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2019v1.0
Basic Geriatric
Nursing
Contents in Brief

UNIT I Overview of Aging, 1 13 Coing nd Stress, 241

1 Trends nd Issues, 1 14 Vlues nd Beliefs, 252
2 Theories of Aging, 29 15 End-of-Life Cre, 261
3 Physiologic Chnges, 33 16 Sexulity nd Aging, 278

UNIT II Basic Skills for Gerontologic Nursing, 78
4 Helth Prootion, Helth Mintennce, nd
Hoe Helth Considertions, 78
5 Counicting With Older Adults, 95
6 Mintining Fluid Blnce nd Meeting
Nutritionl Needs, 111
7 Medictions nd Older Adults, 140
8 Helth Assessent for Older Adults, 158
9 Meeting Sfety Needs of Older Adults, 174
UNIT III Psychosocial Care of the Elderly, 191
10 Cognition nd Percetion, 191
11 Self-Percetion nd Self-Concet, 214
12 Roles nd Reltionshis, 230
UNIT IV Physical Care of the Elderly, 286
17 Cre of Aging Skin nd Mucous Mebrnes, 286
18 Eliintion, 308
19 Activity nd Exercise, 325
20 Slee nd Rest, 353
APPENDIXES
A Lbortory Vlues for Older Adults, 363
B The Geritric Deression Scle (GDS), 367
C Dily Nutritionl Gols for Older Adults, 368
D Resources for Older Adults, 369
Glossry, 371
Index, 377
 EDITION

8
Basic Geriatric
Nursing

Patricia Williams, RN, MSN, CCRN

Nursing Professor
De Anza College
Cupertino, California

Formerly, Nursing Educator

University of California Medical Center
San Francisco, California

Alumnus, iSAGE Mini Fellowship Program

Successful Aging Project
Stanford University Medical School
Stanford, California
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

BASIC GERIATRIC NURSING, EIGHTH EDITION ISBN: 978-0-323-82685-3

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Printed in India

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 I dedicate this book to Cynthia—
You were deeply loved, are terribly missed,
and your legacy lives on through your grandchildren.

Patricia
Contributors and Reviewers
CONTRIBUTORS
Karen Anderson, MSN, RN
Nursing Fculty nd Siultionist,
Sn Diego Stte University,
Sn Diego, Cliforni
Online Nursing Fculty, West Cost University,
Irvine, Cliforni
Sheri Saretsky, RN, MSN/Ed, DSD
Consultnt, Nursing Eduction, Helthcre Trining
Assocites, Sn Diego, Cliforni
Susan M. Schmitz, RN, BSN, PHN
Prt-Tie Fculty, Helth Technology Dertent,
De Anz College, Cuertino, Cliforni
Flu Nurse nd Reserch Assistnt, Flu nd Wellness,
AC Wellness, Cuertino, Cliforni
vi
REVIEWERS
Beth Kasparisin, RN, MSN
Associte Degree Director of Nursing, Texs Southost
College, Brownsville, Texs
Molly M. Showalter, MSN/Ed, RN
Interi Voctionl Nursing Progr Director,
Texs Southost College, Brownsville, Texs
Vaneida Soto, MSN, RN
Fculty Instructor, Texs Southost College,
Brownsville, Texs
Brittany Williams, DNP, RN, CMSRN
Doctorte of Nursing Prctice, Adinistrtion MSN,
Adinistrtion BSN, CMSBN-Certied Medicl
Surgicl Nurse, Centrl Texs College, Killeen, Texs
LPN/LVN Advisory Board
Nancy Bohnarczyk, MA
Adjunct Instructor
College of Mount St. Vincent
New York, New York
Sharyn P. Boyle, MSN, RN-BC
Instructor, Associte Degree Nursing
Pssic County Technicl Institute
Wyne, New Jersey
Nicola Contreras, BN, RN
Fculty
Glen College
Sn Antonio, Texs
Dolores Cotton, MSN, RN
Prcticl Nursing Coordintor
Meridin Technology Center
Stillwter, Oklho
Patricia Donovan, MSN, RN
Director of Prcticl Nursing
nd Curriculu Chir
Porter nd Chester Institute
Rocky Hill, Connecticut
Nancy Haughton, MSN, RN
Prcticl Nursing Progr Fculty
Chester County Interedite Unit
Downingtown, Pennsylvni
Dawn Johnson, DNP, RN, Ed
Prcticl Nurse Progr Director
Gret Lkes Institute of Technology
Erie, Pennsylvni
Mary E. Johnson, RN, MSN
Director of Nursing
Dorsey Schools
Roseville, Michign
Bonnie Kehm, PhD, RN
Fculty Progr Director
Excelsior College
Albny, New York
Tawnya S. Lawson, MS, RN
Den, Prcticl Nursing Progr
Hondros College
Westerville, Ohio
Kristin Madigan, MS, RN
Nursing Fculty
Pine Technicl nd Counity College
Pine City, Minnesot
Hana Malik, DNP, FNP-BC
Acdeic Director
Illinois College of Nursing
Lobrd, Illinois
Mary Lee Pollard, PhD, RN, CNE
Den, School of Nursing
Excelsior College
Albny, New York
Barbara Ratliff, MSN, RN
Progr Director, Prcticl Nursing
Cincinnti Stte
Cincinnti, Ohio
Mary Ruiz-Nuve, RN, MSN
Director of Prcticl Nursing Progr
St. Louis College of Helth Creers
St. Louis, Missouri
Renee Sheehan, RN, MSN/Ed
Director of Nursing, Voctionl Nursing
Nursing Assistnt Progrs
Suit College
Colton, Cliforni
Faye Silverman, RN, MSN/Ed, WOCN, PHN
Nursing Eduction Consultnt
Online Nursing Instructor
Lncster, Cliforni
Fleur de Liza S. Tobias-Cuyco, BSc, CPhT
Den, Director of Student Affirs, nd Instructor
Preferred College of Nursing
Los Angeles, Cliforni
vii
To the Instructor
The chnging deogrhic of tody’s world resents
n iense chllenge to helth cre roviders nd so-
ciety s  whole. Nurses ust be well rered to rec-
ognize nd resond roritely to the needs of our
ging oultion. The gol of this text is to give the be-
ginning nurse  blnced ersective on the relities of
ging nd to broden the beginning nurse’s viewoint
regrding ging eole so tht their needs cn be et
in  cossionte, cring, nd rofessionl nner.
ABOUT THE TEXT
The eighth edition of Basic Geriatric Nursing resents
the theories nd concets of ging, the hysiologicl
nd sychosocil chnges nd robles ssocited
with the rocess, nd the rorite nursing inter-
ventions. The LPN Threads design rovides consistency
ong Elsevier’s LPN/LVN textbooks. Key fetures
include extensive coverge of culturl issues, clinicl
situtions, delegtion, hoe helth cre, helth ro-
otion, tient teching, nd coleentry helth
roches. Nuerous Criticl Thinking exercises
rovide rctice in synthesizing infortion nd -
lying it to nursing cre of the older dult.
LPN THREADS
The eighth edition of Basic Geriatric Nursing shres
soe fetures nd design eleents with other Else-
vier LPN/LVN textbooks. The urose of these LPN
Threads is to ke it esier for students nd instructors
to use the vriety of books required by the reltively
brief nd dending LPN/LVN curriculu. The fol-
lowing fetures re included in the LPN Threads:
• The full-color design, cover, photos, nd illustra-
tions re visully eling nd edgogiclly
useful.
• Objectives (nubered) begin ech chter nd ro-
vide  frework for content nd re esecilly i-
ortnt in roviding the structure for the TEACH
Lesson Plns for the textbook.
• Key Terms with honetic ronuncitions nd ge
nuber references re listed t the beginning of ech
chter. They er in color in the chter nd re
dened briey, with full denitions in the Glossary.
The gol is to hel the student with liited ro-
ciency in English to develo  greter cond
of the ronuncition of scientic nd nonscientic
English terinology.
viii
• Key Points t the end of ech chter correlte to
the objectives nd serve s  useful chter review.
• In ddition to consistent content, design, nd su-
ort resources, these textbooks benet fro the d-
vice nd inut of the Elsevier LPN/LVN Advisory
Board (see . vii).
ORGANIZATION
Unit I resents n overview of ging, exining the
trends nd issues ffecting the older dult. These in-
clude deogrhic fctors nd econoic, socil, cul-
turl, nd fily inuences. The unit exlores vrious
theories nd yths ssocited with ging nd reviews
the hysiologic chnges tht occur with ging.
Unit II includes  wide rnge of infortion on
odifying bsic nursing skills for the ging oul-
tion. There is  strong focus on (1) helth rootion
nd helth intennce for older dults; (2) ge--
rorite verbl nd nonverbl couniction; (3)
relevnt nutritionl nd uid needs, ltertions in
hrcodynics, nd concerns relted to edic-
tion dinistrtion for older dults; (4) helth ssess-
ent of older dults; nd (5) eeting sfety needs of
the older dults.
Unit III ddresses the sychosocil needs of the
older dult through the nursing rocess nd clinicl
judgent odel. Psychosocil cre recedes hysi-
ologic cre, reecting the order in which the content is
ost often tught. Ares of content include (1) cogni-
tion robles, (2) self-ercetion nd self-concet, (3)
chnging roles nd reltionshis, (4) coing nd stress
ngeent, (5) vlues nd beliefs, nd (6) sexulity.
Unit IV ddresses the hysicl needs of the older
dult through the nursing rocess nd clinicl judg-
ent odel. Ares of content include (1) sfety, (2)
hygiene nd skin cre, (3) eliintion, (4) ctivity nd
exercise, nd (5) slee nd rest. Units III nd IV both
offer ssessent (dt collection), dt nlysis/rob-
le identiction, lnning, nd ileenttion of
nursing interventions cross cre settings.
SPECIAL FEATURES
• Nursing process/Clinical Judgment Model sections
tht rovide  strong frework for discussing cre
of older dults in the context of secic disorders
• Nursing interventions groued by helth cre set-
ting (e.g., cute cre, extended cre, hoe cre)
• Special boxes for criticl thinking, clinicl situ-
tions, helth rootion, sfety, tient eduction,

coleentry helth roches, delegtion,
nurse lerts, nd ore
• QSEN highlighting infortion relted to the six
relicensure coetency ctegories
• Incresed cultural content on the ict of ging in
vrious cultures
• Focus on changing demographics including bby
booers nd the ict of their ging on helth cre
• Additionl infortion on home health for both -
tients nd cregivers
• Review Questions for the Next Generation NCLEX®
Examination t the end of every chter
• Udted Laboratory Values for Older Adults(Aen-
dix A)
• The Geriatric Depression Scale (AendixB)
• Daily Nutritional Goals for Older Adults (Aen-
dix C)
• Revised list of Resources for Older Adults, includ-
ing relevnt websites (Aendix D)
• References groued by chter nd listed t the
end of the book for esy ccess
TEACHING AND LEARNING PACKAGE
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TEACH Instructor Resource include the following:
• Test Bank with roxitely 400 ultile-choice
nd lternte-fort questions with toic, ste
of the nursing rocess, objective, cognitive level,
NCLEX® ctegory of client needs, correct nswer,
rtionle, nd textbook ge reference
• 6 All New Next Generation NCLEX®Exam–style
Case Studies and Review Questions rovide thor-
ough rertion nd rctice for the Next Gener-
tion NCLEX Exintion
• TEACH Instructor Resource with Lesson Plns,
Lecture Outlines, nd PowerPoint slides—with
Audience Resonse Syste questions ebedded—
tht correlte ech text nd ncillry coonent
TO THE INSTRUCTOR ix
• Image Collection tht contins ll the illustrtions
nd hotogrhs in the textbook
FOR STUDENTS
The Evolve Student Resources include the following
ssets:
• Answers and Rationales for Review Questions for
the Next Genertion NCLEX® Exintion
• Review Questions for the NCLEX® Exam
• Study Guide for dditionl rctice.
• Audio Glossary with ronuncitions in English nd
Snish
• Calculators for deterining body ss index
(BMI), body surfce re, uid decit, Glsgow
Co Scle score, intrvenously dinistered dos-
ges, nd conversion of units
• Fluids and Electrolytes Tutorial
ACKNOWLEDGMENTS
I would like to thnk Nncy O’Brien, Brndi Grh,
Brooke Knndy, Shereen Jeel, Renee Duenow nd
Vishnu T. Jiji s well s the other stff t Elsevier for
their rofessionl exertise, tencity, insights, innite
tience, nd stedy encourgeent throughout the
develoent of this edition. I would lso like to ex-
tend thnks to reviewers of this book s well s writ-
ers of the ncillry terils—your questions nd cri-
tique were helful in king this book even stronger.
Thnks lso to Dr. V. J. Periykoil of Stnford Univer-
sity for her entorshi during y ini-fellowshi on
Successful Aging nd for roviding vluble resources
for this text. Thnks to y collegue Din Whittiker,
RN, MDiv. We hd so uch fun ileenting our
Stnford eldwork with the Hisnic older dults nd
relly brought our rojects to life. Lst but not lest—I
thnk Kren Anderson, Susn Schitz, Sheri Sretsky,
nd Cherie Rebr for their wonderful contributions to
nd suggestions for the textbook.
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To the Student
Nurses re rivileged to shre in soe of the ost inti-
te sects of eole’s lives. We not only hel eole
when they re wek nd vulnerble but lso hel eo-
le gin nd recite new strengths. Although uch
of our youth nd young dulthood focus on chieving
indeendence, our older dult yers deonstrte the
vlue in interdeendence—being ble to rely on others,
s well s give bck to others in new nd different
wys. As nurses, we hel others coenste for their
decits nd build uon their strengths. We rejoice in
nd oint out sll successes nd hel build these to
greter successes. It is iortnt to reeber tht the
older erson for who you re cring ws once  lot
like you. Try to view the older dult under your cre
not just s the erson in need tht you see in front of
you but rther in the context of their whole life: Ws
he  three-str generl who now needs your hel get-
ting dressed? Ws she soeone who devoted her life
to rising children nd cring for grndchildren nd
now needs cre of her own? Ws he  neurosurgeon
who now cnnot control his oveent becuse of Pr-
kinson disese? Ws she  judge who is now unble to
exress her references becuse of Alzheier disese?
Cre for every older dult the wy you would cre for
your unt, your grndother, your grndfther, or the
wy you wish to be cred for one dy. The older dults
under your cre re fortunte: reching n dvnced
ge is  rivilege not grnted to everyone.
READING AND REVIEW TOOLS
• Objectives introduce the chter toics.
• Key Terms re listed with ge nuber references,
nd difcult edicl, nursing, or scientic ters re
cconied by sile honetic ronuncitions.
• Ech chter ends with  Get Redy for the Next
Genertion NCLEX® Exintion! section tht in-
cludes (1) Key Points tht reiterte the chter ob-
jectives nd serve s  useful review of concets, (2)
 list of Additional Resources including the Study
Guide nd Evolve Resources, nd (3) n extensive
set of Review Questions for the Next Generation
NCLEX® Examination with Answers nd Rtio-
nles on Evolve.
• References t the end of ech chter cite evidence-
bsed infortion nd rovide resources for en-
hncing knowledge.
• A Glossary of key ters rovides denitions of ll
the ters tht er t the beginning of chters.
SPECIAL FEATURES
The following secil fetures re designed to foster
effective lerning nd corehension nd reect the
LPN Threds design:
Clinical Situation boxes relte the text to tient situ-
tions nd cre scenrios.
Complementary Health Approaches boxes ddress
nontrditionl nd djunct theries.
Coordinated Care boxes ddress ledershi nd n-
geent issues for the LPN/LVN nd include to-
ics, such s suervision of ncillry ersonnel nd
end-of-life cre.
Critical Thinking boxes ose questions designed to
stiulte thought nd to hel students develo nd
irove their criticl thinking skills.
Cultural Considerations boxes rovide dvice on cul-
turlly diverse tient cre of older dults.
Health Promotion boxes recoend qulity-of-life
tis for older dults.
Home Health Consideration boxes give essentil in-
fortion for hoe cre for the older dult.
Medication tbles rovide quick ccess to infor-
tion bout edictions coonly used in geritric
nursing cre.
Nursing Care Plans with Alying Clinicl Judgent
Questions rovide students with rel-world ex-
les of nursing cre lns nd encourge the to
think criticlly bout the given scenrios.
Patient Education boxes instruct nd infor both older
tients nd their cregivers bout helth rootion,
disese revention, nd ge-secic interventions.
xi
Contents

UNIT I OVERVIEW OF AGING, 1 Implications for Nursing, 32

References, 32
1 Trends and Issues, 1
Introduction to Geritric Nursing, 1 3 Physiologic Changes, 33
Historical Perspective on the Study of Aging, 1 The Integuentry Syste, 34
What’s in a Name: Geriatrics, Gerontology, and Expected Age-Related Changes, 34
Gerontics, 2 Common Disorders Seen With Aging, 36
Attitudes Towrd Aging, 3 Melanoma and Nonmelanoma, 36
Gerontophobia, 4 Pressure Injuries, 36
Ageism, 4 Inammation and Infection, 36
Age Discrimination, 5 Hypothermia, 37
Deogrhics, 6 The Musculoskeletl Syste, 37
Scope of the Aging Population, 6 Bones, 37
Gender and Ethnic Disparity, 7 Vertebrae, 38
The Baby Boomers, 8 Joints, Tendons, and Ligaments, 38
Geographic Distribution of the Older Adult Muscles, 38
Population, 8 Expected Age-Related Changes, 39
Marital Status, 8 Common Disorders Seen With Aging, 40
Educational Status, 8 Osteoporosis, 40
Econoics of Aging, 9 Degenerative Joint Disease, 41
Poverty, 9 The Resirtory Syste, 42
Income, 9 Upper Respiratory Tract, 42
Wealth, 13 Lower Respiratory Tract, 42
Housing Arrngeents, 13 Air Exchange (Respiration), 42
Helth Cre Provisions, 16 Expected Age-Related Changes, 43
Medicare and Medicaid, 16 Common Disorders Seen With Aging, 43
Rising Costs and Legislative Activity, 17 Chronic Obstructive Pulmonary
Costs and End-of-Life Care, 18 Disease, 43
Advance Directives and Physician Orders for Life- Inuenza, 44
Sustaining Treatment, 18 COVID-19, 44
Impact of Aging Members of the Family, 19 Pneumonia, 44
Reection by a Nursing Professor, 20 Tuberculosis, 45
The Nurse and Family Interactions, 21 Lung Cancer, 45
Self-Neglect, 22 The Crdiovsculr Syste, 45
Abuse or Neglect by the Family, 22 Heart, 46
Physical Abuse, 22 Blood Vessels, 46
Neglect, 23 Conduction System, 46
Emotional Abuse, 23 Expected Age-Related Changes, 47
Financial Abuse, 23 Common Disorders Seen With Aging, 47
Abandonment, 24 Coronary Artery Disease, 47
Responses to Abuse, 24 Coronary Valve Disease, 48
Abuse by Unrelated Caregivers, 25 Cardiac Arrhythmias, 48
Support Groups, 26 Heart Failure, 48
Respite Care, 26 Cardiomegaly, 49
References, 28 Peripheral Vascular Disease, 49
Occlusive Peripheral Vascular Problems, 49
2 Theories of Aging, 29 Varicose Veins, 49
Biologic Theories, 29 Aneurysm, 49
Psychosocial Theories, 31 Hypertensive Disease, 50

