need for affection
Health It is never too late to begin
and physical contact
promotion is good lifestyle habits such as
continues throughout life
wasted on older eating healthy diet and
people engaging in exercise

Although it may not be

possible to reverse all of the
damage caused by bad
habits, it’s never too late to
stop smoking cigarettes or
drinking too much alcohol.
Even people who quit
smoking at older ages enjoy
better health outcomes than DEMOGRAPHICS OF AGING
those who continue to smoke

Older adults do Older people contribute

not pull their greatly to society by
own weight and supporting the arts, doing 7
are a drain in volunteer work, and helping
societal with grand children
- There are currently around 901 million people aged
60 or over worldwide, representing 12.3 percent of the
global population. By 2030, this will have increased to
1.4 billion or 16.5 percent, by 2050, it will have
increased to 2.1 billion or 21.5 percent of the global
population.
- Old age is often considered from the economic
perspective, with assumptions of what ageing
population will cost. Yet wellbeing in later life is an
accumulation of experiences throughout life.
- As older adults increase there is also increase in the
demand for health needs and health providers.
Note: To determine that the country is aging, there
should be at least 10% of the population of 60 years old
and above in a country
FEMINIZATION OF LATER LIFE
- Male exposure to risk factors may account for the
differences
o Smoking, Vices and Occupational Risks
- Increases in females exposures to risk factors will
reduce difference in life expectancy
- Women are known to live for at least 75 years old
- May also occur due to transgenerational which
means there are more born females than males
The Philippines
There are also policies and programs that recognize
older people’s contribution, provide entitlements to
access social services, promote services promote their
full employment and maximize opportunities for their
participation in national development.
The government also recognizes the need to address
older people’s specific needs need in terms of
healthcare, housing and income security.
While older people still face challenges in achieving
income security and health status, the government is
takin g positive action, such as the Expanded Senior
Citizens Act of 2010. Targeted old age allowance is still
too limited to make any difference.
In 2010, Expanded Senior Citizens Act of 2010 or RA
9994
An act granting additional addition benefits to Senior
Citizens
▪ 20% discount in exception to VAT
▪ 5% discount for utility bills (electricity and water)
▪ Exception from training fees (seminars
conducted by the government)
▪ Free medical and dental services in all DOH
hospitals
▪ If the Senior Citizen is considered indigent, s/he
will not be charged for Flu vaccines in DOH
Hospitals; will be given educational assistance;
▪ Pensions from SSS, GSIS or PAG-IBIG
▪ Given death benefits of a minimum 2,000.00 from
the DSWD
▪ Priority lanes in government agencies
▪ Some LGUs grant Php 100,000.00 to centenarians
The Philippines has a
young population with
a small (6.8%)
proportion of the
population in the older
ages (60+)
In the Philippines, the
number of older
people is increasing
rapidly, faster than
growth in the total
population.
In 2000, there were 4.6 million senior citizens (60 years - Provides for the
and older), representing about 6% of the total minimum
population. In two decades, this has grown to 9.4 requirements and
million older people or about 8.6% of the total standards to
population. make buildings,
facilities and
The World Population Prospects 2019 projects that by utilities for public use
2050, older people will make up around 16.5% of the accessible to
total population persons with
disability,
including older
persons who are
confined to
wheelchairs and
those who have difficulty in walking or climbing stairs,
among others

2019 2050 Republic Act No. 7876 entitled “An Act Establishing a
Senior Citizens Center in all Cities and Municipalities of
Population aged 60 and above 9,433,0 23,863,0
the Philippines and Appropriating Funds Therefore”
(total) 00 00
- Provides for the establishment of Senior Citizens
Population aged 60 and above 8.6 16.5 Centers to cater to older persons’ socialization and
(% of total population) interaction needs as well as to serve as a venue for
the conduct of other meaningful activities. The DSWD
Older women aged 60+ (% of 4.83 9.40 in coordination with other government agencies,
total population) NGOs and peoples’ organizations shall provide the
necessary technical assistance in the form of social
Life Expectancy (males) 67.08 71.88
and recreational services, health and personal care
Life Expectancy (females) 75.31 79.5 services, spiritual services, livelihood services and
volunteer resource services.
Old-Age Dependency Ratio 8.6 17.7 ⮚ Office of the Senior Citizens Affairs
Age (Age 65+ / Age 15-64)
⮚
Rural older people (% of total 6.48
⮚
population)

