WHO estimates that about 75% of death in people over the age of 65

in industrialised countries are from heart disease, cancer and

cerebrovascular disease
Another major cause of death and disability is osteoporosis and

associated bone fractures, which affect many women due to post

menopausal bone loss
 New research from Eileen Crommins at the University of Southern
California shows that average “morbidity” or period of life spend
with serious disease or loss of functional mobility has actually
increased in the last few decades. Researcher show that average
number of healthy years has decreased since 1998. We spent fewer
years of our lives without disease though we live longer
 Impaired mobility
Common Causes
1. Parkinson disease
2. Diabetic neuropathy
3. Cardiovascular compromise
4. Osteoporosis
5. Osteoarthritis
6. Rheumatoid arthritis
7. Sensory deficits
 Elderly pts should be encouraged to stay as active as possible to avoid
the downward spiral of immobility
 During illness bed rest should be kept to a minimum
 When bed rest cannot be avoided pts should performed active range of
motion and strengthening exercises with the unaffected extremities
 Both the health care staff and pt’s family can assist in maintaining
current level of mobility
 Frequent position change helps offset the hazards of immobility
 Injuries rank seventh as a cause of death for older people and falls are the
leading cause of injury in the elderly
 Causes of falls ( multifactorial)
 Encourage older adults and their families to make lifestyle and
environmental changes to prevent falls
 Adequate lighting with minimum glare and shadow
 Dull rather than shinny surfaces
 Night. Lights
 Sharply contrasting colours used to mark the edges of steps
 Grab bars by the bath tub, shower, and toilet are useful
 Hazards that increase the risk for falls should be avoided – loose clothing
improperly fitting shoes, scatter rugs, small objects and pets
 In institutionalized elderly people, physical restraints(lap belts, geriatric
chairs, vest, waist and jacket restraints) precipitate many of the
injuries
 May be acute, occurring during an illness
 May be chronic, occurring over a period of years

Causes
Transient
 Psychiatric disorders of late life are major cause of chronic ill
health and disability. Disorders include depression, paranoid and
dementia
 Depression
 Depression is most common affective disorder of old age

 Depression among the elderly often follows a major precipitating

event or secondary to medications interactions or undiagnosed

physical condition
 Cause

Often follows a major precipitating event or loss

May be secondary to a medication interactions
Undiagnosed physical condition
1. Feeling of sadness
2. Fatigue
3. Diminished memory and concentration
4. Feelings of guilt or worthlessness
5. Sleep disturbances
6. Appetite disturbances with excessive wt loss or gain
7. Restlessness
8. Impaired attention span
9. Suicidal ideas
 Assessing the pt’s mental status
 Evaluation of pt’s medication that contribute to depression
 Initial dose of antidepressant be low
 Factors to be considered =age, co- existing conditions, adverse
effects and poor response to these medications
 Definition
Acute confusion state begins with confusion and progresses to disorientation
 Causes
 Treatment of underlying cause
 Therapeutic intervention vary depending on the cause
 Delirium increases the risks of falls, therefore management of pt’s safety
and behavioural problems is essential
 Medication interactions and toxicity are often implicated, therefore
essential medication should be discontinued
 Nutritional and fluid intake should be supervised and monitored
 The environment should be quiet and calm
1. To increase function and comfort, the nurse provides familiar
environmental cures
2. Nurses encourages family members or friends to touch and talk to the pt
3. On going mental status assessment using prior mental cognitive status
as baseline are helpful.In evaluating responses to treatment and to the
admission to a hospital or extended care facility.
4. If the underlying problems is adequately treated, the pt often returns to
baseline within several days.
 Def:
An irreversible type of dementia characterized by progressive impairments
of memory, cognition, language, judgment and ability for self-care
 Cause remain unknown

 Alzheimer’s disease is the most common form of dementia among aged,

affecting approximately 20% of the population of 80 years.

