Chapter 4

Chapter 4
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Assessment of the
Older Adult
Chapter 4
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Table of Contents
I Introduction
II Considerations for Assessment of Older Adults
III Decreased Efficiency of Homeostatic Mechanisms in Older Adults
IV Lack of Standards for Health and Illness Norms in Older Adults
V Altered Presentation of and Response to Specific Diseases in Older Adults

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Table of Contents
VI Cognitive Impairment in Older Adults
VII Cultural Awareness
VII Approach to Physical Assessment

I
IX Comprehensive Health Assessment in Older Adults
I. Introduction
• Nursing assessment of older adults is a complex and challenging process.
• It is important to consider the following factors to ensure an age-specific approach:
o The interrelatedness of physical and psychosocial aspects of aging

o The nature of disease and disability and their effects on functional status
o The need to tailor the nursing assessment to the individual older adult
Interrelationship between physical and Nature of disease and disability

psychosocial aspects of aging
• Older adults are more likely to have multiple chronic
conditions.
• The health of older adults is influenced by a number • These conditions can interact with each other and
of physical and psychosocial factors. with the aging process to cause
• These factors can interact with each other to have a • disability.
significant impact on an older adult's functional • It is important to assess the impact of disease and
status. disability on an older adult's functional status.
• For example, an older adult who is experiencing grief
may be more likely to develop physical problems
such as sleep disturbances or appetite loss.
Tailoring the nursing assessment Case study
• The nursing assessment should be tailored to the • Mrs. M is an 83-year-old woman who was admitted
individual older adult. to the hospital with pneumonia.
• This means considering the older adult's age, health • She developed a number of complications during her
status, cognitive abilities, and cultural background. hospitalization, including congestive heart failure,
• The assessment should also focus on the older adult's confusion, agitation, urinary and fecal incontinence,
strengths and abilities. and a pressure ulcer.
• These complications were the result of the interaction
of several physical and psychosocial factors.
The Effect of Selected Variables on Functional Status
II. Considerations for Assessment of Older Adults

Interrelationship of Physical and Psychosocial
Introduction
Factors
Functional status refers to an individual's ability to Physical and psychosocial factors are interconnected
perform activities of daily living (ADLs) and maintain and can influence functional status.
independence.
Physical problems, such as chronic diseases, can lead
Older adults are more susceptible to functional decline to psychosocial issues, such as anxiety and depression.
due to a combination of physical and psychosocial
factors. Psychosocial issues, such as social isolation, can
worsen physical problems, such as fatigue and sleep
Comprehensive assessment is crucial to identify and disturbances.
address factors that contribute to functional decline.
Visual and Auditory Impairments
Visual and auditory impairments can hinder an older

adult's ability to navigate their environment,
communicate effectively, and engage in ADLs.
Impaired vision can increase the risk of falls and

injuries.
Impaired hearing can lead to social isolation and

communication difficulties.
Apathy
Apathy, characterized by a lack of motivation or

interest in activities, can lead to dependency and
loss of control in older adults.
Apathy may stem from underlying

psychological or physical conditions, such as
depression, dementia, or chronic pain.
Confusion and Disorientation
Confusion and disorientation can result in confusion,

agitation, and dependency in older adults.
These cognitive impairments can hinder an older

adult's ability to make decisions, manage their daily
routines, and maintain independence.
Unfamiliar Environment
Exposure to multiple strange and unfamiliar

environments can contribute to confusion, agitation,
and dependency in older adults.
The unfamiliarity of new settings can cause sensory

overload, anxiety, and difficulty adapting to new
routines.
Sleep Disturbances
Sleep disturbances, such as insomnia and excessive

daytime sleepiness, can negatively impact
functional status in older adults.
Sleep deprivation can lead to cognitive

impairment, decreased mobility, and difficulty
managing ADLs.
Relocation Stress
Relocation stress, often associated with moving to a

new environment, can contribute to confusion,
agitation, and dependency in older adults.
The disruption of routines, loss of familiar