xiii
xiv CONTENTS

The Hetooietic nd Lyhtic Systes, 50 Diplopia, 67

Blood, 50 Cataracts, 67
Erythrocytes, 50 Glaucoma, 67
Leukocytes, 51 Age-Related Macular Degeneration and
Platelets, 51 Retinal Detachment, 67
Lymph System, 51 The Ears, 67
Lymph Vessels, Fluid, and Nodes, 51 Expected Age-Related Changes, 68
Spleen and Thymus, 51 Common Disorders Seen With Aging, 68
Lymphocytes and Immunity, 51 Otosclerosis, 68
Expected Age-Related Changes, 51 Tinnitus, 68
Common Disorders Seen With Aging, 52 Deafness, 68
Anemia, 52 Ménière Disease, 69
Leukemia, 52 Taste and Smell, 69
The Gstrointestinl Syste, 52 Expected Age-Related Changes, 69
Oral Cavity, 52 The Endocrine Syste, 69
Tongue, 52 Pituitary Gland, 70
Salivary Glands, 53 Thyroid Gland, 70
Esophagus, 53 Parathyroid Glands, 70
Stomach, 53 Pancreas, 70
Small Intestine, 53 Adrenal Glands, 70
Large Intestine, 53 Ovaries and Testes, 70
Expected Age-Related Changes, 53 Expected Age-Related Changes, 71
Common Disorders Seen With Aging, 54 Common Disorders Seen With Aging, 72
Hiatal Hernia, 54 Diabetes Mellitus, 72
Gastritis and Ulcers, 55 Hypoglycemia, 73
Diverticulosis and Diverticulitis, 55 Hypothyroidism, 73
Cancer, 55 The Reroductive nd Genitourinry
Hemorrhoids, 55 Systes, 73
Rectal Prolapse, 56 Female Reproductive Organs, 73
The Urinry Syste, 56 Male Reproductive Organs, 73
Kidneys, 56 Expected Age-Related Changes, 74
Ureters and Bladder, 56 Changes in Women, 74
Characteristics of Urine, 56 Changes in Men, 74
Expected Age-Related Changes, 57 Common Disorders Seen With Aging, 74
Common Disorders Seen With Aging, 57 Uterine Prolapse, 74
Urinary Incontinence, 57 Vaginal Infection, 75
Urinary Tract Infection, 57 Breast Cancer, 75
Chronic Kidney Disease, 58 Prostate Cancer, 75
The Nervous Syste, 58 References, 76
Central Nervous System, 58
Medulla, 58
Pons and Midbrain, 58 UNIT II BASIC SKILLS FOR
Cerebellum, 58 GERONTOLOGIC NURSING, 78
Hypothalamus, 59
Cerebrum, 59 4 Health Promotion, Health
Peripheral Nervous System, 59 Maintenance, and Home Health
Expected Age-Related Changes, 59 Considerations, 78
Common Disorders Seen With Aging, 60 Recoended Helth Prctices for Older
Parkinson Disease, 60 Adults,79
Dementia, 60 Diet, 79
Alzheimer Dementia, 61 Exercise, 79
Transient Ischemic Attacks, 63 Tobacco and Alcohol, 79
Stroke, 63 Physical Examinations and Preventive Overall
The Secil Senses, 64 Care, 80
The Eyes, 64 Dental Examinations and Preventive Oral
Refraction, 65 Care, 82
Expected Age-Related Changes, 65 Maintaining Healthy Attitudes, 83
Common Disorders Seen With Aging, 66 Fctors Tht Affect Helth Prootion nd
Blepharitis, 66 Mintennce, 83
 CONTENTS xv

Religious Beliefs, 84 Having Difcult Conversations, 106

Cultural Beliefs, 84
Knowledge and Motivation, 84
Mobility, 85
Perceptions of Aging, 85
Impact of Cognitive and Sensory Changes, 85
Impact of Changes Related to Accessibility, 86
Hoe Helth, 86
Unpaid Caregiver, 86
Paid Caregivers, 87
Types of Home Services, 87
Nursing Process/Clinicl Judgent Model
for Indequte Helth Mintennce nd
Indequte Helth Mngeent, 88
Assessment (Data Collection), 88
Data Analysis/Problem Identication, 89
Planning, 89
Implementation, 89
Nursing Process/Clinicl Judgent Model for
Nondherence With the Tretent Pln, 90
Assessment (Data Collection), 90
Data Analysis/Problem Identication, 90
Planning, 90
Implementation, 90
References, 93
5 Communicating With Older Adults, 95
Information Sharing (Framing the Message), 95
Formal or Therapeutic Communication, 96
Informal or Social Communication, 97
Nonverbal Communication, 97
Symbols, 97
Tone of Voice, 97
Body Language, 98
Space, Distance, and Position, 98
Gestures, 99
Facial Expressions, 99
Eye Contact, 99
Pace or Speed of Communication, 99
Time and Timing, 99
Touch, 100
Silence, 100
Empathy, Acceptance, Dignity, and Respect in
Communication, 101
Active and Empathetic Listening, 101
Barriers to Communication, 101
Hearing Impairment, 102
Aphasia, 102
Dementia, 103
Cultural Differences, 103
Skills nd Techniques, 104
Informing, 104
Direct Questioning, 104
Using Open-Ended Techniques, 104
Confrontating, 105
Communicating With Visitors and Families, 105
Delivering Bad News, 105
Improving Communication Between the
Older Adult and The Primary Care
Provider, 106
Effective Communication With the Health Care
Team, 106
Telephoning Primary Care Providers, 107
Patient Teaching, 108
References, 110
6 Maintaining Fluid Balance and Meeting
Nutritional Needs, 111
Nutrition nd Aging, 111
Caloric Intake, 111
Nutrients, 112
Carbohydrates, 113
Proteins, 113
Fats, 115
Vitamins, 115
Minerals, 117
Functional Foods, 118
Water, 119
Mlnutrition nd the Older Adult, 119
Factors Affecting Nutrition in Older
Adults, 119
Social and Cultural Aspects of
Nutrition, 122
Nursing Process/Clinicl Judgent Model for
Risk for Altered Nutrition, 122
Assessment (Data Collection), 125
Appetite Changes, 125
Nutritional Intake, 125
Social and Cultural Factors, 126
Home Care or Discharge Planning, 126
Data Analysis/Problem Identication, 126
Planning, 126
Implementation, 126
Nursing Process/Clinicl Judgent Model for
Fluid Volue nd Potentil for Altered
Intke, 130
Assessment (Data Collection), 130
Fluid Volume Decit, 131
Fluid Volume Overload, 131
Data Analysis/Problem Identication, 131
Planning, 131
Implementation, 131
Nursing Process/Clinicl Judgent Model for
Altered Swllowing Ability, 133
Assessment (Data Collection), 134
Data Analysis/Problem Identication, 134
Planning, 134
Implementation, 134
Nursing Process/Clinicl Judgent Model for
Asirtion Risk, 136
Assessment (Data Collection), 136
Data Analysis/Problem Identication, 136
Planning, 136
xvi CONTENTS

Implementation, 136 Respiration, 167

References, 139 Blood Pressure, 167
Sensory Assessent of Older Adults, 168
7 Medications and Older Adults, 140 Psychosocil Assessent of Older
Risks Relted to Drug Testing Methods, 141 Adults, 168
Risks Relted to the Physiologic Chnges of Special Assessments, 168
Aging,141 The Minimum Data Set 3.0, 168
Pharmacokinetics, 141 Assessent of Condition
Drug Absorption, 141 Chnge in Older Adults,170
Drug Distribution, 141 Fulmer Spices, 170
Drug Metabolism, 142 FANCAPES, 171
Drug Excretion, 142 References, 173
Pharmacodynamics, 142
Polypharmacy, 142 9 Meeting Safety Needs of Older
Potentilly Inrorite Mediction Use in Older Adults, 174
Adults, 144 Internl Risk Fctors, 174
Risks Relted to Cognitive or Sensory Falls, 175
Chnges,145 Fall Prevention, 176
Risks Relted to Indequte Knowledge, 146 Tools to Assess for Falls, 177
Risks Relted to Finncil Fctors, 147 Specic Strategies to Prevent Falls, 177
Mediction Adinistrtion in n Institutionl Externl Risk Fctors, 178
Setting, 147 Fire Hazards, 179
Nursing Assessent nd Mediction, 147 Home Security, 179
Mediction nd the Nursing Cre Pln, 148 Internet Safety, 179
Nursing Interventions Related to Medication Vehicular Accidents, 179
Administration, 148 Thermal Hazards, 182
Right Patient, 148 Sury, 183
Right Medication, 150 Nursing Process/Clinicl Judgent Model for
Right Amount, 150 Potentil for Injury, 183
Right Dosage Form, 151 Assessment (Data Collection), 183
Right Route, 151 Data Analysis/Problem Identication, 184
Right Time, 152 Planning, 184
Right Documentation, 153 Implementation, 184
Ptient Rights nd Mediction, 153 Nursing Process/Clinicl Judgent Model for
Self-Mediction nd Older Adults, 153 Hyotheri/Hyertheri, 187
In an Institutional Setting, 153 Assessment (Data Collection), 187
In the Home, 153 Data Analysis/Problem Identication, 187
Teching Older Adults About Medictions, 154 Planning, 187
Sfety nd Nondherence Issues, 155 Implementation, 187
References, 157 To Prevent Hyperthermia, 188
To Prevent Hypothermia, 188
8 Health Assessment for Older Adults, 158 References, 189
Helth Screening, 158
Helth Assessents, 159
Interviewing Older Adults, 159 UNIT III PSYCHOSOCIAL CARE OF THE
Preparing the Physical Setting, 159 ELDERLY, 191
Establishing Rapport, 159
Structuring the Interview, 160 10 Cognition and Perception, 191
Obtining the Helth History, 160 Norl Cognitive-Percetul Functioning, 191
Physicl Assessent of Older Adults, 161 Cognitive and Intelligence, 192
Inspection, 162 Cognition and Language, 192
Palpation, 165 Nursing Process/Clinicl Judgent Model for
Auscultation, 165 Altered Sensory Percetion, 194
Percussion, 165 Assessment (Data Collection), 194
Mesuring Vitl Signs in Older Adults, 165 Data Analysis/Problem Identication, 194
Temperature, 165 Planning, 194
Pulse, 166 Implementation, 194

Nursing Process/Clinicl Judgent Model for
Chronic Confusion, 197
Assessment (Data Collection), 200
Data Analysis/Problem Identication, 201
Planning, 201
Implementation, 201
Nursing Process/Clinicl Judgent Model for
Altered Couniction Ability, 205
Assessment (Data Collection), 206
Data Analysis/Problem Identication, 206
Planning, 207
Implementation, 207
Nursing Process/Clinicl Judgent Model
forPin, 207
Assessment (Data Collection), 209
Data Analysis/Problem Identication, 210
Planning, 210
Implementation, 210
References, 213
11 Self-Perception and Self-Concept, 214
Norl Self-Percetion nd Self-Concet, 214
Self-Percetion/Self-Concet nd
Aging, 216
Depression and Aging, 217
Suicide and Aging, 218
Nursing Process/Clinicl Judgent Model for
Altered Self-Percetion nd Altered Self-
Concet, 218
Assessment (Data Collection), 218
Nursing Process/Clinicl Judgent Model for
Altered Body Ige, 219
Assessment (Data Collection), 219
Data Analysis/Problem Identication, 219
Planning, 219
Implementation, 219
Nursing Process/Clinicl Judgent Model for
Potentil for Decresed Self-Estee, 220
Assessment (Data Collection), 220
Data Analysis/Problem Identication, 220
Planning, 221
Implementation, 221
Nursing Process/Clinicl Judgent Model for
Fer, 222
Assessment (Data Collection), 223
Data Analysis/Problem Identication, 223
Planning, 223
Implementation, 223
Nursing Process/Clinicl Judgent Model for
Anxiety, 223
Assessment (Data Collection), 224
Data Analysis/Problem Identication, 224
Planning, 224
Implementation, 224
Nursing Process/Clinicl Judgent Model for
Decresed Hoe, 224
Assessment (Data Collection), 224
CONTENTS xvii
Data Analysis/Problem Identication, 225
Planning, 225
Implementation, 225
Nursing Process/Clinicl Judgent Model for
Loss of Power, 225
Assessment (Data Collection), 226
Data Analysis/Problem Identication, 226
Planning, 226
Implementation, 226
References, 229
12 Roles and Relationships, 230
Norl Roles nd Reltionshis, 230
Roles, Reltionshis, nd Aging, 231
Nursing Process/Clinicl Judgent
Model for Colex Grief, 234
Assessment (Data Collection), 234
Data Analysis/Problem Identication, 235
Planning, 235
Implementation, 235
Nursing Process/Clinicl Judgent Model for
Loneliness nd Potentil for Socil Isoltion, 236
Assessment (Data Collection), 236
Data Analysis/Problem Identication, 236
Planning, 236
Implementation, 236
Nursing Process/Clinicl Judgent Model for
Altered Fily Functioning, 237
Assessment (Data Collection), 237
Data Analysis/Problem Identication, 237
Planning, 237
Implementation, 237
References, 240
13 Coping and Stress, 241
Norl Stress nd Coing, 241
Physical Signs of Stress, 243
Cognitive Signs of Stress, 243
Emotional Signs, 243
Behavioral Signs, 243
Stress and Illness, 244
Stress and Life Events, 245
Stress Reduction and Coping Strategies, 245
Nursing Process/Clinicl Judgent Model for
Liited Coing Ability, 246
Assessment (Data Collection), 246
Data Analysis/Problem Identication, 247
Planning, 247
Implementation, 247
Nursing Process/Clinicl Judgent Model for
Disruted Living Sitution nd Mldtive
Resonse to Disruted Living Sitution, 248
Assessment (Data Collection), 249
Data Analysis/Problem Identication, 249
Planning, 249
Implementation, 249
References, 251
xviii CONTENTS
14 Values and Beliefs, 252
Coon Vlues nd Beliefs of Older
Adults, 254
Economic Values, 254
Interpersonal Values, 254
Cultural Values, 254
Spiritual or Religious Values, 255
Nursing Process/Clinicl Judgent Model for
Siritul Disconnection, 256
Assessment (Data Collection), 256
Data Analysis/Problem Identication, 257
Planning, 257
Implementation, 257
References, 259
15 End-of-Life Care, 261
Deth in Western Cultures, 261
Attitudes Towrd Deth nd End-of-Life
Plnning,262
Advance Directives, 263
Caregiver Attitudes Toward End-of-Life
Care, 263
Vlues Clriction Relted to Deth nd End-of-
Life Cre, 263
Wht Is  “Good” Deth?, 263
Where Peole Die, 264
Pllitive Cre, 265
Collbortive Assessent nd Interventions for
End-of-Life Cre, 265
Couniction t the End of Life, 265
Psychosocil Persectives, Assessents, nd
Interventions, 267
Cultural Perspectives, 267
Communication About Death, 267
Decision-Making Process, 267
Amount and Type of Intervention That Will
Be Accepted, 268
Signicance of Pain and Suffering, 268
Depression, Anxiety, and Fear, 268
Physiologic Chnges, Assessents, nd
Interventions, 269
Pain, 269
Fatigue and Sleepiness, 271
Cardiovascular Changes, 271
Respiratory Changes, 271
Gastrointestinal Changes, 272
Urinary Changes, 273
Integumentary Changes, 273
Sensory Changes, 273
Changes in Cognition, 273
Death, 273
Recognizing Imminent Death, 274
Funerl Arrngeents, 275
Bereveent, 275
References, 277
16 Sexuality and Aging, 278
Fctors Tht Affect Sexulity of Older Adults,278
Age-Related Changes in Women, 279
Age-Related Changes in Men, 279
Impact of Illness on Sexual Health, 280
Effects of Alcohol and Medications on Sexual Health,
280
Loss of a Sex Partner, 280
Mrrige nd Older Adults, 281
Cregivers nd the Sexulity of Older
Adults,281
Sexul Orienttion of Older Adults, 281
Sexully Trnsitted Infections, 281
Privacy and Personal Rights of Older Adults, 282
Nursing Process/Clinicl Judgent Model for
Altered Sexul Function, 282
Assessment (Data Collection), 282
Data Analysis/Problem Identication, 283
Planning, 283
Implementation, 283
References, 285
UNIT IV PHYSICAL CARE OF THE
ELDERLY, 286
17 Care of Aging Skin and Mucous
Membranes, 286
Age-Relted Chnges in Skin, Hir, nd Nils, 286
Skin Color, 287
Dry Skin, 287
Rashes and Irritation, 288
Pigmentation, 288
Tissue Integrity, 288
Pressure Injuries, 289
Amount, Distribution, Appearance, and
Consistency of Hair, 290
Tissue of the Feet, 290
Nails, 290
Other Common Foot Problems, 293
Nursing Process/Clinicl Judgent Model for
Altered Skin Integrity, 293
Assessment (Data Collection), 293
Data Analysis/Problem Identication, 294
Planning, 294
Implementation, 294
Age-Relted Chnges in Orl Mucous
Mebrnes,300
Dental Caries, 301
Periodontal Disease, 301
Pain, 301
Dentures, 302
Dry Mouth, 302
Leukoplakia, 302
Cancer, 302