 Gross pathophysiologic changes include cortical atrophy, enlarged ventricles
and basal ganglia wasting
 Biochemically, neurotransmitter systems have structural and functional
impairments
 Microscopically, changes occur in the proteins of the nerve cells of the cerebral
cortex and lead to accumulation of neurofibrillary ganglia (abnormal) plaques
 Report of scientific research states that there is a significant and
progressive decrease in the activity of the enzyme choline
acetyltransferase, a crucial ingredient in the chemical process that
produces acetylcholine , a neurotransmitter involved in hearing and
memory.
 This cholinergic deficit is the theoretical basis for several research
studies into causes and RXS of Alzheimer disease
 Other neurotransmitters, include nor epinephrine, serotonin and
somatostatin are affected by Alzheimer disease and appear to have some
relevance to memory function
1. Genetic theory supported by:
a. An increased prevalence of Alzheimer’s disease in some families
b. Neuropathologic similarities between Alzheimer’s disease and trisomy
21(Down’s syndrome)
2. ENVIRONMENTAL THEORY
a. HEAD INJURY
Following a latency period of many years, pathologic findings include
neurofibrillary tangles
b. INFECTIOUS AGENTS
Possible association between Alzheimer’s disease histopathology and several
agents, including Herpes Simplex and rabies.
c. NEUROTOXINS
Aluminium and silicon , two common elements are found in the brain of
Alzheimer’s pt. These mineral can be neurotoxic, are found to be increased
in Alzheimer’s diseased brain, but no connecting link has yet been found
 Early to terminal stages
1. Intellectual
Forgetfulness, impaired judgment, memory loss, confusion,
apraxia, amnesia, speech difficulty, no eye contact
2. Behavioral
Personality- mood changes, withdrawal, depression, catastrophe,
behavioral reactions, aggression, agitation, inability to
cooperate, unaware of environment
3.Functional
Work difficulties, poor hygiene, insomnia, wandering, gait disturbances,
incontinence, immobility, dysphasia
 DIAGNOSTIC CRITERIA

Based on clinically determined dementia confirmed by:

Two or more cognitive deficits progressive worsening of memory and
other cognitive functions
•No disturbances of consciousness
•Onset between 40 and 90 yrs of age
•Absence of systemic disorders
 Focus is on caring rather than cure
 Approach is multidisciplinary
 Family members must be involved in management and care plan
 Pt should be regularly assessed and monitored for signs of additional
physical illness sensory deficits and functional impairments
 Emphasis is placed on pts strengths and abilities on preventing excess
disability.
Diseases of joints and bone tissue are extremely common in
old age. Although they result partly from reduced mobility,
they are also a major cause of reduced mobility and are an
often painful and obvious reminder of the ageing process.
 Paget's disease
◦ Paget's disease, a bone disease of unknown aetiology, affects
some 5% of elderly patients. The localized nature of Paget's
disease results in bones becoming expanded, softer and
deformed. Although all bones may be affected, those most
frequently involved are the clavicles, femora, skull, pelvis,
lumbar spine and tibiae. Medical intervention may be required
to treat pain and fractures.
 Osteoporosis
◦ Osteoporosis results in bone tissue becoming generally less dense and therefore
more susceptible to fracture and collapse. Either type of damage may occur as a
result of trauma such as a fall, or may result from minimal stress such as that
caused by walking or being turned in bed. The high frequency of fractures in old
age is largely attributed to the elevated incidence of osteoporosis in both sexes,
but particularly in women. Vertebral collapse, resulting in kyphosis (Dowager's
hump) is common, especially in elderly women.
◦ Treatment in the form of drug therapy, including calcium supplements, is of value.
More important from the nursing viewpoint is the central and effective role of the
nurse in relation to prevention, by health education, which includes the use of
appropriate diet and exercise prior to and during the period of old age.
 Osteomalacia
◦ Osteomalacia is a generalized disease of bone in which the osteoid
matrix is formed normally, but fails to calcify properly. The resulting
'soft bone', pain, muscle weakness and biochemical testing can result
in the diagnosis of this very treatable disease. The major types of
osteomalacia include those due to lack of vitamin D, drug side-
effects, renal failure and inappropriate absorption of calcium.
The treatment of this illness in the form of vitamin D therapy can
result in dramatic improvement.
 Septic arthritis
◦ Septic arthritis, a pyogenic infection of individual joints,
occurs rather infrequently, with joints affected by rheumatoid
arthritis and osteoarthritis being particularly vulnerable.
 Rheumatoid arthritis
◦ Rheumatoid arthritis usually begins in middle age. This
chronic condition is, however, an important cause of
secondary degenerative joint disease in old age. Potent
analgesics, even those which are known to cause addiction,
may be necessary to control the pain frequently experienced by
elderly sufferers. In general, steroid therapy is avoided in
elderly patients with this illness.
 Osteoarthritis
◦ Osteoarthritis, a degenerative joint disease, is the major type
of arthritis found in the elderly population. The major change
caused by osteoarthritis is the loss of articular cartilage in the
joints in which increased friction and crepitus result. Pain and
restricted movement are the principal features with all joints
being at risk.
Almost all forms of chest diseases are experienced by the
elderly with some being particularly common. These diseases
must be seen in the context of the gradual and general
deterioration which takes place in the respiratory system as
part of the ageing process.
 Bronchitis
◦ Bronchitis (acute and chronic), lobar pneumonia,
bronchopneumonia and empyema are all important causes of
morbidity and mortality in older people. Chest infections
frequently precipitate heart failure and result in a combination
of both illnesses. The respiratory changes in old age, in
addition to the 'normal' respiratory limitations imposed by the
ageing process, can make medical diagnosis more difficult in
this age group.
 Pulmonary tuberculosis
◦ Pulmonary tuberculosis, although comparatively rare, can
easily be overlooked, and may be effectively treated.
 Cancer of the lung
◦ Cancer of the lung, particularly the bronchus, is one of the
most common cancers affecting the older person. Treatment is
not very satisfactory, with surgical intervention carrying a
fairly high operative mortality rate. Secondary lung cancer,
and metastasis resulting from the primary bronchial tumor are
common.
 Diabetes mellitus
◦ Diabetes mellitus is often mild and of late onset. Although
symptoms may be minor and only found during routine
blood/urine sugar testing, diabetes can be more serious. In
many instances the illness may be associated with obesity,
occasionally with pancreatic disease, including carcinoma of
the pancreas.
 Hyperparathyroidism
◦ Hyperparathyroidism, which is more common in elderly
women than in men, is associated with a consistently raised
serum calcium level and a normal or elevated level of serum
parathormone. Progressive mental deterioration and renal
failure may result if the disease is left untreated.
 Thyrotoxicosis
◦ Thyrotoxicosis often presents in an atypical fashion in the
