NCM 114 LECTURE
GERIATRICS (ALCON & ZILABBO)
MIDTERM TOPICS
CORE ELEMENTS OF EVIDENCE-BASED
GERONTOLOGICAL NURSING PRACTICE
OBJECTIVES:
Provide appropriate evidence-based practice in the
nursing care of older adults.
TOPICS:
A. Standards
B. Competencies
C. Principles
D. Issues/Concerns
Gerontological Nursing Standards of Practice and
Competencies
⎯ Practice standards describe the appropriate
therapeutic health and wellbeing of gerontological
nurses to facilitate the older person’s health,
recovery and/or wellbeing and comfort.
⎯ “The primary purpose of having standards is to
provide direction for professional practice in order
to promote competent, safe and ethical service
for clients” (CNA, 2008, p. 9).
⎯ COMPETENCIES: Competencies are the
behaviors through which gerontological nurses
enacts the standards during practice encounters
with the older person and their care partners
STANDARD 1: HUMANISTIC AND RELATIONAL
(Tardif, 2006). The competencies explicate the
knowledge, skills, judgement and attitudes that all
gerontological nurses should apply when caring
for the older person, whether individually, within
groups, in communities or across regions.
PURPOSE OF STANDARDS OF PRACTICE
⎯ Define the scope and depth of gerontological
nursing practice
⎯ Establish criteria and expectations for high quality
nursing practice and safe, ethical care
⎯ Provide criteria for measuring actual and desired
performance
⎯ Support ongoing development of gerontological
nursing
⎯ Promote gerontological nursing as a specialty,
providing the foundation for certification of
gerontological nursing by the Canadian Nurses
Association
⎯ Promote components of gerontological nursing
knowledge as entry-to- practice competencies,
setting a benchmark for new graduates
⎯ Inspire excellence in and commitment to
gerontological nursing practice
USING THE STANDARDS OF PRACTICE
⎯ Nurses in clinical practice use the standards to
guide and evaluate their practice
⎯ Nursing educators include the standards in
course curricula to prepare new graduates for
gerontological practice across all settings
⎯ Nurse administrators use the standards to direct
policy and guide performance expectations
⎯ Nurse researchers use the standards to measure
and guide the development of knowledge specific
to gerontological nursing
⎯ Nurse advocates use the standards to support
social justice initiatives for policy change at local
community, provincial and national levels
Standards of Practice
⎯ STANDARD 1 HUMANISTIC AND RELATIONAL
CARE
⎯ STANDARD 2 ETHICAL CARE
⎯ STANDARD 3 EVIDENCE-INFORMED CARE
⎯ STANDARD 4 AESTHETIC/ARTFUL CARE
⎯ STANDARD 5 SAFE CARE
⎯ STANDARD 6 SOCIO-POLITICALLY ENGAGED
CARE
CARE
⎯ Gerontological nurses develop and preserve
relationship care.
⎯ Gerontological nurses understand that reciprocal
communication and respectful interactions are
central to the central human enterprise of nursing
(Sakamoto, et al., 2017).
⎯ Relationship-centered care is the foundation of a
humanistic approach to provide high-quality care
for older people and their care partners and is
dependent upon empathy and understanding
(Arnold & Boggs, 2016; Clune & Gregory, 2015;
Dalhke & Baumbusch, 2015; Gottlieb, 2012;
McCormack & McCance, 2017; McGilton, et al.,
2017; Wright & Leahy, 2016).
Gerontological Nurses address:
⎯ Humanistic nurse, older person and care partner
relationships to optimize health and wellbeing of
older people and their care partners
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MIDTERM TOPICS
⎯ Personal, older person and care partner
preferences, reflecting one’s unique experiences,
cultural context, and social determinants of
health.
⎯ Relational care approaches to value the person-
centred and ethical issues that affect person-
centred care
⎯ Gerontological nurses recognize their role as part
of an inter- professional collaboration
Requires Competencies: (skill, knowledge, attitude,
judgment, and behaviors)
⎯ Assessing need for and encouraging
friendship and social relationships between
older people and those who are meaningful
to the older person
⎯ Communicating effectively, respectfully,
person-centred and compassionately with
older people and their care partners (e.g.,
recognizing and working with individual
characteristics of older people living with
dementia, hearing loss, social determinants
of health and other)
⎯ Appreciating the influence of attitudes, roles,
language, culture, race, religion, gender, and
lifestyle on older people and their care
partners’ views of health, wellbeing, illness,
aging and perceptions of care delivery
⎯ Assuring participation of older people and
their care partners in decision making (e.g.
treatments, advance care planning, health
care proxy, informed consent, elder abuse
reporting, legal guardianship, wills, and any
other decision-making point from the
perspective of the older person)
⎯ Assessing care partners’ knowledge, skills,
and needs, as well as their experiences (e.g.
coping strategies, preferences/wishes,
impact on health, burden) when providing
care to older people
⎯ Facilitating care partners’ self-awareness of
their own abilities, strengths and resilience
and recommending resources for self-care
and maintenance of well-being
⎯ Facilitating communication between older
people and their care partners when they
⎯ Gerontological nurses understand the importance of
transition across and between home,
the ethical underpinnings of nursing.
hospital, home care services, and nursing
⎯ Gerontological nurses are consciously aware of and
home utilizing appropriate technologies (e.g.
think critically about what ought to happen, what
tele-health, computer, digital speakers, and
adaptive devices)
⎯ Mediating situations of conflict between older
people and others by ethically balancing
person-centred care, older people’s
autonomy and wellbeing
⎯ Understanding the principles of capacity,
informed consent and advanced directives to
ensure person-focused decision making
arising from a trajectory of a disease or
adverse event
⎯ Supporting those who are dealing with dying,
death, grief and loss and celebrating
with those who are experiencing
momentous life events
⎯ Facilitating and recognizing the benefits of
inter-professional care by providing care
and services to older people and their
care partners and where appropriate,
connecting them with community
organizations
⎯ Promoting team problem-solving, decision
making and intra-professional
collaboration by jointly assessing care
needs (as perceived by the older person and
care partner); planning interventions
including new strategies; evaluating the
impact and outcomes on older people,
care partners and team members; facilitating
continuity of care; and developing new
and innovative working relationships
⎯ Using decision-making tools and resources,
communication strategies, and making
appropriate referrals, in collaboration
with interdisciplinary members, in order to
provide appropriate care and services
related to the needs and abilities of older
people and their care partners in making
complex decisions that arise with aging
⎯ Facilitating collaboration with inter-
professional resources, group interventions
with older people and their care
partners (e.g. bereavement groups,
reminiscence groups)
STANDARD 2: ETHICAL CARE
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MIDTERM TOPICS
should be done and what is fair and just (Chinn &
Kramer, 2018; Walton, 2019).
⎯ Gerontological nurses are respectful of the person’s
right to self- determination, choice and collaborative
decision making. Gerontological nurses recognize
that the ethical care of older people and their care
partners will involve clarification of conflicting values
and exploring alternatives (Chinn & Kramer, 2018).
⎯ Gerontological nurses understand that ethical
principles and codes form the basis upon which
ethical decisions and actions rest (Chinn & Kramer,
2018; Storch, et al., 2012; Walton, 2019). In
particular,
⎯ Gerontological nurses adhere to the Code of Ethics
(CNA, 2017).
Gerontological Nurses address:
⎯ Older people and care partners as advocates
⎯ Human right for autonomy, diversity, inclusion
⎯ Self-determination and freedom of expression
⎯ Ethical, moral and legal contexts of nursing
practice
⎯ Collaborative decision-making (e.g. beginning
and ending treatments, end-of-life care, medical
assistance in dying)
⎯ Access to and provision of care reflecting the
person’s preferences and cultural requirements
⎯ Promotion and support of autonomy and
independence
This requires competence:
⎯ Creating ethical workplaces
⎯ Providing ethical leadership
⎯ Mitigating the moral distress of nursing
colleagues
⎯ Reporting professional misconduct and
negligence
⎯ Using established criteria to identify elder abuse
and follow standards of care to recognize and
report mistreatment (e.g., physical, financial,
sexual, neglect, emotional, and social)
⎯ Using ethical decision-making care model
⎯ Protecting the older person’s and their care
partners’ rights
⎯ Recognizing vulnerability and risk for adverse
outcomes related to aging and social changes
⎯ Intervening to eliminate or minimize the use of
physical, chemical, and environmental restraints
(e.g. alternate strategies to prevent falls, to
prevent treatment interference, and to
understand personal expressions)
⎯ Preventing or reducing common risk factors that
contribute to functional and cognitive decline,
impaired quality of life, and excess disability in
older adults
⎯ Facilitating older adults’ active participation in all
aspects of their own health care (i.e. access to
information, right to self-determination, right to
live at risk, access to information and privacy)
STANDARD 3: EVIDENCE – INFORMED CARE
⎯ Gerontological nurses recognize that nursing
care for older people and their care partners are
based on evidence-informed knowledge, which is
comprehensive and complex.
⎯ Gerontological nurses have inquiring minds,
question the status quo, and seek new evidence
informed knowledge to answer questions when
faced with nursing care challenges (Boscart &
McCleary, 2012; Chinn & Kramer, 2018; Forbes
et al., 2015).
⎯ Gerontological nurses provide comprehensive
assessment and treatment of older people needs
using standardized assessments, including
reliable and valid measures and evidence-
informed interventions (Baumbusch, et al., 2016;
Hirst & Cole, 2014).
⎯ Gerontological nurses actively engage in
knowledge to action translation (Graham, et al.,
2006; Kislov et al., 2014; Ploeg, et al., 2014;
Ward, 2017) aiming to achieve promotion and
optimization of older person’s well-being,
regardless of presence of acute/chronic illness or
end-of-life care needs (Boscart & McCleary,
2012; Beuthin & Bruce, 2019; Duggleby et al.,
2016; Wickson-Griffiths, et al., 2016).
Gerontological Nurses address:
⎯ All aspects of health and well-being
⎯ Information and educational needs
⎯ Assessment of health, functional and
cognitive capacities
⎯ Geriatric syndromes
⎯ Pain and symptom management
⎯ Acute illness and chronic health conditions
management
⎯ Medication management,
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MIDTERM TOPICS
⎯ Behavior and cognitive therapy ⎯ Assisting older people to optimize
⎯ Adaptive communication needs homeostatic regulation through assessment
⎯ Advance care planning and management of physiological care to
⎯ Coping and grieving minimize adverse events associated with
⎯ End-of-life care (EoLC) and Medical medications, diagnostic or therapeutic
Assistance in Dying (MAiD) procedures, nosocomial infections or
environmental stressors
This requires competence ⎯ Planning and evaluating appropriate
interventions to promote function in response
⎯ Understanding and consideration of normal to change in activities of daily living (ADL)
age-related changes and instrumental activities of daily living
⎯ Completing a nursing history and (IADL)
examinations when there is a change in ⎯ Assessing endurance capacities of older
health status, setting, or well-being adults in supportive living arrangements,
⎯ Performing interventions (i.e. screening, including appropriate use of technology and
immunization, risk- assessment) to promote assistive devices to promote and maintain
wellbeing and optimal care, optimize quality optimal function, independence and safety
of life, prevent disease, injury and excess ⎯ Completing pain assessment and
disability, maximize function, maintain management, which includes the implications
desired level of autonomy and of depression, anxiety, fear, fatigue, and
independence, promote rehabilitation, and cognition
provide palliative care ⎯ Completing pain assessment for cognitively
⎯ Performing standardized assessments impaired people using valid and reliable self-
through the use of valid and reliable tools in report instruments and/or observations of
the domains of physical health and illness older people’s personal expressions (e.g.
conditions, functional and cognitive ability, agitation, withdrawal, vocalizations, and
mental health, and psychological function facial response/grimaces) and intervening as
including social support system and life appropriate
course changes ⎯ Recognizing that all emotional/physical
⎯ Recognizing and managing geriatric personal expressions and behaviours have
syndromes, and the complex interaction of cultural meaning and considering this within
acute and chronic co-morbid conditions its contextual issues
⎯ Distinguishing the clinical presentations of ⎯ Recognizing changes (e.g. sensory,
delirium, dementia, and depression (3D’s) cognitive) and assessing barriers that can
using validated and reliable screening tools affect communication and using
and involving the inter-disciplinary team in communication strategies, including
care planning and management technologies to meet people’s needs for
⎯ Assessing and addressing mental health and optimal communication
well-being needs including risk factors along ⎯ Addressing health-related learning needs
with advocating for treatment and strategies and developing, implementing and evaluating
to promote recovery and well- being learning plans to accommodate changing
⎯ Implementing falls prevention protocols, cognitive and sensory conditions (e.g. font
employing a valid and reliable measure of fall and letter size; additional learning time to
risk assessment, and by promoting least process information; ambient light
restraint approaches in injury prevention adjustments)
programs ⎯ Supporting nutrition/fluid balance (e.g.
⎯ Applying evidence-based standards and best difficulty with chewing and swallowing,
practice guidelines to promote health alterations in hunger and thirst, inability to eat
promotions activities (e.g., rest/sleep, activity by oneself and capacity of others to assist
and exercise in older adults) with meals) in consideration of older persons’
abilities and wishes