Alcohol and Tobacco-Related Problems, 303
Problems Caused by Neurologic Conditions, 303
Nursing Process/Clinicl Judgent Model for
Altered Orl Mucous Mebrnes, 303
Assessment (Data Collection), 303
Data Analysis/Problem Identication, 303
Planning, 303
Implementation, 304
References, 307
18 Elimination, 308
Norl Eliintion Ptterns, 308
Eliintion nd Aging, 308
Constition, 309
Fecal Impaction, 310
Nursing Process/Clinicl Judgent Model for
Constition, 311
Assessment (Data Collection), 311
Data Analysis/Problem Identication, 311
Planning, 311
Implementation, 311
Diarrhea, 313
Nursing Process/Clinicl Judgent Model for
Dirrhe, 313
Assessment (Data Collection), 313
Data Analysis/Problem Identication, 313
Planning, 314
Implementation, 314
Fecal Incontinence, 315
Nursing Process/Clinicl Judgent Model for
Fecl Incontinence, 315
Assessment (Data Collection), 315
Data Analysis/Problem Identication, 315
Planning, 315
Implementation, 316
Urinary Retention, 316
Urinary Tract Infection, 316
Urinary Incontinence, 316
Nursing Process/Clinicl Judgent Model For
Altered Urinry Function, 319
Assessment (Data Collection, 319
Data Analysis/Problems Identication, 319
Planning, 319
Implementation, 319
References, 324
19 Activity and Exercise, 325
Norl Activity Ptterns, 325
Activity nd Aging, 326
Exercise Recommendation for Older Adults, 326
Effects of Disese Processes on Activity, 328
Nursing Process/Clinicl Judgent Model for
Altered Mobility, 329
Assessment (Data Collection), 329
Data Analysis/Problem Identication, 329
Planning, 329
Implementation, 330
CONTENTS xix
Nursing Process/Clinicl Judgent Model for
Altered Activity Tolernce, 335
Assessment (Data Collection), 335
Data Analysis/Problem Identication, 335
Planning, 336
Implementation, 336
Nursing Process/Clinicl Judgent Model for
Probles of Oxygention, 337
Assessment (Data Collection), 337
Data Analysis/Problem Identication, 338
Planning, 338
Implementation, 338
Nursing Process/Clinicl Judgent Model for
Altered Self-Cre Ability, 341
Assessment (Data Collection), 341
Data Analysis/Problem Identication, 342
Planning, 342
Implementation, 342
Nursing Process/Clinicl Judgent Model for
Decient Diversionl Activity, 345
Assessment (Data Collection), 345
Data Analysis/Problem Identication, 345
Planning, 345
Implementation, 345
Rehbilittion, 348
Negative Attitudes: The Controlling or Custodial
Focus, 348
Positive Attitudes: The Rehabilitative Focus, 349
References, 352
20 Sleep and Rest, 353
Slee-Rest Helth Pttern, 353
Normal Sleep and Rest, 353
Sleep and Aging, 354
Sleep Disorders, 355
Insomnia, 355
Sleep Apnea, 357
Circadian Rhythm Sleep Disorders, 358
Rapid Eye Movement Sleep-Behavior
Disorder, 358
Nursing Process/Clinicl Judgent Model for
Disruted Slee Pttern, 358
Assessment (Data Collection), 358
Data Analysis/Problem Identication, 358
Planning, 358
Implementation, 358
References, 362
APPENDIXES
A Lbortory Vlues for Older Adults, 363
B The Geritric Deression Scle (GDS), 367
C Dily Nutritionl Gols for Older Adults, 368
D Resources for Older Adults, 369
Glossary, 371
Index, 377
UNIT I Overview of Aging
Trends and Issues
Objectives
1. Describe the subjective and objective ways in which
aging is dened.
2. Identify personal and societal attitudes toward aging.
3. Dene ageism.
4. Discuss the myths that exist with regard to aging.
5. Identify recent demographic trends and their impact on
society.
6. Describe the effects of recent legislation on the economic
status of older adults.
7. Identify the political interest groups that work as
advocates for older adults.
Key Terms
abuse (p. 22)
ageism (p. 4)
chronologic age (krŏ-nŏ-LŎJ-ĭk, p. 2)
cohort (KŌ-hŏrt, p. 8)
demographics (dĕm-ŏ-GRĂF-ĭks, p. 6)
geriatric (jĕr-ē-ĂT-rĭk, p. 2)
INTRODUCTION TO GERIATRIC NURSING
HISTORICAL PERSPECTIVE ON THE STUDY
OF AGING
Until the iddle of the 19th century, only two stges
of hun growth nd develoent were identied:
childhood nd dulthood. In ny wys, children
were treted like sll dults. No secil ttention
ws given to the or to their needs. Filies hd to
roduce ny children to ensure tht  few would
survive nd rech dulthood. In turn, children were
exected to contribute to the fily’s survivl. Little
or no ttention ws given to those chrcteristics nd
behviors tht set one child rt fro nother.
As tie ssed, society begn to view children dif-
ferently. Peole lerned tht there re signicnt dif-
ferences between children of different ges nd tht
children’s needs chnge s they develo. Childhood
is now divided into substges (i.e., infnt, toddler,
reschool, school ge, nd dolescence). Ech stge
is ssocited with unique chllenges relted to the
individul child’s stge of growth nd develoent.
1
http://evolve.elsevier.com/Williams/geriatric
8. Identify the major economic concerns of older adults.
9. Describe the housing options available to older adults.
10. Discuss the health care implications of a growing
population of older adults.
11. Describe the changes in family dynamics that occur as
family members become older.
12. Examine the role of nurses in dealing with an aging family.
13. Identify the different forms of elder abuse.
14. Recognize the most common signs of abuse.
15. Describe effective approaches for the prevention of elder
abuse.
gerontics (p. 2)
gerontology (p. 2)
gerontophobia (p. 4)
mandated reporter (p. 26)
neglect (nĭ-glĕkt, p. 22)
respite (RĔS-pĭt, p. 26)
Becuse the substges re relted to obvious hysicl
chnges or to signicnt life events, this clssiction
is now cceted s logicl nd necessry.
Until recently, society lso viewed dults of ll
ges interchngebly. Once you bece n dult, you
reined n dult. Perhs society erceived dily
tht older dults were different fro younger dults,
but there ws not uch concern bout these differ-
ences becuse few eole lived to old ge. In ddition,
the hysicl nd develoentl chnges of dulthood
re ore subtle thn those of childhood; therefore
these chnges received little ttention.
Until the 1960s, sociologists, sychologists, nd
helth cre roviders focused their ttention on eet-
ing the needs of the tyicl or verge dult: eole
between 20 nd 65 yers of ge. This grou ws the
lrgest nd ost econoiclly roductive segent
of the oultion; they were rising filies, work-
ing, nd contributing to the econoy. Only  sll
ercentge of the oultion lived beyond 65 yers of
ge. Disbility, illness, nd erly deth were cceted
s nturl nd unvoidble.
1
2 UNIT I Overview of Aging
In the lte 1960s, reserch begn to indicte tht
dults of ll ges re not the se. Then lso, the focus
of helth cre shifted fro illness to wellness. Disbil-
ity nd disese were no longer considered unvoidble
rts of ging. Incresed edicl knowledge, iroved
reventive helth rctices, nd technologic dvnces
heled ore eole live longer, helthier lives.
Older dults now constitute  signicnt grou in
society, nd interest in the study of ging is growing.
The study of ging will be  jor re of ttention for
yers to coe.
WHAT’S IN A NAME: GERIATRICS, GERONTOLOGY,
AND GERONTICS
The ter geriatric coes fro the Greek words geras,
ening “old ge,” nd iatro, ening “relting to
edicl tretent.” Thus geritrics is the edicl se-
cilty tht dels with the hysiology of ging nd with
the dignosis nd tretent of diseses ffecting older
dults. Geritrics, by denition, focuses on bnorl
conditions nd their edicl tretent.
The ter gerontology coes fro the Greek words
gero, ening “relted to old ge,” nd ology, en-
ing “the study of.” Thus gerontology is the study of
ll sects of the ging rocess, including the clinicl,
sychologic, econoic, nd sociologic robles of
older dults nd the consequences of these robles
for older dults nd society. Gerontology ffects nurs-
ing, helth cre, nd ll res of our society—including
housing, eduction, business, nd olitics.
The ter gerontics, or gerontic nursing, ws coined
by Gunter nd Estes in 1979 to dene the nursing cre
nd service rovided to older dults. Gerontic nurs-
ing corises  holistic view of ging, with the gol
of incresing helth, roviding cofort, nd cring for
older dults’ needs. This textbook focuses on gerontic
nursing. It ddresses wys in which to roote high-
level functioning nd ethods of giving cre nd co-
fort to older dults.
The objectives of this book re to
• Exine trends nd issues tht ffect the older
dult’s bility to rein helthy
• Exlore theories nd yths of ging
• Study the norl chnges tht occur with ging
• Review thologic conditions tht re coonly
observed in older dults
• Ehsize the iortnce of effective counic-
tion when working with older dults
• Exlore the generl ethods used to ssess the
helth sttus of older dults
• Describe the secic ethods of ssessing functionl
needs
• Identify the ost coon tient robles
exerienced by older dults nd discuss nursing in-
terventions ied t solving these robles
• Exlore the effects of ediction nd ediction
dinistrtion on older dults
The dictionry denes old s “hving lived or existed
for  long tie.” The ening of this word is highly
subjective; to  gret degree, it deends on how old we
ourselves re. Few eole like to describe theselves
s old. A recent study revels tht eole younger thn
ge 30 view those older thn ge 63 s “getting older.”
Peole over the ge of 65, however, do not think eo-
le re “getting older” until they re 75 yers old.
Aging is  colex rocess tht cn be described
chronologiclly, hysiologiclly, nd functionlly.
Chronologic age, the nuber of yers  erson hs
lived, is ost often used when we sek of ging
becuse it is the esiest to identify nd esure. Mny
eole who hve lived  long tie rein function-
lly nd hysiologiclly young. These individuls
rein hysiclly t, sty entlly ctive, nd re
roductive ebers of society. Others re chronolog-
iclly young but hysiclly or functionlly old. Thus
chronologic ge is not the ost eningful esure-
ent of ging.
In using chronologic ge s the esure, uthorities
use vrious systes to ctegorize the ging oultion
(Tble 1.1). To ny eole, 65 yers is  gic nu-
ber in ters of ging. The wide ccetnce of ge 65 s
 lndrk of ging is interesting. Since the 1930s, the
ge of 65 hs coe to be cceted s the ge of retire-
ent, when it is exected tht  erson willingly or
unwillingly stos id eloyent. However, before
the 1930s, ost eole worked until they decided to
sto working, until they bece too ill to work, or
until they died. When the New Del estblished the
Socil Security rogr, 65 ws set s the ge t which
benets could be collected. However, the verge life
exectncy of the tie ws 63 yers of ge. The Socil
Security rogr ws designed s  firly low-cost
wy to win votes becuse ost eole would not live
long enough to collect the benets. Although ge 65
ws considered old then, it certinly is not considered
old now. If the se stndrds were lied tody, the
retireent ge would rrive t ge 77. However, soci-
ety clings to ge 65 s the retireent ge nd resists
oliticl roosls designed to ove the strt of Socil
Security benets to  lter ge. Desite the resistnce,
the ge to qulify for full Socil Security benets is
Table 1.1 Categorizing the Aging Population
AGE (YEARS) CATEGORY
55 to 64 Older
65 to 74 Elderly
75 to 84 Aged
85 and older Extremely aged
Or
60 to 74 Young old
75 to 84 Middle old
85 and older Old old

chnging. Individuls born before 1937 still qulify
for full benets t 65 yers of ge, but there re incre-
entl increses in ge for ll ersons born fter tht
tie. Individuls born in 1960 or lter ust wit until
ge 67 to qulify for full benets. Reduced benets re
clculted for individuls who cli Socil Security
benets fter ge 62 but before the full retireent ge.
To be consistent with other sources, however, this text
will refer to individuls of ge 65 nd bove s “older
dults.”
ATTITUDES TOWARD AGING
Before we look t the ttitudes of others, it is iortnt
to exine our own ttitudes, vlues, nd knowledge
bout ging. The three following Criticl Thinking
boxes tht follow re designed to hel you ssess how
you feel bout ging.
After you hve lled out these Criticl Thinking boxes,
look t the chrcteristics you described nd think bout
the feelings you exerienced s you considered your
nswers. Do your feelings corresond to your ttitudes
bout ging? In the Criticl Thinking Box bout Vlues,
were the three eole’s chrcteristics siilr or differ-
ent? Wht do these chrcteristics sy bout your vl-
ues? Our ttitudes re the roduct of our knowledge nd
vlues. Our life exeriences nd our current ge strongly
inuence our views bout ging nd older dults. Most
of us hve  rther nrrow ersective, nd our ttitudes
y reect this. We tend to roject our ersonl exeri-
ences onto the rest of the world. Becuse ny of us hve
 soewht liited exosure to older dults, we y
believe quite  bit of inccurte infortion. In deling
with older dults, our liited understnding nd vision
cn led to serious errors nd istken conclusions. If
we view old ge s  tie of hysicl decy, entl con-
fusion, nd socil boredo, we re likely to hve neg-
tive feelings towrd ging. Conversely, if we see old ge
s  tie for sustined hysicl vigor, renewed entl
chllenges, nd socil usefulness, our ersective on
ging will be quite different.
Critical Thinking
Your Current Knowledge About Aging
Respond to the following questions to the best of your
knowledge.
You are “old” at age _________________________________
___________________________________________________.
There are ___________________________________________
_______________________ older adults in the United States.
Most older adults live in_______________________________.
Economically, older adults are _________________________
___________________________________________________.
With regard to health, older adults are __________________
___________________________________________________.
Mentally, older adults are _____________________________
___________________________________________________.
Trends and Issues CHAPTER 1 3
Critical Thinking
Your Views and Attitudes About Aging
• How many older adults do you know personally?
• Do you think they are “old”? Do they consider
themselves “old”?
• How do you personally deýne “old”?
• Why is aging an issue today?
• Should Social Security laws be changed to reþect
today’s longer life expectancy?
Please complete the following statements. Write as many
applicable comments as you can. There are no right or
wrong answers.
A person can be considered “old” when _________________
__________________________________________________.
When I think about getting older, I _______________________
__________________________________________________.
Growing older means _________________________________
__________________________________________________.
When I get older, I will lose my __________________________
__________________________________________________.
Seeing an older person makes me feel ___________________
__________________________________________________.
Older people always _________________________________
__________________________________________________.
Older people never ___________________________________
__________________________________________________.
The best thing about aging is __________________________
__________________________________________________.
The worst thing about aging is __________________________
__________________________________________________.
Looking back at my responses, I feel that aging is _______
__________________________________________________.
It is iortnt to serte fcts fro yths s we
exine our ttitudes towrd ging. The single ost
iortnt fctor tht inuences how oorly or well 
erson will ge is ttitude. This stteent is true not
only for others but lso for ourselves.
Throughout tie, youth nd beuty hve been
viewed s desirble, nd old ge nd hysicl inr-
ity hve been lothed nd fered. Greek sttues
ortry youths of hysicl erfection. Artists’ works
throughout history hve shown heroes nd heroines
s young nd beutiful nd evildoers s old nd ugly.
Little hs chnged to this dy. A few cultures cherish
their older ebers nd view the s keeers of wis-
do. Even in Asi, where trdition dends resect
for older dults, societl chnges re destroying this
venerble indset.
For the ost rt, instre Aericn society does
not vlue its older dults. The United Sttes tends to be
 youth-oriented society in which eole re judged
by ge, ernce, nd welth. Young, ttrctive, nd
welthy eole re viewed ositively; old, ierfect,
nd oor eole re not. It is difcult for young eole
to igine tht they will ever be old. Desite soe cul-
turl chnges, ging continues to hve negtive conno-
ttions. Mny eole continue to do everything they cn
to er young. Wrinkles, gry hir, nd other hysicl
4 UNIT I Overview of Aging

Critical Thinking
Your Values About Aging
Quickly name three older adults who have had an impact on your life. List ve characteristics that you associate with each person.
There are no right or wrong answers.
PERSON 1
Name __________________________
Relationship _____________________
Characteristics:
1. _____________________________
2. _____________________________
3. _____________________________
4. _____________________________
5. _____________________________
PERSON 2
Name __________________________
Relationship _____________________
1. _____________________________
2. _____________________________
3. _____________________________
4. _____________________________
5. _____________________________
PERSON 3
Name __________________________
Relationship _____________________
1. _____________________________
2. _____________________________
3. _____________________________
4. _____________________________
5. _____________________________

chnges of ging re ctively confronted with keu,
hir dye, nd cosetic surgery. Until recently, dvertis-
ing seldo ortryed eole older thn ge 50 excet
to sell eyeglsses, hering ids, hir dye, lxtives, nd
other rther uneling roducts. The essge seeed
to be, “Young is good, old is bd; therefore everyone
should ght getting old.” It is signicnt tht trends
in dvertising er to be chnging. As the nuber
Cultural Considerations
The Role of the Family
Cultural heritage may work as a barrier to getting help for
an older parent. Many cultures emphasize the importance
of intergenerational obligation and dictate that it is the role
of the family to provide for both the nancial and personal
care needs of older adults. This can lead to high stress and
excessive demands, particularly on lower-income families.
Nurses need to recognize the impact that culture has on
expectations and values and how these cultural values affect
the willingness of families to accept outside assistance.
Nurses need to be able to identify the workings of complex
family dynamics and to determine how decision-making
takes place within a unique cultural context.
Critical Thinking
Caregiver Choices
• What expectations does your cultural heritage dictate
regarding your obligation to frail older family members?
• Who in your family culture makes decisions regarding the
care of older family members?
• Should Medicare or insurance plans pay low-income
family members to stay at home and provide care for
inýrm older adults?
• To what extent should family members sacriýce their
personal lives to keep frail or inrm older adults out of
institutional care?
• Can family obligations be met in a society that provides
little support or relief for caregivers?
of helthier, dynic senior citizens with signicnt
sending ower hs incresed, dvertising cigns
hve becoe incresingly likely to ortry older dults
s the consuers of their roducts, including exercise
equient, helth beverges, nd cruises. Desite these
societl iroveents, ny eole do not know
enough bout the relities of ging nd, becuse of igno-
rnce, re frid to get old. Soe edi studies hve
found tht eole who wtch ore television re likely
to hve ore negtive ercetions of ging.
GERONTOPHOBIA
The fer of ging nd refusl to ccet older dults
into the instre of society is known s geronto-
phobia. Senior citizens nd younger ersons cn fll
rey to such irrtionl fers (Box 1.1). Gerontohobi
soeties results in very odd behvior. Teengers buy
ntiwrinkle cres. Thirty-yer-old woen consider
fcelifts. Forty-yer-old woen hve hir trnslnts.
Long-ter rriges dissolve so tht one souse cn
ursue soeone younger. Often these behviors rise
fro the fer of growing older.
AGEISM
The extree fors of gerontohobi re geis nd
ge discriintion. Ageism involves  negtive tti-
tude towrd ging nd older dults bsed on the belief
tht ging kes eole unttrctive, unintelligent,
nd unroductive. It is n eotionl rejudice or dis-
criintion ginst eole bsed solely on ge. Age-
is llows the young to serte theselves hysi-
clly nd eotionlly fro the old nd to view older
dults s soehow hving less hun vlue. Like
sexis or rcis, geis is  negtive belief ttern
tht cn result in irrtionl thoughts nd destructive
behviors, such s intergenertionl conict nd ne
clling. Like other fors of rejudice, geis occurs
becuse of yths nd stereotyes bout  grou of
eole who re “different.”

