Chapter 13, Comfort and Pain Management

With the realization that pain is highly prevalent among older adults, please answer the following questions:

• What is the prevalence of pain in older adults?
• How will you, as a nurse, be more aware of pain issues related to older adults and what will you

incorporate into practice?

Please use your textbook as, at least, one reference.

Please abide by APA 7th edition format in your writing. 

Answers should be 2-3 Paragraphs made up of 3-4 sentences each, at least 250 words (more or less) in length. 

Gerontological
Nursing
Ninth Edition
2

Gerontological
Nursing
Ninth Edition
Charlotte Eliopoulos, PhD, MPH, RN
Specialist in Holistic Gerontological Care
3

Acquisitions Editor: Natasha McIntyre
Director of Product Development: Jennifer K. Forestieri
Development Editor: Meredith L. Brittain
Editorial Assistant: Leo Gray
Production Project Manager: Priscilla Crater
Design Coordinator: Elaine Kasmer
Illustration Coordinator: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Production Services/Compositor: SPi Global
9th Edition
Copyright © 2018 Wolters Kluwer
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means,
including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book
prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To
request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
permissions@lww.com, or via our website at lww.com (products and services).
Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses — Definitions
and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited.
In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining
characteristics of the diagnoses listed in this work.
9 8 7 6 5 4 3 2 1
Printed in China
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ISBN 9780060000387
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy,
comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration
of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to
the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and
not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. 
Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses,
indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should
consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify
any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow
therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or
damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of
this work.
LWW.com
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mailto:permissions@lww.com

http://lww.com

http://LWW.com

Not authorised for sale in United States, Canada, Australia, New Zealand, Puerto Rico, and U.S. Virgin Islands.
Acquisitions Editor: Natasha McIntyre
Director of Product Development: Jennifer K. Forestieri
Development Editor: Meredith L. Brittain
Editorial Assistant: Leo Gray
Production Project Manager: Priscilla Crater
Design Coordinator: Elaine Kasmer
Illustration Coordinator: Jennifer Clements
Manufacturing Coordinator: Karin Duffield
Production Services/Compositor: SPi Global
9th Edition
Copyright © 2018 Wolters Kluwer
All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means,
including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written
permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book
prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To
request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at
permissions@lww.com, or via our website at lww.com (products and services).
Nursing diagnoses in this title are reprinted with permission from: Herdman, T.H. & Kamisuru, S. (Eds.) Nursing Diagnoses — Definitions
and Classification 2015-2017. Copyright © 2014, 1994-2014 NANDA International. Used by arrangement with John Wiley & Sons Limited.
In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining
characteristics of the diagnoses listed in this work.
9 8 7 6 5 4 3 2 1
Printed in China
Cataloging in Publication data available on request from publisher
ISBN 9781496377258
This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy,
comprehensiveness, or currency of the content of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration
of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to
the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and
not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. 
Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses,
indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should
consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify
any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow
therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or
damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of
this work.
LWW.com
5

mailto:permissions@lww.com

http://lww.com

http://LWW.com

6

This book is dedicated to my husband, George Considine, for his unending patience, support, and encouragement.
7

Preface
Whether they are aware of it or not, most nurses today are doing some form of gerontological nursing.
Hospitals are caring for increasing numbers of older adults whose age-related changes, multiple diagnoses,
and psychosocial complexities present many challenges. Settings that provide long-term care are expanding
beyond the nursing home. More older adults are remaining in the community and presenting new demands
for nursing services to be provided in innovative ways. Growing numbers of older individuals are heading
multigenerational households and caring for younger family members, which brings them into contact with
nurses in specialties beyond geriatrics.
Not only do older individuals have a greater presence in various specialties but they also are presenting
new challenges. They are better informed about their health conditions and expect to have explanations for
treatment decisions. Many are using complementary and alternative therapies and desire approaches that
integrate those therapies into conventional care. They not only want their diseases managed but they also
want to enhance their function so they can enjoy an active, meaningful life. They may make choices that
forfeit treatments that can extend the quantity of life for those that offer the freedom to enjoy a high quality of
life for whatever time remains. Such challenges demand that nurses not only be knowledgeable about aging
and geriatric care but also skillful at assessing that which is important to the older person and providing care
that addresses the person holistically. It is indeed an exciting time to be a gerontological nurse!
Gerontological Nursing has evolved since its first publication. In the early editions of the text, the focus was
on providing facts about the aging process and the unique modifications that were necessary to properly assess,
plan, and provide care to older adults. We now understand that a “one size fits all” approach to nursing older
adults is inappropriate as the diversity of this population grows. In addition to expecting from the
gerontological nurse assistance with managing their medical conditions, today’s older adults may seek
guidance on the selection of brain exercises to improve mental function, the value of an herbal supplement
over their prescription drug, strategies to fill the void resulting from retiring from a job they enjoyed,
suggestions for the best lubricant to facilitate sexual intercourse, opinions as to the value of marijuana in
controlling their pain, and recommendations for the best type of approach to reduce their wrinkles. This
edition of Gerontological Nursing provides the evidence-based knowledge that can help the gerontological
nurse address, with competency and sensitivity, the complexities of meeting the comprehensive, holistic needs
of the older population.
8

Text Organization
Gerontological Nursing, Ninth Edition, is organized into five units. Unit 1, The Aging Experience, provides basic
knowledge about the older population and the aging process. The growing cultural and sexual diversity of this
population is discussed, along with the navigation of life transitions and the changes to the body and mind
that typically are experienced.
Unit 2, Foundations of Gerontological Nursing, provides an understanding of the development and scope of
the specialty, along with descriptions of the various settings that provide services to older persons. This unit
reviews legal and ethical issues that are relevant to gerontological nursing and offers guidance in applying a
holistic model to gerontological care.
Unit 3, Health Promotion, addresses the importance of measures to prevent illness and maximize function.
Chapters dedicated to nutrition and hydration, sleep and rest, comfort and pain management, safety, and
medications guide the nurse in promoting basic health and preventing avoidable complications. A chapter
dedicated to spirituality supports the holistic approach that is meaningful in gerontological care. In addition,
because people often feel sufficiently comfortable with nurses to discuss sensitive matters, a chapter on
sexuality and intimacy is included.
Unit 4, Geriatric Care, encompasses chapters dedicated to respiration, circulation, digestion and bowel
elimination, urinary elimination, reproductive system health, mobility, neurologic function, vision and
hearing, endocrine function, skin health, and cancer. A review of the impact of aging, interventions to
promote health, the unique presentation and treatment of illnesses, and integrative approaches to illness are
discussed within each of these areas. In addition to a chapter on mental health disorders, a chapter reviewing
delirium and dementia is included in recognition of the prevalence and care challenges of these conditions in
the geriatric population. Because chronic conditions affect most of this population, the last chapter of this unit
is dedicated to nursing actions that can assist older individuals in living a full life with chronic conditions.
The unique challenges gerontological nurses face in various care settings are discussed in Unit 5, Settings
and Special Issues in Geriatric Care. Chapters in this unit cover rehabilitative care, acute care, long-term care,
family caregiving, and end-of-life care.
9

Features
A variety of features enrich the content:
Learning Objectives prepare the reader for outcomes anticipated in reading the chapter.
Chapter Outlines present an overview of the chapter’s content.
Terms to Know define new terms pertaining to the topic.
Communication Tips offer suggestions to facilitate patient education and information exchange with
older adults.
Consider This Case features present clinical situations that offer opportunities for critical thinking.
Concept Mastery Alerts clarify fundamental nursing concepts to improve the reader’s understanding of
potentially confusing topics, as identified by Misconception Alerts in Lippincott’s Adaptive Learning
Powered by prepU.
Key Concepts emphasize significant facts.
Points to Ponder pose questions to stimulate thinking related to the content.
Assessment Guides outline the components of general observations, interview, and physical assessment
of major body systems.
Nursing Diagnosis Highlights provide an overview of selected nursing diagnoses common in older
adults.
Nursing Care Plans demonstrate the steps in developing nursing diagnoses, goals, and actions from
identified needs.
Bringing Research to Life presents current research and describes how to apply that knowledge in
practice.
Practice Realities pose real-life examples of challenges that could be faced by a nurse in practice.
Critical Thinking Exercises guide application.
Resources and References assist with additional exploration of the topic.
10

Teaching and Learning Package
A comprehensive teaching/learning package has been developed to assist faculty and students.
Resources for Instructors
Tools to assist you with teaching your course are available upon adoption of this text at
http://thePoint.lww.com/Eliopoulos9e.
An E-book on gives you access to the book’s full text and images online.
The Test Generator lets you put together exclusive new tests from a bank containing hundreds of
questions to help you in assessing your students’ understanding of the material. Test questions link to
chapter learning objectives. This test generator comes with a bank of more than 900 questions.
PowerPoint Presentations provide an easy way for you to integrate the textbook with your students’
classroom experience, via either slide shows or handouts. Multiple choice and true/false questions are
integrated into the presentations to promote class participation and allow you to use i-clicker
technology.
Clinical Scenarios posing What If questions (and suggested answers) give your students an opportunity
to apply their knowledge to a client case similar to the one they might encounter in practice.
Assignments (and suggested answers) include group, written, clinical, and web assignments.
An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint
slides or as you see fit in your course.
A QSEN Competency Map and a BSN Essentials Map show you how content connects with these
important competencies.
Suggested Answers to the Critical Thinking Exercises in the book allow you to gauge whether students’
answers are on the right track by giving you main points that students are expected to address in the
answers.
Plus a Sample Syllabus, Strategies for Effective Teaching, and Learning Management System
Cartridges.
Resources for Students
An exciting set of free resources is available to help students review material and become even more familiar
with vital concepts. Students can access all these resources at http://thePoint.lww.com/Eliopoulos9e using the
codes printed in the front of their textbooks.
Current Journal Articles offer access to current research available in Wolters Kluwer journals.
Watch & Learn Video Clips explain How to Assist a Person Who Is Falling, Alternatives to Restraints,
and the Five Stages of Grief. (Icons in the textbook direct readers to relevant videos.)
Recommended Readings expand the network of available information.
Plus Learning Objectives from the textbook, Nursing Professional Roles and Responsibilities, and
Heart and Breath Sounds.
11

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http://thePoint.lww.com/Eliopoulos9e

12

A Fully Integrated Course Experience
We are pleased to offer an expanded suite of digital solutions and ancillaries to support instructors and
students using Gerontological Nursing, Ninth Edition. To learn more about any solution, please contact your
local Wolters Kluwer representative.
Lippincott CoursePoint+
Lippincott CoursePoint+ is an integrated digital learning solution designed for the way students learn. It is the
only nursing education solution that integrates:
Leading content in context: Content provided in the context of the student learning path engages
students and encourages interaction and learning on a deeper level.
Powerful tools to maximize class performance: Course-specific tools, such as adaptive learning powered
by prepU, provide a personalized learning experience for every student.
Real-time data to measure students’ progress: Student performance data provided in an intuitive display
lets you quickly spot which students are having difficulty or which concepts the class as a whole is
struggling to grasp.
Preparation for practice: Integrated virtual simulation and evidence-based resources improve student
competence, confidence, and success in transitioning to practice.
vSim for Nursing: Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing
simulates real nursing scenarios and allows students to interact with virtual patients in a safe,
online environment.
Lippincott Advisor for Education: With over 8,500 entries covering the latest evidence-based
content and drug information, Lippincott Advisor for Education provides students with the most
up-to-date information possible, while giving them valuable experience with the same point-of-
care content they will encounter in practice.
Training services and personalized support: To ensure your success, our dedicated educational
consultants and training coaches will provide expert guidance every step of the way.
13

Simulation and Other Resources
vSim for Nursing | Gerontology, a virtual simulation platform
(available via ). Co-developed by Laerdal Medical and Wolters Kluwer, vSim for Nursing | Gerontology
includes 12 gerontology patient scenarios that correspond to the National League for Nursing (NLN)
Advancing Care Excellence for Seniors (ACES) Unfolding Cases. vSim for Nursing | Gerontology helps
students develop clinical competence and decision-making skills as they interact with virtual patients in
a safe, realistic environment. vSim for Nursing records and assesses student decisions throughout the
simulation, then provides a personalized feedback log highlighting areas needing improvement.
Lippincott DocuCare (available via
thePoint). Lippincott DocuCare combines web-based electronic health record simulation software with
clinical case scenarios. Lippincott DocuCare’s nonlinear solution works well in the classroom,
simulation lab, and clinical practice.
14

Reviewers
Carol Amann, PhD, RN-BC, CDP
Assistant Professor for the Villa Maria School of Nursing
Gannon University
Erie, Pennsylvania
Jan Atwell, MSN, RN
Clinical Assistant Professor
Missouri State University
Springfield, Missouri
Judy L. Barrera, RN, CNS
Clinical Learning Lab Coordinator
Galen College of Nursing
Louisville, Kentucky
Evelyn Biray, RN, MS, PMed, CCRN, CMSRN
Professor of Nursing
Long Island University Brooklyn
New York, New York
Dr.Melissa Brock , MSM, MSN, ANP-C, DHEd
Nursing Professor
Indiana Wesleyan University
Indianapolis, Indiana
Celeste Brown-Apoh, RN, MSN
Instructor
Rowan College at Burlington County
Pemberton, New Jersey
Jean Burt, MSN, RN
Instructor
Wilbur Wright College
Chicago, Illinois
Nicola Contreras, MSN, RN
VN/ADN Faculty
15

Galen College of Nursing
San Antonio, Texas
Sherri Cozzens, RN, MS
Nursing Faculty
De Anza College
Cupertino, California
Jodie Fox, MSN, RN-BC
Assistant Professor
Viterbo University
Lacrosse, Wisconsin
Florida Freeman, PhD, MSN, RN
Professor of Nursing
University of St. Francis
Joliet, Illinois
Betsy D. Gulledge, PhD, RN, CNE, NEA-BC
Associate Dean/Assistant Professor of Nursing
Jacksonville State University
Jacksonville, Alabama
Kris Hale, MSN, RN
Professor/Department Chair
San Diego City College
San Diego, California
Cheryl Harrington, MSN, RN, MHA
Clinical Simulation Specialist
Morningside College
Sioux City, Iowa
Mary Jane Holman, RN
Instructor
Louisiana State University Shreveport
Shreveport, Louisiana
Laly Joseph, DVM, DNP, MSN, RN, C, ARNP, BC
Clinical Assistant Professor
Fairleigh Dickinson University
Teaneck, New Jersey
16

Ronnie Knabe, MSN, RN, CCRN
Associate Professor, Nursing
Bakersfield College
Bakersfield, California
Amy Langley
Health Science Division Director
Snead State Community College
Boaz, Alabama
Debora Lemon, MN, RN
Associate Professor
Lewis-Clark State College
Lewiston, Idaho
Susan McClendon, MSN, RN, CNS
Nursing Faculty
Lakeland Community College
Kirkland, Ohio
Mary Alice Momeyer, DNP, ANP-BC, GNP-BC
Assistant Clinical Professor
The Ohio State University
College of Nursing
Columbus, Ohio
Jon F. Nutting, MA, RN-BC
Instructor
Galen College of Nursing
Tampa Bay Campus
St. Petersburg, Florida
Teresa M. Page, DNP, EdS, MSN, RN, FNP-BC
Assistant Professor of Nursing
Liberty University
Lynchburg, Virginia
LoriAnn Pajalich, MS, RN, CNS, GCNS-BC
Assistant Professor of Nursing
Wilkes University
Wilkes-Barre, Pennsylvania
17

Debra Parker, DNP, RN
Assistant Professor
Indiana Wesleyan University
Marion, Indiana
Cordelia Schaffer, MSN, RN, CHPN
Associate Professor
Westminster College
Salt Lake City, Utah
Crystal Schauerte-O’Connell
Program Coordinator, Year 2
Algonquin College
Ottawa, Ontario
Maura C. Schlairet, EdD, MA, MSN, RN, CNL (A/H)
Professor of Nursing
Valdosta State University
Valdosta, Georgia
Nichole Spencer, MSN, APRN, ANP-C
Assistant Professor of Nursing
William Jewell College
Liberty, Missouri
Carolyn Sue-Ling, MSN, MPA, RN
Instructor
University of South Carolina Aiken
Aiken, South Carolina
Michael T. Valenti, AAS, BS, MS
Assistant Professor of Nursing
Long Island University
Brookville, New York
Stephanie Vaughn, PhD, RN, CRRN, FAHA
Professor/Director School of Nursing
California State University, Fullerton
Fullerton, California
Erica Williams-Woodley, MSN, NP
Assistant Professor of Nursing
18

Bronx Community College
New York, New York
Jane Zaccardi, MA, RN, GCNS-BC
Director of Practical Nursing and Health Occupations Programs
Johnson County Community College
Overland Park, Kansas

For a list of the contributors to the Instructor Resources and a list of the reviewers of the Test Generator
questions accompanying this book, please visit http://thepoint.lww.com/Eliopoulos9e.
19

http://thepoint.lww.com/Eliopoulos9e

Acknowledgments
There are many individuals who played important roles in the birth and development of this book. I will
always be grateful to Bill Burgower, a Lippincott editor, who decades ago responded to my urging that the
new specialty of gerontological nursing needed resources by encouraging me to write the first edition of
Gerontological Nursing. Many fine members of the Wolters Kluwer team have guided and assisted me since,
including Natasha McIntyre, Acquisitions Editor, who consistently offered encouragement and direction;
Meredith Brittain, Senior Development Editor, who brought a new set of eyes to the book and ironed out the
rough edges through her fine editorial skills; Dan Reilly and Leo Gray, Editorial Assistants at different points
in this project, who attended to the details that contribute to a quality finished product; and Priscilla Crater,
Production Project Manager, who shepherded the book from manuscript through printed pages.
Lastly, I am deeply indebted to those mentors and leaders in gerontological care who generously offered
encouragement and the many older adults who have touched my life and showed me the wisdom and beauty
of aging. The insight these individuals provided could have never been learned in a book!
Charlotte Eliopoulos
20