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MIDTERM TOPICS
⎯ Identifying use of prescription medications,
over-the-counter medications, herbal
remedies and complementary and alternative
therapy; and using established criteria for
assessment and management of
polypharmacy
⎯ Identifying factors associated with increased
risks specific to complications (i.e.
cardiovascular disease, renal disease,
diabetes, thromboembolic disease and
neuropsychiatric disorders) and
recommending a management plan that
minimizes the risks for adverse outcomes
⎯ Collaborating with others to include
complementary and integrative health care
practices for health promotion and symptom
management for older people
⎯ Identifying and managing bowel and genital
urinary functions with most appropriate
intervention (e.g. prompting approaches to
voiding, implementing
⎯ regular toileting, selecting appropriate
adaptation devices, avoiding
catheterizations)
⎯ Promoting quality end-of-life care (EoLC) for
older persons, including pain and symptom
management, advance care planning, and
support for care partners
⎯ Implement care within the context of Medical
Assistance in Dying (MAiD) according to
policy and ethical code of conduct
STANDARD IV: AESTHETIC/ARTFUL CARE
⎯ Gerontological nurses recognize that nursing care of
older people and their care partners must reflect
aesthetic practices, the art of nursing (Henry, 2018).
⎯ Gerontological nurses recognize the importance of
searching for the deeper meaning of the older
person’s health/illness/dying experience. Conse
quently, gerontological nurses seek to connect to the
human experience of sickness, suffering, recovery,
transitioning and death through provision of care that
is artful, person-centred, and grounded in evidence-
informed, ecopsychosocial practices (Ziesel, et al.,
2016).
⎯ Gerontological nurses understand that environmental
strategies are effective in supporting the delivery of
person-centered care and can have a strong potential
in making positive impact on aging experiences
(Chaudhury, et al., 2017; Fleming, et al., 2016;
McDonald & Monteiro, 2019).
⎯ Gerontological nurses understand that the
‘experience’ of care is highly influenced by the social
and physical environment within which care is
delivered (Hung, et al., 2017; McCormack &
McCance, 2017).
⎯ Therefore, gerontological nurses are sophisticated in
their ability to interact with older people and their care
partners to create a holistic environment that is
pleasing, comforting and supportive.
⎯ In addition, gerontological nurses ensure that older
people and their care partners have access to
evidence-informed aesthetic practices (music, poetry,
stories, drawings, etc.) that
⎯ promote interpersonal strength, coping and resilience
(Legere et al., 2017).
Gerontological Nurses address:
⎯ Need for older people to share experiences and their
meaning
⎯ Aesthetics of living/caring spaces (e.g. acute,
convalescent and long-term care spaces, bedrooms,
common rooms, bathrooms, bathing environments
and mealtime environments)
⎯ Environmental design (wall colour, pictures, plants,
photographs, drawings, where appropriate)
⎯ Need for music, warmth, comfort, food, artistic
elements, presence of familiar people or objects
⎯ Access to activities that spring from need for creative
expression through interpersonal health resources
such as mindfulness, yoga, dance, massage,
movement, art therapy, interaction with living
organisms such as plants, animals, pets, nature
⎯ Appropriate skill mix, shared decision-making, shared
power, effective staff relationships and supportive
organizational systems
This requires competence:
⎯ Developing and sustaining interpersonal
connections that provide the foundation for
knowing the older person at a deeper level of
understanding
⎯ Promoting an environment within which the older
person and care partner are free to express their
concerns, hope, dreams, feelings, values and
beliefs
⎯ Searching for the deeper meaning of the older
person’s health/illness/dying experience
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 NCM 114 LECTURE
GERIATRICS (ALCON & ZILABBO)
MIDTERM TOPICS
⎯ Providing care that is artful, person-centred, and
grounded in evidence- informed, eco-
psychosocial practices
⎯ Providing input to environmental design features
of care facilities being renovated or newly built to
ensure they incorporate features critical for the
aesthetic and safe needs unique to older people
and their care partners
⎯ Ensuring that the environment promotes healing,
nurturing, care, belonging and sensory
engagement through strategic placement of
pictures, sculptures, installations, use of light,
sounds, and smells to promote relaxation
⎯ Collaborating with inter-professional team
members to advocate for adequate equipment for
older people to engage in meaningful activities
⎯ Collaborating with inter-professional team
members and organizational leaders to ensure
that the environment permission to share ideas,
develop new care approaches that contribute to
build and sustain a culture of care innovation
STANDARD V: SAFE CARE
⎯ Gerontological nurses are responsible for assessing
the older person and the environment for hazards that
threaten safety, as well as planning and intervening
appropriately to maintain a safe environment (Hirst,
2014; Parke, et al., 2013).
⎯ Gerontological nurses collaborate with the older
person and care partners in acknowledgement of their
right to live at risk and need for autonomy (Gillis,
2019; Hirst, et al., 2016; Potter & Perry, 2019; Varcoe
& Kolar, 2019).
Gerontological Nurses address:
⎯ Health literacy (e.g. accessible access to
accurate, relevant and safe health
information resources, including
technology)
⎯ Culturally competent and safe care
⎯ Equipment requirements for maintaining
safety (e.g. transfers, mobility, stairs)
⎯ Risk reduction and monitoring of risk over
time
⎯ Assessment, prevention and mitigation of all
forms of abuse
⎯ Safe interpersonal relationships, including
relationships of intimacy
⎯ Assessment of risk; reduction, mitigation, and
monitoring of risk over time (e.g. falls,
depression, disaster planning, suicide,
self-harm, self-neglect, access to required
medication, review of medication or
substances abuse or misuse, polypharmacy,
STIs)
⎯ Food security
⎯ Access to safe and affordable housing
This requires competence:
⎯ Analyzing the effectiveness of community
resources in assisting older people and their care
partners to retain personal goals, maximize
function, maintain independence in accordance
with the desired level of autonomy, and live safely
in the least restrictive environment
⎯ Forming partnerships and engaging in
collaborative decision-making with older people,
their care partners and communities, to achieve
mutually agreed upon health outcomes and
transition safely through the system
⎯ Respecting and promoting older peoples’ rights to
dignity and self-determination, safety, freedom
from abuse within the context of the law and
safety concerns
⎯ Maximizing self-care (e.g. immunizations,
accident prevention)
⎯ Identifying that older people may be at risk and
need education/protection in relation to their right
to privacy and information
STANDARD VI: SOCIO-POLITICALLY ENGAGED
CARE
⎯ Definition: Gerontological nurses are aware of the
socio- economic-political contexts that influence
all aspects of care. As such,
⎯ Gerontological nurses collaborate with older
people and their care partners to advocate for
equitable access to health system resources that
address their care needs.
⎯ Gerontological nurses provide systems to support
and sustain practice changes, including ongoing
social justice advocacy, education, policies and
procedures and job descriptions (Gillis, 2019;
McIntyre & McDonald, 2019).
Gerontological Nurses address:
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 NCM 114 LECTURE
GERIATRICS (ALCON & ZILABBO)
MIDTERM TOPICS
⎯ Ageism that limits health care delivery and
stigmatizes older people within society
⎯ Care inequities across all sectors of health care
delivery
⎯ Inadequate health policy at the local, provincial
and national levels
⎯ Advocacy needs of the older person within the
healthcare system
This requires competence:
⎯ Collaborating with a variety of public and
professional organizations as well as other
stakeholders to influence building of health policy
⎯ Meeting educational needs of older people, their
care partners and other stakeholders regarding
emergent trends and issues that will impact on
health care needs of the aging population in the
future
⎯ Identifying and evaluating the accessibility,
availability, and affordability of health care for
older adults to promote their goals
⎯ Identifying gaps, barriers, and fragmentation in
the health care system and applying evaluation
and research findings to improve the health care
system in achieving intended outcomes for older
adults and their care partners
⎯ Lobbying governmental policy makers to
influence building of health policy using
comprehensive strategies such as electronic and
social media, letters to officials, briefing notes,
letters to the editor, media releases and
resolutions
⎯ Advocating for health care services that will
enhance care of older people within specific
organizations and across society
⎯ Collaborating with the older person and their
partner in care to advocate for health care needs
and requirements from health care system,
community, societal and global perspectives
EXPANDED SENIOR CITIZENS ACT OF 2010
REPUBLIC ACT NO. 9994
Who are considered as Senior Citizens?
- Any Filipino who is a resident of the Philippines,
and who is sixty (60) years old or above.
- It nay apply to senior citizens with “dual
citizenship” status provided they prove their
Filipino citizenship and have at least six (6)
months residency in the Philippines.
Senior citizens are entitled to the following:
a. Discount privileges
b. Free services
c. Exemptions
d. Incentives
e. Government financial assistance, and
f. Priority in express lanes
Discount Privileges granted to Senior Citizens:
a. 20% discount on the purchase of certain goods
and services
b. Special 5% discount on prime commodities and
basic necessities
c. 5% utility discount on electric and water
consumption, and
d. 50% discount on electric, water and telephone
consumption of senior citizens centers and
residential or group homes.
What transactions by senior citizens are covered by
the 20% discount and VAT-exemption?
a. The purchase of medicines
b. The professional fees of attending physician
c. The professional fees of licensed professional
health workers providing home health care
services
d. Medical and dental services, diagnostic and
laboratory fees
e. Actual face for land transportation travel
f. Actual transportation fare for domestic air
transport services and sea shipping vessels.
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NCM 114 LECTURE
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MIDTERM TOPICS

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GERIATRICS (ALCON & ZILABBO)

MIDTERM TOPICS
Prevalence may also be dependent on comorbidity
-More drugs among diabetics than age or sex matched
non-diabetics (Good, 2002)
- Other predictors include number of starting drugs, CAD
diabetes, and use of medications without indications
(Veehof et al. 2000)

Question: Any substance may have an interaction

with the following EXCEPT:

a. Another drug
b. Food
c. Disease
d. None of the above

Consequences

Adverse Drug Reactions (ADRs) which may include:

- Drug-drug interactions
- Drug-disease interactions
- Drug-food interactions
- Drug side effects
- Drug toxicity
POLYPHARMACY IN THE ELDERLY
Note: May incrwse from 7% in those using 2 drugs to 50%
in those using 5 and 100% in those using >10 (Lin 2003;
OBJECTIVES:
Brazeau 2001)
- Definition of polypharmacy
Quality of Life
- Prevalence
- Consequences ⎯ In ambulatory elderly: 35% of experience ADRs and
- Pharmacology and Aging 29% require medical intervention
- Specific Examples ⎯ In nursing facilities: 2/3 of residents experience ADRs
- Interventions and 1 in 7 of these require hospitalization
Question: How many drugs must an older person ⎯ Up to 30% of elderly hospital admissions involve
take to make him at risk for polypharmacy??? ADRs
a. 2 ⎯ Linked to preventable geriatric syndromes
b. 5
c. 10 ECONOMIC
d. A gazillion

Polypharmacy ⎯ In 2000: ADRs caused 10, 600 deaths

The use of more than 5 medications, some of which may
be clinically inappropriate
Prevalence:
As much as 25% of the overall population
Chumney et al,, 2006)
For those >65 years old, prevalence increases to 50%
⎯ Annual cost of $85 billion
⎯ $76.6 billion in ambulatory care
⎯ $20 billion in hospitals
⎯ $4 billion in SNF
PHARMACOKINETICS AND AGING
Characterization and mathematical description of the
absorption, distribution, metabolism, and excretion of
drugs, their by-products, and other substances of biologic
interest as affected by the elderly body.