Box 1.1 Aging: Myth Versus Fact
MYTHS: OLDER ADULTS…
• Are pretty much all alike.
• In general, are lonely and alone.
• Tend to be sick and frail and to live in nursing homes.
• Are often cognitively impaired.
• Have no interest in sex.
• Suffer from depression more than younger adults.
• Become more difýcult and rigid in their thinking.
• Have difýculty coping with age-related changes.
FACTS: OLDER ADULTS…
• Are a very diverse age group.
• Typically remain engaged and productive, often work
ing or volunteering or keeping in contact via social
networks.
• Usually live independently. Only about 1% of older
adults between the ages of 65 and 74 and 2% of those
between 74 and 85 live in nursing homes.
• May experience some cognitive decline, but this is usu
ally not severe enough to cause problems in daily living.
• Typically remain sexually active, although frequency
may decline.
• In general, have lower rates of depression as com
pared with younger adults, although the consequences
can be more severe.
• Tend to maintain a consistent personality throughout
the lifespan.
• Typically adjust well to the challenges of aging.
The cobintion of societl stereotying nd  lck
of ositive ersonl exeriences with older dults
ffects  cross section of society. Studies hve shown
tht helth cre roviders shre the views of the gen-
erl ublic nd re not iune to geis. Secilizing
in geritrics is unoulr by nursing nd edicl stu-
dents, even though older dults re frequent users of
the helth cre syste (Hebditch etl., 2020); therefore
ny nurses ctully do function s geritric nurses to
 gret extent. Soe helth cre roviders erroneously
believe tht they re not fully using their skills when
working with the ging oultion. Working in inten-
sive cre, the eergency dertent, or ny other high
technology re is viewed s exciting nd chllenging.
Working with older dults is viewed s routine, bor-
ing, nd deressing. As long s negtive ttitudes such
s these re held by helth cre roviders, this chl-
lenging nd otentilly rewrding re of service will
continue to be underrted nd the older dult oul-
tion will suffer for it.
Becuse geis cn hve  negtive effect on the
wy helth cre roviders relte to older tients,
such tients cn, s  result, hve oor helth cre
outcoes. Ageis leds to signicntly worse helth
outcoes worldwide; this cn be due to externl fc-
tors, such s denied ccess to helth services nd
tretent, or internl fctors, s when  reciient of
geis develos  disese-cusing intion
Trends and Issues CHAPTER 1 5
(Chng etl., 2020). Becuse the older dult oul-
tion is growing, helth cre roviders need to think
crefully bout their own ttitudes. Furtherore, they
ust confront signs of geis whenever nd wher-
ever they er. Activities such s greter ositive
interctions with older dults nd iroved rofes-
sionl trining designed to ddress isconcetions
regrding ging re two wys of ghting geis.
The Hrtford Institute for Geritric Nursing (HIGN),
fored in 1996, hs the gol of shing the helth cre
of older dults by rooting excellent nursing rc-
tice. Their website, www.hign.org, is  tresure trove
of geritric nursing resources, including the Try This
series of ssessent tools. Reserch shows tht neg-
tive ercetions of ging re redictive of entl nd
hysicl decline (Chng etl., 2020); therefore keeing
 ositive ttitude towrd ging ight just revent
soeone fro becoing fril in their older yers.
AGE DISCRIMINATION
Age discriintion reches beyond eotions nd
leds to ctions; older dults re often treted differ-
ently sily becuse of their ge. Exles of ge
discriintion include refusing to hire older eole,
not roving the for hoe lons, nd liiting the
tye or ount of helth cre they receive. Age dis-
criintion is illegl. Soe older dults resond to
ge discriintion with ssive ccetnce, wheres
others re bnding together to sek u for their
rights.
The relity of getting old is tht no one knows wht
it will be like until it hens. But tht is the nture of
life—growing older is just the continution of  ro-
cess tht strted t birth. Older dults re funden-
tlly no different fro the eole they were when they
were younger. Physicl, nncil, socil, nd oliti-
cl conditions y chnge, but the erson reins
essentilly the se. Old ge hs been described s
the “ore-so” stge of life becuse soe ersonlity
chrcteristics y er to lify. Older dults
re not  hoogeneous grou. They differ s widely
s ny other ge grou. They re unique individuls
with unique vlues, beliefs, exeriences, nd life sto-
ries. Becuse of their extended yers, their stories re
longer nd often fr ore interesting thn those of
younger ersons.
Aging cn be  liberting exerience. Aging sees
to decrese the need to intin retenses, nd the
older dult y nlly be cofortble enough to
revel the rel erson beneth the fcde. If  erson
hs been essentilly kind nd cring throughout life,
they will generlly revel ore of these ositive er-
sonl chrcteristics over tie. Likewise, if  erson
ws iserly or unkind, they will often revel ore
of these negtive ersonlity chrcteristics with ge.
The ore successful  erson hs been t eeting the
develoentl tsks of life, the ore likely they will
be to fce ging successfully. Perhs the best dvice to
6 UNIT I Overview of Aging
ll who re rering for old ge is to be found in the
Serenity Pryer:
O God, give us the serenity to accept what cannot be
changed; courage to change what should be changed; and
wisdom to distinguish one from the other.
Reinhold Niebuhr
DEMOGRAPHICS
Demographics is the sttisticl study of hun ou-
ltions. Deogrhers re concerned with  oul-
tion’s size, distribution, nd vitl sttistics. Vitl sttis-
tics include birth, deth, ge t deth, rrige(s), rce,
nd ny other vribles. The collection of deo-
grhic infortion is n ongoing rocess. The Bureu
of the Census conducts the ost inclusive deogrhic
reserch in the United Sttes every 10 yers. The ost
recent census ws coleted in the yer 2020.
Deogrhic reserch is iortnt to ny grous.
Deogrhic infortion is used by the governent
s  bsis for grnting id to cities nd sttes, by cities
to roject their budget needs for schools, by hositls
to deterine the nuber of beds needed, by ublic
helth gencies to deterine the iuniztion needs
of  counity, nd by rketers to sell roducts.
The oliticins of the 1930s used deogrhics to for-
ulte lns for the Socil Security rogr. Deo-
grhic studies rovide infortion bout the resent
tht llows rojections into the future.
One iortnt iece of deogrhic infortion is
life exectncy, or the nuber of yers n verge er-
son cn exect to live. Projected fro the tie of birth,
life exectncy is bsed on the ges of ll eole who
hve died in  given yer. If  lrge nuber of infnts
die t birth or during childhood, the life exectncy
of tht yer’s grou tends to be low. Life exectncy
throughout history hs been low becuse of environ-
entl hzrds, wrs, ccidents, the scrcity of food nd
wter, indequte snittion, nd contgious diseses.
• During biblicl ties, the verge life exectncy
ws roxitely 20 yers. Soe eole did live
signicntly longer, but 40 yers ws considered 
good long life.
• By 1776, when the Declrtion of Indeendence ws
signed, the life exectncy hd risen to 35 yers. It
ws very uncoon for nyone to live into their 60s.
• By the 1860s, t the tie of the Aericn Civil Wr,
life exectncy hd incresed to 40 yers. The 1860
census reveled tht 2.7% of the Aericn oul-
tion ws older thn ge 65.
• By the beginning of the 20th century, the overll life
exectncy hd incresed to 47 yers, nd 4% of the
Aericn oultion ws 65 yers of ge or older.
In  sn of ore thn 2000 yers, life exectncy
hd incresed by only 27 yers.
• During the 20th century, the life exectncy of
Aericns incresed by roxitely 29 yers. A
child born in the United Sttes in the yer 2004 hs
n verge life exectncy of nerly 77.4 yers.
• Projections indicte tht  le child born in 2017
will hve  life exectncy of 75.97 yers nd  fele
child born in the se yer will hve  life exectncy
of 80.96 yers (Socil Security Adinistrtion, 2020).
• The COVID-19 ndeic hs lredy decresed life
exectncy rojections by one full yer in the Unit-
ed Sttes (Thoson, 2021).
Since the beginning of the 20th century, dvnces in
technology nd helth cre hve drticlly chnged
the world, esecilly in industrilized ntions, where
food roduction exceeds the needs of the oultion.
Diseses such s choler nd tyhoid hve been elii-
nted or signicntly reduced by iroved snittion
nd hygiene rctices. Dreded counicble dis-
eses tht t one tie were often ftl (e.g., sllox,
esles, whooing cough, nd dihtheri) re now
reventble through iuniztion. Even neuo-
ni nd inuenz re no longer the ftl diseses they
once were—or so we thought until the recent COVID-
19 ndeic ered; before effective vccines were
develoed, it killed  disroortionte nuber of older
dults. Tody, vccines for ny diseses cn be given
to those who re t higher risk, nd tretent cn be
given to those who becoe infected.
A longer life is  worldwide henoenon. Soe 9%
of the world’s oultion is 65 yers of ge or older
(United Ntions, Dertent of Econoic nd Socil
Affirs, Poultion Division, 2019). Monco is the to
rnked country for longevity; Singore, Jn, Icelnd,
nd Hong Kong re lso in the to 10. The stnding of
the United Sttes hs stedily declined nd, ccording
to the Centrl Intelligence Agency’s estites (Centrl
Intelligence Agency, 2020), it now rnks 43rd of 224
countries. Soe ossible exlntions for the disrity
between the United Sttes nd other countries include
higher levels of ccidentl nd violent deths, obesity,
reltively high infnt ortlity, nd the high cost of
helth cre. Much of the world’s net gin in older er-
sons hs occurred in the develoing countries of Afric,
South Aeric, nd Asi (Fig. 1.1).
SCOPE OF THE AGING POPULATION
According to the U.S. Census Bureu (2018), by 2034,
for the rst tie in recorded history, the nuber of
eole over 65 yers of ge is rojected to exceed the
nuber of children under ge 18. In 2018, there were
52.4 illion eole in the United Sttes, or 16% of the
oultion, who were 65 yers of ge nd older. By
2040, this nuber is exected to increse to 80.8 il-
lion eole 65 yers of ge or older, or roughly 21.6%
of the totl oultion. The nuber of those 85 yers
of ge nd older is exected to double fro 6.5 illion
in 2018 to ore thn 14 illion in 2040 (Adinistr-
tion on Aging, 2020). We re becoing n incresingly
older society (Fig. 1.2).
 Trends and Issues CHAPTER 1 7

Fig. 1.1 Life expectancy world map. (From Roser, M., Ortiz-Ospina, E., Ritchie, H. [2013, revised 2019]. “Life Expectancy.”
Published online at OurWorldInData.org. Retrieved from https://ourworldindata.org/life-expectancy [Online Resource].)

Fig. 1.2 Percentage of the population in ýve age groups: United States, 1950, 2010, and 2060. (Data from the U.S.
Census Bureau.)

GENDER AND ETHNIC DISPARITY
The Adinistrtion on Aging (2020) rojects tht rcil
nd ethnic inority oultions will reresent 34% of
the older oultion by 2040, n increse fro 19%
in 2008. It is rojected tht by 2040, the White non-
Hisnic oultion will increse by 32%. During the
se tie eriod, the ercentge of rcil nd ethnic
inority ersons of the se ge cohort is exected
to grow by 125% (Hisnics, 175%; Africn Aericns,
88%; Aericn Indin nd Alsk Ntives, 75%; nd
Asins, 113%).
Life exectncy within the U.S. oultion is vri-
ble. The oultions of en nd woen re not
8 UNIT I Overview of Aging
equl, nd in the older-thn-65 ge grou, this disro-
ortion is very noticeble. There re now 29.1 illion
older woen to 23.3 illion older en. Woen cur-
rently outlive en by 2.6 yers, nd Whites tend to
live longer thn Blcks, lthough disrities see to
be declining (Adinistrtion on Aging, 2020).
Current life exectncies in ters of rce re s
follows: White woen, bout 81 yers; Blck woen,
bout 77.9 yers; White en, 76.1 yers; nd Blck
en, 71.5 yers. Hisnic eole in the United Sttes
hve  lower ortlity nd higher life exectncy
thn both non-Hisnic White nd non-Hisnic
Blck eole. Hisnic en cn exect to live to
79.1 yers; Hisnic woen hve the longest life
exectncy of 84.2 yers (Centers for Disese Control
nd Prevention, 2017). This longer life exectncy is
known s the Hispanic or Latino paradox, suggesting
tht desite ny socioeconoic disdvntges tht
y exist, Ltino oultions in the United Sttes
hve lower reture ortlity rtes thn White
nd Blck oultions; this hs been docuented in
severl Ltin Aericn countries s well (Chen etl.,
2020).
In 2018, 23% of those over ge 65 were identied
s inorities. Aroxitely 9% were Africn
Aericn (not Hisnic), 5% Asin (not Hisnic),
0.5% Aericn Indin nd Alsk Ntive (not His-
nic), 0.1% Ntive Hwiin/Pcic Islnder (not
Hisnic). Soe 0.8% identied theselves s being
descended fro two or ore rces. Peole identify-
ing s “Hisnic origin (who y be of ny rce)”
constituted 8% of the older oultion (Adinistr-
tion on Aging, 2020).
THE BABY BOOMERS
A jor contributing fctor to this rid exlosion in
the older dult oultion is the ging of the cohort
coonly clled the baby boomers. Age cohort is  ter
used by deogrhers to describe  grou of eole
born within  secied tie eriod. The bby booers
re eole born fter World Wr II, between 1946 nd
1964. Although now outnubered by the illennils
(those born between 1982 nd 2000), the bby boo-
ers ccount for roxitely 21% of the oultion
(Sttistic, 2020b) nd continue to hve  signicnt
inuence in ll res of society. In fct, t resent,
10,000 bby booers rech 65 yers of ge every dy!
It reins to be seen whether this grou will exe-
rience ging in the se wy tht revious gener-
tions hve or whether they will reinvent the ging
nd retireent exerience. The oldest bby booers
reched ge 65 in 2011; by 2029, ll bby booers
will be 65 yers of ge or older. Bsed on the sheer
size of this grou, the older oultion in 2030 will
be twice the size it ws in 2000. The ilictions of
this for ll res of society, rticulrly helth cre, re
unrecedented.
Critical Thinking
Demographics and You
• What impact will the changing demographics have on
you personally?
• How is your community’s age distribution changing?
• Are you a baby boomer? Do you ýnd this to be an
advantage or disadvantage as you age?
• Were you born after the baby boom? Before the baby
boom? What difýculties do you expect to encounter as
you age?
GEOGRAPHIC DISTRIBUTION OF THE OLDER
ADULT POPULATION
The older dult oultion is not eqully distributed
throughout the United Sttes. Clite, txes, nd other
issues regrding the qulity of life inuence where
older dults choose to live. All regions of the country
re ffected by the increse in life exectncy, but not to
the se degree. In 2018, bout hlf of the older-thn-65
oultion resided in 9 sttes. In descending order of
the older dult oultion, these sttes re Cliforni
(5.7 illion); Florid (4.4 illion); Texs nd New York
(ore thn 3 illion ech); nd Pennsylvni, Ohio, nd
Illinois (ore thn 2 illion ech). Michign nd North
Crolin round out the list, ech with 1.7 illion resi-
dents over the ge of 65 (Fig. 1.3). Three sttes reorted
ore thn 20% of their residents s being over the ge
of 65: Florid, Mine, nd West Virgini. Three sttes—
including Alsk, Nevd, nd Colordo—hve shown
n increse in the older-thn-65 oultion of 57% or
ore (U.S. Dertent of Helth nd Hun Services,
Adinistrtion for Counity Living, 2020).
MARITAL STATUS
In 2019, soe 69% of en over ge 65 were rried,
cored with 47% of older woen. About one-third
of older woen were widows; there were ore thn
3 ties s ny widows (8.9 illion) s widowers
(2.6 illion). The ercentge of older dults who were
serted or divorced ws roxitely 15%. A fur-
ther increse in the nuber of divorced elders is re-
dicted s  result of  higher incidence of divorce in
the oultion roching 65 yers of ge.
The nuber of single, never-rried seniors re-
ins soewht consistent t bout 5% (woen) to 6%
(en) of the older-thn-65 oultion (U.S. Dert-
ent of Helth nd Hun Services, 2020).
EDUCATIONAL STATUS
The eductionl level of the older dult oultion in
the United Sttes hs incresed drticlly over the
st 3 decdes. In 1970, only 28% of senior citizens
hd grduted fro high school. By 2019, soe 88%
were high school grdutes or ore, nd 31% hd 

Fig. 1.3 Persons 65 years or older as a percentage of total population, 2018. (From the U.S. Department of
Health and Human Services, Administration for Community Living. https://acl.gov/aging-and-disability-in-america/
data-and-research/prole-older-americans)
bchelor’s degree or higher. Coletion of high school
vried by rce nd ethnicity, with Whites (92%) co-
leting high school t higher rtes, followed by Asins
(80%), Africn Aericns (79%), nd Hisnics (59%).
In ddition to being better educted, tody’s older
dult oultion is ore technologiclly sohisti-
cted. The World Econoic Foru (2019) reorts tht
70% of Aericns over ge 65 use the internet. Also
oulr ong older dults re s such s Google
Ms, with rking sot reinders, nd Medisfe, 
obile ediction ngeent syste. About 81% of
dults in their 60s use  srthone, droing to 62%
fter ge 70 (AARP, 2020). Socil networking sites,
such s Fcebook nd LinkedIn, re used by  growing
nuber of older dults.
ECONOMICS OF AGING
The stereotyicl belief tht ny older dults re
oor is not necessrily true. The econoic sttus of
older ersons is s vried s tht of other ge grous.
Soe of the oorest eole in the country re old, but
so re soe of the richest.
POVERTY
In 2018, over 5.1 illion (9.7%) older dults lived t
or below the overty level A second indictor clled
the Suleentl Poverty Mesure—which con-
siders regionl vritions in housing costs, edicl
Trends and Issues CHAPTER 1 9
out-of-ocket exenses, nd other fctors—showed n
even greter ercentge of older dults (12.8%) living
in overty in 2019. Older woen were ore likely to
be ioverished thn older en. The highest rtes of
overty were ong older Hisnic woen who live
lone (37.8%).
INCOME
As of 2018, the edin incoe of en over ge 65 ws
$34,267, wheres tht for woen over ge 65 ws only
$20,431. The edin incoe of households heded by
 erson 65 yers of ge or older ws roxitely
$64,023. Medin incoe is the iddle of the grou,
with hlf erning less nd hlf erning ore. It is not
n verge ount. Medin gures cn be dece-
tive becuse incoe is not distributed eqully ong
Whites nd inority grous (Fig. 1.4).
The jor sources of ggregte incoe for older
dults include Socil Security benets, sset incoe,
ensions, nd other ernings. Fig. 1.5 shows the
sources of incoe for ve different incoe levels
(incoe quintiles).
Overll, Socil Security incoe ccounts for rox-
itely 33% of the incoe for eole ge 65 nd older.
Of older dults who receive Socil Security, hlf of
those rried nd 70% of those unrried rely on this
benet for 50% of their incoe. Averge onthly Socil
Security incoe in 2020 ws $1545 for  retired worker
(Socil Security Adinistrtion, 2020b). Low-erning
10 UNIT I Overview of Aging

Fig. 1.4 Percent distribution of the U.S. population by income, 2018. (From the U.S. Department of Health and Human
Services, Administration for Community Living. https://acl.gov/aging-and-disability-in-america/data-and-research/
prole-older-americans)

Fig. 1.5 Sources of income in the United States. (From the U.S. Census Bureau. https://agingstats.gov/docs/LatestReport/
Older-Americans-2016-Key-Indicators-of-WellBeing.pdf)

individuls nd coules re ore likely to rely on
Socil Security s their jor source of incoe. High
erners re less relint on Socil Security.
Socil Security funding y becoe indequte
s the nuber of retirees drwing benets increses,
while the ool of workers ying into the syste
decreses. There re resently 2.8 workers for ech
Socil Security beneciry; by 2035, this nuber will
decrese to 2.3. Peole both within nd outside the
governent hve roosed lns to ensure the long-
ter survivl of the Socil Security rogr. If no
chnges re de, it is estited tht Socil Security
csh reserves will be deleted in 2034 (AARP, 2020b).
This does not en tht the rogr will be bnkrut;
rther, it will be ble to y out only wht it collects
through Socil Security txes.

