Chapter 28

OLDER ADULTS

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 Ageism

Ageism is any stereotyping, prejudice, or discrimination

against the older adult or, in fact, any age group. Ageism
can be systemic, organizational, and interpersonal
discrimination.

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 Concept: Ageism
• Systemic ageism is “the totality of ways in which
societies foster discrimination” against older adults.
(Palmore, 2005; Krieger, 1999)
• Organizational ageism is “discriminatory policies or
practices carried out by state or non-state institutions” that
are detrimental to older adults. (Palmore, 2005; Krieger,
1999)
• Interpersonal ageism refers to “directly perceived
discriminatory interactions between individuals.”
(Palmore, 2005; Krieger, 1999)

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 Older Adults

According to the U.S. Surgeon General:

• Older adults can continue to learn and contribute to
society, despite physiologic changes as a result of aging
and increased health problems.
• Continued intellectual, social, and physical activities
throughout the life cycle are important to maintain mental
health in later life.
• Normal aging is not characterized by mental or cognitive
disorders.

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 Older Adults—cont’d
• On average, an older adult has three to four chronic
illnesses annually.
• Up to 20% are at risk for annual hospitalization.
• After 85 years of age, older adults have a 1 in 3 chance
of developing dementia, immobility, incontinence, or other
age-related disability.
• Women generally outlive men on an average of
7 years.
• About 9.7% of elderly persons are living below the
poverty level (AOA, 2010).

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 Older Adults—cont’d
Psychologists have divided older adults into the following
age categories:
• Young-old: 65 to 74 years of age
• Middle-old: 75 to 84 years of age
• Old-old: 85 to 94 years of age
• Elite-old: 94 years or older

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Pharmacology and the Aging Adult

What are your thoughts? Prejudices?

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 Pharmacology and the Aging Adult—
cont’d
• Pharmacokinetic effects of any drug change as adults age.
• Of all accidental drug-related deaths, 50% occur in the older
adult population.
• Hearing and visual impairment, cognitive and memory deficits,
child-resistant packaging, and an inability to afford medication
all interfere.
• Anticholinergic activity (i.e., side effects of many commonly
used drugs) are linked with reduced brain function and early
death.
– Nifedipine, codeine, chlorpromazine, certain tranquilizers,
antihistamines, antidepressants, and others.

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 Pharmacology and the Aging Adult—
cont’d
• Anticholinergic properties are found in medications for
hypertension and congestive heart failure.
• Review all prescription and over-the-counter (OTC)
medications.
• Be alert to anticholinergic side effects.
– Notify a physician, because anticholinergic effects are
cumulative.

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 Ageism
• Ageism refers to deeply rooted negative attitudes or
biases toward older people because of their age.
• Age discrimination is a set of actions and/or outcomes
that are perpetrated on an older adult that reflect this bias
(treated on an unequal basis).
• Ageism not limited to the way a young adult may look at
an old adult.
• Is also observed in the views of older people who tend to
be critical about themselves and peers.

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 Ageism—cont’d
• The threat of social contagion by association with the frail
and infirm may simply be too strong to bear. Age
proximity raises feelings of vulnerability.
• Ageism differs from other forms of discrimination in that it
cuts across gender, race, religion, sexual orientation, and
national origin.
• In our culture, old age does not award a desirable status
or membership in a sought-after club; rather, it is a social
category with negative connotations.

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 Class Discussion
• Today, a new form of ageism places the older adult in a
no-win situation: those who are well-to-do are envied for
their economic progress, those who are middle-class are
blamed for making Social Security too costly, and those
who are poor are resented for being tax burdens.
• The results of ageism can be observed throughout every
level of society. Even health care providers are not
immune to its effects. Negative values can surface in
myriad ways in the health care system. Financial and
political support for programs for older adults is difficult
to obtain; their needs are addressed only after those of
younger, albeit smaller, population groups.

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 Ageism Among Health Care
Workers
Class discussion: What are your observations?
• Health care personnel do not always share medical information,
recommendations, and opportunities with older adults.
• Older adults receive less information—sometimes, less care—
than those younger.
• Health care workers who manage confused, ill, or frail older
adults on a daily basis may tend to develop a somewhat
negative or biased view of them.
• Negative views of the older adult are frequently held by nurses.
Studies show that nursing recruits hold ageist views, which
have significant implications for practice, education, and
research.