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 NCM 114 LECTURE
GERIATRICS (ALCON & ZILABBO)
MIDTERM TOPICS
Question: In which of the following situations is drug
absorption decreased in the elderly?
a. Amoxicillin taken with food
b. Vitamin B12 in patients with atrophic gastritis
c. Calcium carbonate taken with food
d. Ferrous sulfate taken while on omeprazole
Absorption
Age- related gastrointestinal tract and skin changes seem
to be of minor clinical significance for medication usage
- Decrease in small intestine surface area
- Increase in gastric pH
Medical conditions (e.g. achlorhydria), other medications
or feedings may modify absorption
- Vitamin B12 in atrophic gastritis
- PPIs with sucralfate
- Amoxicillin with food
Distribution
Age-related changes
- Decrease in lean body weight
- Decrease in total body water (10-15%)
- Increased percentage body fat (-15-30%)
- Increased fat; water ratio
- Decreased plasma proteins, especially
albumin
Occurrence of heart failure, kidney disease with resulting
water retention
Question: Drugs that are lipophilic tend to have:
a. Shorter half-lives
b. Shorter effects
c. Longer effects
d. None of the above
Increase in volume of distribution for lipophilic drugs
- Sedatives that penetrate CNS
- Leads to longer half-lives
Metabolic capacity of phase I reactions decrease
Phase II reactions are largely unaffected
Greater, active, free concentration in highly protein-bound
drugs
Metabolism
Some overall decline in liver metabolic capacity due to
decreased liver mass and hepatic blood flow
- Highly variable, no good estimation algorithm
- Minimal clinical manifestations
Concurrent drug use may affect metabolism in both
directions
No formula to estimate this effect
Renal Elimination
Age-related decrease in renal blood flow
GRF decreases by 8 mL/min/1.73m2/decade
Decreased lean body mass leads to decreased creatinine
production
- Serum creatinine not reliable
- Need to estimate creatinine clearance and
adjust medications accordingly
Question: In bedridden, demented, and constipated
older patient, which agent may be more appropriate
to use
a. Fiber bulking agents (e.g. psyllium)
b. Bisacodyl
c. Lactulose
d. Commercial enema (e.g. Fleet Enema)
PHARMACODYNAMICS AND AGING
⎯ Effect of the drug on the body with regard to aging
⎯ Generally, lower drug doses are required to achieve
the same effect with advancing age.
- Receptor number, affinity, or post0receptor
cellular effects may change.
- Changes in homeostatic mechanisms can
increase or decrease drug sensitivity.
INAPPROPRIATE MEDICATIONS: BEERS CRITERIA
⎯ One of the most, if not the widely used consensus
data for inappropriate medication use in the elderly
⎯ Latest revision in 2003
⎯ Covers 2 statements regarding drug use in elderly:
⎯ Those inappropriate for elderly in general
⎯ Those inappropriate for the elderly with regard to
specific conditions
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VITAMINS AND HERBAL USE IN OLDER ADULTS

-Highly prevalent among older adults

-77% in Johnson and Wyandotte country
community dwelling elderly
-Generally not reported to the physician
-serious drug interactions possible:
-Warfarin, gingko biloba, vitamin E

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⎯ Talk to your patient about potential ADRs
NON-ADHERANCE TO MEDICATION REGIMENS ⎯ Warn them of potential side effects and report
symptoms
⎯ Educate the family and caregiver
Related to both physician and patient factors
⎯ Ask pharmacist for help in identifying interactions
⎯ Assist your patient in making and updating a
⎯ Large number of medications
medication list-personal medical record
⎯ Expensive medications
⎯ Avoid seeing multiple physicians
⎯ Complex or frequency changing schedule
⎯ Do not use medications from others
⎯ Adverse reactions
⎯ Confusion about brand name/trade name
PERSONAL HEALTH RECORD
⎯ Difficult-to-open containers
⎯ Rectal, vaginal, SQ modes of administration ⎯ It will reduce polypharmacy and ADRs
⎯ Limited patient understanding ⎯ Multiple specialist involved in care
⎯ Transitions in care from independent living,
Geriatric Prescribing Principles hospitals, nursing homes and assisted living
facilities
⎯ First consider non-drug therapies
⎯ Great aid in emergency care
⎯ Match drugs to specific diagnoses
⎯ Provides the patient with more peace of mind
⎯ Try to give medications that will trat more than one
condition
It includes:
⎯ Reduce meds whenever possible
⎯ Patient identifying information
⎯ Avoid using a drug to treat side effects of another drug
⎯ Doctors contacts
⎯ Review meds regularly (at least q3 months) ⎯ Caregiver contacts
⎯ Avoid drugs with similar actions/same class
⎯ Past Medical History and Allergies
⎯ Clearly communicate with patient and caregivers ⎯ List of all Medications, dose, reason they are
⎯ Consider cost of meds taking it and whether it is new.

CARE: AVOIDING POLYPHARMACY

Caution and Compliance

⎯ Understand side effects profiles
⎯ Identify risk factors for an ADR
⎯ Consider a risk to benefit ratio
⎯ Keep dosing simple-QD or BID
⎯ Ask about compliance
Adjust the Dose
⎯ Start low and go slow-titrate
⎯ Consider the pharmacokinetics and
pharmacodynamics of the medication
Review Regimen Regularly
ETHICO-LEGAL CONSIDERATIONS IN THE OLDER
⎯ Avoid automatic refills
ADULTS
⎯ Look for other sources of medications -OTC
⎯ Caution with multiple providers ETHICAL PRINCIPLES
⎯ Don’t use medications to treat side effects of
other meds ⎯ Beneficence
⎯ Choose drugs to discontinue or substitute safer ⎯ Non-maleficence
medications ⎯ Futility of Treatment
Educate ⎯ Confidentiality
⎯ All medicines, even over-the-counter, have ⎯ Autonomy and Informed Consent
adverse effects-report all products used ⎯ Justice

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ones.
BENEFICENCE
LONG-TERM CARE
⎯ Do right (“good”) by the patient.
⎯ The physician’s main concern is the welfare of the Includes a broad range of personal, social, and medical
patient. services and support that ensure people with, or at risk of
⎯ Do what is medically helpful a significant loss of intrinsic capacity can maintain a level
of functional ability consistent with their basic rights and
NON-MALEFICENCE human dignity.
GOALS:
⎯ Avoiding harm. ⎯ Help people live as independently and safely
⎯ Implement effective non-hospital as possible
treatment when possible (due to
⎯ Prevent, reduce, or rehabilitate functional
complications that can arise with
decline
during hospitalization of elderly
patients).
LONG-TERM CARE PROVIDED IN DIFFERENT
⎯ Withhold diagnostic work-up or
treatment when intervention is SETTINGS
unlikely to result in meaningful
survival or patient well-being. ⎯ Home based care
⎯ Community based care
FUTILITY OF TREATMENT ⎯ Facility based care

⎯ Treatment should be consistent with the patient’s HOME BASED CARE - Includes health, personal, and
(clinically realistic) goals. support services to help people stay at home and live as
⎯ Assess each case individually so as to determine independently as possible.
whether treatment would be beneficial. - It involves a range of healthcare services,
⎯ Avoid interventions that would not benefit the including medical treatment, nursing care,
patient and/or prolong suffering.
rehabilitation, assistance with daily activities,
and health education, delivered by trained
CONFIDENTIALITY
professionals, caregivers, or family
⎯ Complete and absolute confidentiality is the members.
underlying tenet. - Home Health Care
⎯ Comply with state laws regarding disclosure to - Personal Care
public health authorities and third parties. - Homemaker Services
- Friendly visitor/Companion Services
AUTONOMY AND INFORMED CONSENT - Emergency Response Systems

⎯ A patient has the inherent right of self-
determination.
⎯ A patient has the right to consent and a right to
refuse diagnostic work-up or treatment. This
includes protection from unwanted touching.
⎯ A patient has the right to be educated on the pros
and cons of a medical decision.
JUSTICE
⎯ Distribute resources and treatment in an equitable
manner.
⎯ Be fair and lawful
⎯ Use objective decision
making processes, not
emotional or subjective
COMMUNITY-BASED CARE - Services available in the
home, making it easier for a person to live at home.
- Community-based services, are services that
available in the community. Generally, they
supplement the services that people get and
need in their homes and they help people to
stay in their homes
- Adult day service programs
- Senior centers
- Transportation services
- Meals program
- Respite Care
FACILITY-BASED CARE – Is for those require help
and can no longer live on their own.

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- Adult foster care Goals:
- Board and care homes ⎯ Prevent or relieve suffering
- Assisted living facilities available while respecting end-
- Nursing homes of-life patients.
- Continuing care retirement ⎯ Support holistic patient care and enhance quality of
life.
ETHICAL CONSIDERATIONS IN LONG TERM CARE ⎯ Render care to patients to live as actively as
possible.
⎯ Autonomy ⎯ Maintain their dignity and hope while they are alive.
⎯ Beneficence
⎯ Nonmaleficence Nurses in Palliative Care
⎯ Justice ⎯ providing comfort
⎯ establishing a therapeutic and empathetic
relationship
AUTONOMY – This principle emphasizes ⎯ being there with the patient
respecting the individual's right to self-
determination, independence, and HOSPICE CARE VS PALLIATIVE CARE
decision-making. In long-term care, this
means honoring the resident's preferences, PALLIATIVE care- simultaneously receive curative and
choices, and values as much as possible palliative treatment

BENEFICENCE - Long-term care HOSPICE care – provided once a person decides to forgo
providers must act in the best interests of curative treatment
the residents, promoting their well-being
and health. This principle becomes ETHICAL ISSUES IN
particularly crucial when residents may PALLIATIVE CARE- Common
have compromised decision-making ethical issues include goal of care,
abilities due to conditions like dementia. advanced directives issues, patient
and family goal conflicts, physician
NONMALEFINCE - This principle and patient goal conflicts,
underscores the importance of transitioning focus of care, pain
avoiding actions that might cause and symptom management, and
harm to residents. Care workers, palliative care treatment.
administrators, and the entire care
community should prioritize DILEMMAS:
minimizing potential harm
Decision-making for end of life care
JUSTICE - In long-term care has earned paramount importance
settings, justice involves fair as it has capability to prolong the
treatment, equal access to human life with the support of
resources and services, and medical technologies or can let the
equitable distribution of natural death process continue by
benefits and burdens among foregoing the treatment option.
residents.
Dilemmas are associated with decisions made concerning
continuing, limiting, or withdrawing life-sustaining
PALLIATIVE CARE
treatments.
Specialized medical care for people living with a
terminal illness COMMON ETHICAL ISSUES

1. BROKEN COMMNUNICATION
According to WHO, it is an approach that improves the
quality of life of patients and their families who face End-of-life conversations are always difficult, but they need
problems associated with life-threateningillness to happen.