Asset incoe—or incoe derived fro investents
such s stocks, bonds, nd other retireent ccounts
—hs droed drsticlly since 2008. The econoic
downturn hs been cored in severity with the
Gret Deression of the 1930s. Mny retirees nd those
ner retireent lost  lrge ercentge of the onies
they hd sved nd invested for retireent. Mny of
those who invested ersonlly nd those who hd their
oney in eloyer-directed rogrs were severely
ffected. These nncil losses hve forced ny indi-
viduls nering retireent to continue working.
Aroxitely one-fth of eole ge 65 nd
older receive ensions fro ublic or rivte sources,
lthough this vries by incoe quintile (see Fig. 1.5).
Peole who retire fro  governent gency re ore
likely to receive  ension thn those who retire fro
 rivte industry. Not only re forer governent
eloyees ore likely to receive ensions, but gov-
ernent ensions lso tend to be ore generous thn
those in the rivte sector becuse governent wges
hve historiclly been below those of the rivte sec-
tor. The edin federl governent ension in 2018
ws $30,061, the edin stte or locl governent
ension ws $22,546, nd the edin rivte ension
or nnuity ws $9827 (Pension Rights Center, 2020).
Erly retireent ws oulr fro the 1970s until
bout 1985. Since then, the trend hs shown ore eo-
le working for y fter ge 65. For those over ge
65 who worked, the edin weekly wge in the third
qurter of 2020 ws $1006 ($52,000 nnully) (Bureu
of Lbor Sttistics, 2020). This is tyiclly signicntly
less thn wht the erson erned erlier in life nd
reects  decrese in hours worked nd in wges. Addi-
tionlly, these dt were gthered during  ndeic
tht iosed unusul work rctices on ll eole, but
they re consistent with dt trends of rior yers.
Ernings ke u  substntil ortion of incoe
for ny eole over ge 65. Those who re in higher
incoe brckets, generlly rofessionls, y con-
tinue to work well beyond ge 65 s long s they re
helthy nd interested in wht they re doing. Socil-
iztion, tie wy fro  retired souse, intellectul
chllenge, nd  sense of self-worth re verblized s
resons for working, rticulrly by those in the bby
boo genertion. Soe bby booers need to continue
to work to intin the stndrd of living they desire.
Soe need to work becuse they neglected to sve
enough for retireent or need to ke u for losses in
their investents. Those in lower incoe brckets y
need to continue to work, or to seek work, to y for
necessities of life or  few luxuries.
Legisltion nd oliticl ctivis ong older
eole hve heled irove the econoic outlook for
older dults (Tble 1.2). Beginning in 1965, key legis-
ltion ws ssed, including Medicre nd Medicid,
estblishent of the Adinistrtion on Aging, nd
the Older Aericns Act, which suorts nuerous
hoe- nd counity-bsed services such s Mels
Trends and Issues CHAPTER 1 11
Table 1.2 Legislation That Has Helped Older Adults
YEAR LEGISLATION
1965 Medicare and Medicaid established
Administration on Aging established
Older Americans Act (OAA) passed
1967 Age Discrimination Act passed
1972 Supplemental Security Income Program instituted
Social Security beneýts indexed to reþect inþation,
cost-of-living adjustment
Nutrition Act passed, providing nutrition programs
for older adults
1973 Council on Aging established
1978 Mandatory retirement age changed to 70 years
1986 Mandatory retirement age eliminated for most
employees
1988 Catastrophic health insurance made part of
Medicare
1990 Americans With Disabilities Act passed
1992 Vulnerable Elder Rights Protection Program
initiated
1997 Balanced Budget Act (Medicare Part C) passed
2000 Amendment to Older Americans Act (nutrition
programs) passed
2006 Drug Beneýt Program added to Medicare
2010 The Patient Protection and Affordable Care Act
passed
2016 Reauthorization of the Older Americans Act
2020 CARES Act passed
on Wheels, in-hoe services for older dults, elder
buse revention, nd cregiver suort. In 2020,
the Coronvirus Aid, Relief, nd Econoic Security
(CARES) Act rovided nerly $1 billion in grnt fund-
ing to ssist older dults who wished to shelter in
lce, y for hoe-delivered els, nd offer ny
other resources designed to iniize exosure to
COVID-19 (U.S. Dertent of Helth nd Hun
Services, Adinistrtion for Counity Living,
2020b). Through ctivist orgniztions, older dults
hve united to consolidte their oliticl ower nd to
use the ower of the vote to initite rogrs tht ben-
et the (Box 1.2). Over the st 25 yers, these grous
hve heled to irove the econoic welfre of older
dults. The Federl Housing Authority nd other
lending gencies hve roosed the use of reverse
ortgges, which re lns tht llow older dults to
rein in their hoes nd receive onthly yents
bsed on their hoe equity. Monthly incoe relized
fro these lns could rnge fro hundreds to sev-
erl thousnds of dollrs, deending on the roerty
vlue nd the ge of the residents. The ost coon
tye of reverse ortgge is  Hoe Equity Conver-
sion Mortgge (HECM). This oney could be  uch-
needed incoe suleent for ny older dults.
12 UNIT I Overview of Aging
Box 1.2 Politically Active Senior Citizen Groups
AARP (FORMERLY KNOWN AS THE AMERICAN ASSOCIATION OF
RETIRED PERSONS)
• Membership is open to people who are at least 50
years of age and their spouses (regardless of age).
• Currently has 38 million members.
• Uses volunteers and lobbyists to advance the political
and economic interests of older adults.
• Provides a wide variety of membership beneýts, includ
ing insurance programs and discounts.
• Was instrumental in helping to enact Medicare in 1965.
AMERICAN SENIORS ASSOCIATION (ASA)
• Does not report current numbers but claims to be the
fastest-growing senior advocacy group in America.
• Describes itself as the “conservative alternative to
AARP.”
ALLIANCE FOR RETIRED AMERICANS (ARA)
• Reports 4.3 million members.
• Focuses on political and legislative issues.
• Formerly known as the National Council of Senior
Citizens.
• Occasionally clashes with AARP on issues such as
Medicare drug benets.
NATIONAL COUNCIL OF GRAY PANTHERS NETWORKS (NCGPN,
FORMERLY GRAY PANTHERS)
• As a social justice action network, is involved in the
promotion of economic security, civil rights, marriage
equality, and other issues.
• Has approximately 500 activists from 32 states.
• In addition, has 16 local Gray Panthers Networks with
an estimated 500 additional activists.
• Issues action alerts on important senior issues; main
tains an active NCGPN Facebook page.
Reverse ortgges re not right for everyone, how-
ever. Extreely high fees, u to $40,000, re ssocited
with the, nd such yents cn becoe due in full
if the older erson oves out of the hoe for  yer or
ore—which is not outside the rel of ossibilities
if the erson exerienced  serious illness nd lce-
ent in  cre fcility. In such  cse, it is ossible tht
such  erson ight need to sell the hoe to rey the
HECM (Nolo.co, 2020).
Soe older dults y choose not to seek eco-
noic hel desite the nuerous ssistnce rogrs
designed for the. Mny eole re susicious of “get-
ting soething for nothing” or re reluctnt to disclose
ersonl nncil detils, which is necessry to qulify
for ost ssistnce rogrs. Mny older eole feel
tht sking for hel is huiliting. Soe fer tht they
will lose wht little they hve if they seek ssistnce. As
in ll ge grous, other older eole hve no difculty
seeking or, in soe cses, dending nncil ssis-
tnce or concessions. Fctors tht cn ffect the nn-
cil well-being of older dults re described in Box 1.3
Factors That Inuence the Economic
Box 1.3
Conditions of Older Adults
• Many older adults bought their homes when housing
costs and inþation were low. If they have paid off their
mortgages, their housing costs are limited to taxes,
maintenance, and utility bills.
• The number of older adults who receive pensions is
greater now than it will be in the future. Businesses
now offer smaller pensions to fewer employees, and
the traditional “dened benet” pensions have largely
been replaced by “dened contribution” pensions,
which are affected by stock market þuctuations.
• Older adults qualify for several tax breaks that are
unavailable to younger people.
• Most older adults pay no Social Security taxes;
younger working adults pay increasingly higher rates.
• Social Security and government pensions are largely
exempt from taxation.
• Taxpayers older than 65 years of age can take ad
ditional tax deductions.
• If an older adult is a homeowner and sells the home, a
one-time capital gains tax exclusion applies.
• Most older adults qualify for government income programs.
• Some 97% of people over age 60 receive Social Secu
rity benets or will in the future (Center on Budget and
Policy Priorities, 2020a).
• More than 61 million people were Medicare recipients
in 2015 (Kaiser Family Foundation, 2020).
• More than 2 million low-income, blind, or disabled older
adults receive Supplemental Security Income (SSI)
(Center on Budget and Policy Priorities, 2018).
Be sensitive in deling with the nncil issues of
older dults. The Criticl Thinking box should hel
you ssess your ttitudes, nd therefore your sensitiv-
ity, towrd these kinds of situtions. Mny older dults
who nd it esy to tlk bout their intite hysicl
nd edicl robles re reluctnt to discuss nnces.
Nurses y susect nncil need if n older erson
lcks dequte shelter, clothing, het, food, or edicl
ttention. When n econoic roble cuses rel or
otentil dngers, be rered to resond roritely.
Critical Thinking
Your Sensitivity to the Financial Problems of Older Adults
Respond to the following statements:
• Older adults control all of the money in the country.
• Most older adults are poor.
• Older adults have it easy; the younger working people
have it rough.
• Older adults have too much political power, and they get
too many benets and entitlements.
• Older adults worked for what they are getting, and they
deserve everything they receive from the government.
• A society that does not care for its older people is cruel
and uncivilized.
• The properties of older adults should be used to pay for
their physical needs and medical care.

Becuse regultions covering ssistnce ro-
grs often chnge, it is difficult for older tients
nd the nurses trying to hel the to kee current
nd u to dte. Nurses y be clled on to hel
older dults del with the erwork required
when they re lying for ssistnce, to rovide
eotionl suort s they work through frustrt-
ing bureucrtic rocesses, or to rrnge trnsor-
ttion to the rorite gencies. Nurses usully
re not exected to be exerts in this re, but they
should know how to locte rorite resources.
Nurses working in counity helth should be
wre of counity gencies roviding ssis-
tnce to older dults so tht rorite referrls
cn be de. Nurses working in hositls nd
nursing hoes cn initite referrls to socil work-
ers or other rofessionls who re knowledgeble
bout ssistnce rogrs. Most sttes nd coun-
ties throughout the United Sttes hve services for
older dults or dertents on ging. These re
tyiclly listed in the governent section of  tele-
hone directory or on governent websites. Mny
ublish directories of resources vilble in their
secific counity.
WEALTH
Although ny older eole receive less csh on 
yerly bsis fro Socil Security nd ensions thn
soe younger individuls ern,  substntil nuber
hve ccuulted ssets nd svings fro their work-
ing yers. Frugl lifestyles nd self-reorts by older
dults of being “oor” should be viewed cutiously.
Soe individuls re truly ioverished, wheres
others hve signicnt ssets.
In 2019, roxitely 78% of Aericns over 65
yers of ge owned their hoes (Sttistic, 2020).
A hoe is usully n older erson’s lrgest sset.
Mny older eole choose not to sell their hoes
becuse they fer tht they will hve nowhere to
live. Mny refer to rein “house rich nd csh
oor,” king do on  liited incoe, rther thn
sell their hoes.
Econoic well-being is usully esured in ters
of incoe, which is the ount of oney  household
receives on  weekly, onthly, or yerly bsis. How-
ever, this esureent is not lwys  relible indic-
tor of nncil security in older dults. Peole older
thn 65 yers of ge generlly hve ore discretionry
incoe (i.e., oney left fter ying for necessities,
such s housing, food, nd edicl cre) vilble
thn do younger eole. Younger individuls, rticu-
lrly those with growing filies, y hve  higher
incoe, but they lso hve higher nondiscretionry
dends.
Trends and Issues CHAPTER 1 13
HOUSING ARRANGEMENTS
Mny eole ssue tht older dults live in senior cit-
izen housing or nursing hoes. They re wrong. Most
older dults live either with  souse or lone. Arox-
itely 3% of dults over ge 75 live in institutionl
settings, such s nursing hoes, lthough this gure
increses to bout 10% for eole over ge 85 (Federl
Intergency Foru on Aging-Relted Sttistics, 2020).
Older individuls often try to kee their hoes,
desite the hysicl or econoic difculties of doing
so. A hoe is ore thn just  hysicl shelter; it re-
resents indeendence nd security. The hoe holds
ny eories. Being in  filir neighborhood close
to friends nd church is iortnt. A sense of cou-
nity is iortnt to ny older dults, who dislike the
thought of leving security for the unknown. The hys-
icl exertion nd eotionl tru involved in ov-
ing cn be intiidting, even overwheling, to older
dults. Moving to  different, often sller residence is
 difcult decision, rticulrly when it involves giv-
ing u recious ossessions due to lck of sce.
For soe older eole, keeing the fily hoe
is not  sensible otion for ny resons. Mny of
the hoes owned by older dults re in centrl cit-
ies with high crie rtes. Exenses, such s incres-
ingly high roerty txes nd ongoing intennce
costs, often ut excessive strin on older ersons
with liited nncil resources. Hoe intennce,
including even sile tsks such s houseclening,
becoes incresingly difcult with dvncing ge or
illness. Ownershi y require ore effort in ters
of oney nd tie thn soe older eole ossess,
yet ny struggle to rein indeendent nd kee
their hoes.
Soe older individuls rein in their own hoes
nd refuse to give the u long fter it is sfe for the
to be lone. They y be ble to coe s long s fily,
friends, nd neighbors re willing to hel. However,
if there is  chnge in their suort syste, dnger-
ous, life-thretening situtions y rise. Soe older
eole try to live in their hoes desite broken lub-
ing, indequte het, nd insufcient ccess to food.
Filies, helth cre rofessionls, nd socil service
gencies y hve to ste in to rotect the welfre of
these ging individuls.
Soe older eole recognize the robles ssoci-
ted with living lone nd decide to seek housing
rrngeents tht re better tched to their needs
nd bilities. They y ove into n rtent, con-
doiniu, senior colex, or other tye of hous-
ing. As the older dult oultion grows, new tyes
of housing nd living rrngeents re evolving
(Fig. 1.6). The following Criticl Thinking box should
hel you exine your ttitudes towrd housing for
older dults.
14 UNIT I Overview of Aging

Fig. 1.6 A living plan for a community-based residential facility with evacuation plan. (Courtesy Elness Swenson Graham
Architects, Inc., Minneapolis, MN.)

Critical Thinking
Your Attitudes Toward Housing for Older Adults
• Is it safe for older adults to remain indeýnitely in their
own homes?
• When should an older person sell their home?
• Once a home is sold, what are the best types of living
accommodations for older adults?
• What kinds of alternative housing for older adults are
available in your community?
• Should older adults live in housing that is separated from
people in other age groups? Why? Why not?

Indeendent or ssisted living centers re beco-

ing coon. These centers cobine rivcy with
esily vilble services. Most consist of rivte rt-
ents tht re either urchsed or rented. For ddi-
tionl chrges, the residents cn be served els in
resturnt-style dining roos nd receive lundry
nd housekeeing services (Fig. 1.7). Different levels
of edicl, nursing, nd ersonl cre services re
Fig. 1.7 Dining room in an assisted living facility. (Photo courtesy Era
Living, Seattle, WA.)
vilble. Helth cre services y include ssistnce
with hygiene, routine ediction dinistrtion, nd
even reventive helth clinics. Mny centers hve co-
unl ctivity roos, rts-nd-crfts hobby centers,

swiing ools, lounges, beuty slons, ini-grocery
stores, greenhouses, nd other enities. Trnsort-
tion to church, shoing, nd other ointents is
rovided by soe of these fcilities. Most indeendent
nd ssisted living fcilities re rivtely oerted,
nd costs re signicnt—lthough fr cheer thn
nursing hoe cre. Soe sttes offer subsidies to older
individuls with liited resources becuse these living
rrngeents re often ore cost-effective thn other
housing lterntives.
Did You Know?
Cruise Care
Some older adults are choosing to live on cruise ships
instead of assisted living or long-term-care facilities. The
ship provides a higher employee-to-resident ratio, more ac-
tivities, more and better choices of food, better scenery,
and more companionship for a lower price than nursing
homes and a comparable price to assisted living facilities.
Additionally, they have physicians and nurses on board
(Bandoim, 2019). Although not appropriate for individuals
suffering from dementia or immune compromise or those
who require frequent medical appointments, cruise care
might be an option (at least temporarily) for some adventur
ous seniors.
Life-lese or life-contrct fcilities re nother hous-
ing otion. For  lrge initil investent nd substn-
til onthly rentl nd service fees, older ersons or
coules re gurnteed  residence for life. Indeen-
dent residents occuy rtent units, but extended-
cre units re either ttched to the rtent colex
or locted nerby for residents who require skilled
nursing services. If one souse needs skilled cre,
the other y continue to live in the rtent nd
cn esily visit the hositlized loved one. When the
occunts die, control of the rtent reverts to the
owners of the fcility. The costs for this tye of hous-
ing re high nd y be out of the rnge of the ver-
ge older dult. However, desite the costs, ny nd
this otion eling becuse it eets their needs for
indeendence, sociliztion, nd services. Mny nd
security in knowing tht skilled cre is esily vilble
if needed.
Less welthy older dults hve fewer housing
otions. Soe older dults qulify for governent-
subsidized housing if they eet certin nncil stn-
drds nd liits. Governent-subsidized housing
units y be sile rtents without ny secil
services, or they y hve liited services, such s
ccess to nursing clinics nd secil trnsorttion
rrngeents. Most counities re nding tht the
dend for these fcilities exceeds the vilbility.
Witing lists with u to 2-yer delys re coon;
soe counities wrd the housing vi lotteries.
Interrettion of governent regultions is cusing
Trends and Issues CHAPTER 1 15
soe concern with regrd to senior citizen housing.
Residences originlly intended for older dults y be
required to ccet  vriety of ediclly disbled eo-
le regrdless of ge. Soe of these younger residents
suffer fro sychitric or drug-relted robles, nd
the resence of these individuls y leve older dult
residents feeling thretened nd unsfe.
Soe older dults who re not relted to ech
other re foring grou housing lns. In this tye
of rrngeent, unrelted eole shre  household
in which they hve rivte bedroos but shre the
coon recretionl nd leisure res s well s
hoe intennce tsks. Soe counities offer
services to hel tch eole who re interested
in this otion. Rootes re selected so tht the
strengths of one individul coenste for the wek-
nesses of the other. In soe cses,  lrge house y
shelter 10 or ore residents. Not ll such rrnge-
ents re liited to older dults. In soe situtions,
younger dults who need resonble housing y be
included. By roviding services for older dult resi-
dents, the younger residents cn reduce their rentl
costs. Both younger nd older individuls who hve
chosen this otion reort benets fro the extended-
fily toshere.
A ore forl tye of grou hoe, clled 
counity-bsed residentil fcility (CBRF), is vil-
ble in soe counities. For  onthly fee, this tye
of fcility rovides services such s roo nd bord,
hel with ctivities of dily living (ADLs), ediction
ssistnce, yerly edicl exintions, infortion
nd referrls, leisure ctivities, nd recretionl or
thereutic rogrs. Fees for this tye of housing
y be id by the individul or y be rovided by
county or stte gencies. Most of these fcilities ro-
vide rivte or seirivte roos with counity
res for dining nd sociliztion.
Older dults who require ore extensive ssistnce
y need lceent in nursing hoes or extended-
cre fcilities. Nursing hoes rovide roo nd
bord, ersonl cre, nd edicl nd nursing ser-
vices. They re licensed by individul sttes nd regu-
lted by federl nd stte lws. Three levels of cre re
rovided by nursing hoes: skilled cre, interedite
cre, nd custodil cre. Skilled cre is dily nursing
cre, including ediction dinistrtion nd skilled
tretents or rocedures tht require the exertise of
licensed nurses. It lso includes services erfored by
secilly trined rofessionls, such s seech, hysi-
cl, occutionl, nd resirtory therists. Inter-
edite cre describes rofessionl cre tht is not
required on  dily bsis. It is  ste down fro skilled
cre. Custodil cre is the next ste down nd refers to
cre tht is considered nonskilled ersonl cre, such
s ssistnce with ADLs.
Subcute cre fcilities rovide corehensive
intient cre designed for individuls who hve n
16 UNIT I Overview of Aging
Critical Thinking
Nursing Home Insurance
Medicare will pay for a maximum of 100 days in a skilled care
facility after a 3-day hospital stay. After that time, the cost of
care is usually the responsibility of the older person or their
family unless they qualify for Medicaid. In light of this, do you
think that people approaching retirement should purchase
nursing home insurance? Why or why not?
cute illness, injury, or excerbtion of  disese ro-
cess. Subcute cre flls between the trditionl cre
rovided in n cute cre hositl nd tht rovided
in  skilled nursing hoe. For exle,  ventiltor-
deendent tient or soeone requiring frequent
resirtory tretents would nd rorite cre in
 subcute fcility.
Secilty cre fcilities—such s residences
designed to eet the secil needs of eole with
Alzheier disese or other eory loss nd their
filies—re gining in oulrity round the coun-
try. Other secilty cre fcilities re nuerous nd
include intient hosice fcilities, long-ter cre si-
nl cord injury fcilities, nd skilled nursing fcilities
tht rovide dilysis tretent.
HEALTH CARE PROVISIONS
Helth cre is  jor re of concern in the United
Sttes. Everyone wnts the best nd ost corehen-
sive edicl cre for theselves nd their filies.
The exense of this level of cre is the roble. At one
tie, individuls were ersonlly resonsible for the
yent of hysicin nd hositl bills. This grdu-
lly chnged, nd helth cre insurnce, either individ-
ully urchsed or id for by n eloyer, bece
the nor. Insurnce conies id the bills, nd the
individul bece less wre nd involved in the ris-
ing cost of helth cre.
Governent lyed  inil role until the estb-
lishent of Medicre in 1965.
MEDICARE AND MEDICAID
Medicre is the governent rogr tht rovides
helth cre funding for older dults nd disbled er-
sons. Medicre is  oulr rogr, nd ost Aeri-
cns believe tht it ust be reserved. This hs becoe
incresingly difcult s the bby boo genertion hs
becoe older; by 2030, ll eole in this cohort will be
Medicre eligible. In 2020, Medicre rovided coverge
for roxitely 61.2 illion citizens (Kiser Fily
Foundtion, 2020). By 2050, this nuber is exected to
swell to 90.7 illion citizens (Kiser Fily Found-
tion, 2021). Most Aericns older thn 65 yers of ge
qulify for Medicre.
Medicre hs four distinct rogrs, none of which
ys ll of the helth cre costs. Medicre Prt A is
hositl insurnce. It covers intient hositl cre;
skilled nursing cre following hositliztion; soe
hoe helth services, such s visiting nurses nd
occutionl, seech, or hysicl therists; nd hos-
ice services, but only fter the tient ys n initil
deductible nd ny coyents. During the 1980s,
Medicre instituted the dignosis-relted grou (DRG)
syste in n ttet to contin hositl costs. Under
this syste,  hositl is id  set ount bsed on
the tient’s ditting dignosis. If the tient is dis-
chrged in fewer dys thn redicted, the hositl
kees the excess oney. If the tient needs to sty lon-
ger thn rojected, the hositl bsorbs the dditionl
costs. Although DRGs hve resulted in cost reduction,
they hve lso led to the dischrge of eole “quicker
nd sicker” thn in the st. Mny older eole re
relesed fro the hositl before they hve ctully
recovered fro their illnesses, lcing  greter helth
cre burden on filies nd hoe helth gencies.
Medicre Prt B is edicl insurnce for outtient
cre. It is otionl, but ost eole choose this cov-
erge. This ln covers 80% of the “custory nd
usul” rtes chrged by roviders fter deductibles
re et. In ddition to roviders’ fees, Medicre Prt
B covers ediclly necessry bulnce trnsort;
hysicl, seech, nd occutionl thery; hoe
helth services when ediclly necessry; entl
helth services; x-rys nd lb tests; chirorctic cre;
edicl sulies nd equient; nd outtient sur-
gery or blood trnsfusions. The tient is resonsible
for the reining 20% of the costs lus the difference
between the ctul fee nd the governent’s “custo-
ry nd usul” rte. The true costs of edicl cre
often exceed the ount tht the governent ys.
Mny older dults y for rivte suleentl helth
cre insurnce to cover these exenses rther thn y
out of ocket.
Medicre Prt C, or Medicre Advntge Plns, re
otionl lns offered by rivte conies roved
by Medicre to individuls who re eligible for Prt
A nd enrolled in Prt B. These lns llow beneci-
ries to receive their Medicre benets through rivte
insurnce conies. The older dult enrolls in  ri-
vte ln, such s  helth intennce orgniztion
(HMO) or referred rovider orgniztion (PPO).
These lns re designed to cover totl costs, so tht
suleentl insurnce coverge is not necessry.
They usully lso include rescrition drug benets.
They do, however, liit the ool of vilble helth
cre roviders, nd reius nd rules vry deend-
ing on the ln selected.
Medicre Prt D, or rescrition drug coverge, is
 voluntry ln vilble to nyone enrolled in Prt
A or B of Medicre. It includes both stnd-lone re-
scrition lns nd Medicre Advntge drug lns.