Urban older people (% of total 6.54 Republic Act No. 8425

population) - Provides for the institutionalization and enhancement
of the social reform agenda by creating the National
Older persons living alone aged 5.4 Anti-Poverty Commission (NAPC). Through its multi-
60 and above (% of total dimensional and cross-sectoral approach, NAPC
population) provides a mechanism for older persons to
participate in policy formulation and decision-
Old-Age Dependency Ratio –comparing number of making on matters concerning poverty alleviation
adolescence to senior citizens o In 2015, there was a research conducted on
how senior how does senior citizens citizen get
their money aside from pensions. Results
LEGISLATIVE MILESTONES included are from children, farming
Republic Act No. 344 or the Accessibility Law of 1982 and their own
and own jobs.

Republic Act No. 10155
- Known as “The General Appropriations Act of 2012”
- Under Section 28 mandates that all government
agencies and instrumentalities should allocate one
percent of their total budget to programs and
projects for older persons and persons with disabilities
Republic Act No. 9994
- Known as the “Expanded Seniors Citizens Act of 2010”
- An act granting additional benefits and privileges to
senior citizens, further amending Republic Act No.
7432 and otherwise known as “an Act to maximize
the contribution of senior citizens to nation building,
grant benefits and special privileges and for other
purposes”
- The RA 9994 provides health care services for poor
older persons such as free medical services on
government hospitals, discounted services on private
hospitals and clinics, free vaccines, discounted
medicines and mandatory PhilHealth Coverage.
By 2025, we would have 11.9 million older people
accounting for about 10% of the total population.
By then, the Philippines will be an aging population
by UN definition.Area where Senior Citizens can
socialize and interact based on their needs as well
as venues for meaningful activitiesPresidential
Proclamation No. 470, Series of 1994, declaring the
first week of October of every year as “Elderly
Filipino Week”
- contributed contributes in nation building
Presidential Proclamation No. 1048, Series of 1999,
declaring a “Nationwide Observance in the Philippines
of the International Year of Older Persons”
Executive Order No. 1054, Series of 2003
- Approved and directed the implementation of the
program providing for group homes and foster homes
for neglected, abandoned, abused, detached, and
poor older persons and persons with disability
The Department of Social Welfare Development (DSWD)
has issued Administrative Order No. 4 Series of 2010,
“Guidelines on the Home Care Support Services for
Senior Citizens”, establishing community based health
careservices for older persons.
The Plan of Action on Ageing 1999 – 2004
- Included health promotion and disease prevention
for adults by providing free flu vaccinations,
osteoporosis screening and eye tests. The National
Action Plan on Senior Citizens focused on aspects of
quality of life such as living independently
The Philippine Plan of Action for Senior Citizens (2011 -
2016)
- Aims to ensure giving priority to community-based
approaches which are gender-responsive, with
effective leadership and meaningful participation of
senior citizens in decision-making processes, both in
the context of family and community. This plan of
action aims to ensure active aging for senior citizens
where preventive and promotive aspects of health
are emphasized in communities and where health
services are accessible, affordable and available at
all times. Envisioning a population of senior citizens
who are self-sufficient and self-reliant, this plan aims
to promote financial security and financial
independence of senior citizens by developing
community-based local delivery systems to address
their needs.
Theories on ageing
Senescence
- Used to define the ageing process.
- Progressive deterioration of body systems that
can increase the risk of mortality as the
individual gets older.
Biological ageing theories
- Programmed- aging follows a biological
timetable and may represent a continuation of
the cycle that regulates childhood growth and
development.
 - Error- emphasize environmental status assaults
to the human system that gradually cause
things to go wrong.
Programmed theories
- Programmed longevity - aging is the result of the
sequential switching on and off of certain
genes, with the senescence defined as the
point int time when age-associated functional
deficits are manifested.
- Endocrine- biological clocks act through
hormones to control the pace of aging.
- Immunological- a programmed decline in
immune system functions leads to an increased
vulnerability to infectious disease, aging, and
eventual death.
Error theories
- Wear and tear- cells and organs have the vital
parts that wear out after years of use.
- Cross-link - accumulation of cross-linked proteins
resulting from the binding of glucose (simple
sugars) to protein (a process that occurs under
the presence of oxygen) causes various
problems
- Free radicals - accumulated damage caused
by oxygen radicals causes cells, and eventually
organs, to lose function and organ reserve.
- Somatic DNA damage - genetic mutations
occur and accumulate with increasing age,
causing cells to deteriorate and malfunction
- Emerging biologica l- study and mapping of the
human genome may have led to the belief that
many genes may be responsible for human
aging.
Psychological ageing theories
- Jung’s theory of individualism - as a person ages,
the shift of focus is away from the external world
(extroversion) towards the inner experience
(introversion)
- Erikson’s developmental theory - ego integrity
versus despair, the older adult will become
more preoccupied with acceptance of
eventual death without becoming morbid or
obsessed with these thoughts.
Sociological ageing theories
- Disengagement - the appropriate pattern of
behavior in the later life is for the older person
and society at large
to engage in a mutual and recip
l.
- Activity- older adults should stay active and
engage if they are to age successfully
- Continuity - successful aging involves
maintaining or continuing previous values,
habits, preferences, family ties, and all other
linkages that have formed the basic underlying
structure of adult life.
In the application of our growing knowledge of
biological aging, it appears reasonable to
expect that slowing or reducing cellular
damage may have the potential for promoting
healthy aging, such as helping reduce
external factors, also levels of naturally
occurring antioxidants can be increased
through regular exercise.
While psychosocial theories and perspectives
of aging provide the gerontological nurse with
serve as a background
for the development of one's philosophy of
care . These theories have been used as
rationale for the creation of policies of the
older persons, from senior activity centers to
laws regulating employment.
Violence and elder mistreatment
Introduction
- The nurse has role in identifying and managing
the serious and potentially life-threatening
syndrome of elder mistreatment.
- Elder mistreatment is a part of a larger societal
problem, domestic violence.
o One of the most common problems with
older adults
 o Intended acts that cause harm or
create serious serios risks to a vulnerable
elderly by a caregiver, family, or another
Theories
person.
o Whether harm is intended or not o Transgenerational violence
o Physical emotional, and financial abuse ▪
o protect the elderly from harm
Happens during the developmental perio
o
Usually happens in nursing facilities or homes
ko