elderly with cardiac complications of heart failure being
common. 'Apathetic' thyrotoxicosis in the form of apathy,
weight loss and depression may occur with general muscle
weakness and fatigue.
 Myxoedema
◦ Myxoedema presents in the elderly in a way which is usually
similar to the onset in younger adults with mental and physical
slowing, apathy, puffiness of the face, a croaky voice, cold
intolerance, occasionally deafness, and constipation. Apparent
dementia, or a depressive-type psychosis, is not unusual.
Therapy in the form of lifelong L-thyroxine replacement is
often effective.
 In addition to the age-related changes which take place, a
number of gastrointestinal diseases often affect the elderly.
 Parotitis
◦ Parotitis (inflammation of the parotid glands) results from a
number of primary causes which include local and general
bacterial infection, febrile illnesses and dehydration.
 Hiatus hernia
◦ Hiatus hernia, which may be asymptomatic, most frequently
affects women and is usually associated with obesity. In the
most common type of hiatus hernia, the 'sliding' type, the upper
part of the stomach and the cardio-oesophageal junction rise
up through the diaphragm. Although treatment is usually
conservative, surgery may be required despite its relatively
high mortality rate in the elderly.
 Peptic ulcer
◦ Peptic ulcer, with a peak incidence in middle life, presents in
the elderly in the same way as in the younger adult. Pain, in
any of a number of abdominal areas, although most common in
the left side of the lower chest, weight loss, vomiting, anaemia
and general debility are common symptoms. At one time it was
thought that very large peptic ulcers were often malignant, this
is now known to be untrue. Drug therapy is the treatment of
choice, with surgery being required in some cases.
 Malabsorption
◦ Malabsorption, caused by a combination of disease and age-
related deterioration of the gastrointestinal tract, can result in
a variety of nutrition-deficiency-related diseases, including
general malnutrition and a range of vitamin deficiencies.
 Carcinoma
◦ Carcinoma of the gastrointestinal tract, with cancer of the
stomach being one of the most common malignancies in the
elderly, can occur in various parts of the system. The
pancreas, oesophagus and rectum are commonly affected.
Radical treatment, in the form of surgery, does not have a high
success rate and may be inappropriate because of late
diagnosis, resulting metastasis and general physical frailty.
 Gall-stones
◦ Gall-stones, which are often asymptomatic and not detected
until postmortem examination, give rise to symptoms such as
intolerance of fat, dyspepsia, cholecystic attacks and episodes
of obstructive jaundice. Cholecystectomy may be the treatment
of choice if the symptoms are severe. Otherwise, conservative
treatment is more usual.
 Jaundice
◦ Jaundice, often of the obstructive type with malignant diseases
being a major cause, is common. Pancreatic carcinoma and
others such as carcinoma of the stomach and resultant
metastasis are major causes of obstructive jaundice. Gall-
stones, which will result in fluctuating levels of jaundice, are
another common cause.
 Diverticular disease
◦ Diverticular disease, most frequently affecting the sigmoid
colon, has been found in almost half the post-mortem
examinations of the elderly. The role of diet, particularly the
lack of dietary fibre, is well documented in relation to
diverticular disease. A high-fibre diet, such as that achieved by
adding bran, is a simple and effective means of reducing the
symptoms of diarrhoea, abdominal pain and bleeding.
 Haemorrhoids
◦ Haemorrhoids, internal and external, result in painful dilated veins
covered with a film of mucous membrane. Internal haemorrhoids
originate inside the bowel and become thicker and more painful as
they develop. Bright red blood is present in the stools and, in long-
standing cases, anaemia occurs. External haemorrhoids occur at the
external margin of the anus and consist of small, dilated, painful
veins.
◦ While surgery is an effective form of treatment, local applications
(cream or suppositories), phenol injections and/or control of
constipation are also used to reduce haemorrhoidal tissue. The role
of constipation control in preventing this disease is very important.
◦ Kidney size reduces in old age, with the nephrons becoming
smaller in size and number. The general reduction in renal
capacity and efficiency means that the elderly have much less
'reserve' and are more vulnerable to the risks of disease.
 Uraemia
◦ Uraemia of the pre-renal, post-renal and renal types results
from substantial renal impairment commonly found in the
elderly. This condition requires prompt recognition with
treatment usually being conservative, with renal transplant or
dialysis rarely being considered. The role of the nurse in
encouraging appropriate fluid intake, compliance with
medication regimen and diet control is of obvious importance.
 Urinary tract infections
◦ Urinary tract infections generally, polynephritis and cystitis in
particular, have a high incidence rate. Additionally,
asymptomatic bacteriuria may be associated with mild dysuria
or frequency of micturition, particularly in women.
 Prostatic disease
◦ Prostatic disease of the benign prostatic hypertrophic type is
often found in old men and leads to the troublesome symptoms