Brief Contents
UNIT 1 THE AGING EXPERIENCE
1 The Aging Population
2 Theories of Aging
3 Diversity
4 Life Transitions and Story
5 Common Aging Changes
UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING
6 The Specialty of Gerontological Nursing
7 Holistic Assessment and Care Planning
8 Legal Aspects of Gerontological Nursing
9 Ethical Aspects of Gerontological Nursing
10 Continuum of Care in Gerontological Nursing
UNIT 3 HEALTH PROMOTION
11 Nutrition and Hydration
12 Sleep and Rest
13 Comfort and Pain Management
14 Safety
15 Spirituality
16 Sexuality and Intimacy
17 Safe Medication Use
UNIT 4 GERIATRIC CARE
18 Respiration
19 Circulation
20 Digestion and Bowel Elimination
21 Urinary Elimination
22 Reproductive System Health
23 Mobility
24 Neurologic Function
25 Vision and Hearing
21

26 Endocrine Function
27 Skin Health
28 Cancer
29 Mental Health Disorders
30 Delirium and Dementia
31 Living in Harmony With Chronic Conditions
UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE
32 Rehabilitative and Restorative Care
33 Acute Care
34 Long-Term Care
35 Family Caregiving
36 End-of-Life Care

Index
22

Contents
UNIT 1 THE AGING EXPERIENCE
1 The Aging Population
Views Of Older Adults Through History
Characteristics Of The Older Adult Population
Population Growth and Increasing Life Expectancy
Marital Status and Living Arrangements
Income and Employment
Health Insurance
Health Status
Implications Of An Aging Population
Impact of the Baby Boomers
Provision of and Payment for Services
2 Theories of Aging
Biological Theories Of Aging
Stochastic Theories
Nonstochastic Theories
Sociologic Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
Subculture Theory
Age Stratification Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Functional Consequences Theory
Theory of Thriving
Theory of Successful Aging
Applying Theories of Aging to Nursing Practice
3 Diversity
Increasing Diversity Of The Older Adult Population
Overview Of Diverse Groups Of Older Adults In The United States
Hispanic Americans
Black Americans
Asian Americans
Jewish Americans
23

Native Americans
Muslims
Gay, Lesbian, Bisexual, and Transgender Older Adults
Nursing Considerations For Culturally Sensitive Care Of Older Adults
4 Life Transitions and Story
Ageism
Changes In Family Roles And Relationships
Parenting
Grandparenting
Loss Of Spouse
Retirement
Loss of the Work Role
Reduced Income
Changes In Health And Functioning
Cumulative Effects Of Life Transitions
Shrinking Social World
Awareness of Mortality
Responding To Life Transitions
Life Review and Life Story
Self-Reflection
Strengthening Inner Resources
5 Common Aging Changes
Changes To The Body
Cells
Physical Appearance
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Nervous System
Sensory Organs
Endocrine System
Integumentary System
Immune System
Thermoregulation
Changes To The Mind
Personality
Memory
Intelligence
24

Learning
Attention Span
Nursing Implications Of Age-Related Changes
UNIT 2 FOUNDATIONS OF GERONTOLOGICAL NURSING
6 The Specialty of Gerontological Nursing
Development Of Gerontological Nursing
Core Elements Of Gerontological Nursing Practice
Evidence-Based Practice
Standards
Competencies
Principles
Gerontological Nursing Roles
Healer
Caregiver
Educator
Advocate
Innovator
Advanced Practice Nursing Roles
Self-Care And Nurturing
Following Positive Health Care Practices
Strengthening and Building Connections
Committing to a Dynamic Process
The Future Of Gerontological Nursing
Utilize Evidence-Based Practices
Advance Research
Promote Integrative Care
Educate Caregivers
Develop New Roles
Balance Quality Care and Health Care Costs
7 Holistic Assessment and Care Planning
Holistic Gerontological Care
Holistic Assessment Of Needs
Health Promotion–Related Needs
Health Challenges–Related Needs
Requisites to Meet Needs
Gerontological Nursing Processes
Examples Of Application
Applying the Holistic Model: The Case of Mrs. D
The Nurse As Healer
Healing Characteristics
25

8 Legal Aspects of Gerontological Nursing
Laws Governing Gerontological Nursing Practice
Legal Risks In Gerontological Nursing
Malpractice
Confidentiality
Patient Consent
Patient Competency
Staff Supervision
Medications
Restraints
Telephone Orders
Do Not Resuscitate Orders
Advance Directives and Issues Related to Death and Dying
Elder Abuse
Legal Safeguards For Nurses
9 Ethical Aspects of Gerontological Nursing
Philosophies Guiding Ethical Thinking
Ethics In Nursing
External and Internal Ethical Standards
Ethical Principles
Cultural Considerations
Ethical Dilemmas Facing Gerontological Nurses
Changes Increasing Ethical Dilemmas for Nurses
Measures to Help Nurses Make Ethical Decisions
10 Continuum of Care in Gerontological Nursing
Services In The Continuum Of Care For Older Adults
Supportive and Preventive Services
Partial and Intermittent Care Services
Complete and Continuous Care Services
Complementary and Alternative Services
Matching Services To Needs
Settings And Roles For Gerontological Nurses
UNIT 3 HEALTH PROMOTION
11 Nutrition and Hydration
Nutritional Needs Of Older Adults
Quantity and Quality of Caloric Needs
Nutritional Supplements
Special Needs of Women
Hydration Needs Of Older Adults
Promotion Of Oral Health
26

Threats To Good Nutrition
Indigestion and Food Intolerance
Anorexia
Dysphagia
Constipation
Malnutrition
Addressing Nutritional Status And Hydration In Older Adults
12 Sleep and Rest
Age-Related Changes in Sleep
Circadian Sleep–Wake Cycles
Sleep Stages
Sleep Efficiency and Quality
Sleep Disturbances
Insomnia
Nocturnal Myoclonus and Restless Legs Syndrome
Sleep Apnea
Medical Conditions That Affect Sleep
Drugs That Affect Sleep
Other Factors Affecting Sleep
Promoting Rest and Sleep in Older Adults
Pharmacologic Measures to Promote Sleep
Nonpharmacologic Measures to Promote Sleep
Pain Control
13 Comfort and Pain Management
Comfort
Pain: A Complex Phenomenon
Prevalence Of Pain In Older Adults
Types of Pain
Pain Perception
Effects of Unrelieved Pain
Pain Assessment
An Integrative Approach To Pain Management
Complementary Therapies
Dietary Changes
Medication
Comforting
14 Safety
Aging And Risks To Safety
Importance Of The Environment To Health And Wellness
Impact Of Aging On Environmental Safety And Function
Lighting
27

Temperature
Colors
Scents
Floor Coverings
Furniture
Sensory Stimulation
Noise Control
Bathroom Hazards
Fire Hazards
Psychosocial Considerations
The Problem Of Falls
Risks and Prevention
Risks Associated With Restraints
Interventions To Reduce Intrinsic Risks To Safety
Reducing Hydration and Nutrition Risks
Addressing Risks Associated With Sensory Deficits
Addressing Risks Associated With Mobility Limitations
Monitoring Body Temperature
Preventing Infection
Suggesting Sensible Clothing
Using Medications Cautiously
Avoiding Crime
Promoting Safe Driving
Promoting Early Detection of Problems
Addressing Risks Associated With Functional Impairment
15 Spirituality
Spiritual Needs
Love
Meaning and Purpose
Hope
Dignity
Forgiveness
Gratitude
Transcendence
Expression of Faith
Assessing Spiritual Needs
Addressing Spiritual Needs
Being Available
Honoring Beliefs and Practices
Providing Opportunities for Solitude
28

Promoting Hope
Assisting in Discovering Meaning in Challenging Situations
Facilitating Religious Practices
Praying With and for
16 Sexuality and Intimacy
Attitudes Toward Sex And Older Adults
Realities Of Sex In Older Adulthood
Sexual Behavior and Roles
Intimacy
Age-Related Changes and Sexual Response
Menopause As A Journey To Inner Connection
Symptom Management and Patient Education
Self-Acceptance
Andropause
Identifying Barriers To Sexual Activity
Unavailability of a Partner
Psychological Barriers
Medical Conditions
Erectile Dysfunction
Medication Adverse Effects
Cognitive Impairment
Promoting Healthy Sexual Function
17 Safe Medication Use
Effects Of Aging On Medication Use
Polypharmacy and Interactions
Altered Pharmacokinetics
Altered Pharmacodynamics
Increased Risk of Adverse Reactions
Promoting The Safe Use Of Drugs
Avoiding Potentially Inappropriate Drugs: Beers Criteria
Reviewing Necessity and Effectiveness of Prescribed Drugs
Promoting Safe and Effective Administration
Providing Patient Teaching
Monitoring Laboratory Values
Alternatives To Drugs
Review Of Selected Drugs
Analgesics
Antacids
Antibiotics
Anticoagulants
Anticonvulsants
29

Antidiabetic (Hypoglycemic) Drugs
Antihypertensive Drugs
Nonsteroidal Anti-inflammatory Drugs
Cholesterol-Lowering Drugs
Cognitive Enhancing Drugs
Digoxin
Diuretics
Laxatives
Psychoactive Drugs
UNIT 4 GERIATRIC CARE
18 Respiration
Effects Of Aging On Respiratory Health
Respiratory Health Promotion
Selected Respiratory Conditions
Chronic Obstructive Pulmonary Disease
Pneumonia
Influenza
Lung Cancer
Lung Abscess
General Nursing Considerations For Respiratory Conditions
Recognizing Symptoms
Preventing Complications
Ensuring Safe Oxygen Administration
Performing Postural Drainage
Promoting Productive Coughing
Using Complementary Therapies
Promoting Self-Care
Providing Encouragement
19 Circulation
Effects Of Aging On Cardiovascular Health
Cardiovascular Health Promotion
Proper Nutrition
Adequate Exercise
Cigarette Smoke Avoidance
Stress Management
Proactive Interventions
Cardiovascular Disease And Women
Selected Cardiovascular Conditions
Hypertension
30

Hypotension
Congestive Heart Failure
Pulmonary Emboli
Coronary Artery Disease
Hyperlipidemia
Arrhythmias
Peripheral Vascular Disease
General Nursing Considerations For Cardiovascular Conditions
Prevention
Keeping the Patient Informed
Preventing Complications
Promoting Circulation
Providing Foot Care
Managing Problems Associated With Peripheral Vascular Disease
Promoting Normality
Integrating Complementary Therapies
20 Digestion and Bowel Elimination
Effects Of Aging On Gastrointestinal Health
Gastrointestinal Health Promotion
Selected Gastrointestinal Conditions And Related Nursing Considerations
Dry Mouth (Xerostomia)
Dental Problems
Dysphagia
Hiatal Hernia
Esophageal Cancer
Peptic Ulcer
Cancer of the Stomach
Diverticular Disease
Colorectal Cancer
Chronic Constipation
Flatulence
Intestinal Obstruction
Fecal Impaction
Fecal Incontinence
Acute Appendicitis
Cancer of the Pancreas
Biliary Tract Disease
21 Urinary Elimination
Effects Of Aging On Urinary Elimination
Urinary System Health Promotion
31

Selected Urinary Conditions
Urinary Tract Infection
Urinary Incontinence
Bladder Cancer
Renal Calculi
Glomerulonephritis
General Nursing Considerations For Urinary Conditions
22 Reproductive System Health
Effects Of Aging On The Reproductive System
Reproductive System Health Promotion
Selected Reproductive System Conditions
Problems of the Female Reproductive System
Problems of the Male Reproductive System
23 Mobility
Effects Of Aging On Musculoskeletal Function
Musculoskeletal Health Promotion
Promotion of Physical Exercise in All Age Groups
Exercise Programs Tailored for Older Adults
The Mind–Body Connection
Prevention of Inactivity
Nutrition
Selected Musculoskeletal Conditions
Fractures
Osteoarthritis
Rheumatoid Arthritis
Osteoporosis
Gout
Podiatric Conditions
General Nursing Considerations For Musculoskeletal Conditions
Managing Pain
Preventing Injury
Promoting Independence
24 Neurologic Function
Effects Of Aging On The Nervous System
Neurologic Health Promotion
Selected Neurologic Conditions
Parkinson’s Disease
Transient Ischemic Attacks
Cerebrovascular Accidents
General Nursing Considerations For Neurologic Conditions
Promoting Independence
32

Preventing Injury
25 Vision and Hearing
Terms to Know
Effects of Aging on Vision and Hearing
Sensory Health Promotion
Promoting Vision
Promoting Hearing
Assessing Problems
Selected Vision and Hearing Conditions and Related Nursing Interventions
Visual Deficits
Hearing Deficits
General Nursing Considerations for Visual and Hearing Deficits
26 Endocrine Function
Effects Of Aging On Endocrine Function
Selected Endocrine Conditions And Related Nursing Considerations
Diabetes Mellitus
Hypothyroidism
Hyperthyroidism
27 Skin Health
Effects Of Aging On The Skin
Promotion Of Skin Health
Selected Skin Conditions
Pruritus
Keratosis
Seborrheic Keratosis
Skin Cancer
Vascular Lesions
Pressure Injury
General Nursing Considerations For Skin Conditions
Promoting Normalcy
Using Alternative Therapies
28 Cancer
Aging And Cancer
Unique Challenges for Older Persons With Cancer
Explanations for Increased Incidence in Old Age
Risk Factors, Prevention, And Screening
Treatment
Conventional Treatment
Complementary and Alternative Medicine
Nursing Considerations For Older Adults With Cancer
Providing Patient Education
33

Promoting Optimum Care
Providing Support to Patients and Families
29 Mental Health Disorders
Aging And Mental Health
Promoting Mental Health In Older Adults
Selected Mental Health Conditions
Depression
Anxiety
Substance Abuse
Paranoia
Nursing Considerations For Mental Health Conditions
Monitoring Medications
Promoting a Positive Self-Concept
Managing Behavioral Problems
30 Delirium and Dementia
Delirium
Dementia
Alzheimer’s Disease
Other Dementias
Caring for Persons With Dementia
31 Living in Harmony With Chronic Conditions
Chronic Conditions And Older Adults
Goals For Chronic Care
Assessment Of Chronic Care Needs
Maximizing The Benefits Of Chronic Care
Selecting an Appropriate Physician
Using a Chronic Care Coach
Increasing Knowledge
Locating a Support Group
Making Smart Lifestyle Choices
Using Complementary and Alternative Therapies
Factors Affecting The Course Of Chronic Care
Defense Mechanisms and Implications
Psychosocial Factors
Impact of Ongoing Care on the Family
The Need for Institutional Care
Chronic Care: A Nursing Challenge
UNIT 5 SETTINGS AND SPECIAL ISSUES IN GERIATRIC CARE
32 Rehabilitative and Restorative Care
Rehabilitative And Restorative Care
34

Living With Disability
Importance of Attitude and Coping Capacity
Losses Accompanying Disability
Principles Of Rehabilitative Nursing
Functional Assessment
Interventions To Facilitate And Improve Functioning
Facilitating Proper Positioning
Assisting with Range-of-Motion Exercises
Assisting with Mobility Aids and Assistive Technology
Teaching About Bowel and Bladder Training
Maintaining and Promoting Mental Function
Using Community Resources
33 Acute Care
Risks Associated With Hospitalization Of Older Adults
Surgical Care
Special Risks for Older Adults
Preoperative Care Considerations
Operative and Postoperative Care Considerations
Emergency Care
Infections
Discharge Planning For Older Adults
34 Long-Term Care
Development Of Long-Term Institutional Care
Before the 20th Century
During the 20th Century
Lessons to Be Learned From History
Nursing Homes Today
Nursing Home Standards
Nursing Home Residents
Nursing Roles and Responsibilities
Other Settings For Long-Term Care
Assisted Living Communities
Community-Based and Home Health Care
Looking Forward: A New Model Of Long-Term Care
35 Family Caregiving
The Older Adult’s Family
Identification of Family Members
Family Member Roles
Family Dynamics and Relationships
Scope Of Family Caregiving
Long-Distance Caregiving
Protecting The Health Of The Older Adult And Caregiver
35

Family Dysfunction And Abuse
Rewards Of Family Caregiving
36 End-of-Life Care
Definitions Of Death
Family Experience With The Dying Process
Supporting The Dying Individual
Stages of the Dying Process and Related Nursing Interventions
Rational Suicide and Assisted Suicide
Physical Care Challenges
Spiritual Care Needs
Signs of Imminent Death
Advance Directives
Supporting Family And Friends
Supporting Through the Stages of the Dying Process
Helping Family and Friends After a Death
Supporting Nursing Staff

Index
36

Index of Selected Features
Consider This Case
For Chapter 1
For Chapter 2
For Chapter 3
For Chapter 4
For Chapter 5
For Chapter 6
For Chapter 7
For Chapter 8
For Chapter 9
For Chapter 10
For Chapter 11
For Chapter 12
For Chapter 13
For Chapter 14
For Chapter 15
For Chapter 16
For Chapter 17
For Chapter 18
For Chapter 19
For Chapter 20
For Chapter 21
For Chapter 22
For Chapter 23
For Chapter 24
For Chapter 25
For Chapter 26
For Chapter 27
For Chapter 28
For Chapter 29
For Chapter 30
For Chapter 31
37

For Chapter 32
For Chapter 33
For Chapter 34
For Chapter 35
For Chapter 36
38

Assessment Guides
Assessment Guide 11-1 Nutritional Status
Assessment Guide 13-1 Pain
Assessment Guide 15-1 Spiritual Needs
Assessment Guide 16-1 Sexual Health
Assessment Guide 18-1 Respiratory Function
Assessment Guide 19-1 Cardiovascular Function
Assessment Guide 20-1 Gastrointestinal Function
Assessment Guide 21-1 Urinary Function
Assessment Guide 22-1 Reproductive System Health
Assessment Guide 23-1 Musculoskeletal Function
Assessment Guide 24-1 Neurologic Function
Assessment Guide 25-1 Vision and Hearing
Assessment Guide 27-1 Skin Status
Assessment Guide 29-1 Mental Health
Assessment Guide 30-1 Mental Health
39

Nursing Care Plans
Nursing Care Plan 7-1 Holistic Care For Mrs. D
Nursing Care Plan 18-1 The Older Adult With Chronic Obstructive Pulmonary Disease
Nursing Care Plan 19-1 The Older Adult With Heart Failure
Nursing Care Plan 20-1 The Older Adult With Hiatal Hernia
Nursing Care Plan 20-2 The Older Adult With Fecal Incontinence
Nursing Care Plan 21-1 The Older Adult With Urinary Incontinence
Nursing Care Plan 22-1 The Older Adult Recovering From Prostate Surgery
Nursing Care Plan 23-1 The Older Adult With Osteoarthritis
Nursing Care Plan 24-1 The Older Adult With A Cerebrovascular Accident: Convalescence Period
Nursing Care Plan 25-1 The Older Adult With Open-Angle Glaucoma
Nursing Care Plan 30-1 The Older Adult With Alzheimer’s Disease
40