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Asking patients early about their wishes and providing
them with accurate information and resources ensures a
clear line of communication.
Nurses should advocate for regular family meetings so
everyone can understand the patient’s condition and the
best steps to take as the disease progresses
2. COMPROMISED PATIENT AUTONOMY
Patients have the right to voice their choices for end-of-life
treatment, but this stage of life may come withlimitations.
It is vital to respect patient autonomy while keeping in
mind the best treatment route without compromising the
patient’s decision.
Nurses should encourage patients and their significant
others to discuss end-of-life care and to use advance
directives so patients’ wishes can be maintained if patients
lose their ability to make decisions about their care.
Help the patient understand what the situation and
respect theirvalues.
NON-MALEFICENCE
It is the obligation not to inflict harm intentionally
JUSTICE
Considered an individual’s decision of what is better
for the better of the patients and society.
ADVANCED DIRECTIVES
⎯ Advanced directives are legal documents that
state the patient’s wishes when the patient’s
becomeunabletospeakforthemselves
⎯ Advanced directives are created ahead of any
medical incapacitation in order to ensure that the
patient has the ability to make their own
decisionswhentheyareunabletodo
TYPES OF ADVANCED DIRECTIVES

3. POOR SYMPTOMS MANAGEMENT ⎯ Living will

⎯ Durable power of attorney
Symptom treatment is a major factor in nurses caring for ⎯ POLST (Physician Order for life Sustaining
patients at the end of their lives, as it brings up the question Treatment
of whether the benefits of using medication outweigh
potential risk and side effects. LIVING WILL

Relief of symptoms must be balanced with the possible
side effects of medications and to keep focused on what is
in the best interest of the patient’s quality of life.
4. SHARED DECISION MAKING
One of the most important factors of end-of- life care.
The living will is a legal document used to state
certain future health care decisions only when a
person becomes unable to make the decisions and
choices on their own. (only used at the end of life if a
person is terminally ill (can't be cured) or
permanently unconscious.

Decision-making becomes an ethical issue when more

than one party is involved.

Advance directives, such as a living will, medical power of

attorney, Physician Orders for Life-Sustaining Treatment
and DNR orders should be considered in advance to
present during the decision-making process.

DECISION-MAKING&ETHICAL PRINCIPLES
AUTONOMY
Ability of the person to choose and act for one’s self free
of controlling influences. Ability to make decisions based
upon our personal values and wishes.
BENEFICENCE

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THINGS TO THINK ABOUT WHEN WRITING A LIVING ⎯ Your adultchild;
WILL: ⎯ Your adultsibling;
⎯ A close friend; or
⎯ Cardiopulmonary ⎯ Your nearestliving relative.
⎯ Resuscitation (CPR)
⎯ Mechanical Ventilation CAN I APPOINT MORE THAN ONE AGENT?
⎯ Tube Feeding
⎯ Dialysis Yes. The law allows you to appoint co-agents (two
⎯ Antibiotics or Anti-viral Medications people who will serve together as equals) or
⎯ Comfort Carre (Palliative Care) successive agents (a second person who will serve in
⎯ Organ and Tissue donations case the first agent is unable to do so).
⎯ Donating your body
IS MY AGENT LEGALLY LIABLE FOR WHAT SHE
DOES?
HOW LONG ARE LIVING WILLS GOOD FOR?

No, As long as the agent is acting in “good faith” and

⎯ Your living will remains effective for as long
in accordance with your instructions, the law protects
as you live, unless you intentionally revoke it
him or herfrombeingsuedforhisorheractions.
or the courts get involved

PHYSICIAN ORDERS FOR LIFE-SUSTAINING

DO NOT RESUCITATE & DO NOT INTUBATE
TREATMENT (POLST)

⎯ You don’t need to have Advance Directive or

The document may also be called provider orders for
Living will to have a DNR or DNI orders. You
life-sustaining treatment (POLST) or medical orders
can establish DNR & DNI orders by telling to
forlife-sustainingtreatment(MOLST).
your doctor and she/he can put them in your
medicalrecord
A POLST is intended for people who have already
beendiagnosedwithaseriousillness
DURABLE POWER OF ATTORNEY FOR HEALTH
CARE

⎯ A durable power of attorney for health care,

also known as amedicalpowerofattorney,is
a legal document in which you name a person
to be a proxy (agent) to make all your health
caredecisionsifyoubecomeunabletodo so.
⎯ Before a medical power of attorney can be used
to guide
⎯ medical decisions, a person's physician must
certify that the person is unable to make their
own medical decisions

WHAT HAPPENS IF I DO NOT HAVE A DURABLE

POWER OF ATTORNEY FOR HEALTH CARE?

The following people are in order of priority, they are

legally authorized to make your health care decisions
for you:

⎯ Your court-appointed guardian or conservator;

⎯ Yourspouseordomesticpartner;

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PHYSICIAN FOR LIFE-SUSTAINING
TREATMENT (POLST)
⎯ This form does not replace your other
directives. Instead, it serves as doctor-
ordered instructions — not unlike a
prescription - to ensure that, in case of an
emergency, you receive the treatment you
prefer. Your doctor will fillout theformbased
onthecontentsofyouradvancedirectives.
⎯ POLST enables your doctor to include details
about what treatments not to use, under what
conditions certain treatments. can be used,
how long treatments may be used and when
treatments should be withdrawn.
ISSUES COVERED IN A POLST MAY INCLUDE:
⎯ RESUSCITATION
⎯ MECHANICAL VENTILATION
⎯ TUE FEEDING
⎯ USE OF ANTIBIOTICS
⎯ REQUESTS NOT TO TRANSFER TO AN
EMERGENCY ROOM
⎯ REQUEST NOT TO BE ADMITTED TO THE
HOSPITAL
⎯ PAIN MANAGEMENT
CREATING ADVANCED DIRECTIVES
⎯ Advanced directives need to be in writing.
⎯ Must be signed by a witness or notarized
⎯ Review your advanced directives with your
doctor and your health care agent to be sure
you have filled out forms correctly.
Note: Each state has different forms and
requirements for creating legal documents.
WHEN YOU HAVE COMPLETED YOUR
DOCUMENTS, YOU NEED TO DO THE
FOLLOWING:
⎯ Keep the originals in a safe but easily
accessible place
⎯ Give a copy to your doctor
⎯ Give a copy to your health care agent and
any alternate agents
⎯ Keep a record of who has your advance
directives.
⎯ Talk to family members and other important
people in your life about your advance
directives and your health care wishes
⎯ Carry a wallet-sized card that indicates you
have advance directives
⎯ Keep a copy with you when you are traveling
REVIEWING AND CHANGING ADVANCED
DIRECTIVES:
⎯ You can change your directives at any
time.
⎯ If you want to make changes, you must
create a new form, distribute new copies
and destroy allold copies.
Consider reviewing your directives and creating
newones in the following situations:
⎯ New diagnosis.
⎯ Change of marital status. Change inwishes
⎯ Aboutevery10 years.
LOSS AND END OF LIFE CARE
BEREAVEMENT
⎯ Bereavement is the state or situation of having
experienced a death-related loss.
⎯ Bereavement includes grief and mourning, both
the inner emotional response and the outward
response of the survivor.
⎯ Bereavement adjustments are multidimensional
in that nearly every aspects of a person’s life may
be affected by the loss.
⎯ Bereavement is a highly stressful process, but
many older surviving spouses are resilient.
⎯ The overall effect of bereavement on the physical
and mental health of many older spouces is not
as devastating as expected
⎯ Older bereaved spouses commonly experience
both positive and negative feelings
simultaneously.
⎯ Loneliness and problems associated with the
tasks of daily living are two of the most common
and difficult adjustments for older bereaved
spouses.
⎯ Spousal bereavement in later life might best be
described as a process that is most difficult in the
first several months but that improves gradually,
if unsteady, over time. The improvement may
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continue for many years, but it may never end for
some.
⎯ A great deal of diversity exists in how older
bereaved adults adjust to the death of a spouse.
Mourning
⎯ Mourning is often used to refer to the ritualistic
behaviors in which people engage during
bereavemen
⎯ More recently, mourning is the term used for
processes related to learning how tolive with one’s
lossand grief
STAGES OF MOURNING
1. Avoidance
2. Assimilation
3. Accommodation
TASK OF MOURNING
1. Accepting the reality of the loss
2. Experiencing or working through the pain of
grief
3. Adjusting to an environment in which the
deceased is missing.
4. Emotionally relocating the deceased and
moving on with life.
MEANING MAKING
⎯ The study reveals that older individuals' meaning in lifeis
primarily derived from family relationships, but when
loved ones die, their meaning changes. Personal
beliefs and attitudes, including cultural and religious
ones, influence how they perceive illness and death,
affecting their responses andthe needforcaregiversto
understand and assist them
⎯ The study suggests that mourning involves
reconstructing meaning in a person's life after a
loved one's death, influencedbysocialcontextand
individualresources
⎯ The study highlights the importance of "sense making"
and "benefit finding" in understanding the impact of
death on asurvivor'slife, ratherthansolelyfocusingon
reorderinglifepriorities
⎯ Researchers expanded the concept of "meaning"
and "grief" to include identity change and purpose in
life. The dual process model suggests that bereaved
individuals waver between loss-oriented and
restoration-oriented approaches to everyday life
experiences, eventually focusing on positive meaning
reconstruction. This process helps individuals make
meaning from their experiences, allowing them to
navigatetheirgriefandidentity
LOSSES
⎯ A loss may involve a person, thing relationship, or
situation
⎯ Gradual and abrupt life transitions such as
retirement, change of residence, ill health, loss of pets
and the inability to drive are losses that evoke varying
responses to grief
⎯ Older adults often experience multiple losses, which
can lead to emotional crises and discusses factors like
coping styles, support systems, and spiritual beliefs
thatinfluence howpeoplerespondrothislosses
GRIEF
A personalizedemotionalresponsethatanindividual
makestoareal,perceivedoranticipatedloss.
1. Early Phase – People accept the reality of loss
2. Middle Phase – Intense emotional pain and
separation and may be accompanied by physical
symptoms and labile emotions
3. Last Phases – reintegration and relief occur as
the pain gradually subsides and degree of
physical and mental balance returns.
COMMON SYMPTOMS OF NORMAL GRIEF
RESPONSES
1. PHYSICAL SYMPTOMS-tearful, loss of appetite,
fatigue, sleep difficulties, tension, and various bodily
sensationsliketightnessinthechestorthroat.
2. PSYCHOLOGICAL RESPONSE
feelings of sadness, guilt, anxiety, anger,
depression, apathy, and loneliness.
shock and disbelief may follow the death,
and the bereved peson may
experience a preoccupation with the
deceased.
3. SOCIAL RESPONSES- The social changes following
a loss depend on the type of relationship and social
roles. Widowhood can have a significant impact on
social role change, and the bereaved person may
needtolearnnewskillsandroles.
Socialization and interaction patterns may also
change.
4. SPIRITUAL ASPECTS- The social changes following
a loss depend on the type of relationship and social
roles. Widowhood can have a significant impact on
social role change, and the bereaved person may need
to learn new skills and roles. Socialization and
interactionpatternsmayalsochange.
TYPES OF GRIEF
1. Anticipatory grief - occurs before the
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actual loss, involving mourning,
coping, and planning when the
impending death of a loved one is
recognized. It can be healthy but might
affect the relationship with the dying
person.

2. Complicated mourning or
abnormal grief - is when grief does
not progress towards resolution and
becomes severe and prolonged. This
condition is known as D ysfunctional
Grieving and should be addressed by
advanced practice nurses or other
professionals experienced in
complicated grieving. Anticipatory grief
can help reduce early shock and
confusionbefore the actualdeath.

3. Disenfranchised grief- is unacknowledged or

invalidate grief, which can complicatethe grieving
process du to a lack of social support. This type of grief
can arise from situations like unrecognized
relationships, unacknowledged losses, perceived
inability to grieve, or circumstances surrounding
death.

4. COMPLICATED GRIEF
⎯ Chronic Grief
⎯ Delayed
⎯ Exaggerated
⎯ Masked A

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COMMUNICATING WITH OLDER PERSONS Stats

Communication -process of exchanging Information: - only 7% of communication comes from the actual
sending messages back and forth between individuals or words we use; the other 93% is nonverbal.
groups of people. - 38% of communication is transmitted by
- The most effective way to bridge the gulf between paralinguistic cues (i.e., tone, pitch, rate, speed,
the generations is good communication and volume of voice)
- 55% is transmitted by body cues
Effective communication requires the following:
FORMAL OR THERAPEUTIC COMMUNICATION
1. The need or desire to share information
Therapeutic communication is a conscious and
2. Acceptance that there is value and merit in what the
deliberate process used to gather information related to a
other person has to say, demonstrated by a willingness to
patient’s overall health status.
treat the other person with genuine dignity and respect
• respond with verbal and nonverbal approaches
3. Understanding of factors that may interfere with or that promote the patient’s well-being or improve
become barriers to communication the patient’s understanding of ongoing care.
• Effective verbal communication requires the
4. Development of the skills and techniques that facilitate ability to use a variety of techniques when
effective interchange of information sending and receiving messages.
• nurses should know as much as possible about
the other person involved.
INFORMATION SHARING • Avoid acronyms, such as TURP or CBC, unless
• you are sure that the person understands them.
Verbal communication involves sending and receiving
messages using words. Some verbal communication is
formal, structured, and precise; some is informal,
INFORMAL OR SOCIAL COMMUNICATION
unstructured, and flexible.
Older patients often like to know something about
the nurses who care for them; they may ask about your
family, hobbies, and interests.