▪
Abuse is already existing in the family

▪ Family violence continuum

o
Starts at child abuse and ends up in
erson doing harm is in a trusting
relationship with the elderly (family,
caregiver, or significant other)
- Elder mistreatment is the outcome of abuse,
neglect, or exploitation, or abandonment of
older adults and represents some of the most
tragic behavior in the area of family violence.
- protect the elderly from harm
- Usually happens in nursing facilities or homes

Theories of elder mistreatment

o
Psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their capacity to give appropri
Theories of elder mistreatment - If older persons tend to be violent towards the
nurses, assess first why they are hurting you and
-
understand their stature, especially with severe
Psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their capacity to give appropriate care
dementia.

Theories

- Transgenerational violence
o
Happens during the developmental period of person, therefore the person, abuses people as he grows up.

o Abuse is already existing in the family

o Family violence continuum
- Starts at child abuse and ends up in elderly
mistreatment
o Under the learning theory, when a child
sees abuse during childhood, the child
learns how to abuse people as well.
- Situational theory
o Stresses or situations that may lead to
mistreatment
o Sudden outburst of anger and lashing
out on an elderly
- Isolation theory - But if they know what they are doing tell them
o Mistreatment prompted by a problem in what they did was wrong and ask why they did
the social network it.
o “you are no longer part of the society” - Observation, interview, and assessment are the
o Older adults are left alone in the house best tools to identify abuse, neglect
with little to no interaction to the society - Always look at hygiene, scratches, wounds, and
- The identification of elder mistreatments is most bruises.
often done by healthcare professionals
Definition of elder mistreatment

Additional notes:

- If older elder adults have attitude problems due

to past experiences, how will it be handled?
o As nurses, we should provide comfort
measures if you are aware that they
have experienced abuse in the past.
Provide protection, security, and safety.
o Create a trusting relationship and talk to
them directly
 - Physical, sexual, emotional/ psychological elder mistreatment, and the nurse’s role is of
abuse, neglect, abandonment, financial/ utmost importance.
material exploitation, and self-neglect are all - Provides basic tools to be used to assess the
subtypes of elder mistreatment. client comprehensively

*highlighted words are the most prevalent

Cultural perceptions of older mistreatment

- Elder mistreatment needs to be understood I the

context of individual cultures.
- Elder mistreatment cannot be tolerated, despite
differing cultural perceptions.
- Cultural and linguistic competences are
important for successful intervention in the care
of elder mistreatment.