UNIT 1 The Aging Experience
1. The Aging Population
2. Theories of Aging
41

3. Diversity
4. Life Transitions and Story
5. Common Aging Changes
42

CHAPTER 1
The Aging Population
43

CHAPTER OUTLINE
Views Of Older Adults Through History
Characteristics Of The Older Adult Population
Population Growth and Increasing Life Expectancy
Marital Status and Living Arrangements
Income and Employment
Health Insurance
Health Status
Implications Of An Aging Population
Impact of the Baby Boomers
Provision of and Payment for Services
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Explain the different ways in which older adults have been viewed throughout history.
2. Describe characteristics of today’s older population in regard to:
life expectancy
marital status
living arrangements
income and employment
health status
3. Discuss projected changes in future generations of older people and the implications for health care.
TERMS TO KNOW
Comorbidity: the simultaneous presence of multiple chronic conditions
Compression of morbidity: hypothesis that serious illness and decline can be delayed or postponed so that an extended life expectancy
results in more functional, healthy years
Life expectancy: the length of time that a person can be predicted to live
Life span: the maximum years that a person has the potential to live
“Families forget their older relatives … most people become senile in old age … Social Security provides every
older person with a decent retirement income … a majority of older people reside in nursing homes …
Medicare covers all health care–related costs for older people.” These and other myths continue to be
perpetuated about older people. Misinformation about the older population is an injustice not only to this age
group but also to persons of all ages who need accurate information to prepare realistically for their own senior
years. Gerontological nurses must know the facts about the older population to effectively deliver services and
educate the general public.
44

45

VIEWS OF OLDER ADULTS THROUGH HISTORY
The members of the current older population in the United States have offered the sacrifice, strength, and
spirit that made this country great. They were the proud GIs who served in wars, the brave immigrants who
ventured into a new country, the bold entrepreneurs who took risks that created wealth and opportunities for
employment, the campus rebels who advocated for the rights of minorities, and the unselfish parents who
struggled to give their children a better life. They have earned respect, admiration, and dignity. Today, older
adults are viewed with positivism rather than prejudice, knowledge rather than myth, and concern rather than
neglect. This positive view was not always the norm, however.
Historically, societies have viewed their elder members in a variety of ways. In the time of Confucius,
there was a direct correlation between a person’s age and the degree of respect to which he or she was entitled.
The early Egyptians dreaded growing old and experimented with a variety of potions and schemes to maintain
their youth. Opinions were divided among the early Greeks. Plato promoted older adults as society’s best
leaders, whereas Aristotle denied older people any role in governmental matters. In the nations conquered by
the Roman Empire, the sick and aged were customarily the first to be killed. And, woven throughout the
Bible is God’s concern for the well-being of the family and desire for people to respect elders (Honor your
father and your mother … Exodus 20:12). Yet, the honor bestowed on older adults was not sustained.
Medieval times gave rise to strong feelings regarding the superiority of youth; these feelings were
expressed in uprisings of sons against fathers. Although England developed Poor Laws in the early 17th
century that provided care for the destitute and enabled older persons without family resources to have some
modest safety net, many of the gains were lost during the Industrial Revolution. No labor laws protected
persons of advanced age; those unable to meet the demands of industrial work settings were placed at the
mercy of their offspring or forced to beg on the streets for sustenance.
The first significant step in improving the lives of older Americans was the passage of the Federal Old
Age Insurance Law under the Social Security Act in 1935, which provided some financial security for older
persons. The profound “graying” of the population started to be realized in the 1960s, and the United States
responded with the formation of the Administration on Aging, enactment of the Older Americans Act, and
the introduction of Medicaid and Medicare, all in 1965 (Box 1-1).
Box 1-1 Publicly Supported Programs of Benefit to Older
Americans
1900 Pension laws passed in some states
1935 Social Security Act
1961 First White House Conference on Aging
1965 Older Americans Act: nutrition, senior employment, and transportation programs
Administration on Aging
Medicare (Title 18 of Social Security Act)
Medicaid (Title 19 of Social Security Act) for poor and disabled of any age
46

1972 Supplemental Security Income (SSI) enacted
1991 Omnibus Budget Reconciliation Act (nursing home reform law) implemented
Since that time, American society has demonstrated a profound awakening of interest in older persons as their
numbers have grown. A more humanistic attitude toward all members of society has benefited older adults,
and improvements in health care and general living conditions ensure that more people have the opportunity
to attain old age and live longer, more fruitful years in later adulthood than previous generations (Fig. 1-1).
FIGURE 1-1 • It is important for gerontological nurses to be as concerned with adding quality to the lives of
older adults as they are with increasing the quantity of years.
47

CHARACTERISTICS OF THE OLDER ADULT
POPULATION
Older adults are generally defined as individuals aged 65 years and older. At one time, all persons over 65
years of age were grouped together under the category of “old.” Now it is recognized that much diversity exists
among different age groups in late life, and older individuals can be further categorized as follows:
young-old: 65 to 74 years
old: 75 to 84 years
oldest-old 85+
The profile, interests, and health care challenges of each of these subsets can be vastly different. For example,
a 66-year-old may desire cosmetic surgery to stay competitive in the executive job market; a 74-year-old may
have recently remarried and want to do something about her dry vaginal canal; an 82-year-old may be
concerned that his arthritic knees are limiting his ability to play a round of golf; and a 101-year-old may be
desperate to find a way to correct her impaired vision so that she can enjoy television.
In addition to chronological age, or the years a person has lived since birth, functional age is a term used
by gerontologists to describe physical, psychological, and social function; this is relevant in that how older
adults feel and function may be more indicative of their needs than their chronological age. Perceived age is
another term that is used to describe how people estimate a person’s age based on appearance. Studies have
shown a correlation between perceived age and health, in addition to how others treated older adults based on
perceived age and the resultant health of those older adults (Sutin, Stephan, Carretta, & Terracciano, 2014).
How people feel or perceive their own age is described as age identity. Some older adults will view peers of
similar age as being older than themselves and be reluctant to join senior groups and other activities because
they see the group members as “old people” and different from themselves.
Any stereotypes held about older people must be discarded; if anything, greater diversity rather than
homogeneity will be evident. Further, generalizations based on age need to be eliminated as behavior,
function, and self-image can reveal more about priorities and needs than chronological age alone.
COMMUNICATION TIP
Not all persons of the same age will be similar in terms of language style, familiarity with current terms,
use of technology, education, and life experience. Communication style and method must be based on
assessed language competency, style, and preference of the individual.
48

49

Population Growth and Increasing Life Expectancy
There was a significant growth in the number of older people for most of the 20th century. Except for the
1990s, the older population grew at a rate faster than that of the total population under age 65. The U.S.
Census Bureau projects that a substantial increase in the number of individuals over age 65 will occur between
2010 and 2030 due to the impact of the baby boomers, who began to enter this group in 2011. In 2030, it is
projected that this group will represent nearly 20% of the total U.S. population.
Currently, persons older than 65 years represent more than 13% of the population in the United States.
This growth of the older adult population is due in part to increasing life expectancy. Advancements in
disease control and health technology, lower infant and child mortality rates, improved sanitation, and better
living conditions have increased life expectancy for most Americans. More people are surviving to their senior
years than ever before. In 1930, slightly more than 6 million persons were aged 65 years or older, and the
average life expectancy was 59.7 years. The life expectancy in 1965 was 70.2 years, and the number of older
adults exceeded 20 million. Life expectancy has now reached 78.2 years, with over 34 million persons
exceeding age 65 years (Table 1-1). Not only are more people reaching old age, but they are living longer once
they do; the number of people in their 70s and 80s has been steadily increasing and is expected to continue to
increase. The population over age 85 years is projected to double by the year 2036 and triple by 2049. The life
span currently is 122 years for humans.
TABLE 1-1 Differences in Life Expectancy at Birth by Race, Sex, and Hispanic Origin
Source: National Center for Health Statistics. (2013). Table 18. Life expectancy at birth, at age 65, and at age 75 by sex, race, and national
origin: United States, selected years. Health, United States, 2013. Hyattsville, MD: National Center for Health Statistics. Retrieved from
http://www.cdc.gov/nchs/data/hus/hus13 #018; U.S. Census Bureau. Table 10. Projected life expectancy at birth by sex, race, and Hispanic
origin for the United States. Retrieved from http://www.census.gov/population/projections/data/national/2012/summarytables.html
KEY CONCEPT
More people are achieving and spending longer periods of time in old age than ever before in history.
Although life expectancy has increased, it still differs by race and gender, as Table 1-1 shows. From the late
1980s to the present, the gap in life expectancy between white people and black people has widened because
the life expectancy of the black population has declined. The U.S. Department of Health and Human Services
attributes the declining life expectancy of black people to heart disease, cancer, homicide, diabetes, and
perinatal conditions. This reality underscores the need for nurses to be concerned with health and social issues
50

http://www.cdc.gov/nchs/data/hus/hus13 #018

http://www.census.gov/population/projections/data/national/2012/summarytables.html

of persons of all ages because these impact a population’s aging process.
Whereas the gap in life expectancy has widened among the races, the gap is narrowing between the sexes.
Throughout the 20th century, the ratio of men to women had steadily declined to the point where there were
fewer than 7 older men for every 10 older women. The ratio declined with each advanced decade. However, in
the 21st century, this trend is changing, and the ratio of men to women is increasing.
Although living longer is desirable, of significant importance is the quality of those years. More years to
life means little if those additional years consist of discomfort, disability, and a poor quality of life. This has
led to a hypothesis advanced by James Fries, a professor of medicine at Stanford University, called the
compression of morbidity (Fries, 1980; Swartz, 2008). This hypothesis suggests that if the onset of serious
illness and decline would be delayed, or compressed, into a few years prior to death, people could live a long
life and enjoy a healthy, functional state for most of their lives.
POINT TO PONDER
A higher proportion of older adults in our society means that younger age groups will be carrying a
greater tax burden to support the older population. Should young families sacrifice to support services
for older adults? Why or why not?
51

Marital Status and Living Arrangements
The higher survival rates of women, along with the practice of women marrying men older than themselves,
make it no surprise that more than half of women older than 65 years are widowed, and most of their male
contemporaries are married. Married people have a lower mortality rate than do unmarried people at all ages,
with men having a larger advantage.
Most older adults live in a household with a spouse or other family member, although more than twice the
number of women than men live alone in later life. The likelihood of living alone increases with age for both
sexes. Most older people have contact with their families and are not forgotten or neglected. Realities of the
aging family are discussed in greater detail in Chapter 35.
KEY CONCEPT
Women are more likely to be widowed and living alone in late life than are their male counterparts.
52

Income and Employment
The percentage of older people living below the poverty level has been declining, with about 10% now falling
into this category. However, older adults still do face financial problems. Most older people depend on Social
Security for more than half of their income (Box 1-2). Women and minority groups have considerably less
income than do white men. Although the median net worth of older households is nearly twice the national
average because of the high prevalence of home ownership by elders, many older adults are “asset rich and
cash poor.” The recent decline in housing prices, however, has made that asset a less valuable one for many
older adults.
Box 1-2 Social Security and Supplemental Security Income
Social Security: a benefit check paid to retired workers of specific minimum age (e.g., 65 years),
disabled workers of any age, and spouses and minor children of those workers. Benefits are not
dependent on financial need. It is intended to serve as supplement to other sources of income in
retirement.
Supplemental Security Income (SSI): a benefit check paid to persons over age 65 and/or persons
with disabilities based on financial need.
Although the percentage of the total population that older adults represent is growing, they constitute a
steadily declining percentage of workers in the labor force. The withdrawal of men from the workforce at
earlier ages has been one of the most significant labor force trends since World War II. There has been,
however, a significant rise in the percentage of middle-aged women who are employed, although there has
been little change in the labor force participation of women 65 years of age and older. Most baby boomers are
expressing a desire and need to continue working as they enter retirement age.
CONSIDER THIS CASE
Mr. and Mrs. Murdock are both 67 years of age and in good
health. Mr. Murdock owns and manages several investment properties that require him to maintain
records, respond to tenants’ service calls, and plan maintenance work. Mrs. Murdock is a nurse who
works in a community health center for children. Both of them are working full-time and enjoy their
work; however, they both admit that their energy level is not what it used to be and that it takes them
53

more time to complete activities than it did in the past.
Although she does see positives to her work activities, Mrs. Murdock feels that after many years of
working, she deserves to relax and enjoy other activities. When she suggests to her husband that he
either retire or, at the least, reduce his work activities so that they can enjoy this season of life together,
he is adamant about continuing to work because he believes the income is beneficial to maintaining their
lifestyle and he has no other activities that he is interested in doing. She thinks he is being unrealistic,
claims that they can “get along just fine on Social Security,” and repeatedly reminds him that they are at
the age when people retire.
THINK CRITICALLY
What issues would be helpful for each of these individuals to consider regarding their decision to
retire or continue working?
What challenges could each of these individuals potentially face if they continued to work for
another 5 years? 10 years?
What actions could the Murdocks have taken in the past to face their decisions about continued
work or retirement differently?
What are the implications to society of people like the Murdocks continuing to stay in the labor
force?
KEY CONCEPT
Although Social Security was intended to be a supplement to other sources of income for older adults, it
is the main source of income for more than half of all these individuals.
54

HEALTH INSURANCE
This decade has shaken the health care reimbursement systems in the United States, and changes will be
unfolding as the need to assure that every American will have access to health care is balanced against
unsustainable costs to support that care. Passed in 1965 as Title 18 of the Social Security Act, Medicare is the
health insurance program for older adults who are eligible for Social Security benefits. This federally funded
program primarily covers hospital and physician services with very limited skilled home health and nursing
home services under Part A. Preventive services and nonskilled care (e.g., personal care assistance) are not
covered. To supplement the basic coverage, a person can purchase Medicare Part B, which includes physician
and nursing services, x-rays, laboratory and diagnostic tests, influenza and pneumonia vaccinations, blood
transfusions, renal dialysis, outpatient hospital procedures, limited ambulance transportation,
immunosuppressive drugs for organ transplant recipients, chemotherapy, hormonal treatments, and other
outpatient medical treatments administered in a doctor’s office. Part B also assists with the payment of
durable medical equipment, including canes, walkers, wheelchairs, and mobility scooters for those with
mobility impairments. Prosthetic devices such as artificial limbs and breast prosthesis following mastectomy,
as well as one pair of eyeglasses following cataract surgery, and oxygen for home use are also covered.
Medicare Part C or Medicare Advantage Plans give people the option of purchasing coverage through private
insurance plans to cover benefits not provided by Medicare Parts A and B plus additional services. Although
regulated and funded by the federal government, these plans are managed by private insurance companies.
Some of these plans also include prescription drug benefits, known as a Medicare Advantage Prescription
Drug Plan or Medicare Part D.
Persons who meet the income criteria can qualify for Medicaid, the health insurance program for the poor
of any age. This program was developed at the same time as Medicare and is Title 19 of the Social Security
Act. Medicaid supplements Medicare for poor elderly individuals, and most nursing home care is paid for by
this program. Medicaid is supported by federal and state funding. Provisions in the Affordable Care Act
expand Medicaid benefits to many older persons who did not previously qualify for the program.
People of any age can purchase long-term care insurance to cover health care costs not paid by Medicare
or other health insurance. These policies can provide benefits for home care, respite, adult day care, nursing
home care, assisted living, and other services. Policies vary in waiting periods, amount of funds paid per day or
month, and types of services that qualify. Although beneficial, long-term care insurance has not attracted a
significant number of subscribers. Part of the reason for this is that policies are expensive for older adults, and
although less costly for persons of younger age groups, younger and healthier individuals tend not to think
about long-term care.
55