Under Prt D, rescrition drugs re distributed
through locl hrcies nd dinistered by  wide
vriety of rivte insurnce lns. In ny lns,
there is  signicnt g between the cost of the drugs
nd the benets rovided. After eeting  deduct-
ible, reciients of Medicre Prt D y 25% of their
rescrition costs until they rech the out-of-ocket
sending liit nd qulify for ctstrohic coverge;
in 2020, this sending liit ws $6350 (Medicre Inter-
ctive, 2021).
Suleentl Medicid (Title 19) ssistnce y
be vilble for those older dults who eet certin
nncil need requireents. Mny of those who hve
ssets do not qulify; they re left with  Medicre
g (or “edig”) tht they ust ll (y for) the-
selves. Mny older eole buy rivte edicl insur-
nce—often t unresonble rices—to y edicl
bills tht re not covered by Medicre. The Affordble
Cre Act ndted sttes to exnd Medicid cover-
ge; however, not ll sttes hve exnded coverge
t this tie.
Critical Thinking
Medicaid and Personal Assets
Do you think that people should qualify for Medicaid if they
hold valuable assets—that is, if they own a home or expen-
sive cars? Or do you think they should liquidate their assets
(i.e., sell the home and cars) before receiving Medicaid? Why
or why not?
RISING COSTS AND LEGISLATIVE ACTIVITY
The costs of helth cre hve incresed drticlly in
recent yers. The United Sttes sends ore oney on
helth cre thn ny other country in the world, yet
such cre is not rovided for ll U.S. citizens. Mny
other ntions do  better job of eeting their citizens’
helth cre needs.
The Centers for Medicre & Medicid Services
(2020) reorted tht the United Sttes sent roxi-
tely $3.8 trillion on helth cre in 2019. This
ccounts for 17.7% of our gross doestic roduct. A
signicnt roortion of helth cre sending is sent
on the older dult oultion. These costs re stgger-
ing, esecilly considering the exnding oultion
of older dults. There hs been n usurge in initi-
tives to contin helth cre costs, such s nged cre
nd insurnce refor. If we exect to continue to ro-
vide dequte helth cre in the future, we cn exect
to see ore chnges in the wy helth cre is nnced
nd delivered. This is  jor nd often divisive oliti-
cl issue.
The cost of Medicre lone hs grown drticlly
fro $3 billion in 1967, the rst yer of funding, to
$55.5 billion in 1983; $297 billion in 2004; $551 billion
in 2012; nd $799 billion in 2019. The Congressionl
Trends and Issues CHAPTER 1 17
Budget Ofce (CBO) (2019) rojects tht it will surss
$1 trillion in 2023 nd hit $1.5 trillion ($1500 billion)
in 2029 (Fig. 1.8). The reciients of Medicre, however,
y quite  bit in out-of-ocket exenses: soe 50% of
tyicl Medicre reciients y roxitely 16% of
their incoe on helth cre nd reiu costs (Noel-
Miller, 2020).
The Ptient Protection nd Affordble Cre Act
(PPACA) ws signed into lw in 2010. It includes
nuerous helth-relted rovisions designed to tke
effect over severl yers. This legisltive inititive
includes jor chnges in helth insurnce, helth cre
funding, student lons, nd  wide rnge of send-
ing considertions. The costs of these rovisions re
to be offset by  vriety of txes, fees, nd cost-sving
esures.
There is  gret del of controversy regrding the
PPACA becuse its long-ter effects re still unknown.
Those in fvor of the legisltion cite exnded cover-
ge, greter coetition ong insurnce conies,
coverge of eole with reexisting edicl condi-
tions, nd closure of the donut hole ffecting senior
citizens ( lrge funding g tht lced  burden on
older dults for ediction yent; the donut hole
“closed” in 2020) . Those oosed to the legisltion
cite cuts in Medicre funding, cuts in the Medicre
Advntge rogr, increses in the Medicre tx,
nd exnsion of Medicid. They fer incresed costs
of helth cre, ore txes, nd decresed incentives to
riry cre roviders.
Fig. 1.8 Projected Medicare spending in billions of dollars. (Data from
Congressional Budget Ofýce, 2019, Medicare—CBO’s May 2019
Baseline. https://www.cbo.gov/system/ýles/2019-05/51302-2019-
05-medicare_0.pdf and Congressional Budget Ofýce, 2020, 10-Year
Budget Projections and Historical Budget Data. https://www.cbo.gov/
about/products/budget-economic-data#2)
18 UNIT I Overview of Aging
Legl chllenges regrding the constitutionlity of
this bill were rised by severl sttes, yet it ws ruled
constitutionl by the U.S. Suree Court in June of
2012. In writing the jority oinion, however, Justice
John Roberts stted tht the rogr is  tx—which
y ve the wy for different legl chllenges. Efforts
re now under wy to strike down the entire PPACA,
which would result in 21 illion eole becoing
uninsured nd illions ore being denied helth
insurnce due to reexisting conditions (Center on
Budget nd Policy Priorities, 2020b). Helth cre ro-
viders should y ttention, becuse this legisltion
is likely to hve n ict on how helth cre is ro-
vided nd funded. Other sects of the lw continue to
be chllenged in court.
COSTS AND END-OF-LIFE CARE
Not ll older eole use the vilble helth cre
resources eqully. Most helth cre services re con-
sued by the very ill or terinlly ill inority, ny
of who hen to be older dults. It is estited tht
between 13% nd 25% of ll Medicre dollrs sent
on those 65 yers of ge or older ws sent on ben-
eciries in their lst yer of life (Duncn etl., 2019).
Desite this, those tients’ ersonl ssets re quite
often deleted. Serious questions re being rised
bout the roriteness of using intensive, exen-
sive interventions to extend the lives of terinlly ill
older eole.
Finncil concerns re forcing helth cre roviders
nd society to fce ethicl diles regrding the llo-
ction of liited helth cre resources. This is  highly
eotionl issue with no esy nswers. Mny eole
re live tody becuse of dvnces in edicl tech-
nology. Soe of those who benet re young, wheres
others re old. Soe go on to led lives of high qul-
ity; others never led norl lives gin. By virtue of
their trining, hysicins re inclined to try to cure
everyone. Most doctors do not feel cofortble llow-
ing  tient to die, regrdless of the erson’s ge, nd
will use ll vilble technology to sve  life. Tlking
bout deth is not esy for nyone, including edicl
roviders. It is esier to void end-of-life issues thn to
tke the tie to consider this difcult discussion. Cre
roviders need to tke the tie needed to hve honest
discussions with tients while the tients re co-
etent to understnd nd ke infored decisions
bout how they would like to send their nl dys.
Reutble uthorities, ethicists, nd oliticins hve
widely differing oints of view on this issue. Soe
believe tht helth cre restrictions on older dults re
the ultite in ge discriintion. Others rgue tht
the benets gined, which cn usully be esured
in onths, do not outweigh the costs. Privte citizens
exining this dile re eqully confused. Even
those who believe tht helth cre costs re excessive
frequently wnt everything ossible done to sve their
lives or those of their loved ones. This orl, ethicl,
nd legl dile hs no sile solution. Prt of the
debte regrding helth cre refor involves differ-
ing viewoints regrding end-of-life cre. Perhs this
issue will encourge n honest ntionl discussion
ong souses, filies, siritul dvisors, hysi-
cins, nd other helth cre roviders.
The following Criticl Thinking box is designed
to increse your wreness of nd insight into these
robles.
Critical Thinking
Your Understanding of the Health Care Dilemma
• Should an 80-year-old person have coronary bypass
surgery at a cost of approximately $123,000? A cardiac
transplant at a cost of approximately $1.3 million?
• Should dialysis be provided to individuals older than
65 years of age? Older than 75? Older than 85?
• Should people older than age 65 receive organ
transplants?
• Should a ventilator be used on a terminally ill patient?
• Are feeding tubes a part of basic physical care or are
they extraordinary means?
• Should the individual, family, or primary care provider
decide on the type and amount of medical intervention
necessary?
• What should be the role of the government in health
care?
ADVANCE DIRECTIVES AND PHYSICIAN ORDERS
FOR LIFE-SUSTAINING TREATMENT
All dults who re 18 yers of ge or older nd of sound
ind hve the right to ke decisions regrding the
ount nd tye of helth cre they desire. Becuse
older dults re ore likely to exerience signicnt
helth robles, the question of wht nd how uch
edicl cre to dinister ust be ddressed. Such
iortnt decisions re best de during  stress-free
tie when the individul is lert nd exeriencing no
cute helth robles. A erson’s wishes cn best be
counicted using dvnce directives, which re
leglly recognized docuents tht secify the tyes
of cre nd tretent tht individuls desire when
they cnnot sek for theselves. Tyiclly included
in dvnce directives re: (1) do not resuscitte/do
not ttet to resuscitte (DNR/DNAR) nd llow
nturl deth (AND) orders, (2) directives relted to
echnicl ventiltion, nd (3) directives relted to
rticil nutrition nd hydrtion.
Two forl tyes of dvnce directives re recog-
nized in ost sttes: (1) the durble ower of ttor-
ney for helth cre nd (2) the living will. Infortion
bout both of these is tyiclly rovided when soe-
one enters the hositl. Ech tient is exected to
ke  decision bout the tye nd extent of cre to be
dinistered if their condition becoes terinl.

These docuents re designed to hel guide the
fily nd edicl rofessionls in lnning cre. The
fily is often relieved to hve this infortion when
they re king difcult decisions during  stressful
tie. Advnce directives re generlly recognized nd
resected, but vrious gencies or helth cre rovid-
ers y hve beliefs or olicies tht rohibit the
fro honoring certin dvnce directives. Individuls
should discuss their wishes with their helth cre ro-
viders when these docuents re written. If there re
irreconcilble differences between n individul nd
the cre rovider, chnges in either the docuent or
the cre rovider ust be considered.
A durble ower of ttorney for helth cre trnsfers
the uthority to ke helth cre decisions to nother
erson, clled the health care agent. The gent y ct
only in situtions in which the ersons involved re
unble to ke such decisions for theselves. Becuse
the helth cre gent ust be trusted to follow through
with the older erson’s wishes, the gent secied in
the docuent is usully  fily eber or friend.
These wishes re secied in writing nd usully
witnessed by unrelted individuls so s to reduce
the ossibility of undue inuence. Stndrdized legl
fors re vilble to initite  ower of ttorney for
helth cre.
A living will infors the hysicin tht the individ-
ul wishes to die nturlly if  terinl illness devel-
os or if the erson receives n injury tht cnnot be
cured. Living wills rohibit the use of life-rolonging
esures nd equient when the individul is ner
deth or in  ersistent vegettive stte. Living wills go
into effect only when two hysicins gree in writing
tht the necessry criteri hve been et.
Usully, either of these docuents is dequte to
counicte  erson’s wishes; both re not needed.
Those who choose to initite both docuents should
ensure tht there is no conict between the directions
rovided in ech docuent. Either docuent cn be
revoked t ny tie. An dvnce directive should be
stored in  sfe lce where it cn be locted esily
when needed. A sfe deosit box is not recoended
for this urose. Fily ebers nd the fily lw-
yer should know the content of the docuent nd its
loction. An dvnce directive should be rovided to
the riry cre rovider so tht it becoes rt of the
tient’s ernent edicl record. These docuents
re often required nd ket vilble for eergency sit-
utions when n individul resides in n institutionl
setting such s n indeendent or ssisted-living rt-
ent, counity-bsed residentil fcility, or nursing
hoe.
Lws nd secics differ fro stte to stte. Nurses
should be wre of the legl stnding of such docu-
ents in the rticulr stte where they rctice nd
should understnd ny legl rictions engen-
dered by these docuents. Physicin orders for life-
sustining tretent (POLST) is  legl docuent tht
Trends and Issues CHAPTER 1 19
hs been doted by lost every stte nd tkes the
erson’s wishes further by creting ctul doctor’s
orders to be crried out by eergency ersonnel. The
POLST contins three or four sections, deending on
the stte, including secics bout crdioulonry
resuscittion (CPR) (whether to ttet resuscit-
tion or llow nturl deth), edicl interventions
(cofort cre, liited interventions, or full tretent
including when to trnsfer to hositl), ntibiotics (use
freely, use for cofort, or do not use t ll), nd rti-
cil nutrition (no tube feeding, tril of tube feeding,
or long-ter tube feeding). The POLST is rinted on
bright er, the color of which is deterined by the
stte, nd signed by the hysicin nd tient. Sle
POLST fors re freely vilble on the internet.
Critical Thinking
Advance Directives and Physician Orders for Life-Sustaining
Treatment (POLST)
• How would you as a nurse approach a patient regarding
the initiation of an advance directive?
• Can a person who is diagnosed with Alzheimer disease
initiate a living will or durable power of attorney?
• Does your state have POLST?
• How do hospitals and extended-care facilities identify a
patient’s advance directive?
IMPACT OF AGING MEMBERS OF THE FAMILY
The fily is undergoing signicnt chnge in our
society. Mny fctors—including incresing divorce
rtes, single renting, corenting, nd  obile o-
ultion—re creting  less stble, less redictble f-
ily structure. Blended filies, extended filies, nd
serted filies ll resent chllenges. In ddition
to these societl chnges, the deogrhic chnges
discussed reviously re hving nd will continue to
hve reercussions tht we cn only begin to reci-
te (Box 1.4).
Filies tody fce historiclly unrecedented
situtions. Becuse of the lifesn extension, it is not
Box 1.4 Demographic Changes Affecting the Family
• Because of extended lifespans, the number of family
members over age 65 is growing.
• More people are living with chronic conditions and need
some degree of care or assistance.
• The number of people in the younger generations is de
creasing in proportion to the number of older members.
• There is a growing number of widows who may be
unprepared to provide for their own needs and will need
assistance.
• The role of women is changing. As women increasingly
must work outside the home, many are attempting
to meet the demands of their parents as well as their
homes, children, and workplaces.
20 UNIT I Overview of Aging
Fig. 1.9 Fun—quality time with granddaughter.
uncoon for 4 or 5 genertions of  fily to be live
t one tie (Fig. 1.9). Until recently, this ws unherd
of. Using 20 yers s  tyicl genertion,  fily
ight reseble the one described in Tble 1.3. If the
genertion tie is less thn 20 yers, even ore gen-
ertions ight be live t the se tie.
REFLECTION BY A NURSING PROFESSOR
Some years ago, as death was approaching for a 91-year-old
gentleman, his family gathered at the hospital. His wife of
69 years asked that “the children” come into the room. This
sounded rather strange because “the children” were all in
their 60s, the grandchildren were all mature adults, and
the great-grandchildren were fast approaching adulthood. It
sounded even stranger to me, because this older man was my
grandfather, and my father was “the baby” of the family.
Glori Wold
Mny older dults who need cre will receive ssis-
tnce, both econoic nd hysicl, fro their filies.
The robles encountered in such situtions cn differ
widely, deending on the resective ges of the f-
ily ebers. In soe filies, the “children” who re
tteting to rovide cre for the oldest ebers re
likely to be st ge 65 theselves. They y hve
helth robles of their own tht ke cregiving
difcult or ircticl. They y lso hve nncil
obligtions to their own children, such s ying for
eduction.
Table 1.3 The Family
AGE (YEARS) GENERATION
80+ Parents
60+ Children
40+ Grandchildren
20+ Great-grandchildren
Less than 20 Great-great-grandchildren
Middle-ged fily ebers often becoe the
cregivers. The genertion in their 40s nd erly 50s
is soeties clled the sandwich genertion becuse
its ebers re cught in the iddle—trying to work,
to rise their own children, nd erhs rovide
ssistnce to one or two genertions of ging f-
ily ebers. Soeties they re lso trying to hel
rise grndchildren by giving nncil or hysicl
ssistnce.
Although the nncil, sychologic, nd hysicl
dends of ssisting ging reltives ffect ll fily
ebers, woen re likely to be the ost ffected. It
is estited tht 75% of the cregivers in the United
Sttes re fele (Box 1.5). Tyiclly, sons contribute
nncilly, but the brunt of the burden of eotionl
nd hysicl cre flls on the dughters. It is estited
tht s the oultion ges, woen will send ore
tie cring for their rents thn they did cring for
their children.
Filies try to hel ging fily ebers in ny
wys. If the older dult is ble to live lone, filies
y ssist by visiting frequently nd heling with
trnsorttion to shoing nd edicl oint-
ents. Soe rere els, hel with houseclening,
nd ke jor hoe reirs. Running between two
households nd trying to intin both cn be en-
tlly nd hysiclly exhusting, but ny re willing
to hel their loved ones in ny wy they cn.
A fily crisis y occur when the ging erson is
no longer ble to live lone. Iortnt decisions ust
be de. Most filies nd tht there is no erfect
solution. The two ost coon otions re bringing
the ging rent into the hoe of one of the children
or lcing the rent in n ssisted living or long-ter
cre fcility. There re robles nd concerns with ny
otion tht requires  jor chnge in living rrnge-
ents. It is essentil tht the fily king this dif-
cult decision consider ny fctors. The ount of
cre needed by the rent; the vilbility of  will-
ing nd ble fily eber; the ount of vilble
sce in the child’s hoe; the dded nncil nd
eotionl burden of n dditionl household eber;
Box 1.5 Caregivers in the United States
Data from Family Caregiver Alliance: Caregiver Statistics:
Demographics https://www.caregiver.org/caregiver-
statistics-demographics
• The average caregiver age is 49 years.
• About 49% of caregivers are caring for a parent or
parent-in-law.
• Some 75% of caregivers are female, and female care
givers typically spend more time providing care and
performing personal care tasks.
• Family caregivers spend an average of 24.4 hours per
week in giving care.
• The average duration of caregiving for a family caregiver
is 4 years.