surroundings, and social isolation can exacerbate
existing physical and psychosocial problems.
Acute Medical Illnesses
Acute medical illnesses, such as infections or

exacerbations of chronic conditions, can lead to
dependency and loss of control in older adults.
These illnesses can cause physical weakness, cognitive

impairment, and increased reliance on assistance for
ADLs.
Mobilily Impairment
Mobility impairment, including limitations in

walking or performing physical tasks, can
contribute to dependency and loss of control in
older adults.
Reduced mobility can restrict participation in

activities, increase the risk of falls, and hinder
independent living.
Inadequate Food Intake
Inadequate food intake, resulting from factors

such as poor appetite, dysphagia, or social
isolation, can lead to pressure ulcers in older
adults.
Malnutrition can impair wound healing,

weaken muscles, and increase susceptibility to
infections.
Altered Pharmacokinetics and Pharmacodynamics
Changes in pharmacokinetics and

pharmacodynamics associated with aging can lead
to persistent confusion and drug toxicity in older
adults.
Altered drug absorption, distribution, metabolism,

and excretion can result in adverse medication
effects, cognitive impairment, and functional
decline.
Decreased Efficiency of Homeostatic Mechanisms in Older Adults
III. Decreased Efficiency of Homeostatic Mechanisms in Older

Adults
• Homeostasis is the body's ability to maintain a stable internal environment.

• This includes regulating factors such as body temperature, blood pressure, and blood sugar
levels.
• As we age, our homeostatic mechanisms become less efficient.
Factors that contribute to decreased homeostatic efficiency

• Decreased immune system function: The immune system is responsible for fighting off infections. As we age, our
immune system produces fewer antibodies and becomes less effective at fighting off infections.
• Reduced ability to respond to stress: The body's response to stress is mediated by the release of cortisol. As we age, our
bodies produce less cortisol, making it more difficult to cope with stress.
• Multiple chronic conditions: Many older adults have multiple chronic conditions, such as heart disease, diabetes, and
arthritis. These conditions can make it difficult for the body to maintain homeostasis.
• Polypharmacy: Polypharmacy is the use of multiple medications. Older adults are more likely to take multiple
medications than younger adults. This is because they are more likely to have multiple chronic conditions. Polypharmacy
can increase the risk of side effects and drug interactions.
Consequences of decreased homeostatic efficiency
• Increased risk of illness and disease: Older adults are more likely to get sick than younger adults. This is
because their immune systems are less efficient at fighting off infections.
• Slower healing: Older adults take longer to heal from wounds and injuries than younger adults. This is
because their bodies are less efficient at repairing tissues.
• Increased risk of falls: Older adults are more likely to fall than younger adults. This is because their balance
and coordination are not as good as those of younger adults.
• Decreased quality of life: Decreased homeostatic efficiency can make it difficult for older adults to
participate in activities they enjoy and can lead to a decline in their quality of life.
What can be done to improve homeostatic efficiency?

• Eat a healthy diet: A healthy diet includes plenty of fruits, vegetables, and whole grains. It is also important to limit
processed foods, sugary drinks, and unhealthy fats.
• Exercise regularly: Exercise helps to strengthen muscles and bones, improve cardiovascular health, and reduce stress.
Older adults should aim for at least 30 minutes of moderate-intensity exercise most days of the week.
• Get enough sleep: Sleep is important for overall health and well-being. Older adults should aim for 7-8 hours of sleep
each night.
• Manage stress: Stress can take a toll on physical and mental health. Older adults can manage stress by practicing
relaxation techniques, such as yoga or meditation.
• Get regular medical checkups: Regular medical checkups can help to identify and treat health problems early, when they
are easier to manage.
• Take medications as prescribed: It is important to take medications as prescribed by the doctor. This will help to control
chronic conditions and prevent complications.
Lack of Standards for Health and Illness Norms in Older Adults
IV. Lack of Standards for Health and Illness