Health Status
The older population experiences fewer acute illnesses than younger age groups and a lower death rate from
these problems. However, older people who do develop acute illnesses usually require longer periods of
recovery and have more complications from these conditions.
Chronic illness is a major problem for the older population. Most older adults have at least one chronic
disease, and typically, they have multiple chronic conditions, termed comorbidity, that requires them to
manage the care of several conditions simultaneously (Box 1-3). Chronic conditions result in some limitations
in activities of daily living and instrumental activities of daily living for many individuals. The older the person
is, the greater the likelihood of difficulty with self-care activities and independent living.
Box 1-3 Ten Leading Chronic Conditions Affecting
Population Aged 65 Years and Older
1. Arthritis
2. High blood pressure
3. Hearing impairments
4. Heart conditions
5. Visual impairments (including cataracts)
6. Deformities or orthopedic impairments
7. Diabetes mellitus
8. Chronic sinusitis
9. Hay fever and allergic rhinitis (without asthma)
10. Varicose veins
Source: Centers for Disease Control and Prevention, Chronic Disease Prevention and Health Promotion. Retrieved April 14, 2012
from http://www.cdc.gov/chronicdisease/index.html
KEY CONCEPT
The chronic disorders most prevalent in the older population are ones that can have a significant impact
on independence and the quality of daily life.
Chronic diseases are also the leading causes of death (Table 1-2). A shift in death rates from various causes of
death has occurred over the past three decades; deaths from heart disease have declined, whereas those from
cancer have increased.
TABLE 1-2 Leading Causes of Death for Persons 65 Years of Age and Older
56

http://www.cdc.gov/chronicdisease/index.html

From National Center for Health Statistics. (2016). Table 1. Deaths, percentage of total deaths, and death rates for the 10 leading causes of
death in selected age groups, by race and sex: United States, 2013. National Vital Statistics Reports, Vol. 65, No. 2, February 16, 2016.
Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_02
Concept Mastery Alert
When planning health education sessions for older adults that address the health risks they face, the
nurse should provide teaching about cancer risks, screening, recognition, and treatment. Often,
educational sessions prioritize heart disease, although deaths from this cause are declining while cancer
deaths are rising.
Despite the advances in the health status of the older population, disparities exist. Studies have found that
older minorities have lower levels of health and function. The number of older Hispanics, blacks, and Asians
admitted to nursing homes has been increasing, whereas the number of older white nursing home residents
has been declining (Feng, Fennell, Tyler, Clark, & Mor, 2011).
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IMPLICATIONS OF AN AGING POPULATION
The growing number of persons older than 65 years impacts health and social service agencies and health care
providers—including gerontological nurses—that serve this group. As the older adult population grows, these
agencies and providers must anticipate future needs of services and payment for these services.
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Impact of the Baby Boomers
In anticipating needs and services for future generations of older adults, gerontological nurses must consider
the realities of the baby boomers—those born between 1946 and 1964—who will be the next wave of senior
citizens. Their impact on the growth of the older population is such that it has been referred to as a
demographic tidal wave. Baby boomers began entering their senior years in 2011 and will continue to do so
until 2030. Although they are a highly diverse group, representing people as different as Bill Clinton, Bill
Gates, and Cher, they do have some clearly defined characteristics that set them apart from other groups:
Most have children, but this generation’s low birth rate means that they will have fewer biologic
children available to assist them in old age.
They are better educated than preceding generations with slightly more than half having attended or
graduated from college.
Their household incomes tend to be higher than other groups, partly due to two incomes (three out of
four baby boomer women are in the labor force), and most own their own homes
They favor a more casual dress code than do previous generations of older adults.
They are enamored with “high-tech” products, are likely to own a computer, and spend several hours
online daily.
Their leisure time is scarcer than other adults, and they are more likely to report feeling stressed at the
end of the day.
As inventors of the fitness movement, they exercise more frequently than do other adults.
Some assumptions can be made concerning the baby boomer population as senior adults. They are informed
consumers of health care and desire a highly active role in their care; their ability to access information often
enables them to have as much knowledge as their health care providers on some health issues. They are most
likely not going to be satisfied with the conditions of today’s nursing homes and will demand that their long-
term care facilities be equipped with bedside Internet access, gymnasiums, juice bars, pools, and alternative
therapies. Their blended families may need special assistance because of the potential caregiving demands of
several sets of stepparents and stepgrandparents. Plans for services and architectural designs must take these
factors into consideration.
COMMUNICATION TIP
Many baby boomers want to be informed health care consumers and are comfortable communicating
via e-mail and text messages. They may prefer electronic appointment reminders and reports from
diagnostic tests rather than telephone calls, and they appreciate links to fact sheets about their
conditions and treatments. However, some members of this generation are not tech savvy and prefer
traditional communication means, so it is important to ask about preferred style of communication
during the assessment.
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Provision of and Payment for Services
The growing number of persons older than 65 years also impacts the government that is the source of
payment for many of the services older adults need. The older population has higher rates of hospitalization,
surgery, and physician visits than other age groups (Table 1-3), and this care is more likely to be paid by
federal dollars than private insurers or older adults themselves.
TABLE 1-3 Average Length of Hospital Stay
National Center for Health Statistics. (2013). Health, United States, 2013. Table 98. Average length of stay in nonfederal short-stay hospitals,
by sex, age, and selected first-listed diagnosis: United States, selected years 1990–2010. Retrieved from
http://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2011-a
Less than 5% of the older population is in a nursing home, assisted living community, or other institutional
setting at any given time. Approximately one in four older adults will spend some time in a nursing home
during the last years of their lives. Most people who enter nursing homes as private pay residents spend their
assets by the end of 1 year and require government support for their care; most of the Medicaid budget is
spent on long-term care.
As the percentage of the advanced-age population grows, society will face an increasing demand for the
provision of and payment for services to this group. In this era of budget deficits, shrinking revenue, and
increased competition for funding of other special interests, questions may arise about the ongoing ability of
the government to provide a wide range of services for older adults. There may be concern that the older
population is using a disproportionate amount of tax dollars and that limits should be set.
Gerontological nurses must be actively involved in discussions and decisions pertaining to the rationing of
services so that the rights of older adults are expressed and protected. Likewise, gerontological nurses must
assume leadership in developing cost-effective methods of care delivery that do not compromise the quality of
services to older adults.
KEY CONCEPT
Gerontological nurses need to be advocates in ensuring that cost-containment efforts do not jeopardize
the welfare of older adults.
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BRINGING RESEARCH TO LIFE
Geographical Variation in Health-Related Quality of Life Among Older US Adults, 1997–2010
Source: Kachan, D., Tannebaum, S. L., LeBanc, W. G., McClure, L. A., & Lee, D. J. (2014). Preventing Chronic
Disease, 11:140023. doi: 10.5888/pcd11.140023#_blank. Retrieved from http://dx.doi.org/10.5888/pcd11.140023
Although the health-related quality of life (HRQOL) has been considered a predictor of morbidity and
mortality, there had not been an exploration of its geographic variation. This study sought to investigate this
issue by comparing the HRQOL in all of the states and the District of Columbia using the Health and
Activities Limitation Index (HALex), in which higher values indicated better health. Data from the National
Health Interview Survey for people aged 65 and older were analyzed as part of the study.
According to the study, the lowest health scores were found among older residents of Alaska, Alabama,
Arkansas, Mississippi, and West Virginia, and the highest health scores were found among residents of
Arizona, Delaware, Nevada, New Hampshire, and Vermont. Residents in the Northeast had health scores
higher than those in the Midwest and South after adjustment for sociodemographics, health behaviors, and
survey design. It was noted that older adults who migrated from the South to other states had higher disability
rates. Older Floridians had a higher life expectancy than did older persons in other states, attributed to a high
degree of compliance with physical exercise recommendations and a lower prevalence of smoking. Older
Alaskans had the highest prevalence of drinking of all states, which could contribute to their low health
scores.
Understanding differences in health status among states and the factors affecting them could assist in
identifying and tailoring health promotion and education needs for persons of all ages that could contribute to
healthier future generations of older adults.
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http://dx.doi.org/10.5888/pcd11.140023

PRACTICE REALITIES
You are in the break room of a hospital unit where several of the nurses are eating the birthday cake of Nurse
Clark who is celebrating her 66th birthday. “I’m so glad to have coworkers like you and work that gives me a
sense of purpose,” Nurse Clark commented as she thanked everyone and left the room.
Nurse Blake, in a low voice commented to the person sitting next to her, “I just don’t get it. I’m half her
age and this job drains me, so you know it’s got to be taking its toll on her. Plus, we often get stuck doing the
heavy work that she can’t do.”
“I know she doesn’t have the physical capabilities that some others may,” says Nurse Edwards, “but she
sure is a storehouse of information and the patients love her.”
“Yes, but that isn’t helping my back when I have to pick up the slack for her,” responds Nurse Blake.
What are the challenges of having different generations in the workplace? Should allowances be made for
older workers, and if so, what can be done to support these?
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CRITICAL THINKING EXERCISES
1. What factors influence a society’s willingness to provide assistance to and display a positive attitude
toward older individuals (e.g., general economic conditions for all age groups)?
2. List the anticipated changes in the characteristics of the older population of the future, and describe the
implications for nursing.
3. What problems may older women experience as a result of gender differences in life expectancy and
income?
4. What are some of the differences between older white and black Americans?
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Chapter Summary
Increases in life expectancy have resulted in persons over the age of 65 years now constituting more than 13%
of the U.S. population. Although life expectancy has increased in general, the black population has a lower life
expectancy than does the white population, reinforcing the importance of addressing health and social
problems throughout the life span to promote longer and healthier life expectancies. In addition to extending
life, there also must be concern for the compression of morbidity to assure added years of life are high-quality
ones.
The primary source of health insurance for older adults is Medicare. Medicaid provides supplemental
insurance for individuals with low incomes.
Although acute conditions occur at a lower rate in older adults than younger age groups, when they do
develop they usually result in more complications and longer periods for recovery. Chronic conditions are the
major health problems among older persons, with a majority being affected by at least one chronic disease.
Chronic conditions contribute to the leading causes of death.
Baby boomers, a group composed of persons born between 1946 and 1964, have begun entering their
senior years and are changing the profile of the older population. They are highly diverse, are better educated,
have fewer children, have had higher incomes, and are greater users of technology than previous generations.
Gerontological nurses will be challenged to recognize diversity among older adults as they assist these
individuals in health promotion and disease management activities.
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Online Resources
National Center for Health Statistics
http://www.cdc.gov/nchs
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http://www.cdc.gov/nchs