Do not be afraid to be “human” when

communicating with older adults but be careful not to over
disclose information that might make the patient view you
in an unprofessional light.

Be honest with your older patients. When you do

not have time to visit, explain why so that patients do not
personalize and think they have done something wrong.

Do not be afraid to use humor appropriately, but

choose the right time and place, and make sure it is
culturally sensitive. “laughter is the best medicine.”

Aging does not cause people to lose their sense

of humor. A humorous story or cartoon may help brighten
their day.

NON-VERBAL COMMUNICATION

1. Symbols:

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The white uniform and cap- helped older adults
distinguish nurses from other caregivers, and to
distinguish the level of education attained by that nurse.
• other settings, nurses may not wear any uniform,
or they may wear scrubs.
Street clothes (navy blue outfit with an identifying name
tag)- preferred in some agencies, particularly in home
care or public health center.
• can be confusing to older adults because such
clothing is not distinctive enough to identify the
individual as a nurse and because many older
adults cannot read the small print on name tags.
2. Tone of Voice:
Tone of voice is a fairly reliable way of judging a person’s
emotions.
• Shouting is often associated with anger or
displeasure.
o not an appropriate way to deal with
hearing problems, because our tone of
voice may lead the hearing-impaired
person to think we are angry.
• low tone of voice close to the person’s good ear
is much more effective.
• Use of other nonverbal methods of
communication, such as communication
boards or gestures, can also help.
3. Body Language
• Standing at the door, hurrying down the
hallway, sitting behind the nurses’ station,
and working in the medication- communicate
that you are busy and do not want to be
interrupted.
o Many older adults and their families are
intimidated by this body language and
may hesitate to interrupt, even to report
serious concerns.
• Going into the rooms to talk with patients,
sitting down at eye level with residents, and
spending time in the lounge with visitors- are
all ways of nonverbally communicating that you
are truly interested and concerned.
• patients who slump down or slouch in their
chairs- may be communicating many things,
such as fatigue or physical weakness, lack of
interest, sadness, or defiance.
• Turning away from the nurse- could indicate
anger, fear, or lack of interest
NOTE: When body language says something different
from the words, believe the body language. Explore the
situation using techniques, such as reflective or open-
ended statements
4. SPACE, DISTANCE, AND POSITION
Proxemics- The study of the use of personal space in
communication
Personal space- refers to how close we allow someone
to get to us before we feel uncomfortable.
Public space
o 12 feet or more away
o There is no real positive or negative
connection with the other person.
Social space
o Between 4 and 12 feet
o comfortable distance for a casual
relationship, in which communication is
at an impersonal level.
o you are communicating indifference.
Personal space
o 18 inches to 4 feet
o optimal distance for close interpersonal
communication with another person.
o A nurse who communicates from within
this space is usually viewed as
concerned and interested.
Intimate space
o only trusted individuals to get this close.
o Entering the intimate space without
permission is usually perceived as a
threat.
It is essential to recognize the importance of
personal space and to obtain the older adult’s attention
and permission before attempting to perform any physical
care.
5. Gestures
Gestures- a specific type of nonverbal communication
intended to convey ideas.
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- highly cultural and generational; those
that are acceptable in one culture may be
offensive in another.
Example:
- nodding the head up and down means
yes in most cultures, but to some Eskimo
tribes it means no
Gestures are helpful for people who cannot use
words. After a stroke, many individuals suffer from a
condition called aphasia. Because of brain damage,
these individuals may not be able to recognize words or
to “find” the words they want to use. This inability to
communicate wants, needs, and feelings is often
frustrating, and the use of gestures and other nonverbal
forms of communication can be effective
6. Facial expression
The human face is most expressive, and facial
expressions have been shown to communicate across
cultural and age barriers.
We must be aware of this fact and ensure that our
expressions communicate what is intended.
- A frown may lead the individual to think
that he or she has done something
wrong.
- A wrinkled nose could be viewed as a
lack of acceptance.
- A smile when listening to serious
concerns may make the person wonder
whether the nurse really cares about
what is being said.
7. Eye Contact
Looking someone in the eye is perceived in our
culture and other cultures as a measure of honesty.
- In some cultures, averting the eyes
communicates respect.
Eye contact is often interpreted to be a sign of
attentiveness and acceptance.
Face-to-face contact also maximizes the chance
that an older adult with hearing problems can read lips if
necessary. Sitting at the bedside may facilitate eye
contact.
8. Pace or speed of communication
The resulting difference in rate of speech and
movement can be overwhelming and frustrating to older
adults.
- Do not become impatient or uneasy with
silence
- Provide encouragement and
reassurance that they will have all of the
time they need.
- Patience and active listening are greatly
needed skills when working with older
adults.
“Slower is better” should be the motto impressed
in the mind of anyone who chooses to work with older
adults.
9. Time and timing
Timing is related to the pace of communication.
Delays in response to a call light or direct request
from a person may be interpreted as a lack of concern.
Many older individuals have an altered sense of
time.
Communicating an exciting message late in the
evening (either good or bad news) may disturb older
adults to the point that they are unable to sleep.
Be aware of these issues and choose the proper
time to communicate.
10. Touch
Caring touch is a basic need for all humans, and
many older adults suffer from touch deprivation.
Empathetic use of touch is a much-needed skill
when working with older adults. When words do not work,
touch often does.
Inappropriate touching can be destructive.
- Touch is inappropriate when it is used to
communicate anger or frustration.
- Rough handling, slapping, pushing, or
otherwise communicating displeasure
constitutes patient abuse and is
completely unacceptable.
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Ask FIRST what they wished to be addressed.
If there is any question regarding the
appropriateness of touch, clarification should be obtained
beforehand. It is important to Avoid speaking in sing-song
cadence
11. Silence
Cadence- using inflection to like statements sound like
Saying nothing is also saying something. At questions, or referring to older adults by names such as
times, words can be intrusive; they can interfere with true “sweetie” or “honey.”
communication.
Why Avoid?
Silence permits them to focus on the point of • Patronizing
discussion, while continuous talking is distracting. At • Disrespectful
times, no words are necessary; silence is therapeutic. • Inappropriate
This type of communication
During intense grief, pain, or anxiety, simply is termed “elderspeak” and is a form of ageism.
being there without saying or doing anything may be the
most appropriate form of communication you can give. Elderspeak- incorrect use of the pronoun we when the
The simple presence of another human expresses true correct pronoun would be you, as in “Are we ready to get
concern and can be worth more than all the words in the dressed now?”
world. • Elderspeak should always be avoided because it
has a subtle way of diminishing an older person’s
self-esteem
ACCEPTANCE, DIGNITY AND RESPECT IN • Humanize elder patients.
COMMUNICATION o “Mr. Maggay, who has diabetes,” not “the
Empathy is defined as the willingness to attempt to diabetic in bed 14B.”
understand the unique world of another person.
Avoid Instead use...
It is the ability to put oneself in another person’s place and Diapers Brief, Pads
to understand what they are feeling and thinking in that Blind/Deaf Visually/Hearing
situation. Impaired
- Empathetic listening involves actively Senile/Demented Cognitively challenged
trying to truly understand the other
Nursing Home Care Facility
person.

Effective communication starts with
introductions.
Determine how each older adult wishes to be addressed.
- Older Adults prefer to be called in
different ways:
- Proper titles (Mr., Mrs. Ms., Maam, Sir,
Dr.) to be followed by surname
- First name only
- Nicknames
- Nanay, Tatay, Lolo, Lola
- others. (specifics ex. dementia pts.)
Clarification is important.
BARRIERS IN COMMUNICATION
proper
Communication: is the activity of conveying meaningful
information. It requires a sender, a message, and an
intended recipient.
Barrier: An obstacle in a place that prevents us from
completing certain tasks
Communication barriers: the aspects or conditions that
interfere with effective exchange or ideas or thoughts.
Hearing and vision are the senses used most often in
communication, but touch, smell, and even taste also play
a part in the relay of messages. It is important to

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remember this when communicating with older adults
because their perceptions may be altered by the normal
physiologic changes of aging.
• Hearing Impairment
• Aphasia
• Dementia
• Cultural differences
1. Hearing Impairment
- If a person in your care wears a hearing aid, make sure
that it is clean, that the batteries are working, and that
the device has been placed in the correct ear. Try to
minimize background noise, because this can distort
sounds and make hearing more difficult. Many people
who are hearing impaired spontaneously begin to read
lips. In addition to the basic strategies, the following
actions are likely to be beneficial:
1.Keep messages simple but appropriate to the adult’s
develomental level; do not speak to older adults as if they
were babies or children.
2. Use nonverbal modes of communication, such as
picture boards, gestures, yes/no responses, and facial
expressions.
3. Use visual aids for support.
4. Try increasingly specific guesses or questions to
determine concerns (e.g., Is something wrong with your
meal? The coffee? It’s too hot? You want milk?).
5. Praise attempts to speak, and avoid correcting or
criticizing errors.
6. Reassure the person that it is okay to be frustrated, but
avoid empty platitudes such as “You’ll be fine.”
2. Aphasia
- Individuals who have had a stroke or other held
injuries may experience aphasia, which is a partial or
total loss of the ability to use or understand words. It
affects the ability to understand and express oneself
through words, gestures, and writing but does not
necessarily affect intellectual function. Consultation with a
speech therapist can help the nurse devise approaches
that will optimize function. In addition to the basic
strategies, some commonly recommended approaches
include the following:
1. Stand in front of the person, at eye level.
2. Do not eat or drink while you are having a conversation.
3. Keep your hands away from your face when you are
speaking.
4. Try different ways of saying the same thing, such as
using various words to communicate a thought.
5. Speak more slowly and slightly louder while modulating
your voice to a lower pitch.
6. Avoid exaggerated mouth motions during speech.
7. Use visual cues or written materials that support the
spoken words
3. Dementia
- Dementia causes both cognitive and language
deficits. The older person suffering from dementia has no
control over these changes, so the responsibility for
effective communication rests with the nurse. Depending
on the severity of the dementia, the individual may
demonstrate different levels of functioning. Some
characteristics of dementia include a limited attention
span, inability to focus on more than one thought at a time,
confusion of fact and fantasy, and the inability to follow
complex instructions. In addition to the basic strategies,
some recommended approaches include the following:
1.Talk about one thing or ask only one question at a time.
2. Limit choices; too many options are confusing.
3. Keep the conversation in the here and now.
4. Ask simple yes/no questions.
5. Try “filling in” or “repairing” thoughts. Rather than letting
a person get upset trying to find the right words, you may
offer some likely choices if you have a reasonable idea of
what the person is trying to communicate. However, be
careful not to finish the thoughts and sentences of patients
who are not cognitively impaired.
6. Avoid asking questions that require information or
recall, such as “How was your day”
7. Use gestures or demonstrate an action so that the
person can mimic your behavior.
8. Avoid the use of an intercom, which may confuse the
person.
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9. Avoid arguing if the person does not accept your reality.
10. Redirect the person who is acting out to an
appropriate activity.
11. Share activities, such as looking at a magazine,
viewing family photos, or listening to music.
12. Avoid trying too hard to communicate.
13. Watch your tone of voice, because patients with
dementia are often very sensitive to nonverbal cues and
may sense your frustration and become more agitated or
upset.
•Encourage the patient to ask questions of the staff
through the interpreter.
In addition to making adaptations for language, pay
close attention to nonverbal communications. Lack of
recognition of cultural beliefs and practices can lead
to mistakes that damage rapport. When in doubt, ask
the older adult or family member if there are any
special actions or behaviors that should be observed
or avoided.