Norms in Older Adults
• Determining older adults’ physical and psychosocial health status is challenging due to the ever-
evolving norms for health and illness.
• Established standards for normalcy and abnormality are constantly changing as scientific
knowledge expands.
Impact of Laboratory Values

• Relying on established norms for laboratory values when analyzing older adults’ assessment
data can lead to erroneous conclusions.
• For instance, a fasting blood glucose level of 80 milligrams (mg) per 100 milliliters (mL) may
be normal for a young adult but could cause hypoglycemia symptoms in an older adult.
• Polypharmacy and the prevalence of multiple illnesses and diseases can also influence
laboratory data interpretation for older adults.
Heterogeneity among Older Adults

• Developmental norms for later life often categorize all older adults as belonging to the "older
than 65" group.
• However, there is substantial variation in developmental characteristics among older adults,
similar to that observed among children between the ages of 2 and 5.
Unclear Norms for Pathologic Conditions

• Definitive aging norms are lacking for many pathologic conditions.
• For example, the definition of isolated systolic hypertension in older adults remains
• debatable.
• Some argue that high systolic pressure is simply an age-related phenomenon, while others
advocate for treatment.
Nurses' Role in Gerontological Care

• Nurses must possess a comprehensive, current, scientific knowledge base and skills in
gerontologic nursing to effectively care for older adults.
• This includes understanding the complexities of aging, the impact of multiple chronic
conditions, and the importance of individualized care.
Nursing Approach to Normative Standards

• Given the lack of definitive standards, nurses should assume heterogeneity rather than
homogeneity when caring for older adults.
• Respecting the uniqueness of each individual's life experiences and preserving their
individuality is crucial.
• Nurses can compare the older person's current health status to their previous patterns of
physical and psychosocial health and function, using the individual as the standard.
Altered Presentation of and Response to Specific Diseases in Older Adults
V. Altered Presentation of and Response

to Specific Diseases in Older Adults
• The presentation of illness and disease can change with age.
• Older adults may not exhibit the classic symptoms of illness, making it more
difficult to diagnose and treat them.
Blunted or Atypical Symptoms

• Older adults may experience modified symptoms, such as a dry cough instead of a productive cough in
pneumonia.
• They may also experience unrelated symptoms, such as confusion due to a urinary tract infection.
• In some cases, older adults may not experience any expected symptoms at all, such as chest pain in a
myocardial infarction.
Factors Contributing to Altered Presentation

• Diminished Physiologic Reserve: As we age, our bodies have less reserve to fight off illness and
disease.
• Changes in Organ Function: Older adults' organs may not function as well as they did when they were
younger.
• Polypharmacy: Older adults may take multiple medications, which can interact with each other and
mask symptoms of illness.
Examples of Altered Presentation
⚬ Delirium: Delirium is a common symptom in older adults, but it can be difficult to recognize
because it can manifest in various ways, such as confusion, agitation, and changes in sleep-wake
cycle.
⚬ Urinary Tract Infection: Older adults may not experience classic UTI symptoms, such as frequent
urination and burning sensation. Instead, they may experience confusion, lethargy, or a change in
mental status.
⚬ Myocardial Infarction: Older adults may not experience classic MI symptoms, such as chest pain.
Instead, they may experience shortness of breath, nausea, vomiting, or abdominal pain.
Cognitive Impairment in Older Adults
VI. Cognitive Impairment in Older Adults
• Cognitive impairment is a common problem in older adults, affecting up to

50% of people over the age of 85.
• It can manifest in a variety of ways, including confusion, memory loss, and

difficulty with problem-solving.
• Cognitive impairment can be caused by a number of factors, including aging,

dementia, and medication side effects.
Types of Cognitive Impairment
There are two main types of cognitive impairment:
Acute Confusional State (ACS): Also known as delirium, an ACS is a sudden and temporary
decline in cognitive function that is caused by an underlying medical condition. ACS is
characterized by symptoms such as confusion, disorientation, and agitation.
Dementia: Dementia is a progressive and irreversible decline in cognitive function that is severe
enough to interfere with daily life. Dementia is characterized by symptoms such as memory loss,
difficulty with language, and impaired judgment.
Causes of Cognitive Impairment