References
Feng, Z., Fennell, M. L., Tyler, D. A., Clark, M., & Mor, V. (2011). Growth of racial and ethnic minorities
in U.S. nursing homes driven by demographics and possible disparities in options. Health Affairs, 33(7),
1358–1365.
Fries, J. F. (1980). Aging, natural death, and the compression of morbidity. New England Journal of
Medicine, 303(3), 130–135.
Sutin, A. R., Stephan, Y., Carretta, H., & Terracciano, A. (2014). Perceived discrimination and physical,
cognitive, and emotional health in older adulthood. American Journal of Geriatric Psychiatry, 22(3), 164–167.
Swartz, A. (2008). James Fries: healthy aging pioneer. American Journal of Public Health, 98(7), 1163–1166.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 2
Theories of Aging
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CHAPTER OUTLINE
Biological Theories Of Aging
Stochastic Theories
Nonstochastic Theories
Sociologic Theories of Aging
Disengagement Theory
Activity Theory
Continuity Theory
Subculture Theory
Age Stratification Theory
Psychological Theories of Aging
Developmental Tasks
Gerotranscendence
Nursing Theories of Aging
Functional Consequences Theory
Theory of Thriving
Theory of Successful Aging
Applying Theories of Aging to Nursing Practice
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Discuss the change in focus regarding learning about factors influencing aging.
2. List the major biological theories of aging.
3. Describe the major psychosocial theories of aging.
4. Identify factors that promote a healthy aging process.
5. Describe the way in which gerontological nurses can apply theories of aging to nursing practice.
TERMS TO KNOW
Aging:the process of growing older that begins at birth
Nonstochastic theories:explain biological aging as resulting from a complex, predetermined process
Stochastic theories:view the effects of biological aging as resulting from random assaults from both the internal and external environment
For centuries, people have been intrigued by the mystery of aging and have sought to understand it, some in
hopes of achieving everlasting youth and others seeking the key to immortality. Throughout history, there
have been numerous searches for a fountain of youth, the most famous being that of Ponce de León. Ancient
Egyptian and Chinese relics show evidence of concoctions designed to prolong life or achieve immortality,
and various other cultures have proposed specific dietary regimens, herbal mixtures, and rituals for similar
ends. Ancient life extenders, such as extracts prepared from tiger testicles, may seem ludicrous until they are
compared with more modern measures such as injections of embryonic tissue and Botox. Even persons who
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would not condone such peculiar practices may indulge in nutritional supplements, cosmetic creams, and
exotic spas that promise to maintain youth and delay the onset or appearance of old age.No single known
factor causes or prevents aging; therefore, it is unrealistic to think that one theory can explain the complexities
of this process. Explorations into biological, psychological, and social aging continue, and although some of
this interest focuses on achieving eternal youth, most sound research efforts aim toward a better understanding
of the aging process so that people can age in a healthier fashion and postpone some of the negative
consequences associated with growing old. In fact, recent research has concentrated on learning about keeping
people healthy and active for a longer period of time, rather than on extending their lives in a state of long-
term disability. Recognizing that theories of aging offer varying degrees of universality, validity, and reliability,
nurses can use this information to better understand the factors that may positively and negatively influence
the health and well-being of persons of all ages.
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BIOLOGICAL THEORIES OF AGING
The process of biological aging differs not only from species to species but also from one human being to
another. Some general statements can be made concerning anticipated organ changes, as described in Chapter
5; however, no two individuals age identically (Fig. 2-1). Varying degrees of physiologic changes, capacities,
and limitations will be found among peers of a given age group. Further, the rate of aging among different
body systems within one individual may vary, with one system showing marked decline while another
demonstrates no significant change.
FIGURE 2-1 • Aging is a highly individualized process, demonstrated by the differences between persons of
similar ages.
KEY CONCEPT
The aging process varies not only among individuals but also within different body systems of the same
person.
To explain biological aging, theorists have explored many factors, both internal and external to the human
body, and have divided them into two categories: stochastic and nonstochastic. Stochastic theories view the
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effects of aging as resulting from random assaults from both the internal and external environment.
Nonstochastic theories see aging changes resulting from a complex, predetermined process.
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Stochastic Theories
Cross-Linking Theory
The cross-linking theory proposes that cellular division is threatened as a result of radiation or a chemical
reaction in which a cross-linking agent attaches itself to a DNA strand and prevents normal parting of the
strands during mitosis. Over time, as these cross-linking agents accumulate, they form dense aggregates that
impede intracellular transport; ultimately, the body’s organs and systems fail. An effect of cross-linking on
collagen (an important connective tissue in the lungs, heart, blood vessels, and muscle) is the reduction in
tissue elasticity associated with many age-related changes.
Free Radicals and Lipofuscin Theories
The free radical theory suggests that aging is due to oxidative metabolism and the effects of free radicals
(Hayflick, 1985). Free radicals are highly unstable, reactive molecules containing an extra electrical charge that
are generated from oxygen metabolism. They can result from normal metabolism, reactions with other free
radicals, or oxidation of ozone, pesticides, and other pollutants. These molecules can damage proteins,
enzymes, and DNA by replacing molecules that contain useful biological information with faulty molecules
that create genetic disorder. It is believed that these free radicals are self-perpetuating; that is, they generate
other free radicals. Physical decline of the body occurs as the damage from these molecules accumulates over
time. However, the body has natural antioxidants that can counteract the effects of free radicals to an extent.
Also, beta-carotene and vitamins C and E are antioxidants that can offer protection against free radicals.
There has been considerable interest in the role of lipofuscin “age pigments,” a lipoprotein by-product of
oxidation that can be seen only under a fluorescent microscope, in the aging process. Because lipofuscin is
associated with the oxidation of unsaturated lipids, it is believed to have a role similar to that of free radicals in
the aging process. As lipofuscin accumulates, it interferes with the diffusion and transport of essential
metabolites and information-bearing molecules in the cells. A positive relationship exists between an
individual’s age and the amount of lipofuscin in the body. Investigators have discovered the presence of
lipofuscin in other species in amounts proportionate to the life span of the species (e.g., an animal with one
tenth the life span of a human being accumulates lipofuscin at a rate approximately 10 times greater than
human beings).
Wear and Tear Theories
The comparison of the body’s wearing down to machines that lost their ability to function over time arose
during the Industrial Revolution. Wear and tear theories attribute aging to the repeated use and injury of the
body over time as it performs its highly specialized functions. Like any complicated machine, the body will
function less efficiently with prolonged use and numerous insults (e.g., smoking, poor diet, and substance
abuse).
In recent years, the effects of stress on physical and psychological health have been widely discussed.
Stresses to the body can have adverse effects and lead to conditions such as gastric ulcers, heart attacks,
thyroiditis, and inflammatory dermatoses. However, because individuals react differently to life’s stresses—one
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person may be overwhelmed by a moderately busy schedule, whereas another may become frustrated when
faced with a slow, dull pace—the role of stress in aging is inconclusive.
Evolutionary Theories
Evolutionary theories of aging are related to genetics and hypothesize that the differences in the aging process
and longevity of various species occur due to interplay between the processes of mutation and natural selection
(Ricklefs, 1998; Gavrilov & Gavrilova, 2002). Attributing aging to the process of natural selection links these
theories to those that support evolution.
There are several general groups of theories that relate aging to evolution. The mutation accumulation
theory suggests that aging occurs due to a declining force of natural selection with age. In other words, genetic
mutations that affect children will eventually be eliminated because the victims will not have lived long
enough to reproduce and pass this to future generations. Genetic mutations that appear late in life, however,
will accumulate because the older individuals they affect will have already passed these mutations to their
offspring.
The antagonistic pleiotropy theory suggests that accumulated mutant genes that have negative effects in late
life may have had beneficial effects in early life. This is assumed to occur either because the effects of the
mutant genes occur in opposite ways in late life as compared with their effects in early life or because a
particular gene can have multiple effects—some positive and some negative.
The disposable soma theory differs from other evolutionary theories by proposing that aging is related to the
use of the body’s energy rather than to genetics. It claims that the body must use energy for metabolism,
reproduction, maintenance of functions, and repair, and with a finite supply of energy from food to perform
these functions, some compromise occurs. Through evolution, organisms have learned to give priority of
energy expenditure to reproductive functions over those functions that could maintain the body indefinitely;
thus, decline and death ultimately occur.
KEY CONCEPT
Evolutionary theories suggest that aging “is fundamentally a product of evolutionary forces, not
biochemical or cellular quirks … a Darwinian phenomenon, not a biochemical one” (Rose, 1998).
Concept Mastery Alert
The evolutionary theory of aging proposes that people are living longer due to the emphasis on natural
selection through reproduction, whereas the biogerontology theory of aging attributes longer life to the
prevention and control of pathogens.
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Biogerontology
The study of the connection between aging and disease processes has been termed biogerontology (Miller,
1997). Bacteria, fungi, viruses, and other organisms are thought to be responsible for certain physiologic
changes during the aging process. In some cases, these pathogens may be present in the body for decades
before they begin to affect body systems. Although no conclusive evidence exists to link these pathogens with
the body’s decline, interest in this theory has been stimulated by the fact that human beings and animals have
enjoyed longer life expectancies with the control or elimination of certain pathogens through immunization
and the use of antimicrobial drugs.
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Nonstochastic Theories
Apoptosis
Apoptosis is the process of programmed cell death that continuously occurs throughout life due to
biochemical events (Green, 2011). In this process, the cell shrinks and there is nuclear and DNA
fragmentation, although the membrane maintains its integrity. It differs from cell death that occurs from
injury in which there is swelling of the cell and loss of membrane integrity. According to this theory, this
programmed cell death is part of the normal developmental process that continues throughout life.
Genetic Theories
Among the earliest genetic theories, the programmed theory of aging proposes that animals and humans are
born with a genetic program or biological clock that predetermines the life span (Hayflick, 1965). Various
studies support this idea of a predetermined genetic program for life span. For example, studies have shown a
positive relationship between parental age and filial life span. Additionally, studies of in vitro cell proliferation
have demonstrated that various species have a finite number of cell divisions. Fibroblasts from embryonic
tissue experience a greater number of cell divisions than those derived from adult tissue, and among various
species, the longer the life span, the greater the number of cell divisions. These studies support the theory that
senescence—the process of becoming old—is under genetic control and occurs at the cellular level (Harvard
Gazette Archives, 2001; Martin, 2009; University of Illinois at Urbana-Champaign, 2002).
The error theory also proposes a genetic determination for aging. This theory holds that genetic mutations
are responsible for aging by causing organ decline as a result of self-perpetuating cellular mutations, as
illustrated in Figure 2-2.
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FIGURE 2-2 • The error theory proposes a genetic determination for aging.
Other theorists think that aging results when a growth substance fails to be produced, leading to the cessation
of cell growth and reproduction. Others hypothesize that an aging factor responsible for development and
cellular maturity throughout life is excessively produced, thereby hastening aging. Some hypothesize that the
cell’s ability to function and divide is impaired. Although minimal research has been done to support the
theory, aging may be the result of a decreased ability of RNA to synthesize and translate messages.
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POINT TO PONDER
What patterns of aging are apparent in your biological family? What can you do to influence these?
Autoimmune Reactions
The primary organs of the immune system, the thymus and bone marrow, are believed to be affected by the
aging process. The immune response declines after young adulthood. The weight of the thymus decreases
throughout adulthood, as does the ability to produce T-cell differentiation. The level of thymic hormone
declines after age 30 and is undetectable in the blood of persons older than 60 years (Goya, Console, Herenu,
Brown, & Rimoldi, 2002; Williams, 1995). Related to this is a decline in the humoral immune response, a
delay in the skin allograft rejection time, a reduction in the intensity of delayed hypersensitivity, and a
decrease in the resistance to tumor cell challenge. The bone marrow stem cells perform less efficiently. The
reduction in immunologic functions is evidenced by an increase in the incidence of infections and many
cancers with age.
Some theorists believe that the reduction in immunologic activities also leads to an increase in
autoimmune response with age. One hypothesis regarding the role of autoimmune reactions in the aging
process is that the cells undergo changes with age, and the body misidentifies these aged, irregular cells as
foreign agents and develops antibodies to attack them. An alternate explanation for this reaction could be that
cells are normal in old age, but a breakdown of the body’s immunochemical memory system causes it to
misinterpret normal cells as foreign substances. Antibodies are formed to attack and rid the body of these
“foreign” substances, and cells die.
CONSIDER THIS CASE
You volunteer with a service organization that is involved with
several community projects. Mrs. Janus, one of the volunteers you work with, shares with you and the
other volunteers that she and her husband have become distributors for “a fantastic product that makes
you look and feel younger.” She claims they have been using the product for nearly a year and have seen
significant improvements in the way they look and feel. The couple is in their 70s and are attractive and
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active.
Mrs. Janus passes out invitations to you and the other volunteers to attend a meeting at their home
to learn more about the products. Many of the volunteers show considerable interest and indicate they
will attend. One of the volunteers then turns to you and says, “You’re a nurse. Do you think these things
work?”
THINK CRITICALLY
How can consumers judge the validity of claims of antiaging products?
What evidence-based advice can be given to aging persons to help them reduce the potential for
some of the negative outcomes of aging?
Neuroendocrine and Neurochemical Theories
Neuroendocrine and neurochemical theories suggest that aging is the result of changes in the brain and
endocrine glands. Some theorists claim that specific anterior pituitary hormones promote aging. Others
believe that an imbalance of chemicals in the brain impairs healthy cell division throughout the body.
Radiation Theories
The relationship between radiation and age continues to be explored. Research using rats, mice, and dogs has
shown that a decreased life span results from nonlethal doses of radiation. In human beings, repeated exposure
to ultraviolet light is known to cause solar elastosis, the “old age” type of skin wrinkling that results from the
replacement of collagen by elastin. Ultraviolet light is also a factor in the development of skin cancer.
Radiation may induce cellular mutations that promote aging.
Nutrition Theories
The importance of good nutrition throughout life is a theme hard to escape in our nutrition-conscious society.
It is no mystery that diet impacts health and aging. Obesity is shown to increase the risk of many diseases and
shorten life (NIDDK, 2001; Preston, 2005; Taylor & Ostbye, 2001).
The quality of diet is as important as the quantity. Deficiencies of vitamins and other nutrients and
excesses of nutrients such as cholesterol may cause various disease processes. Recently, increased attention has
been given to the influence of nutritional supplements on the aging process; vitamin E, bee pollen, ginseng,
gotu kola, peppermint, and kelp are among the nutrients believed to promote a healthy, long life (Margolis,
2000; Smeeding, 2001). Although the complete relationship between diet and aging is not well understood,
enough is known to suggest that a good diet may minimize or eliminate some of the ill effects of the aging
process.
KEY CONCEPT
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It is beneficial for nurses to advise aging persons to scrutinize products that claim to cause, stop, or
reverse the aging process.
Environmental Theories
Several environmental factors are known to threaten health and are thought to be associated with the aging
process. The ingestion of mercury, lead, arsenic, radioactive isotopes, certain pesticides, and other substances
can produce pathologic changes in human beings. Smoking and breathing tobacco smoke and other air
pollutants also have adverse effects. Finally, crowded living conditions, high noise levels, and other factors are
thought to influence how we age.
POINT TO PONDER
Do you believe nurses have a responsibility to protect and improve the environment? Why or why not?
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Sociologic Theories of Aging
Disengagement Theory
Sociologic theories address the impact of society on older adults and vice versa. These theories often reflect
the view held about older adults at the time they were developed. The norms of society affected how the older
adult’s roles and relationships were viewed.
Developed by Elaine Cumming and William Henry, the disengagement theory (Cumming, 1964;
Cumming & Henry, 1961) has been one of the earliest, most controversial, and most widely discussed
theories of aging. It views aging as a process in which society and the individual gradually withdraw, or
disengage, from each other, to the mutual satisfaction and benefit of both. The benefit to individuals is that
they can reflect and be centered on themselves, having been freed from societal roles. The value of
disengagement to society is that some orderly means is established for the transfer of power from the old to
the young, making it possible for society to continue functioning after its individual members die. The theory
does not indicate whether society or the individual initiates the disengagement process.
Several difficulties with this concept are obvious and this theory has now been discredited (Johnson,
2009). Many older persons desire to remain engaged and do not want their primary satisfaction to be derived
from reflection on younger years. Senators, Supreme Court justices, college professors, and many senior
volunteers are among those who commonly derive satisfaction and provide a valuable service to society by not
disengaging. Because the health of the individual, cultural practices, societal norms, and other factors
influence the degree to which a person will participate in society during his or her later years, some critics of
this theory claim that disengagement would not be necessary if society improved the health care and financial
means of older adults and increased the acceptance, opportunities, and respect afforded to them.
A careful examination of the population studied in the development of the disengagement theory hints at
its limitations. The disengagement pattern that Cumming and Henry described was based on a study of 172
middle-class persons between 48 and 68 years of age. This group was wealthier, better educated, and of higher
occupational and residential prestige than the general aged population. No black people or chronically ill
people were involved in the study. Caution is advisable in generalizing findings for the entire aged population
based on fewer than 200 persons who are generally not representative of the average aged person. (This study
exemplifies some of the limitations of gerontological research before the 1970s.) Although nurses should
appreciate that some older individuals may wish to disengage from the mainstream of society, this is not
necessarily a process to be expected from all aging persons.
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Activity Theory
At the opposite pole from the disengagement theory, the activity theory asserts that an older person should
continue a middle-aged lifestyle, denying the existence of old age as long as possible, and that society should
apply the same norms to old age as it does to middle age and not advocate diminishing activity, interest, and
involvement as its members grow old (Havighurst, 1963). This theory suggests ways of maintaining activity in
the presence of multiple losses associated with the aging process, including substituting intellectual activities
for physical activities when physical capacity is reduced, replacing the work role with other roles when
retirement occurs, and establishing new friendships when old ones are lost. Declining health, loss of roles,
reduced income, a shrinking circle of friends, and other obstacles to maintaining an active life are to be
resisted and overcome instead of being accepted.
This theory has some merit. Activity is generally assumed to be more desirable than inactivity because it
facilitates physical, mental, and social well-being. Like a self-fulfilling prophecy, the expectation of a
continued active state during old age may be realized to the benefit of older adults and society. Because of
society’s negative view of inactivity, encouraging an active lifestyle among the aged is consistent with societal
values. Also supportive of the activity theory is the reluctance of many older persons to accept themselves as
old.
A problem with the activity theory is its assumption that most older people desire and are able to maintain
a middle-aged lifestyle. Some aging persons want their world to shrink to accommodate their decreasing
capacities or their preference for less active roles. Many older adults lack the physical, emotional, social, or
economic resources to maintain active roles in society. Aged people who are expected to maintain an active
middle-aged lifestyle on an income of less than half that of middle-aged people may wonder if society is
giving them conflicting messages. More research and insights are needed regarding the effects on the older
adults of not being able to fulfill expectations to remain active.
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Continuity Theory
The continuity theory of aging, also referred to as the developmental theory, relates personality and
predisposition toward certain actions in old age to similar factors during other phases of the life cycle
(Neugarten, 1964). Personality and basic patterns of behavior are said to remain unchanged as the individual
ages. For instance, activists at 20 years of age will most likely be activists at 70 years of age, whereas young
recluses will probably not be active in the mainstream of society when they age. Patterns developed over a
lifetime will determine whether individuals remain engaged and active or become disengaged and inactive.
The recognition that the unique features of each individual allow for multiple adaptations to aging and
that the potential exists for a variety of reactions gives this theory validity and support. Aging is a complex
process, and the continuity theory considers these complexities to a greater extent than most other theories.
Although the full implications and impact of this promising theory are at the stage of research, it offers a
reasonable perspective. Also, it encourages the young to consider that their current activities will lay a
foundation for their own future old age.
KEY CONCEPT
Basic psychological patterns are consistent throughout the life span.
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Subculture Theory
This theory views older adults as a group with distinct norms, beliefs, expectations, habits, and issues that
separate them from the rest of society (Rose, 1965). Their formation of a subculture is a response to the
negative attitudes and treatment by society. Older persons are accepted by and more comfortable among their
own age group. A component of this theory is the argument for social reform and greater empowerment of
the older populations so that their rights and needs can be respected.
As the population of older adults becomes more diverse, their needs better addressed, and their power
recognized, the question can be raised that this theory is less relevant today than it was in the 1960s when it
was first offered.
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Age Stratification Theory
This theory, appearing in the 1970s, suggests that society is stratified by age groups (Riley, Johnson, & Foner,
1972). Persons within a similar age group generally have similar experiences, beliefs, attitudes, and life
transitions that offer them a unique shared history. New age groups are continually being formed with the
birth of new individuals; thus, the interaction between society and the aging population is dynamic. As each
group ages, they have their own unique experience with and influence on society, and there is an
interdependence between society and the group.
POINT TO PONDER
How would you expect the aging experience of Generation X and Generation Y to differ from that of
the baby boomers and their parents?
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Psychological Theories of Aging
Developmental Tasks
Psychological theories of aging explore the mental processes, behavior, and feelings of persons throughout the
life span, along with some of the mechanisms people use to meet the challenges they face in old age. Among
these theories are those that describe the process of healthy psychological aging as the result of the successful
fulfillment of developmental tasks. Developmental tasks are the challenges that must be met and adjustments
that must be made in response to life experiences that are part of an adult’s continued growth through the life
span.
Erik Erikson (1963) described eight stages through which human beings progress from infancy to old age
and the challenges, or tasks, that confront individuals during each of these stages (Table 2-1). The challenge
of old age is to accept and find meaning in the life the person has lived; this gives the individual ego integrity
that aids in adjusting and coping with the reality of aging and mortality. Feelings of anger, bitterness,
depression, and inadequacy can result in inadequate ego integrity (e.g., despair).
TABLE 2-1 Erikson’s Developmental Tasks
Refining Erikson’s description of old age tasks in the eighth stage of development, Robert Peck (1968)
detailed three specific challenges facing the older adults that influence the outcome of ego integrity or despair:
Ego differentiation versus role preoccupation: to develop satisfactions from oneself as a person rather than
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through parental or occupational roles
Body transcendence versus body preoccupation: to find psychological pleasures rather than become absorbed
with health problems or physical limitations imposed by aging
Ego transcendence versus ego preoccupation: to achieve satisfaction through reflection on one’s past life and
accomplishments rather than be preoccupied with the finite number of years left to live
Robert Butler and Myrna Lewis (1982) outlined additional developmental tasks of later life:
Adjusting to one’s infirmities
Developing a sense of satisfaction with the life that has been lived
Preparing for death
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Gerotranscendence
Gerotranscendence is a recent theory that suggests aging entails a transition from a rational, materialistic
metaperspective to a cosmic and transcendent vision (Tornstam, 2005). As people age, they are less concerned
with their physical bodies, material possessions, meaningless relationships, and self-interests and instead desire
a life of more significance and a greater connection with others. There is a desire to shed roles and invest time
in discovering hidden facets of oneself.
POINT TO PONDER
How do you see examples of gerotranscendence in the lives of others and yourself?
KEY CONCEPT
Nurses can promote joy and a sense of purpose in the older adults by viewing old age as an opportunity
for continued development and satisfaction rather than a depressing, useless period of life.
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Nursing Theories of Aging
Although there are many classic theories that describe biological, social, and psychological aging, none
integrate all of these various dimensions of aging into a holistic theory. Because nurses address all aspects of
the person, theories that offer the holistic perspective would be valuable in guiding nursing care. In an effort
to address this need, several nurses have recently developed theories of aging.
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Functional Consequences Theory
The Functional Consequences Theory for Promoting Wellness in Older Adults (Miller, 2014) integrates
theories from aging and holistic nursing. It holds that nurses can promote wellness by addressing individuals
holistically, recognizing the interconnection of body, mind, and spirit. The consequences of age-related
changes and risk factors can result in either positive or negative functional consequences (i.e., wellness
outcomes) for older adults. Through interventions that promote wellness and alleviate or reduce the impact of
negative factors, nurses can promote positive functional consequences.
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Theory of Thriving
Based on their view that aging theories have been remiss in linking theories together, the authors of this
theory propose that everything that impacts people throughout their lives must be linked to create a holistic
view of aging (Haight, Barba, Tesh, & Courts, 2002). They base their theory on the failure to thrive concept
as it related to older adults in nursing homes (Newbern & Krowchuk, 1994); the clinical characteristics of
older persons experiencing failure to thrive include disconnectedness, inability to find meaning in life,
problems with social relationships, and physical and cognitive dysfunction. In contrast, thriving is possible
when harmony exists between individuals and their physical and human environments. The process of
thriving is continuous and enables aging individuals to find meaning in life and adapt to changes. This theory
reinforces the importance of nurses considering the many factors that can impact health and quality of life for
older adults.
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Theory of Successful Aging
By integrating Roy’s adaptation model with the theory of gerotranscendence and other aging literature, Flood
(2005) attempt to develop a nursing theory to guide the care of older adults. The Adaptation Model of
Nursing, developed by Sister Callista Roy, saw the individual as a biopsychosocial being that continuously
interacts with and adapts to the changing internal and external environment (Roy & Andrews, 2008). Roy
viewed health on a continuum and involves the person becoming an integrated, whole individual.
The Theory of Successful Aging not only considers successful aging in terms of the older adult’s physical,
mental, and spiritual well-being but also includes the individual’s self-appraisal. Flood hypothesizes that
people with high levels of personal control and a positive affect will experience higher levels of wellness in
aging due to their ability to participate in health-promoting activities. Higher levels of physical health, in turn,
contribute to deeper spirituality. These factors contribute to greater life satisfaction and the aging individual’s
positive perception of his or her status. By aiding older adults in achieving high levels of health and personal
control over their lives, nurses can help aging individuals to have a positive view of their lives, which in turn
can promote their ability to cope and achieve greater life satisfaction with age.
COMMUNICATION TIP
Nurses occasionally may hear people mentioning factors that influence aging and suggestions for
addressing them. This can range from them stating that “there’s nothing that can be done about how we
age” to “taking supplement x can keep you from showing any signs of aging.” These thoughts can result
in people either not taking actions that can influence a healthy aging process or risking their health and
finances on unproven antiaging products. Clarifying misconceptions is beneficial. (See Box 2-1.)
Box 2-1 Factors Contributing to a Long and Healthy Life
Diet. A positive health state that can contribute to longevity is supported by reducing saturated fats in
the diet, limiting daily fat consumption to less than 30% of caloric intake, avoiding obesity, decreasing
the amount of animal foods eaten, substituting natural complex carbohydrates for refined sugars, and
increasing the consumption of whole grains, vegetables, and fruits.
Activity. Exercise is an important ingredient to good health. It increases strength and endurance,
promotes cardiopulmonary function, and has other beneficial effects that can affect a healthy aging
process.
Play and laughter. Laughter causes a release of endorphins, stimulates the immune system, and
reduces stress. Finding humor in daily routines and experiencing joy despite problems contribute to
good health. It has been suggested since the time of Solomon that “a cheerful heart is good medicine,
but a crushed spirit dries up the bones” (Proverbs 17:22).
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Faith. A strong faith, church attendance, and prayer are directly related to lower rates of physical
and mental illness. Religion and spirituality can have a positive effect on the length and quality of life.
Empowerment. Losing control over one’s life can threaten self-confidence and diminish self-care
independence. Maximum control and decision making can have a positive effect on morbidity and
mortality.
Stress management. It is the rare individual who is unaware of the negative consequences of stress.
The unique stresses that may accompany aging, such as the onset of chronic conditions, retirement,
deaths of significant others, and change in body appearance, can have significantly detrimental effects.
Minimizing stress when possible and using effective stress management techniques are useful
interventions.
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Applying Theories of Aging to Nursing Practice
The number, diversity, and complexity of factors that potentially influence the aging process show that no one
theory can adequately explain the cause of this phenomenon. Even when studies have been done with
populations known to have a long life expectancy, such as the people of the Caucasus region in southern
Russia, longevity has not been attributable to any single factor.
The biological, psychological, and social processes of aging are interrelated and interdependent.
Frequently, loss of a social role affects an individual’s sense of purpose and speeds physical decline. Poor
health may force retirement from work, promoting social isolation and the development of a weakened self-
concept. Although certain changes occur independently as separate events, most are closely associated with
other age-related factors. Wise nurses will be open-minded in choosing the aging theories they use in the care
of older adults; they will also be cognizant of the limitations of these theories.
Nurses can adapt these theories by identifying elements known to influence aging and using them as a
foundation to promote positive practices. Box 2-1 highlights some factors to consider in promoting a healthy
aging process.
In addition, gerontological nurses play a significant role in helping aging persons experience health,
fulfillment, and a sense of well-being. In addition to specific measures that can assist the older adults in
meeting their psychosocial challenges (Box 2-2), nurses must be sensitive to the tremendous impact their own
attitudes toward aging can have on patients. Nurses who consider aging as a progressive decline ending in
death may view old age as a depressing, useless period and foster hopelessness and helplessness in older
patients. However, nurses who view aging as a process of continued development may appreciate late life as an
opportunity to gain new satisfaction and understanding, thereby promoting joy and a sense of purpose in
patients.
Box 2-2 Assisting Individuals in Meeting the Psychosocial
Challenges of Aging
OVERVIEW
As individuals progress through their life span, they face challenges and adjustments in response to life
experiences called developmental tasks. These developmental tasks can be described as:
Coping with losses and changes
Establishing meaningful roles
Exercising independence and control
Finding purpose and meaning in life
Satisfaction with oneself and the life one has lived is gained by successfully meeting these tasks;
unhappiness, bitterness, and fear of one’s future can result from not adjusting to and rejecting the
realities of aging.
GOAL
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Aging persons will express a sense of ego integrity and psychosocial well-being.
ACTIONS
Learn about patients’ life stories; ask about family backgrounds, faith, work histories, hobbies,
achievements, and life experiences. Encourage patients to discuss these topics, and listen with
sincere interest.
Build on lifelong interests and offer opportunities for patients to experience new pleasures and
interests.
Accept patients’ discussions of their regrets and dissatisfactions. Help them to put these in
perspective of their total lives and accomplishments.
Encourage reminiscence activities between patients and their families. Help families and staff to
understand the therapeutic value of reminiscence.
Respect patients’ faith and assist them in the fulfillment of spiritual needs (e.g., help them locate a
church of their religious affiliation, request visits from clergy, pray with or for them, and obtain a
Bible or other religious book).
Use humor therapeutically.
If patients reside in an institutional setting, personalize the environment to the maximum degree
possible.
Recognize the unique assets and characteristics of each patient.
POINT TO PONDER
How would you evaluate the quality of the factors that promote longevity in your own life?
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BRINGING RESEARCH TO LIFE
Construction, Deconstruction, and Reconstruction: The Roots of Successful Aging Theories
Source: Topaz, M., Troutman-Jordan, M., & MacKenzie, M. (2014). Nursing Science Quarterly, 27(3), 226–233.
This article reviews the evolution of theories explaining successful aging as they relate to nursing. Theories
of aging arising in the early 20th century were dominated by the belief that absolute truth could be derived
through scientific objectivity and observation. The aging process was considered to be similar for all
individuals and characterized by decreasing functional capacity. Most nurse theorists at this time concurred
with the thinking of the theorists and viewed aging as a biological and functional process common to all.
The postmodern era deconstructed boundaries. Rather than view aging as a universal experience, theorists
of this era believed that each individual personally defines what aging means. They challenged the
stereotyping of older adults. During this era, there was a growth in qualitative methodologies and diverse
nursing theories that promoted a holistic approach to individuals and their care.
The 21st century brought the reconstruction of theories of aging. Subjective understanding was valued
along with the objective of gaining knowledge about aging. Successful aging was conceptualized as the ability
to preserve physical and mental function and adapt to change into old age to enable continued active
engagement in life. Positive spirituality also was recognized as serving an important role in successful aging.
Interventions to assist older adults to adapt and meet their own personal goals became part of nursing’s focus.
It is important for nurses to understand the evolution of theories of successful aging because they
influence values and beliefs about the aging process and older adults. From viewing all aging individuals
similarly and focusing care on anticipated functional declines to adopting a holistic view that respects
individual differences in aging experiences and desires, approaches to care are significantly influenced by
predominant theories.
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PRACTICE REALITIES
You are presenting a class on positive health practices to a group at a local senior center. At the end of the
class, there is a lively discussion and one of the older participants comments, “No matter what you do, how
you age is decided by your ancestors. My grandparents ate tons of fatty foods and never exercised and they
lived to their 90s.”
“Oh, you’re wrong,” offers another member of the group. “I’ve been taking a supplement that my neighbor
sells that will override the problems you inherited and I’m much healthier than my parents were at my age.”
How would you react to these comments and guide the discussion?
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CRITICAL THINKING EXERCISES
1. What disease processes are caused by or related to factors believed to influence aging?
2. You are asked to speak to a community group regarding environmental issues. What recommendations
could you make for promoting a healthy environment?
3. Think about everyday life in your community. What examples do you see of opportunities to engage and
disengage older adults?
4. What specific methods could you use to assist an older adult in achieving ego integrity?
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Chapter Summary
The aging process varies not only among individuals but among systems within an individual. Biological aging
has been described by stochastic theories that view aging as the result of random assaults from the internal and
external environment and nonstochastic theories that view aging as being a complex, predetermined process.
Stochastic theories include the cross-link, free radicals, lipofuscin, wear and tear, evolutionary, and
biogerontology theories. Nonstochastic theories describe the role of apoptosis, genetic programming and
mutations, autoimmune reactions, neuroendocrines, neurochemicals, radiation, nutrition, and the
environment in the aging process.
Among the sociologic theories of aging, the disengagement theory is one of the earliest, viewing aging as a
process in which society and the individual gradually withdraw, or disengage, from each other, to the mutual
satisfaction and benefit of both; this theory has fallen out of favor. The activity theory proposes that to age in
a healthy manner, individuals need to stay active and engaged in society. Recognizing that not all individuals
disengage or are active in society as they age, the continuity theory suggests that individuals will maintain the
patterns of engagement in old age that they practiced throughout their life span. Due to their distinct norms,
beliefs, and issues, some theorize that older adults constitute a subculture; however, this theory may have less
relevancy as the population of older adults becomes increasingly diverse. The age stratification theory suggests
the similarities among various age groups cause them to have unique experiences and interactions with society.
Psychological theories of aging explore the mental processes, behavior, and feelings of persons throughout the
life span, along with some of the mechanisms people use to meet the challenges they face in old age. Erikson
described developmental tasks that face people during each stage of life, with the task in old age to find ego
integrity versus despair. Peck developed this further by offering specific challenges that older adults face as
they strive for ego integrity; Butler and Lewis also offered specific developmental tasks of late life. Some
theorists propose that with age, there is a transition from material to nonmaterial concerns, known as
gerotranscendence.
The journey of aging can be unique for each individual and impacted by many factors. Therefore, nurses
need to have a holistic focus in assessing, planning, and providing care.
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Recommended Readings
Recommended readings associated with this chapter can be found on the Web site that accompanies the
book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://thepoint.lww.com/Eliopoulos9e