the wishes of the rent, the child, nd the child’s f-
ily; nd the interersonl dynics within the fily
ust ll be considered before  decision is de.
Children y tke older rents into their hoes
when the older rents cn no longer intin their
own hoes. Although this rrngeent works well in
soe filies, in others it is robletic for everyone
involved. The filir roles nd resonsibilities re
often reversed when children ste in nd ttet to
tke cre of their rents. This lces the ging er-
son into the role of the child, which they usully resent
strongly. “Don’t tell your other wht to do!” or “I’
still your fther!” is often herd in such rent-child
interctions.
Loss of indeendence is robbly the ost signi-
cnt issue tht ging rents nd their children ust
fce. The ging fily ebers hve sent decdes
king their own decisions. As indeendent dults,
they de their own choices bout where to live,
wht to do, nd when to do it. They chose wht to et,
obtined their food, nd rered it without interfer-
ence. They went to bed when nd where they chose.
They went where they wnted to go without sking
erission. They hd control of their lives. Most inde-
endent dults do not wnt to sk nyone for hel.
As hysicl chnges or diseses ffect older dults,
soe or ll of their indeendent function y be lost.
Aging eole nd it difcult to ccet tht they cn no
longer do the things they once did. It is lso distressing
for the fily to wtch their loved ones chnge. While
the ging erson tries to coe with these chnges, the
fily tries to deterine how to resond. If “the right
thing to do” is not obvious, fily ebers begin to
exerience ixed feelings nd confusion. Feelings of
grief, nger, frustrtion, nd loss re coon in ll
ffected individuls.
When n older dult oves in with  child’s f-
ily, the dynics within the hoe re unvoidbly
chnged. The bility of the fily to dt nd coe
with n dditionl eber of the household vries
gretly fro sitution to sitution. If ll rties re
greeble to the ove nd if the older dult cn be
given enough rivcy to intin indeendence, the
blending of the older erson into the child’s hoe y
be successful. Soe filies feel tht hving  resident
grndrent cn be rewrding nd enriching. How-
ever, if the resence of the older erson intrudes exces-
sively on the fily unit, the sitution y be unles-
nt for both the fily nd the older erson.
If the older fily eber requires  substntil
ount of hysicl cre, the dends on fily e-
bers cn be intense. Nevertheless, ny children feel
duty bound to cre for their ging rents. This sense
of obligtion y be bsed on culturl, religious, or
ersonl beliefs. If the children deterine tht they
re unble to cre for their rent nd insted ot for
nursing hoe lceent, the children often feel tht
they hve filed in their resonsibilities. This cn led
Trends and Issues CHAPTER 1 21
to intense feelings of guilt even if nursing hoe lce-
ent is the ost relistic nd resonble otion.
THE NURSE AND FAMILY INTERACTIONS
When we s nurses cre for older dults, rticulrly
in hositl or nursing hoe settings, we see the erson
only s they re now. We often forget tht these eole
hve not lwys been old. They lived, loved, worked,
rgued, nd wet s we ll do. Often, the older dults
we cre for re very ill or inr nd, s nurses, we
tend to focus on their hysicl needs, cres, nd tret-
ents. In our reoccution with our duties, we cn
esily lose our ersective of the older tient s both
 erson nd  eber of  fily.
In hositls nd nursing hoes, fily ebers coe
nd go. Soe filies show  gret del of interest nd
concern for their ging ebers, visit regulrly, nd inter-
ct with the tient nd stff. This llows us to increse
our understnding nd recition of our tients s
eole. Other older individuls y never hve fily
ebers visit the. They see to be lone in the world,
even though the edicl record lists children nd their
telehone nubers for eergencies. Even in hoe set-
tings, fily ttention nd interction vry gretly. In
soe households,  gret del of interest is given to ech
fily eber; in others, little or none is shown. Why do
we see such  wide vrition of fily ttention?
The nswer often lies in fily dynics nd ro-
cesses tht begn long go when the older dult ws
 young souse nd rent. Soe filies re very
stble nd cohesive. They re together often nd shre
close, loving bonds. They hve develoed helthy
ethods for intercting, resonding, nd eeting ech
other’s needs. Becuse of the strong bonds tht hve
develoed over ny yers, these filies rein
interested in nd suortive of their ging ebers.
Other filies never develo the closeness tht is
idel in  fily. The fily unit y hve been dis-
ruted by divorce, entl illness, or other serious
robles. There y hve been robles with buse,
lcohol use disorder, or drugs. Long-ter robles
tht hve develoed over tie do not go wy when
 erson gets old. When the fily unit is wek, su-
ortive behvior fro fily ebers is unlikely.
Most filies we interct with fll soewhere
between these extrees. Few filies re erfect nd
few re terrible. Filies re de u of hun beings
who resond to stress in ny different wys. Coing
with the stresses relted to ging is difcult for both
the older dult nd the fily. The behvior we see t
ny given tie is the best tht the erson is cble
of t tht oent. Tht does not en tht it is the
best tht they will be cble of t soe other tie.
We s nurses need to exine the stresses ffecting the
fily so tht we cn best resond to the needs of ll
fily ebers. The following Criticl Thinking box
should hel you deterine your stress fctors.
22 UNIT I Overview of Aging
Critical Thinking
You and Your Family
Complete the following:
When my parents are unable to care for themselves, I will
___________________________________________________.
If both my parents and grandparents were alive and in need
of assistance, I would ________________________________
___________________________________________________.
If both my children and my parents needed help from me, I
would _____________________________________________
___________________________________________________.
If my parents were in a nursing home, I would want the
nurses to ___________________________________________
___________________________________________________.
When I grow old, I want my family to ____________________
___________________________________________________.
SELF-NEGLECT
Abuse nd neglect usully involve soething done to
soeone, but, unfortuntely, self-neglect is  coon
roble in the older dult oultion. Self-neglect is
ore likely to be seen when n older erson hs few or
no close fily or friends, but it cn occur desite their
resence. Becuse our society hs lws to rotect the
rights of dults, it y be difcult for concerned r-
ties to intervene until  sitution hs reched criticl or
even life-thretening roortions.
Self-neglect is dened s the filure to rovide for
the self becuse of  lck of bility or lck of wreness.
Indictors of self-neglect include:
1. The inbility to intin ADLs, such s ersonl
cre, shoing, el rertion, or other house-
hold tsks
2. The inbility to obtin dequte food nd uid, s
indicted by lnutrition or dehydrtion
3. Poor hygiene rctices, s indicted by body odor,
lesions, rshes, or indequte or soiled clothing
4. Chnges in entl function, such s confusion, in-
rorite resonses, disorienttion, or incoherence
5. The inbility to nge ersonl nnces, s in-
dicted by the filure to y bills or by hording,
squndering, or giving wy oney inroritely
6. Filure to kee iortnt business or edicl
ointents
7. Life-thretening or suicidl cts, such s wndering,
isoltion, or substnce buse
Self-neglect in the counity is ost likely to be
recognized by neighbors nd reorted to the olice,
ublic helth nurses, or socil workers. It y lso
be susected by eergency dertent nurses who
see these individuls fter they re found injured on
the street, fter  re, or in soe other stte of distress.
Self-neglect is often connected with soe for of
entl illness or deenti. Once the roble is recog-
nized, legl ction through the courts y be needed
to lce the erson in the custody of  fily eber
or dult rotective services.
ABUSE OR NEGLECT BY THE FAMILY
Mny older dults will need soe for of long-ter
cre in the hoe. Attets to eet these dends
y be cconied by high levels of stress for the
cregivers. The Ntionl Council on Aging (2021) esti-
tes s ny s 5 illion older Aericns re the
victis of buse or neglect every yer, nd tht 10%
of eole over ge 65 hve exerienced soe for of
buse. Incresed dends on liited resources, hysi-
cl exhustion, or entl ftigue cn result in devint
behviors on the rt of the cregiver. Inrorite
behviorl resonses include buse nd neglect of the
older fily ebers. Intentionl buse occurs when
ny erson delibertely lns to istret or hr
nother erson. Abusive behvior cnnot be justied
t ny tie or in ny wy. Intentionl buse is ost
likely to occur in filies with reexisting behviorl
or socil robles. High-risk filies include those
tht hve  history of fily conict, those with  his-
tory of violence or substnce buse, those with entl
iirent of either the deendent erson or cre-
giver, nd those with severe nncil robles or tht
re exeriencing uneloyent.
Not ll fors of buse re intentionl, but even
unintentionl buse is devstting to older dults.
Unintentionl buse or neglect is ost likely to occur
when the cregiver lcks the knowledge, stin, or
resources needed to cre for n older loved one. Often,
the cregiver is n older souse or n ging child who
hysiclly cnnot eet the high-level dends of cre.
Situtions tht trigger buse re ore likely to rise
when the older erson requiring cre is confused or
needs continul cre.
Continuous dends on cregivers cn ke
the virtul risoners within their own hoes. Stress
builds, leving the cregiver feeling tred, frus-
trted, or ngry. Unble to coe with the stress of the
continul dends, cregivers y strike out t older
dults, lock the in  roo, restrin the in  chir,
or leve the unttended. When the stress is high nd
the cregivers’ coing bilities re low, they y not
be ble to identify ny better otions. They y not
intend to hurt the older erson or y rtionlize tht
they re doing it to only “kee Dd fro hurting hi-
self,” but the end result is still buse.
Abuse cn be hysicl, nncil, sychologicl, or
eotionl. Neglect nd bndonent lso constitute
fors of buse.
PHYSICAL ABUSE
There re ny tyes of hysicl buse. It involves
ny ction tht cuses hysicl in or injury. Abuse
y occur in the for of hysicl ttcks on fril older
dults who re unble to defend theselves ginst
younger, stronger fily ebers. Older eole y
be locked in bedroos, closets, or bseents. Older
woen y be sexully bused or red by cregivers

or fily ebers. Soe older eole re strved by
fily ebers or given food tht is unsuitble or
unt for hun consution. Filure to rovide de-
qute food or uids lso constitutes hysicl buse.
The inrorite use of drugs, force-feeding, nd the
use of hysicl restrints or unishent of ny kind
re exles of hysicl buse. Wrning signs of hys-
icl buse include bruising, lcertions, broken teeth,
broken glsses, srins, frctures, burn rks, wounds
in vrious stges of heling, unexlined injuries, torn
or bloody underwer, signs of vginl tru, dely
in seeking edicl tretent or  history of “doctor
shoing,” nd refusl by the cregiver to let visitors
see the older dult.
NEGLECT
Physicl buse involves one or ore ctions tht cuse
hr. Neglect is  ssive for of buse in which cre-
givers fil to rovide for the needs of older ersons
under their cre. Neglect, whether intentionl on unin-
tentionl, ccounts for lost hlf of the veried cses
of elder buse. Neglect includes situtions in which
cregivers fil to eet the hygiene or sfety needs of
the older dult. Exles include situtions in which
 bedridden erson is left wet nd soiled with body
wstes without cre or in which n older erson suf-
fers fro exosure becuse of lck of dequte cloth-
ing. Filure to rovide necessry edicl cre y
constitute neglect becuse, with no ens of ccessing
cre, the older erson y suffer or die. However, this
is not considered neglect if the older erson is en-
tlly coetent nd refuses tretent. Neglect y
be deliberte on the rt of the cregiver, or it y
result fro lck of knowledge, indequte nncil
resources, or n insufcient suort syste. Neglect
is not uncoon in situtions where one older souse
cres for the other. In site of the best intentions, the
cregiving souse y be unble to rovide de-
qutely for the needs of their ore deendent rtner.
It is not uncoon for n older coule to hide these
decits fro fily ebers out of fer of losing their
indeendence.
EMOTIONAL ABUSE
Even when hysicl buse is bsent nd dequte
hysicl cre is rovided, eotionl buse y occur.
Eotionl buse is the ost subtle nd difcult to rec-
ognize tye of buse. It often includes behviors such
s isolting, ignoring, or deersonlizing n older
dult. Eotionl busers y forbid eole fro visit-
ing nd isolte the older erson fro ore resonsible
nd sythetic friends or fily ebers. They y
rohibit the use of the telehone or interfere with co-
uniction by il or eil.
Eotionl busers cn use verbl or nonverbl
ens to inict their dge. Verbl buse includes
shouting or voicing threts of unishent or conne-
ent. Eotionl busers often threten older dults
Trends and Issues CHAPTER 1 23
with ll nners of horrors if they tell nyone bout
their light. Dislesure, disgust, frustrtion, or nger
cn be counicted nonverblly through sighing,
hed shking, door sling, or other negtive body
lnguge. Reetedly ignoring wht the older erson
hs to sy nd voiding socil interction with the
individul re subtle fors of eotionl buse. Signs
of eotionl buse y include the lck of eye contct,
trebling, gittion, evsiveness, or hyervigilnce on
the rt of the victi.
Negtive counictions re devstting becuse
they cn ttck the older erson’s ind nd eotions.
These essges cn be so subtle nd routine tht they
y not even be recognized s busive. Eotionl
buse is insidious in tht it cn dge the older
dult’s sense of self-estee nd cn even destroy
the victi’s will to live without leving ny obvious
signs.
FINANCIAL ABUSE
Finncil buse exists when the resources of n older
dult re stolen or isused by  erson who is trusted
by the older dult. Children nd grndchildren y
tke oney fro the older dult, rtionlizing tht the
oney is owed to the for roviding cre or tht it
will eventully be theirs nywy. Peole who exect
to benet fro the older erson’s estte y be frid
tht the needs of the older dult will consue ll of the
oney nd leve the with nothing; therefore they
decide to tke it while they cn. Regrdless of the cre-
givers’ rtionliztions in these situtions, it is nn-
cil buse if the older erson’s oney is tken nd
sent by others for their own uroses. On the other
hnd, it is not busive to use the older dult’s resources
to rovide for the ersonl needs of tht older dult.
Mny older dults re overly trusting of fily
ebers, refusing to believe tht their children would
stel fro the. This denil often continues desite
cler evidence to the contrry. Often, ll of the sv-
ings hve been sent, the hoe hs been sold, nd ny
objects of vlue hve disered before the older er-
son will ccet the truth. Even then, soe older dults
ke excuses to try to coe with the hrsh relity. Abu-
sive cregivers often bndon older eole once ll of
their ssets re gone. In such cses, older dults re left
hoeless, enniless, nd in desir. Signs of nncil
buse include unusul bnking ctivity, such s lrge
or frequent withdrwls, issing bnk stteents,
issing ersonl belongings of vlue, nd signtures
on checks or docuents tht do not tch the sign-
ture of the older dult.
Soe ctions tht older dults cn tke to rotect
their nncil ssets include (1) rrnging for the
direct deosit of Socil Security, ension, nd other
benet checks; (2) tking gret cre in the selection
of nyone ointed to hold the ower of ttorney
or give dvice regrding  will; (3) keeing ATM in
nubers nd online sswords secure—not writing
Another random document with
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through the library window to increase the bonfire in the courtyard
below.
Very different was the Celestina, first printed in Burgos in 1499,
and now generally believed to be the work of a lawyer, Fernando de
Rojas. Here are no shadowy Knights condemned to struggle through
endless pages with imaginary beasts; but men and women at war
with sin and moved by passions that are as eternal as human life
itself. The author describes it as a “Tragicomedia,” since it begins in
comedy and ends in tragedy. It is the tale of a certain youth, Calisto,
who, rejected by the heroine, Melibea, bribes an old woman,
Celestina, to act as go-between; until at length through her evil
persuasions virtue yields to his advances. The rest of the book works
out the Nemesis; Calisto being surprised and slain at a secret
meeting with his mistress, Celestina murdered for her ill-gotten
money by her associates, while Melibea herself commits suicide. The
whole is related in dialogue, often witty and even brilliant; but
marred for the taste of a later age by gross and indecent passages.
The Celestina has been classed both as novel and play, and might
indeed be claimed as the forerunner of both these more modern
Spanish developments. It is cast in the form of acts; but their number
(twenty-one) and the extreme length of many of the speeches make it
improbable that it was ever acted. Nevertheless its popularity,
besides raising a host of imitations more or less worthless, insured it
a lasting influence on Castilian literature; and the seventeenth
century witnessed its adaptation to the stage.
Other dialogues, with less plot but considerable dramatic spirit,
are the Coplas de Mingo Revulgo, and the Dialogue between Love
and an Old Man by Rodrigo Cota. The former of these represents a
conversation between two shepherds, satirizing the reign of Henry
IV.; the latter the disillusionment of an old man who, having allowed
himself to be tricked by Love whom he believed he had cast out of his
life for ever, finds that Love is mocking him and that he has lost the
power to charm.
Whether these pieces were acted or no is not certain; but they bear
enough resemblance to the Representaciones of Juan del Enzina,
which certainly were produced, to make it probable that they were.
Juan de Enzina was born about the year 1468, and under the
patronage of the Duke of Alva appeared at Ferdinand and Isabel’s
Court, where he became famous as poet and musician. Amongst his
works are twelve “Églogas,” or pastoral poems, six secular in their
tone and six religious, the latter being intended to celebrate the great
church festivals.
The secular Representaciones deal with simple incidents and show
no real sense of dramatic composition; but with the other six they
may be looked on as a connecting link between the old religious
“Mysteries” and “Miracle Plays” of the early Middle Ages and the
coming Spanish drama. Their author indeed stands out as “Father”
of his art in Spain, for a learned authority of the reign of Philip IV.
has placed it on record that “in 1492, companies began to represent
publicly in Castile plays by Juan del Enzina.”
If the literature of Spain during the fifteenth and early sixteenth
centuries may be described by the general term “transitional,”
marking its development from crudity of ideas and false technique
towards a slow unfolding of its true genius, painting at the same date
was still in its infancy; while architecture and the lesser arts of
sculpture, metal-work, and pottery had already reached their period
of greatest glory.
Schools of painting existed, it is true, at Toledo and in Andalusia;
but the three chief artists of the Court of Isabel came from Flanders;
and most of the pictures of the time exhibit a strong Flemish
influence, which can be recognized in their rich and elaborate
colouring, clearly defined outlines, and the tall gaunt figures so dear
to northern taste. Of Spanish painters, the names of Fernando
Gallegos “the Galician,” of Juan Sanchez de Castro a disciple of the
“Escuela Flamenca,” and of Antonio Rincon and his son Fernando,
stand out with some prominence; but it is doubtful if several of the
pictures formerly attributed to Antonio, including a Madonna with
Ferdinand and Isabel kneeling in the foreground, are really his work.
In architecture at this time the evidence of foreign influence is also
strong. On the one hand are Gothic Churches like San Juan de Los
Reyes at Toledo or amongst secular buildings, the massive castle of
Medina del Campo; on the other, in contrast to these northern
designs, Renaissance works with their classic-Italian stamp, such as
the Hospital of Santa Cruz at Toledo or the College of the same name
at Valladolid. Yet a third element is the Moresque, founded on
Mahometan models, such as the horseshoe arch of the Puerta del
Perdón of the old Mosque at Seville overlaid with the emblems of
Christian worship. The characteristics of North, South, and East, are
distinct; yet moulded, as during the previous centuries, by the race
that borrowed them to express ideals peculiarly its own.
“Let us build such a vast and splendid temple,” said the founders
of Seville Cathedral in 1401, “that succeeding generations of men will
say that we were mad.”
It is the arrogant self-assertion of a people absolutely convinced,
from king to peasant, of their divine mission to astonish and subdue
the world in the name of the Catholic Faith and Holy Church. The
triumphant close of their long crusade intensified this spiritual pride;
and Spanish architecture and sculpture ran riot in a wealth of
ornament and detail, that cannot but arrest though it often wearies
the eye.
Such was the “plateresque” or “silversmith” method of elaborate
decoration, seen at its best at Avila in the beautiful Renaissance tomb
of Prince John, which though ornate is yet refined and pure, at its
most florid in the façade of the Convent of San Pablo at Valladolid.
Under its blighting spell the strong simplicity of an earlier age
withered; and Gothic and Renaissance styles alike were to perish
through the false standard of merit applied to them by a decadent
school.
 FAÇADE OF SAN PABLO AT
VALLADOLID