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 Aging: Facts and Myths
Facts
• Senses and muscular strength
decline.
• Sexual expressions are important.
• Fifty percent of restorative sleep is
lost.
• Older adults are major consumers of
prescription drugs.
• High incidence of depression exists.
• Experience difficulty on retirement.
• Are prone to be victims of crime.
• Older widows adjust better than
younger widows.
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Myths
• Most adults older than 65 years are
demented.
• Sexual interest declines with age.
• Are not able to learn new tasks.
• Are more rigid in their thinking and
are set in their ways.
• Are well off; are no longer
impoverished.
• Are infirm and require help with
activities of daily living (ADLs).
• Are socially isolated and lonely.
• Are significantly hard of hearing and
should be spoken to in a loud voice.
14
 Education for Health Care
Providers
• Information about the aging process
• Discussion of attitudes relating to the care of the older
adult
• Sensitization of participants to patients’ needs
• Exploration of nurse-
patient and staff-
patient interactions
• Grief, loss, and
bereavement
• Ethical and legal issues
• Communication

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 Assessment and Communication
Strategies
• Conduct the interview in a private area.
• Ask the patient the name he or she would like to be
called.
• Sit or stand at the same level.
• Ensure that the lighting is adequate and the noise level
is low.
• Respect the comfort level with a personal touch.
• Summarize the interaction, and invite feedback.

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 Assessment and Communication
Strategies—cont’d
• Assess cognitive, behavioral, and emotional status:
– Is vital for detecting delirium, dementia, and
depression. (See the next slides.)
– In addition to depression, suicide and alcohol or
substance abuse are major health problems among
older adults. (See the next slides.)
• Discreetly evaluate the indications of abuse.

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 Class Activity
Refer to Chapter 15, Mood Disorders, and Table 28-1:
Comparison of Delirium, Dementia, Depression.
Complete the following table:
Assessment Delirium Dementia Depression

Onset

Cause

Cognition

LOC

Activity Level

Emotional Status

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 Psychiatric Disorders in Older Adults
Depression
• Health care providers frequently misinterpret clinical
depression in older adults as a normal part of aging,
especially if the older adult is experiencing dementia or
other physical illness.
• Unlike dementia, depression is treatable with medication
and other interventions.
• Memory loss and other intellectual impairments or asocial
and agitated behaviors are generally associated with
dementia but may be caused by depression.

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Sometimes depression in older adults is expressed
as physical symptoms or negative behaviors.

• Forgetfulness • Rumination
• Agitation and • Easily angered
combativeness • Paranoia and
• Constant complaining suspiciousness
• Irritability • Apprehension and anxiety
• Chronic aches and without any cause
pains that do not • Low self-esteem (feelings
respond to treatment of insignificance or
• Fatigue pessimism)

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 Antidepressant Therapy
• Avoidance of possible side effects vs. efficacy is a
consideration.
• “Start low, go slow.”
• Selective serotonin reuptake inhibitor (SSRI) is a first-line
medication with few side effects and has low toxicity.
• SRRIs may double the risk of bone fractures.
• Low-dose tricyclic antidepressants (TCAs) may be more
suitable in the frail older adult.
• Sertraline (Zoloft) is often a good choice because age
does not appear to affect its pharmacokinetic actions.
• Medications are almost always used in conjunction with
other types of therapy.

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 Suicide
• White men, 65 years of age and older, are at risk five
times higher than the general population.
• Depression is the biggest risk in older adults.
• Of those older adults who commit suicide, 70% visit a
physician within a week to a month before their deaths.
• Older adult suicides are underreported.
• Risk factors include:
– Feelings of hopelessness, uselessness, and despair
– Financial need, medical illness, and functional disability

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 Assessment of Suicide Risk
• High-risk factors that contribute to suicide include
widowhood, acute illnesses, intractable pain, status
change, chronic illness, family history, chronic sleep
problems, alcoholism, depression, and losses (see
Chapter 23).
• Must examine previous suicidal behavior, seriousness of
intent, presence of active plans, availability of means,
lethality of method, and specific details of the plan.

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 Assessment of Suicide Risk—
cont’d
Questions that may be asked in a suicide assessment:
• What kinds of thoughts do you have about a person’s
right to take his or her own life?
• What advantage does ending one’s life offer?
• What is the most important thing you have to live for?
• Have you thought of taking your life?

Refer to Chapter 23, SAD PERSONS Scale.

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 Class Discussion: Right to Die
• Discuss the right to end life by way of physician-assisted
suicide (PAS) or taking one’s own life (see Chapter 23).
• Suicide always raises spiritual and moral issues.
• Some believe that older adults with terminal illnesses
and/or those who suffer intractable pain should be able to
control their own deaths. If an alert older adult patient is
confronted with an intractable, lingering, and painful
illness with no hope of relief except through death, either
by PAS or suicide, is such an intervention justifiable?
Participating in an assisted suicide is a violation of the
American Nurses Association (ANA) Code of Ethics.