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CHAPTER 3
Diversity
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CHAPTER OUTLINE
Increasing Diversity Of The Older Adult Population
Overview Of Diverse Groups Of Older Adults In The United States
Hispanic Americans
Black Americans
Asian Americans
Jewish Americans
Native Americans
Muslims
Gay, Lesbian, Bisexual, and Transgender Older Adults
Nursing Considerations For Culturally Sensitive Care Of Older Adults
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Describe projected changes in the diversity of the older population in the United States.
2. Describe unique views of health and healing among major ethnic groups.
3. Identify ways in which nursing care may need to be modified to accommodate persons of diverse ethnic backgrounds.
TERMS TO KNOW
Bisexual someone sexually attracted to persons of both sexes
Culture shared beliefs and values of a group: the beliefs, customs, practices, and social behavior of a particular group of people
Ethnic a group of people sharing a common racial, national, religious, linguistic, or cultural heritage
Ethnogeriatrics the effects of ethnicity and culture on the health and well-being of older adults
Gay someone sexually attracted to a person of the same sex; homosexual
Lesbian a woman who is sexually attracted to other women
Race a group of people that share some biological characteristics
Transgender a person whose identity, appearance, and/or behavior varies from that which the culture views as conventional for his or her
gender; sometimes referred to as transsexual or transvestite
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INCREASING DIVERSITY OF THE OLDER ADULT
POPULATION
Population projections support the view that the older population in the United States is becoming more
ethnically and racially diverse. Nearly one in eight people in the United States speak a language other than
English at home, with one third of these people speaking Spanish (Wan, Sengupta, Velkoff, & DeBarros,
2005). In 2000, approximately 84% of older Americans were non-Hispanic White, while it is projected that
this population will decrease to 64% by 2050. During this same period, there will be a dramatic growth among
Hispanic older adults, who will represent nearly 20% of the older population. Black individuals will grow from
8% to over 12% of the older population during this time. By 2020, one quarter of America’s older population
will belong to a minority racial or ethnic group (Administration on Aging, 2014; U.S. Census Bureau, 2014).
And, in addition to racial and ethnic diversity, there will be growing numbers of lesbian, gay, bisexual, and
transgender persons entering their senior years who will present a unique set of challenges.
KEY CONCEPT
Ethnogeriatrics is a term used to describe the effects of ethnicity and culture on the health and well-
being of older adults. The American Geriatrics Society has identified this as an important component of
geriatrics.
The growing diversity of the older population presents challenges for gerontological nursing in providing
culturally competent care. Essential to the provision of culturally competent care is an understanding of:
The experiences of individuals of similar ethnic or racial backgrounds
Beliefs, values, traditions, and practices of various ethnic and racial groups
Unique health-related needs, experiences, and risks of various ethnic and racial groups and persons of
similar sexual orientation
One’s own attitudes and beliefs toward people of various ethnic and racial groups, and persons of similar
sexual orientation, as well as those attitudes of coworkers
Language barriers that can affect the ability of patients to communicate health-related information,
understand instructions, provide informed consent, and fully participate in their care
An understanding of cultural, ethnic, and sexual orientation differences can help to erase the stereotypes and
biases that can interfere with effective care and demonstrate an appreciation for the unique characteristics of
each individual.
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OVERVIEW OF DIVERSE GROUPS OF OLDER
ADULTS IN THE UNITED STATES
People from a variety of countries have ventured to America to seek a better life in a new land. To an extent,
they assimilated and adopted the American way of life; however, the values and customs instilled in them by
their native cultures are often deeply ingrained, along with their language and biological differences. The
unique backgrounds of these newcomers to America influence the way they react to the world around them
and the manner in which that world reacts to them. To understand the uniqueness of each older adult
encountered, consideration must be given to the influences of ethnic origin.
Members of an ethnic or cultural group share similar history, language, customs, and characteristics; they
also hold distinct beliefs about aging and older adults. Ethnic norms can influence diet, response to pain,
compliance with self-care activities and medical treatments, trust in health care providers, and other factors.
The traditional responsibilities assigned to the aged of some ethnic groups can afford them opportunities for
meaningful roles and high status.
Studies of cultural influences on aging and effects on older adults have been sparse but are growing.
Experiences and observations can provide insight into the unique characteristics of specific ethnic groups.
Although individual differences within a given ethnic group exist and stereotypes should not be made, an
understanding of the general characteristics of various ethnic groups can assist nurses in providing more
individualized and culturally sensitive care.
KEY CONCEPT
Although ethnic origin is important, the nurse needs to remember that not all individuals conform to
the beliefs, values, roles, and traditions of the group of which they are a part. Stereotyping individuals
who belong to the same cultural or ethnic group runs contrary to individualized care.
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Hispanic Americans
The term Hispanic encompasses a variety of Spanish-speaking persons in America, including those from
Spain, Mexico, Cuba, and Puerto Rico. Hispanic people now represent approximately 6% of the older
population in the United States, but this percentage is expected to increase. Today, there are approximately
250,000 Hispanic Americans living in the United States, and the fastest growing segment of the US
population is Hispanic Americans older than 65 years.
KEY CONCEPT
The terms Hispanic and Latino are often used interchangeably, and in the United States, Latino has
become equated with Hispanics. However, technically, there are differences in that Latino refers to
persons from countries once under Roman rule (e.g., Spain, Italy, and Portugal), whereas Hispanic
describes persons from countries once under Spanish rule (e.g., Mexico, Central America, and most of
South America).
Although Mexican people inhabited the Southwest United States for decades before the arrival of the
Pilgrims, most Mexican immigration occurred during the 20th century as a result of the Mexican Revolution
and the poor economic conditions in Mexico. Poor economic conditions continue to cause Mexicans to
immigrate to the United States. The Mexican population in this country totals more than 8 million, plus an
estimated 3 to 5 million illegal immigrants; most reside in California and Texas.
Most Puerto Rican immigration occurred after the United States granted citizenship to all Puerto Ricans.
After World War II, nearly one third of all Puerto Rico’s inhabitants immigrated to America; in the 1970s,
“reverse immigration” began as growing numbers of Puerto Rican people left the United States to return to
their home island. An estimated 1 million Puerto Ricans live in New York City, where most of them have
settled.
Most Cuban immigrants are recent newcomers to America; the majority of the greater than 1 million
Cuban Americans fled Cuba after Castro seized power. More than 25% of the Cuban American population
resides in Florida, with other large groups in New York and New Jersey. Among all Hispanics, Cuban people
are the most highly educated and have the highest earnings.
KEY CONCEPT
Although cancer deaths have declined for all persons, they remain disproportionately high among
Hispanic Americans and African Americans (American Cancer Society, 2014a, 2014b).
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Many Hispanic people view states of health and illness as the actions of God; by treating one’s body with
respect, living a good life, and praying, one will be rewarded by God with good health. Illness results when
one has violated good practices of living or is being punished by God. Medals and crosses may be worn at all
times to facilitate well-being, and prayer plays an important part in the healing process. Illness may be viewed
as a family affair, with multiple family members involved with the care of the sick individual. Rather than
using practitioners of Western medicine to treat their health problems, some Hispanic persons may prefer
traditional practitioners, such as:
Curanderos: women who have special knowledge and charismatic qualities
Sobadoras: persons who give massages and manipulate bones and muscles
Espiritualistas: persons who analyze dreams, cards, and premonitions
Brujos: women who practice witchcraft
Senoras: older women who have learned special healing measures
The Hispanic population holds older relatives in high esteem. Old age is viewed as a positive time in which
the older person can reap the harvest of his or her life. Hispanic people may expect that children will take care
of their aging parents, and families may try to avoid institutionalization at all costs. Indeed, this group has a
lower rate of nursing home use than the general population; less than 7% of nursing home residents are
Hispanic.
COMMUNICATION TIP
Nurses may find that English is a second language for some Hispanic people, which becomes
particularly apparent during periods of illness when stress causes a retreat to the native tongue. An
interpreter can be used to facilitate communication. In addition, some Hispanic individuals may be
more competent speaking English than reading and writing in English; this needs to be considered
when written instructions or questionnaires are used.
Although older Hispanic and non-Hispanic persons have similar types of chronic conditions, older Hispanic
individuals are less likely to visit physicians or obtain preventive services (e.g., mammograms and vaccines)
and more likely to have difficulty obtaining care (Georgetown University Center on an Aging Society, 2012).
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Black Americans
Although nearly 14% of the entire US population is black, they represent only 8.4% of the older population.
Most of this group is of African descent. Historically, black Americans have experienced a lower standard of
living and less access to health care than their white counterparts. This is reflected in the lower life expectancy
of black Americans (see demographics in Chapter 1). However, once a black individual reaches the seventh
decade of life, survival begins to equal that of similarly aged white people.
To survive to old age is considered by this ethnic group as a major accomplishment that reflects strength,
resourcefulness, and faith; thus, old age may be considered a personal triumph by black people, not a dreaded
curse. Considering their history, it should not be surprising to find that many black older adults:
Possess many health problems that have accumulated over a lifetime due to a poor standard of living and
limited access to health care services
Hold health beliefs and practices that may be unconventional to stay healthy and treat illness
Are twice as likely to live in poverty compared with other older adults, which can influence their
utilization of health care services
Look to family members for decision making and care rather than using formal service agencies
May have a degree of caution in interacting with and using health services, as a defense against prejudice
(Egede, 2006)
Diverse subgroups within the black population, such as Africans, Haitians, and Jamaicans, possess their own
unique customs and beliefs. Differences can be apparent even among black Americans from various regions of
the United States. Nurses should be sensitive to the fact that the lack of awareness and respect for these
differences can be interpreted as a demeaning or prejudicial sign.
Black skin color is the result of high melanin content and can complicate the use of skin color for the
assessment of health problems. To diagnose cyanosis effectively, for instance, examine the nail beds, palms,
soles, and gums and under the tongue. The absence of a red tone or glow to the skin can indicate pallor.
Petechiae are best detected on the conjunctiva, abdomen, and buccal mucosa.
Hypertension is a prevalent health problem among black Americans and occurs at a higher rate than in
the white population. One of the factors responsible for this problem is blunted nocturnal response. Only a
minor decline in blood pressure occurs during sleep, which increases the strain on the heart and vessels; this is
found to occur in the black population more than in any other group. Blood pressure monitoring is an
important preventive measure for black clients (Fig. 3-1).
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FIGURE 3-1 • Blood pressure monitoring is an important intervention for populations at higher risk for
hypertension.
In addition to hypertension, other health conditions are more prevalent in the black population than in the
while population. For instance, as compared with the White population, African Americans have a higher
prevalence of heart disease, cancer, and diabetes and a higher death rate from these diseases (Centers for
Disease Control and Prevention, 2014b).
In recent years, HIV and AIDS have become the third leading cause of death among African American
males; the African American population has the highest rate of HIV infection among other racial and ethnic
groups (Centers for Disease Control and Prevention, 2014b). The high prevalence of these diseases among
African American males suggests the need for education and counseling of younger adults in order to promote
a healthy lifestyle and longevity.
According to the Centers for Disease Control and Prevention (2014c), African American individuals
when compared with the White population are more likely to smoke, be obese, and have a poor health status.
Many causes of morbidity and mortality among black Americans can be prevented and effectively controlled
by lifestyle changes (e.g., good nutrition, regular exercise, and effective stress management) and regular health
screening. These are important considerations in planning health services to communities.
Despite the health problems of aged black Americans, their rate of institutionalization is lower than that
of the white population: about 13% of older black people experience institutional health care in their lifetimes
compared with 23% of older white people (Centers for Disease Control and Prevention, 2014a).
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Asian Americans
More than 10 million Asian Americans reside in the United States, representing approximately 4% of the
population. Asian Americans are a diverse group comprised of individuals from countries such as China,
Japan, the Philippines, Korea, Vietnam, and Cambodia.
Chinese Americans
Although Chinese laborers probably lived in America for centuries before the mid-1800s, it was not until then
that large-scale Chinese immigration occurred. The largest American Chinese populations are in California,
New York, Texas, New Jersey, Massachusetts, and Illinois.
Care of the body and health are of utmost importance in traditional Chinese culture, but their approach
may be vastly different from that of conventional Western medicine (Box 3-1). Chinese medicine is based on
the belief of the balance of yin and yang; yin is the female negative energy that protects the inner body, and
yang is the male positive energy that protects the body from external forces. Traditionally, Chinese people
have used the senses for assessing medical problems (touching, listening to sounds, and detecting odors) rather
than machinery or invasive procedures. Herbs, acupuncture, acupressure, and other treatment modalities,
which are just being recognized by the Western world, continue to be treatments of choice for many Chinese
individuals. These traditional treatments may be selected as alternatives or adjuncts to the use of modern
treatment modalities. Ivory figurines of reclining women, now collectors’ items, were used by female patients
to point to the area of their problems because it was inappropriate for the male physician to touch a woman;
although modern Chinese women may have forfeited this practice, they still may be embarrassed to receive a
physical examination or care from a man. Typically, disagreement or discomfort is not aggressively or openly
displayed by Chinese persons. Nurses may need to observe more closely and ask specific questions (e.g., Can
you describe your pain? How do you feel about the procedure you are planning to have done? Do you have any
questions?) to ensure that the quiet nature of the patient is not misinterpreted to imply that no problems exist.
Box 3-1 Chinese Medicine
For thousands of years, the Chinese have practiced a form of medicine that appears very different from
medicine in the Western world. It is based on a system of balance; illness is seen as an imbalance and
disharmony of the body. One of the theories that explains this balance is that of yin and yang. Yin is the
negative, female energy that is represented by that which is soft, dark, cold, and wet. Organs associated
with yin qualities include the lungs, kidneys, liver, heart, and spleen. Yang is the positive, male energy
that is represented by that which is hard, bright, hot, and dry. The gallbladder, small intestine, stomach,
colon, and bladder are yang organs. Daytime activity is considered more of a yang state, whereas sleep is
more of a yin state.
Chinese medicine also considers the body’s balance in relation to the five elements or phases: wood
(spring), fire (summer), earth (long summer), metal (autumn), and water (winter).
Qi is the life force that circulates throughout the body in invisible pathways called meridians. A
deficiency or blockage of qi can cause symptoms of illnesses. Acupuncture and acupressure can be
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applied to various points along the meridians to stimulate the flow of qi.
In addition to acupuncture and acupressure, traditional Chinese medicine uses herbs, massage, and
therapeutic exercises (such as t’ai chi) to promote a free flow of chi and achieve balance and harmony.
These modalities are gaining increasing acceptance in the United States, and research supporting their
effectiveness is increasing rapidly.
CONSIDER THIS CASE
Mrs. C is a very traditional Chinese woman who began living with
her son and daughter-in-law 3 years ago, after her husband’s death. Mrs. C and her husband had lived
in a “Chinatown” part of the city where they could freely communicate in Chinese and interact with
other Chinese individuals. She never developed fluency in English and has experienced considerable
difficulty communicating with neighbors since moving into her son’s suburban community. Mrs. C’s son
has assimilated American values and practices and has been critical of his mother for her traditional
ways; he would not acknowledge her when she spoke in Chinese and refused to allow her to cook
Chinese foods. His wife is not Chinese but has been sympathetic to the elder Mrs. C.
Last week, Mrs. C suffered a stroke that left her with weakness and some aphasia. She will require
care and supervision. Mrs. C’s son states that he does not want his mother in a nursing home, but that
he is not sure he can manage her; his wife says she is willing to take a leave of absence from work and
help care for her mother-in-law, if that is what her husband wants.
THINK CRITICALLY
What problems do you anticipate for each of the C family members?
What can be arranged to assist the family?
How could you assist Mrs. C in preserving her ethnic practices?
KEY CONCEPT
Traditional Chinese medicine is based on the belief that the female negative energy (yin) and the male
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positive energy (yang) must be in balance.
In Chinese culture, achieving old age is a blessing, and older adults are held in high esteem. They are
respected and sought for advice. The family unit is expected to take care of its elder members; thus, there may
be a reluctance to use service agencies for older adults.
Japanese Americans
In the past, when they first immigrated to the United States, many Japanese Americans had held jobs as
gardeners and farmers. Today, they, like Chinese Americans, have a lower unemployment rate and a higher
percentage of professionals than the national average. Today, there are approximately 796,700 Japanese
Americans, most of whom live in California and Hawaii.
Although Japanese Americans have not tended to live in separate subcommunities to the same extent as
Chinese Americans, they have preserved many of their traditions. They are bonded by their common heritage,
and their culture places a high value on the family. The following terms describe each generation of Japanese
American: Issei, first generation (immigrant to America); Nisei, second generation (first American born);
Sansei, third generation; and Yonsei, fourth generation. It is expected that families will take care of their elder
members. As in the Chinese culture, the aged are viewed with respect.
Similar to the Chinese, Japanese Americans may subscribe to traditional health practices either to
supplement or replace modern Western technology. They may not express their feelings openly or challenge
the health professional; therefore, nursing sensitivity to covert needs is crucial.
Other Asian Groups
In the early 1700s, Filipino people began immigrating to America, but most Filipino immigrants arrived in
the early 1900s to work as farm laborers. In 1934, an annual immigration quota of 50 was enacted; this quota
stayed in place until 1965.
In the early 1900s, Korean people immigrated to America to work on plantations. Many of these
individuals settled in Hawaii. Another large influx of Koreans, many of whom were wives of American
servicemen, immigrated after the Korean War.
The most recent Asian American immigrants have been from Vietnam and Cambodia. Most of these
individuals came to the United States to seek political refuge after the Vietnam War.
Although differences among various Asian American groups exist, some similarities are strong family
networks and the expectation that family members will care for their older relatives at home. Asian Americans
represent about 2% of the total nursing home population.
POINT TO PONDER
What attitudes toward people of different cultures were you exposed to as a child, and how has this
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molded your current attitudes?
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Jewish Americans
In the sense that they come from a variety of nations, with different customs and cultures, Jewish people are
not an ethnic group per se. However, the strength of the Jewish faith forms a bond that crosses national origin
and gives this group a strong sense of identity and shared beliefs.
Jewish Americans have demonstrated profound leadership in business, arts, and sciences and have made
positive contributions to American life. Scholarship is important in the Jewish culture; nearly 60% of all
Jewish Americans have graduated from college (Pew Research Center, 2015). Approximately 6.5 million
Jewish people reside in the United States, representing 2.2% of the total population, with most living in urban
areas of the Middle Atlantic states. It is estimated that half of the world’s Jewish population resides in
America.
Religious traditions are important in the Jewish faith (Fig. 3-2). Sundown Friday to sundown Saturday is
the Sabbath, and medical procedures may be opposed during that time (exceptions may be made for seriously
ill individuals). Because of a belief that the head and feet should always be covered, some Jewish people may
desire to wear a skullcap and socks at all times. Orthodox Jews may oppose shaving. The Kosher diet (e.g.,
exclusion of pork and shellfish, prohibition of serving milk and meat products at the same meal or from the
same dishes) is a significant aspect of Jewish religion and may be strictly adhered to by some. Fasting on holy
days, such as Yom Kippur and Tisha B’Av, and the replacement of matzo for leavened bread during Passover
may occur.
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FIGURE 3-2 • Celebrating religious holidays may be important for certain groups, such as Jewish older
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adults.
Modern medical care is encouraged. Rabbinical consultation may be desired for decisions involving organ
transplantation or life-sustaining measures. Certain rituals may be practiced at death, such as members of the
religious group washing the body and sitting with it until burial. Autopsy is usually opposed.
Family bonds are strong in Jewish American culture; they have strong and positive feelings for older
adults. Illness often draws Jewish families together. Jewish communities throughout the country have shown
leadership in developing a network of community and institutional services for their aged, geared toward
providing service while preserving Jewish tradition.
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Native Americans
Native Americans are comprised of American Indians and Alaskan Natives; together they represent 5.2
million individuals. Native Americans inhabited North America for centuries before Columbus explored the
New World. An estimated 1 to 1.5 million Native Americans populated America at the time of the arrival of
Columbus; however, many battles with the new settlers during the next four centuries reduced the Native
American population to a quarter million. The Native American population has been steadily increasing, with
the U.S. Census Bureau now showing approximately 2.9 million Native American people who belong to more
than 500 recognized tribes, nations, and villages in the United States. The median age for the American
Indian and Alaska Native population is lower than for the general US population. Only 8% of the Native
American population is older than 65 years, representing less than 1% of all older adults; however, they are
one of the fastest growing minorities of the older population.
Less than half of all American Indians live on reservations, with the highest populations found in
Arizona, Oklahoma, California, New Mexico, and Alaska. The Indian Health Service, a division of the
United States Public Health Service, provides free, universal access to health care to American Indians who
reside on reservations. More than half live in urban areas where access to health care is inferior to that on
reservations. An estimated 150 different Native American languages are spoken, although most Native
American people speak English as their first language.
Native American culture emphasizes a strong reverence for the Great Creator. A person’s state of health
may be linked to good or evil forces or to punishment for their acts. Native American medicine promotes the
belief that a person must be in balance with nature for good health and that illness results from imbalance.
KEY CONCEPT
Spiritual rituals, medicine men, herbs, homemade drugs, and mechanical interventions can be used by
Native American people to treat illness.
Close family bonds are typical among the Native American population. Family members may address each
other by their family relationship rather than by name (e.g., cousin, son, uncle, and grandfather). The term
elder is used to denote social or physical status, not just age. Elders are respected and viewed as leaders,
teachers, and advisors to the young, although younger and more “Americanized” members are starting to feel
that the advice of their elders is not as relevant in today’s world and are breaking from this tradition. Native
American people strongly believe that individuals have the right to make decisions affecting their lives. The
typical nursing assessment process may be offensive to the Native American patient, who may view probing
questions, validation of findings, and documentation of responses as inappropriate and disrespectful behaviors
during the verbal exchange. A Native American patient may be ambivalent about accepting services from
agencies and professionals. Such assistance has provided many social, health, and economic benefits to
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improve the life of Native Americans, but it also conflicts with Native American beliefs of being useful, doing
by oneself, and relying on spiritual powers to chart the course of life. Native American patients often remain
calm and controlled, even in the most difficult circumstances; it is important that providers not mistake this
behavior for the absence of feeling, caring, or discomfort.
Various tribes may have specific rituals that are performed at death, such as burying certain personal
possessions with the individual. Consulting with members of the specific tribe to gain insight into special
rituals during sickness and at death would be advantageous for nurses working with Native American
populations.
The last part of the 20th century saw a rise in certain preventable diseases among Native Americans,
attributable to their exposure to new risks, such as a poor diet, insufficient exercise, and unhealthy lifestyle
choices. For example, diabetes, a disease uncommon among Native Americans at the start of the 20th century,
now affects Native Americans 2.7 times as much as White Americans (Office of Minority Health, 2014).
Native Americans are more likely than the White non-Hispanic population to be obese and hypertensive and
to suffer a stroke. The relatively recent high prevalence of rheumatoid diseases among Native Americans as
compared with White older adults may be related to a genetic predisposition to autoimmune rheumatic
disease. The cancer survival rate among Native Americans is the lowest of any US population. Nurses must
promote health education and early screening to aid this population in reducing risks and identifying health
conditions early.
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Muslims
There are over a billion Muslims in the world who share a common culture based on the belief that Allah is
God and Muhammad is his messenger. Muslim customs and traditions are centered on religious beliefs and
customs derived from Muslim’s holy book, the Quran.
Older adults represent less than 1% of the Muslim population. They are viewed with high esteem and
treated with respect; mothers are especially honored. The tradition has been for older Muslims to be cared for
by their families, although this is anticipated to change as more Muslim women enter the workforce.
Muslims eat only meat that has been slaughtered according to religious requirements (halal meat) and do
not eat pork or pork products. Water typically is consumed with every meal. Muslim patients who adhere
strictly to fasting may not take medications during fasting times; sensitivity to this practice may require an
adjustment of medication administration times.
A Muslim patient may prefer to be cared for by a person of the same sex and to have exposure of the body
kept to a minimum. Muslims do not like to have their head touched unless it is part of an examination or
treatment.
Muslim patients who are unconscious or terminally ill should be positioned so that their face is turned to
face Mecca, which typically is west to northwest. Family and friends may recite the Quran or prayers in front
of the patient or in a nearby room. If a chapel is provided for praying, it is important that no crosses or icons
be present. The family should be asked if they would like their religious leader to visit.
POINT TO PONDER
In what ways do you honor and celebrate your unique heritage?
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Gay, Lesbian, Bisexual, and Transgender Older Adults
Despite the growing awareness and acceptance of gay, lesbian, bisexual, and transgender (LGBT) persons in
society as a whole, there has been minimal consideration of the challenges and needs of these individuals when
they reach late life. In fact, they are referred to as a largely invisible population (Fredriksen-Goldsen et al.,
2011). This invisible population is growing, however; as much as 10% of the population identifies themselves
as being lesbian, gay, bisexual, or transgender; the LGBT population is projected to double by 2030.
This generation lived through a period when considerable prejudice and discrimination existed against
persons who were LGBT; therefore, these individuals may not be open about sexual orientation when seeking
health services. Studies have found that LGBT older adults in community and long-term care settings
reported being fearful of rejection and neglect by caregivers, not being accepted by other residents, and being
forced to hide their sexual orientation (Stein, Beckerman, & Sherman, 2010). In addition, among LGBT
elderly (Fredriksen-Goldsen et al., 2011):
Nearly one half have a disability and nearly one third report depression.
There are higher rates of mental distress and a greater likelihood of smoking and engaging in excessive
drinking than heterosexual persons.
Almost two thirds have been victimized three or more times.
Thirteen percent have been denied health care or received inferior care.
More than 20% do not disclose their sexual or gender identity to their physician.
Recent years have noted progress in addressing the needs of the LGBT population. The American
Association of Retired Persons has created an online LGBT community, the American Society on Aging has
an LGBT Aging Issues Network, and the Joint Commission has added respect for sexual orientation to the
rights of residents of assisted living communities and skilled nursing homes. In addition, Services and
Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders (SAGE) and the Movement Advancement
Project (MAP) have been aggressively addressing policy and regulatory changes that are needed to address the
needs of this population.
Nurses need to appreciate that the LGBT elder population represents unique individuals with different
experiences, profiles, and needs. As with any patient, individualized approaches are essential and stereotypes
need to be avoided. Nurses should inquire about partners these patients may desire to have involved with care
and should include these partners as desired by the patients. Further, nurses need to assure that LGBT
individuals can receive services without prejudice, stigmatization, or threat.
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NURSING CONSIDERATIONS FOR CULTURALLY
SENSITIVE CARE OF OLDER ADULTS
Numerous minority, ethnic, or cultural groups that have not been mentioned also possess unique histories,
beliefs, and practices. Rather than viewing differences as odd and forcing patients to conform to “American”
traditions, nurses should respect the beauty of this diversity and make every effort to preserve it. The beliefs,
values, relationships, roles, and traditions associated with cultural and ethnic identity add a special significance
to life.
The effectiveness of care can be largely influenced by the initial impression made by the nurse. Nurses
need to reflect on any personal feelings or attitudes that could influence the nurse–patient relationship or
convey a prejudicial attitude. For example, if a nurse comes from a religious belief that homosexuality is
abnormal and sinful, the nurse may display discomfort in the nurse–patient interactions when faced with a
patient who is gay. As a result, the patient may sense the nurse is prejudiced and be reluctant to share all
aspects of his history and problems. Likewise, if the nurse has had limited experiences with persons of a
different racial group, he or she may appear uneasy or unnatural in communicating with those individuals.
Reflection on their feelings and discussing these issues with other professionals can assist in preventing
personal feelings from interfering with the professional relationship.
Nurses need to be careful not to stereotype patients based on race, ethnicity, sexual orientation, or other
factors. All patients should be addressed by their last name unless they request otherwise. Recognizing that
based on their cultural or ethnic backgrounds some persons may be guarded with the personal information,
nurses should explain the reason various questions will be asked during the interview. Ample time should be
allotted for patients to share their histories and cultural or religious practices. The use of touch (e.g., patting
the person’s hand or touching an arm) often demonstrates caring and assists in putting a person at ease;
however, be aware that in some cultural groups, being touched by a stranger is viewed as inappropriate. The
same holds true for the spatial distance between the nurse and the patient during the interview. This
reinforces the importance of nurses becoming familiar with the beliefs and practices of various groups.
Dietary preferences should be accommodated, adaptations made for special practices, and unique ways of
managing illness understood. Consideration should be given to differences in the expression of pain, fear, and
other feelings. Reactions to illness and care can vary. For example, one person may view illness as punishment
for wrongdoing; however, another sees it as part of the normal human experience. Some individuals may
desire the active participation of family members or traditional healers in their care, whereas others, even those
whose ethnic or cultural group traditionally do desire these things, do not.
If nurses are unfamiliar with a particular group, they should invite the patient and the family members to
educate them or contact churches or ethnic associations (e.g., Polish National Alliance, Celtic League, Jewish
Family and Children’s Services, and Slovak League of America) for interpreters or persons who can serve as
cultural resources. One powerful means to learn about cultural influences for individual patients is to ask them
to describe their life stories (see Chapter 4). Nurses convey sensitivity and caring when they try to recognize
and support patients’ ethnic and cultural backgrounds. Nurses also will become enriched by gaining an
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appreciation and understanding of the various interesting ethnic groups.
The U.S. Department of Health and Human Services has developed standards for culturally and
linguistically appropriate services that can guide clinical settings in working with diverse populations; their
Web site can be accessed at http://minorityhealth.hhs.gov.
The increasing diversity of future aged populations will affect services in a variety of ways. Among the
needs that could present are:
Institutional meal planning that incorporates ethnic foods
Multilingual health education literature
Readily available translators
Provisions for celebration of holidays (e.g., Chinese New Year, St. Patrick’s Day, Black History Month,
Greek Orthodox Easter)
Special interest groups for residents of long-term care facilities and assisted living communities
An uncomfortable reality that a nurse may face is the prejudicial comment by a patient. As patients will reflect
the society in which they live and with prejudices, unfortunately, being alive and well in society, it stands to
reason that the nurse will encounter prejudiced patients. For example, a patient may refuse to receive care
from a nurse of a different race. At times, persons who are highly stressed or who have dementias may use
offensive racial language. Understandably, this can be hurtful to the nurse. The individual patient and
situation, as well as the nurse’s experience in handling these situations, will determine the action the nurse
should take; options include requesting the patient not to make the comment, asking the patient if he or she
would prefer to have someone else assigned as his or her nurse, asking to be reassigned, and discussing the
situation with one’s manager.
Nurses need to ensure that cultural, religious, and sexual orientation differences of older adults are
understood, appreciated, and respected. Demonstrating this sensitivity honors the older adult’s unique history
and preserves the familiar and important. The challenges faced by older adults need not be compounded by
insensitive or prejudicial behaviors by nurses.
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http://minorityhealth.hhs.gov