FROM A PHOTOGRAPH BY LACOSTE,

MADRID

The first impression emerging from a survey of Queen Isabel’s

reign is the thought of the transformation those thirty years had
wrought in the character of her land. It is not too much to say that in
this time Spain had passed from mediævalism to take her place in a
modern world. She had conquered not only her foes abroad but
anarchy at home. She had evolved a working-system of government
and discovered a New World. She had trampled out heresy; and thus
provided a solution of the religious problem at a time when most of
the other nations of Europe were only beginning to recognise its
difficulties.
Not all these changes were for the best. On the heavy price paid in
blood and terror for the realization of the ideal “One people, one
Faith” we have already remarked. We can see it with clear eyes now;
but at the time the sense of orthodoxy above their fellows, that arose
from persecuting zeal, gave to the Spanish nation a special power;
and Isabel “the Catholic” was the heroine of her own age above all for
the bigotry that permitted the fires and tortures of the Inquisition.

A woman ... [says Martin Hume] whose saintly devotion to her Faith blinded her
eyes to human things, and whose anxiety to please the God of Mercy made her
merciless to those she thought His enemies.

With this verdict, a condemnation yet a plea for understanding,

Isabel, “the persecutor” must pass before the modern judgment-bar.
In her personal relations, both as wife and mother, and in her
capacity as Queen on the other hand she deserves our unstinted
admiration.

The reign of Ferdinand and Isabel [says Mariéjol] may be summarized in a few
words. They had enjoyed great power and they had employed it to the utmost
advantage both for themselves and the Spanish nation. Royal authority had been in
their hands an instrument of prosperity. Influence abroad,—peace at home,—these
were the first fruits of the absolute monarchy.

If criticism maintains that this benevolent government

degenerated into despotism during the sixteenth century, while
Spain became the tool and purse of imperial ambitions, it should be
remembered that neither Castilian Queen nor Aragonese King could
have fought the evils they found successfully with any other weapon
than their own supremacy, nor is it fair to hold them responsible for
the tyranny of their successors. Ferdinand indeed may be blamed for
yielding to the lure of an Italian kingdom; but even his astuteness
could not have foreseen the successive deaths that finally secured the
Spanish Crown for a Hapsburg and an Emperor.
These were the tricks of Fortune, who according to Machiavelli is
“the mistress of one-half our actions.” The other half is in human
reckoning; and Isabel in her sincerity and strength shaped the
destiny of Castile as far as in her lay with the instinct of a true ruler.
“It appeared the hand of God was with her,” says the historian,
Florez, “because she was very fortunate in those things that she
undertook.”
 APPENDIX I
HOUSE OF TRASTAMARA IN CASTILE AND
ARAGON
 APPENDIX II
PRINCIPAL AUTHORITIES FOR THE LIFE
AND TIMES OF ISABEL OF CASTILE

A. Contemporary.
Bernaldez (Andrés) (Curate of Los Palacios), Historia de Los
Reyes.
Carvajal (Galindez), Anales Breves.
Castillo (Enriquez del), Crónica del Rey Enrique IV.
Martyr (Peter), Opus Epistolarum.
Pulgar (Hernando de), Crónica de Los Reyes Católicos.
—— Claros Varones.
Siculo (Lucio Marineo), Sumario de la ... Vida ... de Los
Católicos Reyes.
Zurita, Anales de Aragon, vols. v. and vi.
B. Later Authorities.
Altamira, Historia de España, vol. ii.
Bergenroth, Calendar of State Papers, vol. i.
Butler Clarke, “The Catholic Kings,” (Cambridge Modern
History, vol. i.).
—— Spanish Literature.
Clemencin, Elogio de La Reina Isabel.
Flores, Reinas Católicas.
Hume (Martin), Queens of Old Spain.
Irving (Washington), Conquest of Granada.
—— Life of Christopher Columbus.
Lafuente, Historia de España, vols. vi. and vii.
Lea, History of the Inquisition in Spain. 4 v.
Mariéjol, L’Espagne sous Ferdinand et Isabelle.
Prescott, History of the Reign of Ferdinand and Isabella.
Sabatini (Rafael), Torquemada and the Spanish Inquisition.
Thacher (John Boyd), Christopher Columbus. 3 v.
Ticknor, History of Spanish Literature, v. i.
Young (Filson), Life of Christopher Columbus. 2 v.
Some Additional Authorities Consulted.
Volumes xiv., xxxix., lxxxviii., and others of the Documentos
Inéditos.
Volume lxii. and others of the Boletin de La Real Academia.
Amador de los Rios, Historia de Madrid.
Armstrong (E.), Introduction to Spain, Her Greatness and
Decay, by Martin Hume.
Berwick and Alba, Correspondencia de Fuensalida.
Colmenares, Historia de Segovia.
Diary of Roger Machado.
Fitzmaurice-Kelly, History of Spanish Literature.
Mariéjol, Pierre Martyr d’Anghera: Sa vie et ses œuvres.
Memoirs of Philip de Commines.
 INDEX

A
Abraham “El Gerbi,” 211, 213
Aguilar, Alonso de, 177, 180, 182, 281–3
Ajarquia, 176, 181
Alcabala, 384, 394, 395
Alcalá de Henares, University of, 402
Alexander VI. (Rodrigo Borgia), 85, 236, 239, 248, 261, 306, 353,
354, 360, 363
Alfonso V. of Aragon, 24, 25, 35, 115–119, 350
Alfonso of Castile, brother of Isabel, 22, 35, 46, 52, 56, 60, 64, 65
Alfonso II. of Naples, 350, 353, 354, 356
Alfonso V. of Portugal, 52, 70, 96, et seq.; 107, et seq.
Alfonso, son of John II. of Portugal, 223, 337
Alfonso, Archbishop of Saragossa, 244, 330
Alhama, 165, 170
Aliator, 176, 181, 182
Aljubarrota, Battle of, 30
Almeria, 161, 204, 216, 220, 280
Alpujarras, The, 278, 280
Alvaro, Don, of Portugal, 212
Amadis de Gaula, 414
Anne of Beaujeu, 340
Anne of Brittany, 340
Aranda, Council of, 239
Aranda, Pedro de, 261
Architecture, Castilian, 419–420
Arras, Cardinal of, 73, 81
Arthur, Prince of Wales, 373, 374
Atella, capitulation of, 362
“Audiences” in Seville, 136
Auto-de-Fe, 256
Ayora, Gonsalvo de, 192
Azaator, Zegri, 274
B
Baeza, 216, 217, 219, 220, 223, 280
Bahamas, discovery of, 304
Barbosa, Arias, 406
Barcelona, 38, 39, 40, 50, 75, 305, 328, 352
Bernaldez, Andres, Curate of Los Palacios, 168, 263, 412
Berri, Charles, Duke of (later of Guienne), 72, 81, 83
Biscay, Province of, 100, 101, 112, 117
Blanche of Navarre, 26
Blanche, dau. of John II. of Aragon, 27, 28, 43, 44
Boabdil, 172, 181, et seq.; 198, 203, et seq.; 208, 221–223, 227, et seq.
Bobadilla, Beatriz de (Marchioness of Moya), 62, 74, 84, 85, 212, 213,
298
Bobadilla, Francisco de, 314
Borgia, Cæsar, 364. (See also Alexander VI.)
Burgos, 54, 55, 60, 103, 106;
Bishop of, 72, 74
C
Cabrera, Andres de (later Marquis of Moya), 83, 86, 112, 114, 298
Cadiz, Marquis of, 136, 139, 140, 165 et seq.; 175, 177, 180, 183, 200,
201, 209, 212, 216
Cancionero General, 410
Carcel de Amor, 415
Cardenas, Alonso de, 153, 176;
Gutierre de, 88, 217, 229
Carrillo, Archbishop, 58, 59, 60, 63, 64, 68, 76, 78, 79, 80, 85, 89,
90, 94, 96, 100, 105, 108, 109, 111, 232, 239, 240
Castillo, Enriquez del, 87, 411
Catherine of Aragon, 334, 372, 374
Celestina, 416
Charles of Austria, son of Archduke Philip, 378, 384, 390, 396, 408
Charles, The Bold, 116, 117
Charles VIII. of France, 186, 340, 347, 348, 351, et seq.; 363
Charles of Viana, 26, 36, et seq.
Church, Castilian, 13, et seq.; 104, 231, et seq.; 249, 250
Cid Haya, 216, 220, 223
Cifuentes, Count of, 177, 180
Cisneros, Ximenes de, 242, et seq.; 273, et seq.; 402, 403
Claude, dau. of Louis XII., 378
Columbus, Bartholomew, 289, 315
Columbus, Christopher, early life, 286;
nautical theories, 291;
appears at Spanish Court, 295;
character, 294, 298, 300, 302, 314;
appearance, 295;
 prepares to leave Spain, 299;
first voyage, 303, 305;
reception at Barcelona, 305;
second voyage, 307;
views on slavery, 310;
third voyage, 314;
arrest, 315;
fourth voyage, 316;
devotion to Queen Isabel, 298, 313, 317;
death, 317
Columbus, Diego, 294, 299, 317
Commines, Philip de, 48
Conversos, The, 251, 252, 253
Coplas de Manrique, 408
Coplas de Mingo Revulgo, 417
Cordova, Gonsalvo de, 189, 206, 280, 361, 367, 371
Cortes, the Castilian, 18
Cota, Rodrigo, 417
Cueva, Beltran de La (Count of Ledesma, Duke of Alburquerque), 32,
33, 45, 48, 51, 52, 54, 57, 62, 64, 89, 151
D
D’Aubigny, Stuart, 361
Davila, Juan Arias, 261
De Puebla, 374
Diaz, Bartholomew, 289
E
Edict of Grace, 255
Egypt, Sultan of, 219, 278
Eleanor, dau. of John II. of Aragon, 43, 44, 359
Emmanuel of Portugal, 273, 338, 343, 372
Enriquez, Fadrique, Admiral of Castile, 36, 58, 59, 60, 74
Enzina, Juan del, 417, 418
Escalas, Conde de, 205, 206, 207
Española, 305, 309, 313, 314, 316
Estella, 49, 51
Estepar, El Feri Ben, 281, 282
F
Fadrique (the younger), 155
Federigo of Naples, 355, 364, 370
Ferdinand of Aragon (The Catholic) character, 2, 69, 174, 210, 324,
325, 330, 332, 370, 371, 387, 391;
appearance, 89;
diplomacy, 346, 352, 358, 359, 364, 372, 375;
birth, 26;
becomes heir to throne of Aragon, 40;
alliance with Isabel, 35, 69, 77, et seq.;
meeting with Isabel, 208;
reconciliation with Henry IV., 86;
becomes King of Aragon, 118;
attempted assassination of, 328;
military measures, 102, 103, 166, et seq.; 112, 168, 175, 191, 196,
201, 216, 219, 280, 379;
attitude to Jews, 264, 265, 271;
to Mudejares, 283;
to the Inquisition, 249, 255, 258;
to Roman See, 235, 239, 254;
to his children, 335;
to Columbus, 296, 297, 313;
foreign policy of, 335;
receives submission of Boabdil, 229;
second marriage, 388;
regent of Castile, 390;
estimate of his work, 422
Ferdinand, son of Archduke Philip, 379
Ferrante I. of Naples, 36, 349, 350, 353, 356
Ferrante II., 354, 356, 361, 364, 369
Fez, King of, 221, 229
Florence, 349, 350, 353
Foix, Catherine de, 339
Foix, Gaston de, 43, 75
Foix, Gaston de (the younger), 43
Foix, Germaine de, 388, 390
Fonseca, Alonso de, 30, 240
Fornovo, battle of, 361
Francis Phœbus of Navarre, 111, 339
Fuenterrabia, meeting of, 48
G
Galicia, settlement of, 133
Galindo, Beatriz de, 332, 407
Genoa, 25
Geraldino, Alessandro, 299, 333
Giron, Pedro, Master of Calatrava, 36, 60, 62, 63
Granada, City of, 215, 224, 227, et seq.;
Kingdom of, 160, 188;
partition Treaty of, 365, 366
Guadix, 173, 206, 216, 220, 221, 223, 224, 280
Guejar, 280
Guiomar, Doña, 31, 233
Guipuzcoa, 100, 106, 112, 117
Guzman, Ramir Nuñez de, 155, 156
H
Hamet, “El Zegri,” 199, 200, 201, 202, 206, 210, 211, 213, 214
Haro, Count of, 101, 129
Henry IV. of Castile (Prince of Asturias), 23, 27, 28;
(King), 24, 36, 39, 44, 54, 55, 56, 70, 71, 80, et seq.; 158, 160, 253
Henry VII. of England, 373
Henry, “The Navigator,” of Portugal, 289
I
Inquisition in Castile, 249, 253–261
Isabel of Castile, character, 1, 4, 5, 131, 233, 319, 324, 327, 328, 336;
love of her Faith, 325;
attitude to her confessors, 241, 242, 243, 326, 327, 329;
love of learning, 332, 333, 400 et seq.;
devotion to Ferdinand, 329;
her magnificence, 321, 323, 399;
her justice, 130, 135, 136, et seq.; 155;
birth, 22;
childhood, 34, 46, 52, 67;
suggested alliances, 35, 39, 53, 62, 68, 70, 72, 73;
marriage with Ferdinand, 69, 74, 76, 77, et seq.;
joins her brother Alfonso, 65;
reconciliation with Henry IV., 84, 85, 86;
accession, 88, 91, 92;
appeals to Archbishop Carrillo, 100;
celebrates battle of Toro, 109;
quells riot in Segovia, 112, et seq.;
visits Seville, 115, 136;
disputes with Ferdinand, 186;
legislation and reforms of, 147, 150, 153, 392, et seq.;
military measures of, 106, 168, 187, et seq.; 192, 194, et seq.; 218;
visits camps, 207, 211, 226;
entry into Granada, 230;
attitude to the Castilian Church, 234, 235, 236, 247, 248;
to the Inquisition, 249, 254, 255, 258;
to the Jews, 264, 265, 271;
to the Mudejares, 273, 279, 280, 284;
to the Roman See, 235–239, 254;
to Columbus, 285, 295, 297, 298, 303, 315;
to slavery, 312–313;
to her children, 331, 334, 377, 380, 381;
 her will, 383;
her death, 384;
survey of her reign, 421.
Isabel, mother of Isabel of Castile, 33, 34
Isabel, dau. of Isabel of Castile, 82, 207, 223, 337, 338, 343, 344, 345
Isabella, the city, 313
Ismail, Sultan, 162
J
James IV. of Scotland, 374, 375
Jews, 6, 250, 252, 263, et seq.
Joanna, “La Beltraneja,” 45, 46, 81–83, 93, 94, 99, 119, 120, 336
Joanna of Portugal, wife of Henry IV., 30, 31, 32, 33, 44, 45, 52
Joanna of Aragon, dau. of Isabel of Castile, 334, 341, 342, 375, et
seq.; 390
Joanna (Queen of Aragon), 26, 27, 40, 41, 42, 75
John II. of Aragon, 24, 25, 26, 28, 36, 40, 101, 364
John II. of Castile, 22, 23, 27
John II. of Portugal, 107, 108, 118, 289, 292, 307, 338
John, son of Ferdinand and Isabel, 115, 216, 223, 331, 332, 339, 344
L
Lebrija, Antonio de, 406
Lerin, Count of, 280
Lisbon, Treaty of, 118, 336
Literature, Castilian, 407, et seq.
Loja, 175, 176, 201, 205
Lopera, battle of, 200
Louis XI. of France, 42, 43, 47, et seq.; 81, 100, 106, 110, 115, 116, 117,
118, 186, 339, 346, 347
Louis XII. of France (Duke of Orleans), 355, 357;
 (King), 363, 365, 388, 389
Lucena, 181
Ludovico, “Il Moro,” 348, et seq.; 364
M
Machado, Roger, 321, 323, 373
Madeleine, sister of Louis XI., 43, 339
Madrigal, Cortes of, 124
Malaga, 173, 204, 208, 209, et seq.
Margaret of Austria, 340–344
Maria, dau. of Ferdinand and Isabel, 338, 372
Marineo, Lucio, 405
Marriage-settlement of Ferdinand and Isabel, 79
Martyr, Peter, 195, 219, 385, 404–405
Mary of Burgundy, 83, 117
Maximilian, King of the Romans, 340, 358
Medina-Celi, Duke of, 295
Medina del Campo, Concord of, 56, 253;
Junta of, 57
Medina-Sidonia, Duke of, 136, 140, 168, 189, 190
Mendoza, family of, 52, 76, 82, 84, 89;
Diego Hurtado de, 246;
Pedro Gonsalez de (Bishop of Calahorra), 62;
(Bishop of Siguenza), 67;
(Cardinal of Spain), 84, 89, 90, 108, 150, 154, 187, 229, 232, 233,
234, 240, 243, 244, 255, 299, 404
Merlo, Diego de, 165, 169
Miguel, grandson of Ferdinand, 345
Military Orders, 10, et seq., 152, 154
Moclin, 207