4. Cultural differences

- People who speak languages other than English as their

primary language may have varied levels of English
proficiency. To communicate effectively, we need to
know what language a person primarily speaks. To be
an effective interpreter a person needs to be
professionally trained and proficient in both languages,
understand the clinical concepts they are expected to
explain, and have been educated about the ethics of the
job. Even official interpreters can make errors in
communication that are potentially dangerous; however,
studies note that even more mistakes are made by
“unofficial” or ad hoc interpreters, such as family
members.

Some basic rules to keep in mind when working with an

interpreter include the following:

•Ask short questions, and provide brief units of

information so that the interpreter has time to process
translation.

•Avoid excessively technical language.

•Avoid slang, idioms, or colloquial expressions.

•Encourage the interpreter to give you the response using

the patient’s own words, without input or paraphrasing,
whenever possible.

•Focus on the patient, not the interpreter.

•Listen for emotional tone and nonverbal clues when the

patient responds, even if you do not understand the
words.

•Allow enough time for the interaction.

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SKILLS AND TECHNIQUES
1. Informing
- Informing uses direct statements regarding facts.
- nurse is active and the patient is passive.
- least effective form of communication because the
patient is not actively involved.
- ask the patients to restate what they understand
using their own words.
- need to be repeated and rephrased to ensure
understanding
2. Direct Questioning
- keep communication conversational and not too
aggressive.
- Too many direct questions can overwhelm an older
person.
- helpful when nurses need to obtain specific
information
- Direct questions tend to include the words who,
what, when, where ,do you, and don’t you.
- if it is overused, patients may become defensive.
3. Using Open-Ended Techniques
- include open ended questions, reflective
statements, clarifying statements, and
paraphrasing.
- patient is more likely to feel that you are interested
in him
- “And after you moved to the nursing home, what
happened?”; “And then?”; “That must have been
frightening!”; “What I heard you say is …”; “It
sounds like you think (feel)…”
- allow patients to express more about their feelings
and perceptions.
- allow verification that the information being relayed
is accurate.
4. Confronting
- used when there are inconsistencies in
information or when verbal and nonverbal
messages appear contradictory.
- one of the most difficult communication
techniques to use and should be used only after
good rapport has been established.
- never advisable to confront a highly agitated or
confused person.
- should be used only when there is adequate time
to explore the problem and come to some form of
resolution.
5. Communicating With Visitors and Families
- Not only do they turn to nurses for information and
reassurance, but they can also be a good source of
information.
- Significant others
o can help in many ways if nurses are
responsive to them
o Communication with these individuals
may also require special attention and
the use of special techniques.
- Because they have known the patient longer and
better than the nursing staff, they are often able to
detect subtle changes before trained nurses can.
- nurses need to rely on the significant others to
interpret the behaviors and communications of
older adults.
- Listen to what they have to say
6. Delivering Bad News
- This could be information regarding the patient’s
health or about someone close to the patient, for
instance, the death of a spouse or other loved one.
Guidelines for physicians that have relevance for
nursing practice. Important concepts include the
following:
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• Prepare yourself. Make sure you have all of the
information and that it is accurate.
• Think through what you want to say so that the message
is compassionate and culturally sensitive.
• Establish an environment respectful of patient’s privacy.
• Determine whether anyone else (chaplain, family
members, etc.) should be present when the news is
delivered.
• Make sure there is adequate time, free from
interruptions, to deal with the expected emotional
response.
• Determine what the person already knows and, if
possible, how much they want to know.
• Recognize that ethical and cultural variations may
influence the way information is delivered.
• Use simple, direct, but sensitive language to begin the
message, such as, “I’m afraid I have bad news for you.”
• Respond to the person’s emotional reaction, for
example, “I’ll try to help you. Is there anything I can do?”
or “Do you want to talk about how you’re feeling?”
• Develop a follow-up plan. Help the older person and
significant others with appointments, referrals,
transportation, and so forth.
• Communicate significant information to other caregivers
as part of a plan of care
7. Having Difficult Conversations
- Some people prefer to avoid conflict entirely and
pretend it does not exist, but avoidance just delays
solving problems that need to be addressed.
The following guidelines are suggestions based on
conflict resolution research:
• Pick a place that is private and a time when you will be
free from distractions.
• Try to focus on a single topic; do not bring up old
grievances that get in the way.
• If a conversation is not going well, take a look at your
own feelings and motivations. Are you reacting to this
issue or to another issue that was problematic in the past?
• Express your feelings using “I” statements, such as “I get
upset when … doesn’t get done” rather than “you”
statements, such as “You always ignore what I ask you to
do.”
• Respect the right of the other person to agree or
disagree.
• Keep a balance between talking and listening. Try not to
dominate the conversation.
• View each communication as a new opportunity to learn
something about the other person and about his or her
unique feelings, beliefs, and perspectives. Listen to the
other person and seek clarification as to his or her
reasons and feelings.
• Do not prejudge or assume that you already know what
the person is going to say. You may be wrong.
• Be aware of your own feelings regarding the issue under
discussion. Keep feelings separate from facts. The fact
that someone does not do what you want does not mean
that the person does not like you or that he or she is doing
it to upset you.
• Avoid blaming the other person. Look for ways to solve
disagreements.
• Accept that difficult conversations are part of life and that
things do not always go right
• Learn from both negative and positive interactions, and
try to improve future communication.
• Try to achieve a win-win solution
8. Improving Communication Between Older Adult
and Physician
- Most physicians are aware of effective
communication protocols, but, because of time
constraints or other factors, they may not always
use these techniques.
- Ineffective communication can result in frustration
for both parties
- it is not uncommon for an older adult to become
passive, evasive, or tentative when talking with the
physician.
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The nurse can often help minimize these problems

by:

- suggesting that the patient keep a written list of

concerns and questions so nothing is forgotten;
- asking the physician to repeat and summarize
directions to the patient;
- identifying printed materials that support the
physician recommendation;
- suggesting that a trusted friend or family member
be present to take notes and help the older adult
express concerns; or
- acting as a patient advocate by asking the
physician to clarify questions or concerns the
patient has verbalized to you.

9. Communicating With Physicians

- Communication problems between nurses and

physicians can lead to job frustration, blame, and
distrust, all of which diminish the level of care
- good communications tend to improve job
satisfaction, decrease errors, and promote quality
care of the older adult patients.
- Many of the difficulties in nurse-physician
communication have to do with our differences in
training.
o Nurses are taught to communicate in
narrative form, including all possible
details
- When you call a physician, start by identifying who
o Physicians are taught more of a “bullet
you are (name and title), the patient or patients you
point” style of communication, conveying
are calling about, and the specific reason for the
brief descriptions of key elements
contact.
- Many facilities now promote the ISBAR-R
- Keep a list of issues to be reported or discussed
(Introduction, Situation, Background, Assessment,
with each physician so that all issues can be
Recommendation, and Readback)
covered in one interaction
- It is helpful to determine whether there is a best
time and method to use when contacting the
physician regarding nonemergency situations,
such as telephone, cell phone, Fax, e-mail, texting,
or others.
- Planning ahead to identify the best time and
methods approved by your facility will optimize
communication and enhance care of the patient
while minimizing frustration.

10. Patient Teaching

- The ability to teach, explain, and motivate is
increasingly part of the role of today’s nurse.

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- Although younger individuals tend to do better at It is a vital part of the course treatment because:
learning information that requires memorization,
older individuals compensate by using the verbal • It assures the quality of service rendered
skills, experience, and judgment they have • The continuity of care
acquired over time. • Protection of the client and the practitioner
- Learning is maximized when it can draw on the
previous experiences of older adults.
10 important parts of Documentation
- Adult learners are oriented toward problem solving,
and they view learning as most desirable when it is
1. Date and time
relevant to their own lives.
- Document date and time of each recording.
- Prioritize teaching by starting with the area that the
- Avoid recording in advance.
patient perceives to be most important, then linking
that information to the other things the nurse thinks
2. Legibility
are necessary or important.
- Writing must be clear.
- Work in small, discrete blocks of information,
- It is vital in recording numbers and medical terms.
proceeding from simple, more familiar concepts to
more complex or difficult ones.
3. Correct Spelling
- Information that is viewed as personal or private is
- Essential for accuracy.
best taught in a quiet space away from others.
- If unsure, use dictionary or any resource books.
- general information (such as nutrition teaching or
stress reduction) may be best taught in a group,
4. Permanence
where older adults are free to share personal
- Entries must be on dark ink.
experiences and solutions with others.
- It helps identify changes and allows duplicate.
- The temperature should be set appropriately,
chairs should be supportive and comfortable,
5. Accepted Terminology
lighting should be adequate and free of glare, and
- Use commonly accepted abbreviations, symbols,
bathrooms should be readily accessible.
and terms that are specified by the agency.
- When selecting a teaching time, avoid times when
the patient is stressed, fatigued, or in pain
6. Factual
- avoid times when older adults may be distracted by
- Include objective signs of problems.
things of higher priority to them
- The use of inference without supporting data is not
- When selecting a time for teaching, make sure
acceptable.
there is adequate time to discuss the important
information.
7. Accuracy
- Avoid trying to teach too much at one time.
- Use of exact measurement.
- Whenever possible, provide printed materials to
- Chart only your observations and actions.
supplement and reinforce the content
- If the teaching involves a psychomotor skill,
8. Sequence
such as drawing up insulin or changing a
- Document events in order of occurrence.
dressing, the older adult should receive one or
- Update or delete problems as needed.
more demonstrations of the skill and then be
given ample opportunities to practice and
9. Appropriateness
perform the skill with supervision
- Record only information regarding patient’s health
- Be patient and supportive, regardless of the
problems and cares only.
amount of time needed. Remember, the goal is
- Avoid inappropriate personal as needed.
learning, not speed.
10. Completeness
GUIDELINES FOR EFFECTIVE DOCUMENTATION
- Document all necessary information.
- Complete pertinent assessment data such as vital
signs wound drainage, client’s complaint, who was
DOCUMENTATION

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informed, and what interventions are approved out, 2. Vital for establishing and maintaining significant and
should all be recorded. respectful clinical relationship

3. Constitutes social merit

Nurses document their work and outcomes for
several reasons: 4. Privacy requires physicians to keep confidential
information that patients provide or obtain in their
• Communication within the Health Care Team professional interaction with patients.
• Credentialing Nursing documentation
• Legal 5. It provides a secure environment for patients where
• Regulation and legislation they receive medical care and provide complete and
• Reimbursement accurate information, and which reinforces confidence in
• Research health care and
• Quality process and performance improvement emphasizes the importance of respect for patient
autonomy
PRIVACY AND ACCOUNTABILITY
Accountability

- Health service providers are accountable to criminal and

Privacy
-It refers to the right to control access to oneself and
includes physical privacy, such as ensuring curtains are
closed during physical examinations.
-It is typically known as a fundamental human need and a
human right.
civil courts to ensure their activities meet legal
requirements
-registered practitioners are also accountable to
regulatory bodies in terms of standards of practice and
patient care
-the duty of care applies whether they perform specific
activities such as bathing patients or undertaking complex
surgery.