BRINGING RESEARCH TO LIFE
Preparing Nurses to Address Health Care Disparities in the Lesbian, Gay, Bisexual, and
Transgender Population: A Review of Best Practices
Source: Lim, F., Brown, D. V ., Kim, J., & Min, S. (2014). American Journal of Nursing, 114(6), 24–34.
A review of 17 studies of nurses’ attitudes toward persons who were LGBT revealed that although nearly half
of the studies revealed evidence of some positive attitudinal changes, every study found that negative attitudes
persisted. Another literature review of 16 studies related to nursing students’ attitudes toward people with
HIV infection or AIDS found some degree of homophobia and a negative attitude about persons with these
diseases.
The article included a review of research analyzing the major health issues of the LGBT population.
Findings included a greater risk of obesity and its secondary outcomes among lesbians, disproportionately
higher rates of HIV infection among gay men, a higher prevalence of smoking among gay and bisexual men
and lesbians and bisexual women, and a lower likelihood of transgender people to have health insurance.
Health promotion for these individuals is needed, and reducing health care disparities can assist in this effort.
The challenges faced by older individuals who may be subjected to ageism will be greater if they also must
face prejudicial treatment when utilizing health care services. It is recommended that nursing programs assess
the LGBT health issues included in their training curricula, identify gaps, and develop strategies for meeting
those gaps. Nurses should assess their own attitudes toward persons who are LGBT to determine how these
may influence their interactions and care of these individuals. As the largest group of health care providers,
nurses can model positive behaviors toward the LGBT population, which can set an example for others.
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PRACTICE REALITIES
You are a nurse manager in an assisted living community that serves an affluent population. The current
resident population is all White, whereas most of the caregiving staff is African American.
Some of the staff shared with the nurse manager their frustration at the way several residents treat them.
Although most of the residents are courteous and polite in their manner of speaking to staff, many have a
tendency to use terms like “girls,” “you people,” and “help.” A few of the nursing assistants reported that they
have heard residents make comments to each other and their visitors that “You need to watch what you keep
here because these people have sticky fingers,” and “Those people basically are lazy, so you need to stay on
their back.” In addition, staff complain that visitors often ask them to do things that really are not part of their
jobs, such as having them go to visitor’s cars to retrieve something or serve food that the visitor brought in for
herself, the resident, and other family members.
The African American staff believe they are being treated in a prejudicial manner. One nursing assistant
comments, “You would think this was their plantation and we were their slaves.” Another reacts, “Yes, but if
we daresay something to them they’ll be running to administration. I can’t afford to lose this job.” Yet another
adds, “Maybe we should live with it. White people have always been this way to our people.”
As the nurse manager, how would you handle this situation?
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CRITICAL THINKING EXERCISES
1. What are some reasons for older adults of minority groups to be suspicious or distrustful of health care
services in this country?
2. What would you do if faced with a situation in which an older client refused to allow you to provide
nursing care for him because you are of a different ethnic or racial group?
3. You are working in a hospital that serves a large population of immigrants who have not entered the
country legally. These individuals frequently have had poor health care and present with multiple chronic
conditions. The hospital is concerned that the care offered to these immigrants is placing a significant
strain on its budget and may threaten its survival. The local community does not want to lose its hospital
and has voiced opposition to providing free care for this group of immigrants. What do you see as
concerns for all parties involved? What are the implications of either continuing or discontinuing free care
to this group of immigrants? What solutions could you recommend?
4. A nursing home has a variety of ethnic groups represented in the resident population. What can the
facility do to show sensitivity to their backgrounds?
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Chapter Summary
The aging population is becoming more racially, ethnically, and sexually diverse. Older Hispanics are the
fastest growing segment of the US population. English may be a second language to them. They view God as
having an important role in their health and healing and may utilize traditional practitioners to treat health
problems. Families hold older relatives in high esteem and try to avoid placing them in nursing homes.
The black population consists of Africans, Haitians, Jamaicans, and other diverse subgroups who have
unique customs and beliefs. Although the black population has a lower life expectancy, black individuals who
reach their seventh decade of life have the same potential life expectancy as the white population.
Hypertension, heart disease, cancer, and diabetes are leading causes of death among older black persons.
Individuals from China, Japan, the Philippines, Korea, Vietnam, and Cambodia are among the population
of Asian Americans. Some of these individuals may prefer traditional medicine to conventional Western
medicine. Families play an important role in the lives of older Asian Americans.
Jewish Americans are bound by a common faith. Sabbath is from sundown Friday to sundown Saturday;
medical procedures may be opposed during this time. Adhering to a Kosher diet may be important to faithful
Jews, as may fasting on holy days. Western medicine is accepted. Family bonds are important.
American Indians and Alaskan Natives constitute Native Americans and are one of the fastest growing
minorities in the United States. Less than half of American Indians reside on reservations, and those who do
have access to free services from the United States Public Health Service. Diabetes, obesity, hypertension, and
rheumatoid arthritis occur more commonly among Native American elders than in other older populations.
Native rituals and healers may be preferred to Western medicine. Families share close relationships and hold
their elders in high esteem.
Muslims share a common culture based on the belief that Allah is God and Muhammad his messenger.
Customs and rituals arise from their religious beliefs. Older Muslims represent less than 1% of the Muslim
population and are held in high esteem. There are specific dietary practices adhered to by Muslims. They may
prefer care by a person of the same sex. Muslim individuals who are unconscious or terminally ill should lie so
their face is positioned to look toward Mecca.
The LGBT population is growing. Some older LGBT individuals lived during an era when their sexual
preferences were not as accepted as they are today; thus, the sexual preferences of these persons may not be
recognized. Health care facilities are gaining in their understanding of the needs and rights of these
individuals.
Although there may be similar characteristics among members of a group, nurses must be careful to assess
individual characteristics, preferences, and practices and avoid stereotyping. It is important for nurses to
respect individual differences and assess for and incorporate personal preferences and practices into care.
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Online Resources
Bureau of Indian Affairs
http://www.bia.gov
Center of Excellence for Transgender Health
http://transhealth.ucsf.edu#sthash.8g2c7ai7.dpuf
National Asian Pacific Center on Aging
http://www.napca.org
National Association for Hispanic Elderly
http://www.anppm.org
National Caucus & Center on Black Aged
http://www.ncba-aged.org
National Hispanic Council on Aging