of urinary dribbling, nocturia, frequency and dysuria. Acute
retention of urine, or chronic retention with overflow present
serious problems. Prostatectomy carries a low risk, permanent
and indwelling catheters may be used in some instances.
Carcinoma of the prostate is one of the most frequent cancers
found in elderly men.
 Gynaecological disorders
◦ Gynaecological disorders of many types are found in elderly
women, ranging from mild 'senile' vaginitis to more serious
diseases such as carcinoma of the uterus and cervix. The latter
develops in approximately 1.5% of women at some point in
their lives, and occurs twice as often in older women compared
with those aged less than 65 years.
◦ Recent surveys reveal an alarmingly high incidence of
nutritional deficits in the elderly, with general malnutrition
existing despite the ageing process having little impact on the
ability to eat and digest food.
 Dehydration
◦ Dehydration, which is usually secondary to some other more
specific disease process, can have serious, if not fatal,
consequences. The role of the nurse in preventing dehydration,
or treating the 'uncomplicated' form which is simply due to an
inadequate fluid intake, is crucial.
 Malnutrition
◦ Malnutrition, resulting in a range of specific nutritional
deficiencies, is often secondary to other disease processes; for
example, a dementing or depressed person may be incapable
of preparing and/or eating food properly. Vitamin A,B,C and
D, calcium, iron, magnesium and potassium deficiencies result
in their own specific pathology.
 Gout
◦ Gout, caused by the accumulation of excess uric acid which is
deposited in the joints, results in recurring episodes of acute
arthritis. Up to 3% of elderly men and 0.5% of elderly women
suffer from gout.
 Obesity
◦ Obesity, particularly in the elderly female, gives rise to a great
deal of secondary morbidity in the form of arthritis, diabetes,
respiratory and cardiovascular problems and general
inactivity. Excessive calorie intake (particularly if the person's
budget encourages them to buy high-calorie, inexpensive
foods) and reduced activity are the major causes of obesity.
Heart disease of a variety of types is experienced, with some
15% of all persons admitted to geriatric units suffering from
cardiac failure. A selection of the more common diseases are
outlined below.
 Valvular diseases
◦ Valvular diseases of the mitral and aortic valves may require
intensive medical intervention but are, more commonly, of the
chronic, degenerative and (occasionally) asymptomatic types.
 Cardiac arrhythmias
◦ Cardiac arrhythmias increase in incidence with old age with
atrial fibrillation being related to the gradual increase in
fibrous tissue within the conducting system of the heart.
Complete heart block, with a typically slow but regular pulse,
is not uncommon, nor are both right and left bundle branch
blocks.
 Ischaemic heart disease
◦ Ischaemic heart disease is possibly one of the most important classes of
cardiac disease in the old person, with the highest incidence occurring
in men. Myocardial infarction, although acute, often presents in a less
dramatic/critical form in the elderly as compared with-the younger
person. While some infarcts may result in sudden death, others are
'silent' and symptom free. Angina pectoris, less often found in the elderly
bearing in mind the high incidence of other heart diseases, can often be
controlled by chemotherapy when symptoms are troublesome.
 Bacterial endocarditis
◦ Bacterial endocarditis of the subacute type in those aged 60 years
or more, represents one-third of all diagnosed cases. Although
carrying a serious prognosis if untreated, the outlook with
treatment is relatively good.
 Heart failure
◦ Heart failure, which may be secondary to any of a variety of other
diseases, is a major feature of cardiac pathology in old age.
Although the presentation, treatment and prognosis are similar to
that in a younger age group, cardiac failure frequently results in
acute confusional states in the elderly. Where the cause is due to
an irreversible condition, treatment will have to be permanent. In
some instances, short-term medical treatment will cure the
underlying cause and, subsequently, alleviate the cardiac failure.
 Cardiac arrest
◦ Cardiac arrest, and its medical and nursing management,
requires careful consideration and, when possible, planning.
Where a good prognosis is present, and if prompt and efficient
resuscitation is possible, active and intensive intervention may
well be appropriate. However, if resuscitation following
cardiac arrest only represents a means of postponing a
patient's inevitable and imminent death, and suffering, it may
be felt to be inappropriate in some instances.
 Hypotension, postural hypotension, hypertension
◦ Hypotension, including postural hypotension, and
hypertension are both common in old age. Pathological
increases or decreases in blood pressure can, for the most
part, be fairly effectively controlled by appropriate
chemotherapy. Patient education, particularly as it relates to
the causes and consequences of postural hypotension, can do
much to alleviate these conditions and their consequences.
 Atherosclerosis
◦ Atherosclerosis and associated arteriosclerosis are major
causes of pathology in old age, carrying serious consequences
for health status. Resultant conditions include hypertension,