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Alcoholism and Substance Abuse

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Alcoholism and Substance Abuse—
cont’d
The American Medical Association (AMA) states:
• Alcohol and substance abuse among older adults is a
hidden epidemic.
• “The graying of drug users in America.”
• Two major types of abuser:
1. Individual with early alcoholism and is now aging
(long-time drinker)
2. Late-life drinker (LLD)

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 Alcoholism and Substance Abuse—
cont’d
• Work and family
responsibilities may help
keep a potential alcoholic
from drinking too much.
• Once these demands are
gone and the structure
of daily life is disrupted
(as with some older
adults), little impetus exists
to remain sober.

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 Alcohol and Aging
• Tolerance for alcohol is decreased.
• Changes in the response to alcohol include headaches,
reduction in mental abilities, memory losses or lapses,
and feelings of malaise versus well-being.
• Body is less resilient.
• Healing from injury or infection is slower.
• Stress causes a loss of physiologic equilibrium.
• Increased time is available for the body to eliminate
drugs, resulting in a high blood alcohol level (BAL).

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 Alcohol and Medication
• Interaction of drugs and alcohol in the older
adult can have serious consequences.
– Decreased liver enzymes that break down alcohol
– Higher BAL than younger people with equivalent
intake
• Antidepressants and tranquilizers are
particularly harmful because the effects are
further potentiated by alcohol.
• Toxicity of other drugs (e.g., acetaminophen) is
enhanced by alcohol-associated malnutrition.

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 Symptoms of Older Adult
Alcohol Addiction
• Vague geriatric syndromes include contusions,
malnutrition, self-neglect, impaired cognition, sleep
disturbances, depression, and falls.
• Diarrhea, urinary incontinence, a decrease in functional
status, failure to thrive, and apparent dementia are
symptoms.
• Poor coordination or visual changes may also mimic the
normal aging process but may actually be a result of
excessive drinking.

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 Symptoms of Older Adult
Alcohol Addiction—cont’d
• Confusion and disorientation are often associated with
dementia or Alzheimer disease but could be caused by
alcohol abuse.
• When a suspicion or indication exists that an older adult
is abusing alcohol, the health care provider should
conduct a screening test.
• Common tool used to assess alcohol problems is the
Michigan Alcohol Screening Test–Geriatric Version
(MAST-G).

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 Treatment of the Older Adult
Who Abuses Alcohol
• Many older adults do not live in big families or have work-
related contacts.
• Old drinkers are less likely to be referred for treatment
than are young drinkers.
• Ageism has deterred the development of treatment
programs designed specifically for the older adult.
• Older adults often try to hide their alcohol dependence.
• Treatment plans for LLD should emphasize social
therapies (e.g., Alcoholics Anonymous [AA]).

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 Treatment of the Older Adult
Who Abuses Alcohol—cont’d
• Prognosis for the late-life problem drinker (i.e., person
who has lived without recourse to alcohol and whose
drinking is caused by a loss or stress) is excellent.
• If the history of alcohol use is long and the patient meets
the criteria for alcohol addiction, then a more rigorous
treatment plan is required.
• Often the regimen includes detoxification in a 5-
to 7-day inpatient unit.
• Naltrexone (50 mg/day) is safe and effective for older
adults.

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 Illegal Drug Use: Older Adults
• Number of older Americans seeking help from
multiple substance abuse tripled, from 13.7% in
1992 to 39.7% in 2008.
• During the same period (1992-2008):
– Marijuana abuse went from 0.6% to 2.9%.
– Cocaine abuse nearly quadrupled, from 2.9% to
11.4%.
– Heroin abuse doubled, from 7.9% to 16%.

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 Prescription and Over-the-Counter
Drug Use and Abuse
• Older adults use prescription and OTC drugs at a higher rate
than the general population.
• Increased sensitivity increases medication-related adverse
events such as increased sedation, delirium, confusion, and
falls resulting in hip fractures.
• Medication-related adverse events are especially prevalent
with long-acting benzodiazepines and anticholinergic
medications.
• Prescription drug abuse by older adults went from 0.7% to
3.5% during 1992 to 2008.
• Older adults will abuse two or more drugs (multidrug abuse).