Key Components Of Privacy In Healthcare

key components of accountability in healthcare:
• Confidentiality
• Informed Consent • Individual professional accountability
• Legal Frameworks • Patient safety
• Security Measures • Adherence to standards and regulations
• Patient Rights • Collaborative accountability
• Professional Ethics

To be accountable through delegation and policies and

protocols of the organization, Practitioners must:

Patient’s Right to Privacy

1. Have the ability toperform the activity orintervention

1. Involves the confidentiality of information related to the

patient and the bodily privacy of the patient 2.accept responsibility fordoing the activity

3. Have the authority toperform the activity

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Documentation of nursing care
Purpose:
• Provides a written record of the history, care, and
response of the client while under the supervision
of the health provider.
• It is a guide for their imbursement of care.
• It serves as evidence of care in the court.
• It shows the use of the nursing process.
• It provides data for research studies.
• It can serve as legal record evidence of events of
treatments given.
METHODS AND FORMATS
Methods Of Documentation (CHARTING)
Source-oriented/ Narrative Charting
- Organized according to the source of information
- Separate forms for nurses, physicians, and other
health care professionals to document assessment
findings and plan patient care.
- In chronological order
Advantages:
> Information in chronologic order.
> Documents the patient’s baseline condition for each
shift.
> Indicates aspects of all steps of the nursing process.
Disadvantages:
> Documents all finding makes it difficult to separate
pertinent from irrelevant information
> Requires extensive charting time by the staff
> Discourages physicians and other health teams from
reading
Problem-oriented Medical Record Charting (POMR)
Focuses on patient status rather than on medical or
nursing care
The four (4) basic components:
• Database – It includes the nursing assessment, the
physician’s history, social & family data
• Problem List
• Plan of Care – care plans are generated by the person
who lists the problems. Physicians write physician’s
orders or medical care plans; nurses write nursing
orders or nursing care plans.
• Progress Notes – chart entry made by all health
professionals involved in a client’s care; they all use
the same type of sheet for notes.
Advantages:
> Focus on patients' problems
> Promotes a problem-solving approach to care
> Improves continuity of care by writing relevant data
> Allows easy audit on patients record in evaluating staff
performance or quality patient care
> Constant evaluation and revision of care plan
> Reinforces application of the nursing process
Disadvantages:
> Results in loss of chronologic charting
> More challenging to tract trends inpatient status
> Fragments data because more flow sheets are required
Focus Charting
They are focus on nursing diagnosis, patient problem,
concern, sign, symptom, or event.
Components:
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a) D: date A: action R: response (DAR)
b) D: data A: action E: evaluation (DAE)
Advantages:
> Compatible with the use of the nursing process.
> Shortens charting time, many flow sheets, checklist.
Disadvantages:
> If the database insufficient, patient problems missed
> It doesn't adhere to charting with the focus on nursing
diagnoses and expected outcomes.
Charting by exception
Based on the assumption that all standards of practice are
carried out and met with a typical or expected response
unless documented.
A longhand note appears when the standardized
statement on the form has encountered.
Advantages:
> Highlights abnormal data and patients’ trends.
> Decrease narrative charting time.
> Eliminates duplication of charting.
Disadvantages:
> Requires detailed protocols and standards.
> Requires staff to use unfamiliar methods of record-
keeping and recording.
> Nurses so used not to chart that necessary data
sometimes omitted.
Computer - Assisted Charting
Methodology that uses software and powerful medical
algorithms to automate the process of assigning
appropriate medical codes to medical records
Electronic Health Record (HER)
Advantages:
> Date and time of the notation is automatically recorded.
> Quick communication among departments about
patient needs.
> Electronic records can be retrieved quickly.
> Minimizes errors.
Disadvantages:
> A strong security system is needed to prevent
unauthorized personnel from accessing records.
> High price and time to train staff to use the system.
> Computer downtime can create problems of input,
access, and transfer of information.
Case management System Charting
- Method of organizing patient care through an episode
of illness.
- A clinical pathway or interdisciplinary care plan takes
the place of the nursing care plan
Case Managers: These professionals oversee and
coordinate the patient's care plan, ensuring that it aligns
with the patient's needs, healthcare goals, and available
resources. They play a central role in implementing and
monitoring the case management system.
Healthcare Providers: This encompasses various
healthcare professionals such as physicians, nurses,
therapists, social workers, and specialists involved in
delivering direct patient care. They contribute their
expertise and observations to the care plan.
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Patients and Family Members: Active participation and
engagement of patients and their families are integral in
the case management system. Their input, preferences,
and understanding of the care plan are crucial for its
success.
Administrative Staff: Personnel involved in
administrative tasks, including scheduling appointments,
managing documentation, and handling logistical aspects
of care, contribute to the overall process.
Information Technology (IT) Specialists: Professionals
responsible for maintaining and optimizing the technical
infrastructure of the case management system, ensuring
its functionality, security, and data management.
Payers and Insurers: They may be involved in aspects
related to coverage, approvals, and financial
considerations for the care provided within the case
management system.
Community Resources and Support Services: This
involves liaising with community organizations, support
groups, and services that can offer additional support and
resources for patients' holistic care needs.
Advantages:
> Patient-Centric Care
> Coordination of Care
> Efficient information retrieval
> Regulatory Compliance
> Reduced duplication of efforts
Disadvantages:
> Initial implementation costs
> Integration Challenges
> Data security concerns
> Potential for Data entry errors
GERIATRIC HEALTH CARE TEAM
Geriatrics is a branch of medicine that focuses on health
promotion and the prevention and treatment of disease
and disability in later life.
GERONTOLOGIST/GERIATRICIAN
What is a geriatrician?
-A geriatrician is a doctor who specializes in care of the
elderly and the diseases that affect them. The approach
tends to be holistic and involves a multidisciplinary team.
The geriatrician concentrates on managing the medical
conditions affecting the patient.
-Geriatricians also tend to coordinate the team of allied
health specialists like physiotherapists and occupational
therapists that ensure the patient is in the best
environment and is safe and supported in their social
situation whatever that may be.
A geriatrician should be consulted when:
- An older person's condition causes considerable
impairment and frailty. These patients tend to be over
the age of 75 and coping with a number of diseases
and disabilities, including cognitive (mental)
problems.
- Family members and friends are feeling considerable
stress as caregivers.
What is a gerontologist?
- Gerontology is the scientific study of aging, as well
as its
effect on individuals and cultures. It's a multi-disciplinary
field, including aspects of medicine, biology, psychology
and
sociology and other sciences.
A gerontologist is a scientist who. studies the aging
process and its impact on individuals and societies. They
may have a background in biology, sociology,
psychology, or social work.
GERONTOLOGISTS AND GERIATRICIANS
Might work side-by-side in research or elder-care
facilities, each bringing specialized knowledge and skills
to the plan of care.
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MIDTERM TOPICS
GERIATRICIANS
- Registered nurses, social workers, psychologists and
other caregivers can earn credentials in gerontology
through coursework and continuing education,
broadening and deepening their skills in caring for the
elderly.
GERONTOLOGISTS
- Play a more supportive and educational role,
though applied gerontologists might build long-
term relationships with their clients that include
coordinating diet, exercise and cognitive therapies.
NURSE GERONTOLOGIST
Gerontological nursing
- is the specialty of nursing pertaining to older adults.
- Gerontological nurses work in collaboration with
older adults, their families, and
- communities to support healthy aging, maximum
functioning, and quality of life.
What medical conditions do geriatricians treat?
Any condition that may affect the elderly. Particularly
common are:
Dementia
Delirium
Alzheimer’s disease
Falls
- educated to understand and treat the often complex
physical and mental health needs of older people.
They try to help their patients protect their health and
cope with changes in their mental and physical
abilities, so older people can stay independent and
active as long as possible.
Some of the other tasks geriatric nurses perform are
as follows:
• Administering medications
• Changing surgical or wound dressings
• Collecting blood work and laboratory tests when
ordered
• Exercising and massaging patients
• Helping patients with daily living tasks such as
bathing, dressing, and using the bathroom
• Measuring and recording vital signs
• Monitoring for signs of elder abuse
• Transporting patients to doctor visits and other
appointments.
• Triaging/stabilizing patients who require
emergency medical attention.
OCCUPATIONAL THERAPIST
Occupational therapy professionals work with seniors in
several settings, including acute care hospitals,
rehabilitation centers, skilled nursing institutions, and
mental facilities. The goal of an occupational therapist is
to encourage active engagement not only at home or in
particular physical arrangements, but also all areas. They
work on making it easier for clients to complete daily
chores. This type of therapy focuses on enhancing fine
and gross motor abilities so that clients can do specified
daily tasks. Occupational therapists work helps the elderly
in encouraging them to exercise and assisting in
rehabilitation skills that make daily routines like dressing,
eating, and bathing much simpler.
Occupational therapy (OT) is an allied health profession
that involves the therapeutic use of everyday activities, or
occupations, to treat the physical, mental, developmental,
and emotional ailments.
Occupational Therapist
- are practitioners who use therapeutic techniques to
improve, rehabilitate, or maintain a patient’s motor skills
and overall ability to perform everyday activities.
WHAT DOES AN OCCUPATIONAL THERAPIST DO?
• Evaluate clients' conditions
• Develop and implement treatment plans
• Help clients relearn and perform daily living tasks
• Demonstrate exercises
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• Evaluate a client’s home, school, or workplace
• Educate a client’s family about how to
• accommodate and care for them.
• Recommend special equipment
• Assess and record clients’ activities and
• progress for client evaluations, billing, and
• other purpose
5 TYPES OF OCCUPATIONALTHERAPY ACTIVITIES
FOR OLDERADULTS
◦ Relaxation techniques: tensing and releasing muscle
groups.
◦ Physical exercises: range of movement, medicine ball
training, and squatting.
◦ Personal activities: personal care, dressing and
undressing, and household tasks.
◦ Cognitive exercises: loud reading, dual task activity,
and neurobic exercise.
◦ Recreational activities: playing indoor
storytelling, and social events.
PHYSICAL THERAPIST
A physical therapist, often abbreviated as PT, is a
licensed healthcare professional who specializes in
evaluating, diagnosing, and treating a wide range of
musculoskeletal and movement-related conditions.
-Their primary goal is to help individuals of all ages, from
infants to seniors, improve their physical function,
mobility, and overall quality of life.
-Physical therapists use a variety of techniques and
modalities to help patients manage pain, recover from
injuries or surgeries, and regain or enhance their physical
abilities.
Key Responsibilities
MIDTERM TOPICS
• Assess patients' physical condition, including
strength, range of motion, balance, and pain
levels.
• Develop personalized treatment plans, often
involving exercises and manual therapy.
• Aid in post-injury or post-surgery rehabilitation to
restore mobility and function.
• Manage and reduce pain through various
techniques and modalities.
• Focus on improving patients' ability to perform
daily activities.
• Educate patients on their conditions, treatment
options, and injury prevention.
• Recommend and assist with the use of assistive
devices when necessary.
• Specialize in areas like sports rehab, pediatrics,
geriatrics, or others.
SPEECH THERAPIST
speech therapist
• evaluates level of speech, language, or
swallowing difficulty.
games, • speech therapists work with the elderly to
improve their communication and swallowing
abilities.
Services of a speech therapist
• Assessment of speech, language, voice, and
swallowing.
• Educate client on appropriate swallowing
technique.
• Recommend modified food/fluid textures.
• Provide speech therapy to improve speech
intelligibility.
• Provide voice therapy.
• Provide language therapy through remedial
and/or compensatory approaches.
• To promote accessibility and inclusion,
communication technology may be used
• to support communication in daily activities and
social settings.
• Individual or group therapy.
CASE MANAGER
Case Manager
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MIDTERM TOPICS
- Care partners can support family members caring for
A case manager is someone who is appointed to support older adults by assisting them to overcome
you with your rehabilitation. communication barriers as they occur. Health care
providers must be aware of the need to include older
Case management is about assessing your needs and adults in communication regarding health matters as
linking you with right resources and services to help you much as possible and then include family members as
maximize your quality of life. appropriate.

The role of case manager is incredibly important and they

will work closely with you to understand your short and - Caregivers, including family members, can help by
long-term needs. identifying realistic and unrealistic expectations based
on the patient’s habits and lifestyle. Caregivers should
What is the role of case manager? also indicate what kind of support they can provide.