There are many potential causes of cognitive impairment in older adults, including:
Aging: The normal aging process can lead to a decline in cognitive function.
Dementia: Dementia is a group of disorders that are characterized by a decline in cognitive function
that is severe enough to interfere with daily life. Alzheimer's disease is the most common type of
dementia.
Medication side effects: Some medications can cause side effects that can lead to cognitive
impairment, such as confusion, dizziness, and memory loss.
Medical conditions: Some medical conditions, such as stroke, Parkinson's disease, and thyroid
disorders, can also cause cognitive impairment.
Assessment of Cognitive Impairment

• Assessing cognitive impairment in older adults can be complex.
• The nurse should conduct a thorough assessment that includes a physical examination, a mental
status exam, and a review of the patient's medical history.
• The nurse should also talk to the patient's family and friends to get information about the patient's
cognitive function over time.
Treatment of Cognitive Impairment

• Treatment for cognitive impairment depends on the underlying cause.
• In some cases, the underlying cause of cognitive impairment can be treated, which can improve
cognitive function.
• In other cases, the underlying cause of cognitive impairment cannot be treated, but there are
treatments that can help to manage the symptoms of cognitive impairment.
Cultural Awareness
VII. Cultural Awareness
• What is your ethnicity?

• What is your preferred language?
• Do you know that interpreter services are available free of charge? Do you
want to choose one of the available interpreter services (online, telephone, in
person)?
• How much education did you complete (none, <7th grade, >7th grade)?
Cultural Awareness
The Health History
The nursing health history -- the first phase of a comprehensive, nursing-focused health
assessment- provides a subjective account of the older adult's current and past health status.
The interview forms the basis of a therapeutic nurse-patient relationship in which the
patient's well-being is the mutual concern. Establishing this relationship with the older adult
is essential for gathering useful, significant data. The data obtained from the health history
alerts the nurse to focus on key areas of the physical examination that require further
investigation. By talking with the nurse about health concerns, the older adult increases
their awareness of health, and topics for health teaching can be identified. Finally, the
process of recounting a patient's history in a purposeful systematic way may have the
therapeutic effect of serving as a life review.
Cultural Awareness
Patient Profile/Biographic Data: Address and telephone numberdate and place of birth, age,
gender, race, religion, mantal status, education, name, address, and telephone number of
nearest contact
person, advance directives.
Family Profile: Family members' names and addresses, year and cause of death of deceased
spouse and children
Occupational Profile: Current work or retirement status previous jobs sources of income
and perceived adequacy for needs.
Living Environment Profile: Type of dwelling number of rooms, levels, and people residing
degree of privacy, name, address, and telephone number of nearest neighbor.
Cultural Awareness
Recreational/Leisure Profile: Hobbies or interests, organization memberships, vacations or

travel.
Resources/Support Systems Used: Names of physicians, hospital, clinic and other

community services used.
Description of Typical Day: Type and amount of time spent in each activity.
Present Health Status: Description of perception of health in past 1 year and 5 years, health
screenings, chief complaint and full symptom analysis, pre scribed and self prescribed
drugs, immunizations, allergies, eating and nutritional patterns.
Cultural Awareness
Past Health Status: Previous illnesses throughout life, traumatic injuries, hospitalizations,
operations, obstetric history.
Family History: Health status of inmediate and iving relatives, causes of death of
immediate relatives, survey for risk of specific diseases and disorders.
Review of Systems: Head-to-toe review of all body systems and review of health
promotion habits for same
Cultural Awareness
The Interviewer
The interviewer's ability to elicit meaningful data from the patient depends on the
interviewer's attitudes and stereotypes about aging and older people. The nurse must be
aware of these factors because they affect nurse patient communication during the
assessment.
Cultural Awareness
The Patient
Several factors influence the patient's ability to participate meaningfully in the interview.
The nurse must be aware of these factors because they affect the older adult's ability to
communicate all the information necessary for determining appropriate, comprehensive
interventions. Sensory- perceptual deficits, anxiety, reduced energy level, pain, multiple and
interrelated health problems, and the tendency to reminisce are the major patient factors
requiring special consideration while the nurse elicits the health history.
Cultural Awareness
Patient Factors Affecting History Taking and Recommendations