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 Acquired Immunodeficiency
Syndrome Related
• Human immunodeficiency virus and acquired
immunodeficiency syndrome (HIV/AIDS) are growing problems
among older adults.
• Older adults who are sexually active often fail to practice safe
sex.
• Diagnosis and treatment are delayed because health care
providers believe this population is not sexually active.
• Older women are at a higher risk from an infected partner than
are older men.
– Tears in the vagina allow the HIV to penetrate.
• Pregnancy is not a threat; the use of condoms is uncommon.
• Dementia is often a sequela in people with HIV/AIDS.

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 Legal and Ethical Issues that Affect
the Mental Health of Older Adults
Among the most important subjects for practicing nurses to
be familiar with are the following:
• Use of restraints
• Decision making about health care
• Elder abuse—another serious problem for older adults
• End-of-life care (see Chapter 25)

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Control of the Decision-Making Process
Class Activity—Define and Discuss
• Patient Self-Determination Act
• Durable power of attorney for health care
• Omnibus Budget Reconciliation Act (OBRA)
• Advance directives
• Living will
• Directives to physicians
• Physical restraints
• Chemical restraints

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 Class Discussion

• Older adult LGBT (lesbian, gay, bisexual, and

transgender) rights often have many conflicts within state
or federal facilities.
• Sometimes a cruel bias exists, which might result in not
allowing visitation rights or not allowing a power of
attorney.
• Know the state laws regarding the same dignity and
rights to be shown to all patients of any age, gender,
color, cultural background, and sexual persuasion.

How will you respond?

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 Physical Restraints
• Physician’s order must be obtained.
• Restraint application must be time limited.
• Attempts at alternative approaches must be documented.
• Ongoing observation and assessment must be
documented.
• Care (e.g., provision of food and fluids, toileting, help with
ADLs, response to attempted release) must be
documented.
– From The Joint Commission (TJC) guidelines

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 OBRA
The Omnibus Budget Reconciliation Act (OBRA) of
1990 declares that each nursing home resident
has the right to be free from unnecessary drugs
and physical restraints.

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 Chemical Restraints
Unfortunately, with restrictions on physical
restraints and because of the lack of any FDA-
approved medication, there has been an increase
in off-label use of certain medications (particularly
second-generation antipsychotics) as chemical
restraints to control the behavior of elderly
dementia patients, as well as to control the staff’s
working environment (Cassels, 2008).

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Control of the Decision-Making Process

• Patient Self-Determination Act (PSDA)

• Advance directives
• Living will
• Directive to physician
• Durable power of attorney for health care

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 Nursing Role: Decision-Making
Process
• Explains the ethics and legal policies of advance directives.
• Serves as an advocate and knowledgeable resource person.
• Supports a surrogate who can act on the patient’s behalf.
• Prepares (studies) to manage the legal, ethical, and moral
issues involved in advance directives.
• Is now asked to discuss advance directives with patients.
– Although nurses may discuss the options with their patients,
they may not assist patients in writing advance directives.
– Doing so would be considered a conflict of interest.

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 Objectives
Objective 1: Summarize the facts and myths about
aging.
Objective 2: Describe the destructive and negative
effects that ageism and “elderspeak” can have on
older adults.
Objective 3: Analyze the different ways nurses can
challenge ageism in changing attitudes and can
increase the awareness of fellow students and
others who care for older adults.

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 Objectives—cont’d
Objective 4: Describe the positive effects of implementing
teamwork and collaboration in the various group
interventions commonly used with older adults.
Objective 5: Describe the importance of a comprehensive
geriatric assessment including both recommended
guidelines for assessing an older adult and strategies for
using the results to promote safety.
Objective 6: How would you apply communication
strategies during your interview with any older adult?

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 Objectives—cont’d
Objective 7: Demonstrate the differences between the
provision of patient-centered care for an older adult
compared with that for a younger adult if the patient needs
assessment and intervention for the diagnosis of
depression and suicidal ideation.
Objective 8: Evaluate how you could promote safety by
identifying the risk factors for older adult suicide and the
role you would play as a nurse in prevention.

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 Objectives—cont’d
Objective 9: Demonstrate your knowledge of incorporating
evidence-based care with an understanding of the
physiologic effects of alcohol use on an older individual,
compared with those of a younger adult.
Objective 10: Demonstrate your understanding of how to
apply quality improvement methods in the use of physical
and/or chemical restraints.
Objective 11: Discuss institutional requirements related to
the Patient Self-Determination Act (1990).

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 Objectives—cont’d
Objective 12: Use informatics to determine laws and
regulations in your state for the rights of older adults who
are also lesbian, gay, bisexual, or transgender (LGBT).
Compare your results with the guidelines for the state of
New York.
Objective 13: Contrast and compare living wills, directives
to physicians, and durable powers of attorney used in
health care settings.

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