-The case manager’s role is a wide and varied one, but

their primary duty is to the injured claimant, regardless of
who's paying for the rehabilitation. Case management
involves. planning, implementing, coordinating, NURSING AND INTERDISCIPLINARY CARE
monitoring, and evaluating the options and services CONFERENCE TEAM
available that will help meet your needs. The overall aim
is to help you return to your pre-injury quality of life as
Geriatric interdisciplinary teams
closely as possible.
- consist of practitioners from different disciplines who
provide coordinated, integrated care with collectively
Areas case managers are involved in:
set goals and shared resources and responsibilities.
• Setting up and monitoring your commercial care
regime
- Not all older patients need a formal geriatric
• Finding appropriate accommodation if your current
interdisciplinary team. However, if patients have
residence is unsuitable
complex medical, psychologic, and social needs, such
• Coordinating with various health and social services to
teams are more effective in assessing patient needs
ensure your needs can be met and ascertain how
and creating an effective care plan than are
much funding would be required
practitioners working alone.
• Liaising with statutory and private therapy and
rehabilitation services - If interdisciplinary care is not available, an alternative
• Arranging or organizing assessments with statutory is management by a geriatrician or geriatric nurse
and private healthcare professionals, including practitioner or a primary care physician or nurse
therapists, psychologists and other professional practitioner or physician assistant with experience and
services, such as orthotics interest in geriatric medicine.
• Ensuring you have the correct equipment that will help
promote confidence, increase independence and aid
comfort and safety
• Working closely with you and your family. Offering Interdisciplinary teams aim to ensure the following:
help, support and guidance • That patients move safely and easily from one
care setting to another and from one practitioner
to another
FAMILY/SIGNIFICANT OTHERS • That the most qualified practitioner provides care
for each problem
• That care is not duplicated
• That care is comprehensive
Family/significant others

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MIDTERM TOPICS
- To create, monitor, or revise the care plan,
interdisciplinary teams must communicate openly,
freely, and regularly. Core team members must
collaborate, with trust and respect for the contributions
of others, and coordinate the care plan (eg, by
delegating, sharing accountability, jointly
implementing it).
o Team members may work together at the
same site, making communication
informal and expeditious.
o However, with the increased use of
technology (ie, cell phones, computers,
internet, telehealth), it is not unusual for
team members to work at different sites
and use various technologies to enhance
communication.
- A team typically includes physicians, nurses, nurse
practitioners, physician assistants, pharmacists, social
workers, psychologists, and sometimes a dentist,
dietitian, physical and occupational therapists, an
ethicist, or a palliative care or hospice physician. Team
members should have knowledge of geriatric
medicine, familiarity with the patient, dedication to the
team process, and good communication skills.
- To function effectively, teams need a formal structure.
Teams should develop a shared vision of care, identify
patient-centered objectives and set deadlines for
reaching their goals, have regular meetings (to discuss
team structure, process, and communication), and
continuously monitor their progress (using quality
improvement measures).
RESEARCH AGENDA ON AGING
NATIONAL: NIH PUBLICATION -2030 PROBLEMS ON
CARING FOR AGING BABY BOOMERS
- A major public policy concern in the long-term care
field is the potential burden an aging society will place
on the care-giving system and public finances.
- The “2030 problem” involves the challenge of assuring
that sufficient resources and an effective service
system are available in thirty years, when the elderly
population is twice what itis today.
- Much of this growth will be prompted by the aging of
the Baby Boomers, who in 2030 will be aged 66 to 84
the “young old” and will number 61 million people. In
addition to the Baby Boomers, those born prior to 1946
the “oldest old” will number9million people in 2030.
- This is to assess the coming challenges of caring for
large numbers of frail elderly as the Baby Boom
generation ages.
The real challenges of caring for the elderly in 2030
will involve:
- making sure society develops payment
and insurance systems for long-term
care that work better than existing ones.
- taking advantage of advances in
medicine and behavioral health to keep
the elderly as healthy and active as
possible.
- changing the way society organizes
community services so that care is more
accessible, and altering the cultural view
of aging to make sure all ages are
integrated into the fabric of community
life.
INTERNATIONAL: UN PROGRAM ON AGING
The United Nations Decade of Healthy Ageing (2021–
2030) is a global collaboration, aligned with the last ten
years of the Sustainable Development Goals, to improve
the lives of older people, their families, and the
communities in which they live.
The World Health Organization was asked to lead the
implementation of the Decade in collaboration with the
other UN organizations and serves as the Decade
Secretariat.
Governments, international and regional organizations,
civil society, the private sector, academia and the media
are encouraged to actively contribute to achieving the
Decade’s goals through direct action, partnering with
others, and by participating in the Healthy Ageing
Collaborative.
The Decade will address four areas for action:
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MIDTERM TOPICS
Age-friendly Environment
Combatting Ageism
Integrated Care
Long Term Care
Plan Of Action
1. Why we need concerted, sustained action
1. Longer Lives
- Longer lives are one of our most
remarkable collective achievements.
They reflect advances in social and
economic development as well as in
health, specifically our success in dealing
with fatal childhood illness, maternal
mortality and, more recently, mortality at
older ages. A longer life is an incredibly
valuable resource.
b. Adding life to years
- Globally, there is little evidence that older
people
today are in better health than previous
generations. Furthermore, good health
in older age is not distributed equally,
either between or within populations.
For example, there is an average
difference of 31 years of healthy life
expectancy at birth and 11years for
healthy life expectancy at 60 years
between countries.
2. Vision, principles and added value
- Solid Foundations
o The Decade of Healthy Ageing builds on
and responds to global commitments and
calls for action. It is based on the Global
strategy and action plan on ageing and
health (2016-2030), which was drawn up
through extensive consultation and was
itself informed by the World report on
ageing and health.
- Vision and guiding principles
o Our vision is a world in which all people
can live long, healthy lives. It is linked to
the three priorities of the Madrid
International Plan of Action on Ageing
and reflects the vision of the Sustainable
Development Goals to leave no one
behind.
- Added Value
o A decade of action can increase the
significance of an issue, create urgency
to act and generate transformative
change.
o A decade of concerted, sustained
collaboration in healthy ageing is needed
to change the view of population ageing
from a challenge to an opportunity.
GOAL
1. No Poverty
2. Zero Hunger
3. Good Health & Well Being
4. Quality Education
5. Gender Equality
6. Reduced Inequalities
7. Peace, Justice & Strong Institutions
3. Areas for Action
- change how we think, feel and act towards age and
ageing
o Despite the many contributions of older
people to society and their wide diversity,
negative attitudes about older people are
common across societies and are
seldom challenged.
- Deliver person-centered, integrated care and primary
health services responsive to older people
o Older people require non-discriminatory
access to good-quality essential health
services
- Provide access to long-term care for older people who
need it.
o Access to rehabilitation, assistive
technologies and supportive, inclusive
environments can improve the situation;
however, many people reach a point in
their lives when they can no longer care
for themselves without support and
assistance.
4. Partnerships for Change
- The Decade of Healthy Ageing deliberately includes
collaborative multisectoral and multi-stakeholder
partnering in its vision and in each of the four areas for
action to meet its commitment to bring about
transformative change while building trust across
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MIDTERM TOPICS
generations by optimizing everyone’s opportunities for
healthy ageing.
The platform will enable work on the four areas by:
• listening to diverse voices and enabling meaningful
engagement of older people, family members,
caregivers, young people and communities
• nurturing leadership and building capacity to take
appropriate action integrated across sectors
• connecting various stakeholders around the world
to share and learn from the experience of others;
• strengthening data, research and innovation to
accelerate implementation.
5. Understanding and Measuring Success together
- Mechanisms for tracking progress are essential to
improve the lives of older people, their families and
communities. Governments, donors, civil society and
other actors, including private sector, increasingly
recognize that what is measured drives action.
- The plan for the Decade prioritizes the roles of national
and subnational leadership and their ownership of the
results; building strong capacity, including to monitor
and evaluate; and reducing the reporting burden by
aligning the work of multiple stakeholders with the
systems countries use to monitor and evaluate their
national policies and strategies on ageing.
The framework for tracking progress throughout the
Decade of Healthy Ageing therefore:
• takes stock of the vision and action areas;
• extends other WHO and United Nations global
policy instruments to include older people; and
• builds on the indicators of progress agreed on for
the global strategy;
• is linked to the four “enablers”: voice and
engagement, leadership, capacity building and
research and innovation.
6. Making It Work
- The Decade of Healthy Ageing requires a whole-of-
government and whole of-society response.
Implementation will be led by each country, drawing
on its leadership and work of the government and its
parliament at various levels, in partnership with civil
society.
- The Decade’s vision, action areas and
transformative pathways will be championed and
supported by United Nations country teams, led by a
United Nations resident coordinator and, where
relevant, humanitarian coordinators and
humanitarian country teams.
- The United Nations as a whole will support Member
States in delivering the objectives of the Decade
plan, partnering with other international
organizations and non-State actors.
- This will ensure strong communication, reporting,
monitoring and accountability, with the United
Nations system delivering as one entity, and
contribute to progressive realization of the rights of
all older people to the enjoyment of the highest
attainable standard of health. The United Nations
Secretary-General will nominate agency focal points
and coordinators for the Decade, who will be active
from the launch of the plan.
OTHER CURRENT RESEARCH ON AGING
- Today’s Research on Aging is a series intended to
increase awareness of research results and their
application to major public and private decision-
making. Although policy debates may be closely
followed by many members of society, not all people
are aware of the research underlying policy
prescriptions as well as the choices of public and
private decision-makers. By discussing recent
research and the links to major government,
business, social, and private issues, hopes to
increase appreciation of the scientific findings
relevant to aging and their effects on individuals and
society.
1. Medication problems occurring at hospital
discharge among older adults with Heart Failure.
(n.d.-b).
https://journals.healio.com/doi/10.3928/19404921-
20111206-04
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MIDTERM TOPICS
Abstract:
Medication reconciliation problems are common among
older adults at hospital discharge and lead to adverse
events.
The purpose of this study was to examine the rates and
types of medication reconciliation problems among older
adults hospitalized for acute episodes of heart failure who
were discharged home This secondary analysis of data
generated from a transitional care intervention included
198 hospital discharge medical records, representing 162
patients. A retrospective chart review comparing
medication lists between hospital discharge summaries
and patient discharge instructions was completed to
identify medication reconciliation problems. Most hospital
discharges (71.2%) had at least one type of reconciliation
problem and frequently involved a high-risk medication
(76.6%). Discrepancies were the most common problem
(58.9%), followed by incomplete discharge summaries
(52.5%) and partial patient discharge instructions
(48.9%).
More attention needs to be given to the quality of
discharge instructions, and the problem of vague phrases
(e.g., “take as directed”) can be addressed by adding it to
“do not use” lists to promote safer transitions in care.:
2. JR, R. C. E. (n.d.). Older adult stereotypes among care
providers in residential care facilities: Examining the
relationship between contact, education, and ageism.
Journal of gerontological nursing.
https://pubmed.ncbi.nlm.nih.gov/17310663/
Abstract:
One barrier to quality elder care is ageism among care
providers. In the present study, two models of stereotype
reduction were tested with care providers at residential
homes for older adults-
-
the effects of contact and the effects of education on
prejudice.
Caregivers at five residential programs in Australia
completed a survey assessing education, training, contact
with older clients, prior experience, and stereotypes
toward older adults.
Results revealed that contact was not associated with
fewer stereotypes but education (both specific and
general) was associated with fewer stereotypes.
Implications are discussed in terms of possible
interventions and increasing optimal contact with older
clients
3. Knickman, J. R., & Snell, E. K. (2002, August). The
2030 problem: Caring for aging baby boomers. Health
services research.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1464018
/
Abstract:
Objective
To assess the coming challenges of caring for large
numbers of frail elderly as the Baby Boom generation
ages.
Study Setting
A review of economic and demographic data as well as
simulations of projected socioeconomic and demographic
patterns in the year 2030 form the basis of a review of the
challenges related to caring for seniors that need to be
faced by society.
Principal Findings
The economic burden of aging in 2030 should be no
greater than the economic burden associated with raising
large numbers of baby boom children in the 1960s. The
real challenges of caring for the elderly in 2030 will
involve:
(1) making sure society develops payment and insurance
systems for long-term care that work better than existing
ones, (2) taking advantage of advances in medicine and
behavioral health to keep the elderly as healthy and active
as possible,
(3) changing the way society organizes community
services so that care is more accessible, and
(4) altering the cultural view of aging to make sure all ages
are integrated into the fabric of community life.
Conclusions
To meet the long-term care needs of Baby Boomers,
social and public policy changes must begin soon.
Meeting the financial and social service burdens of
growing numbers of elders will not be a daunting task if
necessary changes are made now rather than when Baby
Boomers actually need long-term care.
Goodluck sa exam!
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