Visual Deficit
• Position self In full view of patient.
• Provide diffused, bright light avoid glare.
• Ensure patient's glasses are worn, in good working order, and clean.
• Face patient when speaking do not cover mouth.
Hearing Deficit
• Speak directly to patient in clear, low tones at a moderate rate, do not cover mouth.
• Articulate consonants with special care.
• Repeat if patient does not understand question initially, and then restate Speak toward patient's
"good" ear.
• Reduce background noises.
• Ensure patient's hearing aid is worn, turned on, and working properly.
Cultural Awareness
Patient Factors Affecting History Taking and Recommendations

Anxiety
Give patient sufficient time to respond to questions.
Establish rapport and trust by acknowledging expressed concerns.
Reduced Energy Level

Position comfortably to promote alertness.
Allow for more than one assessment encounter, vary the meeting times.
Be alert to subtle signs of fatigue, inability to concentrate, reduced attention span, restlessness, or posture.
Pain
Position patient comfortably to reduce pain.
Ask patient about degree of pain intervene before interview or reschedule.
Comfort and communicate through touch.
Use distraction techniques.
Provide a relaxed, "warm" environment.
Approach to Physical Assessment
VIII. Approach to Physical Assessment
Physical assessment is typically performed after the health history. The approach
should be a systematic and deliberate one that allows the nurse to:
(I) determine patient strengths and capabilities, as well as disabilities and

limitations;
(2) verify and gain objective support for subjective findings;
(3) gather objective data not previously known.
SPICES
SPICES is an efficient acronym to help gather information necessary to identify patient problems in six common
areas identified as increasing mortality risk, leading to increased cost and longer hospitalizations in older adults.
Sleep disorders: Ask the patient how well they usually sleep.
Problems with eating or feeding: Ask the patient why they do not feel like eating.
Incontinence (of bowel or bladder): Ask the patient if they usually make it to the bathroom on time.
Confusion: Assessed through observation and use of appropriate assessment tools.
Evidence of falls: Ask the patient how often they have fallen.
Skin breakdown: Assess for risk factors using appropriate assessment tools.
General Guidelines
Regardless of the approach and sequence used, the following principles should be considered during the physical assessment of
an older adult:
• Recognize that the older adult may have no previous experience with a nurse conducting a physical assessment; each step
should be explained, and the patient reassured.
• Be alert to the older patient's energy level.
• Respect the patient's modesty.
• Keep the patient comfortably draped.
• Sequence the assessment to keep position changes to a minimum.
• Develop an efficient sequence for assessment that minimizes both nurse and patient movement.
• Make sure the patient is comfortable.
• Explain each step in simple terms.
• Warn of any discomfort that might occur.
• Probe painful areas last.
• For reassurance, share findings with the patient when possible. Encourage the patient to ask questions.
• Take advantage of "teachable moments" that may occur while conducting the assessment (e.g. breast self-examination).
• Develop a standard format on which to note selected findings.
Katz Index of ADLs
The Katz Index of ADLs (Katz et al, 1963) is a tool

widely used to determine the results of treatment and the
prognosis in older and chronically ill. The performance
in six functions bathing, dressing, toileting, transferring,
continence, and feeding. A dichotomous rating of
independence or dependence depend for each function.
One point is given for each dependent item.
Comprehensive Health Assessment in Older Adults
IX. Comprehensive Health Assessment in Older Adults
Purpose of Mental Status Assessment:

• Determine cognitive function in older adults.
• Integrated into interviews and physical exams.
• Consideration of ethnicity in nonthreatening testing.
• Multiple causes of cognitive impairment and incomplete assessments.
• Importance of standardized examinations, focusing on the Montreal
Cognitive Assessment (MoCA).
The Mini-Cog Assessment

The Mini-Cog is an instrument that combines a
simple test of memory with a clock drawing test. It
was created by researchers at the University of
Washington led by Soo Borion. The Mini-Cog is
both quick and easy to use, and has been found to be
as effective as longer, more time-consuming
instruments in accurately identifying cognitive
impairment
Montreal Cognitive Assessment (MoCA)
 Quick screening tool for mild cognitive impairment and Alzheimer's.
 Assesses attention, concentration, language, vasoconstriction skills, & more.
 Extensive testing in multiple languages for older adults over 85.
 Total possible score is 30 points, with 26 or more considered normal.
 Educational background adjustment for 4 to 9 years of education.

Montreal Cognitive
Assessment (MoCA)
Chapter 4 BSN 4-3
Presentation by:
Cabatuando Cuevas Del Rosario Galang Manalastas

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II Considerations for Assessment of Older Adults

III Decreased Efficiency of Homeostatic Mechanisms in Older Adults

IV Lack of Standards for Health and Illness Norms in Older Adults

V Altered Presentation of and Response to Specific Diseases in Older Adults

VII Cultural Awareness

VII Approach to Physical Assessment

o The interrelatedness of physical and psychosocial aspects of aging

Interrelationship between physical and Nature of disease and disability

Tailoring the nursing assessment Case study

II. Considerations for Assessment of Older Adults

Visual and Auditory Impairments

Visual and auditory impairments can hinder an older

Impaired vision can increase the risk of falls and

Impaired hearing can lead to social isolation and

Apathy, characterized by a lack of motivation or

Apathy may stem from underlying

Confusion and Disorientation

Confusion and disorientation can result in confusion,

These cognitive impairments can hinder an older

Exposure to multiple strange and unfamiliar

The unfamiliarity of new settings can cause sensory

Sleep disturbances, such as insomnia and excessive

Sleep deprivation can lead to cognitive

Relocation stress, often associated with moving to a

The disruption of routines, loss of familiar

Acute Medical Illnesses

Acute medical illnesses, such as infections or

These illnesses can cause physical weakness, cognitive

Mobility impairment, including limitations in

Reduced mobility can restrict participation in

Inadequate Food Intake

Inadequate food intake, resulting from factors

Malnutrition can impair wound healing,

Altered Pharmacokinetics and Pharmacodynamics

Changes in pharmacokinetics and

Altered drug absorption, distribution, metabolism,

III. Decreased Efficiency of Homeostatic Mechanisms in Older

• Homeostasis is the body's ability to maintain a stable internal environment.

Factors that contribute to decreased homeostatic efficiency

Consequences of decreased homeostatic efficiency

What can be done to improve homeostatic efficiency?

IV. Lack of Standards for Health and Illness

Impact of Laboratory Values

Heterogeneity among Older Adults

Unclear Norms for Pathologic Conditions

Nurses' Role in Gerontological Care

Nursing Approach to Normative Standards

V. Altered Presentation of and Response

• The presentation of illness and disease can change with age.

Blunted or Atypical Symptoms

Factors Contributing to Altered Presentation

Examples of Altered Presentation

VI. Cognitive Impairment in Older Adults

• Cognitive impairment is a common problem in older adults, affecting up to

• It can manifest in a variety of ways, including confusion, memory loss, and

• Cognitive impairment can be caused by a number of factors, including aging,

Types of Cognitive Impairment

There are two main types of cognitive impairment:

Causes of Cognitive Impairment

Assessment of Cognitive Impairment

Treatment of Cognitive Impairment