Legal issues

- All states have some mechanisms, whether Physical examination

mandatory or voluntary, for reporting elder
- The physical Th physical symptoms of elder
mistreatment. State-by-state variations exist in
mistreatment are often difficult for clinicians to
terms of definitions, mechanisms of reporting,
discern because older adults may suffer from
and appropriate governmental intake
chronic and acute illnesses that mask or mimic
agencies.
the presence of mistreatment.
Current evidence - Cognitively impaired older adults provide an
additional challenge
- Low household income, unemployment, poor
- Always take note of the hygiene
health, self-report, prior family violence, and
- Take note of the skin turgor, oral mucosa, and
poor social support are consistent contextual
energy, because these are signs of dehydration
factors for the outcome of elder mistreatment.
and dehydration is a sign of neglect.
Assessment - Check appropriateness of clothing, set of teeth
(with or without dentures), and haircut
- Interdisciplinary comprehensive geriatric
assessment of the older adult’s cognitive and
psychosocial function is essential in identifying
 Pharmacology and the older adults

Nursing diagnosis - Due to numerous problems older adults also

have a lot of medications (polypharmacy)
- Elder mistreatment may be addressed by the
following nursing diagnosis from the North Age-related changes that increase risk for adverse
American Nursing Diagnosis Association: drug events
o Care giver role strain- die to fatigue
- Older persons tent to have acute and chronic
o Coping, ineffective family
conditions that may alter pharmacokinetics
(compromised or disabled)- limited
(what the body does to the drug) and
capacity to care
pharmacodynamics (what the drug does to the
o Coping, ineffective individual
body)
protection, ineffective rape-trauma
o There are decrease and slowing of the
syndrome
body functions
o Self-care deficit
o Metabolism, digestion, GIT system
▪ A CAT scale is used to assess the
o Therefore, there is also a decrease in
dependency and independency drug effect and absorption
of a client - Decrease in body water (as much as 15%) and
o Self-esteem situational low increase in body fat
▪ Because they cannot do o Increased concentration of water-
activities that they do before soluble drugs
o Social isolation o More prolonged effects of fat-soluble
drugs
▪ No interaction for more than 2
o Some drugs are hydrophilic- water
weeks
increases the potency of the drug, if
Interventions here is decreased water in the body
there is also decrease in drug effect
- Nurses working with older adults must be aware
o Some drugs are lipophilic
of the elder mistreatment reporting laws in their
o Therefore, not only the desired effects
states.
occur but also adverse effects
- Elder mistreatment requires an interdisciplinary
- Hepatic blood flow may be decrease by as
team approach
much as 50% in individuals over 65 years
- Best way to report is to document it
o Increased toxicity with normal doses of
o Should be comprehensive (how and
the “first-pass effect” drugs
why the abuse happened) who is
o Less drug would be detoxified
mistreating the elderly?
immediately by the liver
- Guardian shift- a legal action which aims to
o Hepatic first-pass- metabolism of drugs in
protect the older adult from mistreatment
the liver
o Removed from home and transferred to
o Decreased metabolism of the drug, the
a care facility.
byproducts remains in the system >
- Recognize how mistreatment happened then
increased toxicity, prolonged effects
report.
o Decrease in drug detoxification,
- Reassure the family Reassure family that the
decrease excretion of toxins
client will be going back home if the problem is
o There will be increase in free running
resolved.
medications = toxicity
 o When prescribing medications that are
hepatotoxic, always monitor the liver
function (AST, ALT, SGPT, and SGOT)
▪ If there is an increase in the value
of these tests it signifies that there
is damage or inflammation in the
liver
- Decreases serum albumin
o Leads to altered binding capacity
o May cause increased serum levels of the
“free” or unbound proportion of protein-
bound drugs
▪ Free flowing medications in the
blood will not go to the target
organs, therefore, it will not
achieve its desired effects or
primary goal
o May result in toxic levels of highly
protein- bound drugs because more
unbound drug is available to produce its
effects
o Formula: (140-age) (lean wt- in kg)/(72)
(serum creatinine)
o For females multiply result to 0.85
because women have lesser lean
weight than males
o Males are usually heavier
- Considerable individual variation in the degree
of decline of renal function
o If there is problem in the liver there is less
drug detoxification and if there is a
problem in the kidneys there is less
excretion of the drug