arteriosclerotic dementia, peripheral vascular disease and
strokes.
 Thromboembolic diseases
◦ Thromboembolic diseases, including venous thrombosis and
pulmonary embolism, are commonplace, with post-mortem
studies demonstrating the presence of recent pulmonary
emboli in about 30% of routine examinations of the elderly.
 Anaemia
◦ Anaemia, although not rare in the population generally, is
found among the elderly in the form of iron-deficiency
anaemia or pernicious anaemia.
A number of diseases of this system occur, in addition to
those such as dementia and parkinsonism mentioned earlier
(see pp. 72-8). Additionally, a wide range of illnesses such
as cardiac failure, anaemia, hypotension and toxaemia have
a noticeable effect on the functioning of the central nervous
system.
 Cerebrovascular accidents
◦ Cerebrovascular accidents, commonly referred to as 'stroke' or CVA, may
take the form of cerebral thrombosis, cerebral haemorrhage or cerebral
embolism. Although the mortality rate is high, and the prognosis is poor if
the patient is comatose for 24 hours or more, many elderly people recover
either partially or totally.
Rehabilitation, in the form of immediate and intensive physiotherapy
accompanied by nursing actions to maximize independence, is crucial. The
long-term consequences of a cerebrovascular accident are, for many
patients, serious and very difficult to accept. Dysphasia, which may well be
mistaken for confusion, is particularly stressful for patients and those who
care for them.
 Transient ischaemic attacks
◦ Transient ischaemic attacks, believed to result from arterial
disease in either the carotid or vertebro-basilar systems, cause
a number of disturbances of cerebral functions as evidenced by
such problems as vertigo, temporary speech disturbance,
visual difficulties and giddiness.
 Herpes zoster
◦ Herpes zoster (shingles), a painful condition distributed along
the affected nerve root, can result in considerable general
disablement. Treatment is rather difficult, neural
complications such as those affecting the eye may result in
hospitali/ation.
 Cataracts
◦ Cataracts, a lens opacity causing blurring of vision, may affect
one or both eyes. Treatment of cataract, the most common eye
disease of old age, is by surgical removal of the lens.
 Glaucoma
◦ Glaucoma, which can be either of the acute or chronic type,
may result in loss of vision and is usually responsive to
treatment with chemotherapy.
 Macular degeneration
◦ Macular degeneration causes a loss of central vision so that
the part which is sharpest and clearest deteriorates, resulting
in difficulty with 'fine vision' such as that required to sew or
read fine print. Treatment is usually supportive and
conservative with the use of spectacles.
 Ectropian and entropian
◦ Ectropian and entropian are common and can cause corneal
damage and/or extreme personal irritation.
 Retinal detachment
◦ Retinal detachment, a condition by no means confined to the
elderly, is often treated with bed rest or by surgery if the
elderly person is physically fit.
 Deafness
◦ Deafness, a symptom of disease, is a serious and debilitating
condition frequently experienced by old people. Wax in the
outer ear can result in conductive deafness, infections in the
form of otitis media may result in hearing loss and ear drum
perforation. Perceptive deafness can follow obstruction of the
blood supply to, or nerve damage to, the inner ear.
 Presbycusis
◦ Presbycusis, a naturally occurring diminution in hearing acuity which
accompanies old age, begins around the age of 30 years, becomes noticeable
after age 35-45 years, and becomes gradually worse. High-frequency sounds
become difficult to hear, affecting the quality of the person's speech,
particularly that of women.
◦ Both ears are normally affected, with men more at risk probably because of
their increased exposure to high levels of occupational noise. When
deterioration is severe enough to cause inconvenience, a hearing aid may be
necessary.
 Pruritus
◦ Pruritus, a troublesome complaint taking the form of a localized or
more generalized itch, is either idiopathic or has a known cause. It
may also be secondary to some other primary disease process
including that of diabetes mellitus or renal disease.
 Psoriasis
◦ Psoriasis, which presents with sharply defined reddened skin areas
with abnormal scaling, increases and decreases in severity over time.
 Intertrigo
◦ Intertrigo, a condition affecting touching skin folds, is more common
in the obese elderly and is often associated with lack of personal
cleanliness.
 Scabies
◦ Scabies, an easily treated disease cause by a burrowing mite, is
recognised by the presence of 'burrows' in the skin and by severe
itching and scratch marks.
 Chilblains
◦ Chilblains, resulting in tenderness, burning sensations and itching on
the affected areas, are often, but not exclusively, found on the feet.
 Eczema
◦ Eczema, which can occur at any age, may be in the acute or chronic
form in the old person. The itch associated with eczema can be a
source of con­siderable irritation and distress.
 Pressure sores
◦ Pressure sores may be of the superficial or deep type and are
associated with immobility and a general deterioration in the
physical/mental condition of the elderly person. The role of the
nurse, and of those working under her direction, is of
paramount importance both in terms of preventing and
treating pressure sores.