o Creatinine clearance and blood-urea
nitrogen are indicators of kidney
function
o Nephrotoxic drugs are given at one time
doses, OD
o Etoricoxib (arcoxia)- a cox 2 inhibitor, an
anti-inflammatory drug and is
nephrotoxic
▪ Long term intake of this drug will
Pharmacodynamic alterations
damage the kidneys
Nursing considerations
- If a patient is receiving two or more drugs that
are highly protein-bound, then nurse should
observe for drug interactions and variations in
responses to each drug
o There is decrease in liver and kidney
function in the older adults
o Make sure the drugs taken are
achieving their desired effects. If it has
other effects document it and report
- Oral medications should be given with a
nutritious liquid (e.g. fruit juice) rather than
water. If a patient is anorexic or is likely to refuse
to take adequate amounts of liquid. This
maximizes he nutritional values of liquids
ingested.
o Do not use liquids that are
contraindicated due to food-drug
interactions
o Example: senna tablets are laxative
preparations, do not give it with prune
juice (which is also a laxative in a natural
form) patient will have diarrhea
- The general rule for drug prescription in the
older person is “start low; go slow”
- Drugs that should be used with caution in older
adults:
o Drugs that are new to the market
▪ Because drugs that are new to
the market are not specifically
tested to the elderly but to the
general population
▪ There should be sufficient
researches first before it is used
on the elderly
o Drugs with CNS effects
o Drugs that are highly protein-bound
o Drugs that are eliminated by the kidneys
o Drugs with a high first-pass effect
o Drugs with a low therapeutic-to-toxicity
ratio
 - Pharmacodynamics- what the body does to the
drug and how the drugs affect the body
- Decreased number of receptors
o Receptors are in the target organs
o Drugs that increase receptor responses-
Definitions of adverse drug reactions and adverse drug
antipsychotics and hypnotics
events
o Increase in sedation, analgesic effect,
may make the patient high, and are
respiratory depressants
o Benzodiazepines- antianxiety/
antidepressants can lead to injury due to
falls, because the side effect of this drug
is sleepiness
o Warfarin- anticoagulant, increases
receptor response making patient at risk
of bleeding and hematoma
- Decreased receptor binding
- Altered cellular response to the drug-receptor
interaction
Pivotal role of nurses
- Reviewing, recommending, and monitoring
Nurses role in promoting safe and effective medication
medications
management
- If a medication is not effective and there are still
symptoms refer it to the doctor to change it to a
more effective drug
- General rule: if the physician prescribes
medications it should always start low then
gradually increase if manifestations are the
same in the client
o Sertraline- drug for manic disorder
o If normal dose is 500 mg/tablet at night >
taper it to a lower dose to a half, then
slowly increase if manifestations are the
same after 2 weeks
o Usually it is tried for 2 weeks due to
decrease in absorption, slower binding
of medication to target receptors > slow
binding to organs > medicine will free
flow in the blood > might go to other
organs > deliver different effects
- Ensure drug therapy is effective for the person’s
condition
- Prevent, detect, or intervene as early as possible
if the person develops adverse drug effects
o Antipsychotic drug toxicity may lead to
EPS (extrapyramidal symptoms)
o Levodopa decreases EPS and is an
antiparkinsonian medication
- Adverse drug reactions (ADRs)- response to a
medicine that is noxious and unintended, and
that occurs at normal doses during normal use
(WHO, 2008)
- Adverse drug events (ADEs)- any incident in
which the use of a medication (drug or
biologic) at any dose, a medical device, or a
special nutritional product (e.g. a dietary
supplement, infant formula, medical food) may
have resulted in injury or adverse outcome in a
patient (Joint Commission, 2007)
- Adverse drug experience- any adverse event
associated with the use of a drug in humans,
whether or not considered drug related
- Assure the correct storage, preparation, and
administration (including the five rights in the
institutional setting
o Right patient
o Right drug
o Right time
o Right dosage
o Right route
- Educate the patient and family concerning
storage, preparation, and administration
o There are specific instructions to
medications
o E.g. some drugs should be taken 30
minutes before eating like the PPIs
(proton-pump inhibitors)
- In the institutional setting, be aware of the legal
aspects of medication delegation for the state
in which he or she practices as well as the
policies of the employing agency
o In other countries, other staff can
delegate medications like the nursing
aids. But in the Philippines only a
registered nurse can delegate
medications