Home

National Indian Council on Aging

Home

National Resource Center on Native American Aging
http://www.med.und.nodak.edu/depts/rural/nrcnaa/
Office of Minority Health Resource Center
http://www.minorityhealth.hhs.gov
Organization of Chinese Americans
http://www.ocanational.org
SAGE (Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders)
http://sageusa.org/index.cfm
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http://www.bia.gov

http://transhealth.ucsf.edu#sthash.8g2c7ai7.dpuf

http://www.napca.org

http://www.anppm.org

http://www.ncba-aged.org

Home

Home

http://www.med.und.nodak.edu/depts/rural/nrcnaa/

http://www.minorityhealth.hhs.gov

http://www.ocanational.org

http://sageusa.org/index.cfm

References
Administration on Aging. (2014). Minority aging. Retrieved September 1, 2014 from
http://www.aoa.gov/AoARoot/Aging_Statistics/Minority_Aging/index.aspx
American Cancer Society. (2014a). Cancer facts and figures for African Americans 2013-2014. Retrieved
September 3, 2014 from
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-
036921
American Cancer Society. (2014b). Cancer facts and figures for Hispanics/Latinos 2012–2014. Retrieved
September 3, 2014 from
http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-
034778
Centers for Disease Control and Prevention. (2014a). U.S. census populations with bridged race categories.
Retrieved September 1, 2014 from http://www.cdc.gov/nchs/nvss/bridged_race.htm
Centers for Disease Control and Prevention. (2014b). Minority health: Black or African American
populations. Retrieved September 3, 2014 from
http://www.cdc.gov/minorityhealth/populations/REMP/black.html
Centers for Disease Control and Prevention. (2014c). Health of black or African American non-Hispanic
population. FastStats. Retrieved September 1, 2014 from http://www.cdc.gov/nchs/fastats/black-health.htm
Egede, L. (2006). Race, ethnicity, culture, and disparities in health care. Journal of General Internal
Medicine, 21(6), 667–669.
Fredriksen-Goldsen, K. I., Kim, H. -J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., …
Petry, H. (2011). The aging and health report: Disparities and resilience among Lesbian, Gay, Bisexual, and
Transgender older adults. Seattle, WA: Institute for Multigenerational Health.
Georgetown University Center on an Aging Society. (2012). Older Hispanic Americans. Data Profile, No. 9.
Retrieved March 15, 2012 from http://ihcrp.georgetown.edu/agingsociety/pubhtml/hispanics/hispanics.html
Office of Minority Health. (2014). Diabetes and American Indians/Alaska Natives. Retrieved September 22,
2014 from http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33
Pew Research Center. (2015). A portrait of Jewish Americans. Retrieved July 23, 2015 from
http://www.pewforum.org/2013/10/01/jewish-american-beliefs-attitudes-culture-survey/
Stein, G. L., Beckerman, N. L., & Sherman, P. A. (2010). Lesbian and gay elders and long-term care:
Identifying the unique psychosocial perspectives and challenges. Journal of Gerontological Social Work,
53(5), 421–435.
U.S. Census Bureau. (2014). Population Projections. Retrieved September 2, 2014 from
http://www.census.gov/population/projections/data/national/2012.html
Wan, H., Sengupta, M., Velkoff, V. A., & DeBarros, K. A. (2005). U.S. Census Bureau, current population
reports, 60+ in the United States: 2005 (p. 16). Washington, DC: U.S. Government Printing Office.
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http://www.aoa.gov/AoARoot/Aging_Statistics/Minority_Aging/index.aspx

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036921

http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-034778

http://www.cdc.gov/nchs/nvss/bridged_race.htm

http://www.cdc.gov/minorityhealth/populations/REMP/black.html

http://www.cdc.gov/nchs/fastats/black-health.htm

http://ihcrp.georgetown.edu/agingsociety/pubhtml/hispanics/hispanics.html

http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=33

http://www.pewforum.org/2013/10/01/jewish-american-beliefs-attitudes-culture-survey/

http://www.census.gov/population/projections/data/national/2012.html

Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 4
Life Transitions and Story
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CHAPTER OUTLINE
Ageism
Changes In Family Roles And Relationships
Parenting
Grandparenting
Loss Of Spouse
Retirement
Loss of the Work Role
Reduced Income
Changes In Health And Functioning
Cumulative Effects Of Life Transitions
Shrinking Social World
Awareness of Mortality
Responding To Life Transitions
Life Review and Life Story
Self-Reflection
Strengthening Inner Resources
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Discuss ageism and its consequences.
2. Discuss changes that occur in aging families.
3. Describe challenges faced by widows.
4. Outline the phases and challenges of retirement.
5. Discuss the impact of age-related changes in health and functioning on roles.
6. Describe cumulative effects of life transitions.
7. List nursing measures to assist individuals in adjusting to the challenges and changes of aging.
TERMS TO KNOW
Ageism:applying prejudices to older adults due to their age
Inner resources:strength within the person that can be drawn upon when needed
Life review:a process of reminiscing or reflecting on one’s life
Retirement:the period in which one no longer works
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Growing old is not easy. Various changes during the aging process demand multiple adjustments that require
stamina, ability, and flexibility. Frequently, more simultaneous changes are experienced in old age than during
any other period of life. Many young adults find it exhausting to keep pace with technological advances,
societal changes, cost-of-living fluctuations, and labor market trends. Imagine how complex and complicated
life can be for older individuals, who must also face retirement, reduced income, possible housing changes,
frequent losses through deaths of significant persons, and a declining ability to function. Further, each of these
life events can be accompanied by role changes that can influence behavior, attitudes, status, and psychological
integrity. To promote awareness and appreciation of the complex and arduous adjustments involved in aging,
this chapter considers some of the factors that affect older adults’ ability to cope with multiple changes
associated with aging and their achievement of satisfaction and well-being during the later years.
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AGEISM
Ageism is a concept introduced decades ago and defined as “the prejudices and stereotypes that are applied to
older people sheerly on the basis of their age …” (Butler, Lewis, & Sutherland, 1991). It is not difficult to
detect overt ageism in our society. Rather than showing appreciation for the vast contributions of older adults
and their wealth of resources, society is beset with prejudices and lacks adequate provisions for them, thus
derogating their dignity. The same members of society who object to providing sufficient income and health
care benefits for the older population enjoy an affluence and standard of living that was the result of the efforts
of these older persons.
Although older adults constitute the most diverse and individualized age group in the population, they
continue to be stereotyped by the following misconceptions:
Old people are sick and disabled.
Most old people are in nursing homes.
Dementia comes with old age.
People are either very tranquil or very cranky as they age.
Old people have lower intelligence and are resistant to change.
Old people are not able to have sexual intercourse and are not interested in sex.
There are few satisfactions in old age.
For most older persons, the above statements are not true. Increased efforts are necessary to heighten societal
awareness of the realities of aging. Groups such as the Gray Panthers have done an outstanding job of
informing the public about the facts regarding aging and the problems and rights of older adults. More
advocates for older persons are needed.
COMMUNICATION TIP
Upon first contact with an older adult, assume that interactions should be no different than with adults
of other ages unless information gleaned from the history reveals problems that could alter
communication (e.g., dementia, impaired hearing). Address the person with an honorific (Mr., Mrs.,
etc.) and then his or her last name. Refrain from speaking as though addressing a child or using terms
such as “sweetie” and “dear.” Avoid medical jargon and periodically ask if the person understands what
is being said.
Ageism carries several consequences. By separating people of advanced age from themselves, younger people
are less likely to see the similarities between themselves and older adults. This not only leads to a lack of
understanding of older people but also reduces the opportunities for the young to gain realistic insights into
aging. Furthermore, separating older individuals from the rest of society makes it easier for younger
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individuals to minimize the socioeconomic challenges of the older population. However, systematically
stereotyping and discriminating against older persons will not prevent individuals from growing old
themselves and experiencing the challenges of old age.
Chapter 2 outlines Erikson’s (1963) stages of life in which he describes the last stage of the life cycle as
concerned with achieving integrity versus despair. Integrity results when the older individual derives
satisfaction from an evaluation of his or her life. Disappointment with life and the lack of opportunities to
alter the past bring despair. Ageism, unfortunately, can predispose aging persons to disappointment because
they may believe stereotypical views that old age is a time of purposelessness and decline. The experiences of
our entire lifetime determine whether our old age will be an opportunity for freedom, growth, and
contentment or a miserable imprisonment of our human potential.
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CHANGES IN FAMILY ROLES AND RELATIONSHIPS
The emergence of today’s nuclear family units changed the roles and functions of the individuals in a family.
Older parents are expected to have limited input into the lives of their adult children. Children are not
required to meet the needs of their aging parents for financial support, health services, or housing. Parents
increasingly do not depend on their children for their needs, and the belief that children are the best insurance
for old age is fading. In addition, grandparenting, although satisfying, is not usually as active a role as in the
past, especially because grandchildren may be scattered throughout the country. These changes in family
structure and function are not necessarily negative. Older adults may enjoy the independence and freedom
from responsibilities that nuclear family life offers. Adjusting to changes in responsibilities and roles over
time, though, is an important challenge of aging.
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Parenting
The dynamic parental role frequently changes to meet the growth and development needs of both parent and
child. During middle and later life, parents must adjust to the independence of their children as they become
responsible adult citizens and leave home. The first child usually leaves home and establishes an independent
unit 22 to 25 years after the parents married. For persons who have invested most of their adult lives nurturing
and providing for their offspring, a child’s independence may have significant impact. Although parents who
are freed from the responsibilities and worries of rearing children have more time to pursue their own
interests, they are also freed from the meaningful, purposeful, and satisfying activities associated with child
rearing, and this frequently results in a profound sense of loss.
Today’s older woman has been influenced by a historical period that emphasized the role of wife and
mother. For instance, to provide job opportunities for men returning from World War II, women were
encouraged to focus their interests on raising a family and to forfeit the scarce jobs to men. Unlike many of
today’s younger women, who pursue and may equally value both a career and motherhood, these older women
centered their lives on their families, from which they derived their sense of fulfillment. Having developed few
roles from which to achieve satisfaction other than those of wife and mother, many of these older women feel
a void when their children are grown and gone. Compounding this problem, the highly mobile lifestyle of
many young persons limits the degree of direct contact an older woman has with her adult children and
grandchildren.
The older man shares many of the same feelings as his wife. Throughout the years, he may have felt that
he has performed useful functions that made him a valuable member of the family. Most likely, he worked
hard to support his wife and children, and his masculinity was reinforced with proof of his ability to beget and
provide for offspring. Now, with his children grown, he is no longer required to provide—a mixed blessing in
which he may find both relief and purposelessness. In addition, he learns that the rules have changed—his
ability to support a family without the need for his wife to work is now viewed by some as oppressive, his
efforts to replenish the earth are scorned by zero population proponents, and his attempt to fill the masculine
role for which he was socialized is considered oppressive or inane by today’s standards.
However, this lessening of the parenting role and the changes in family function are not necessarily
negative. Most children do not abandon or neglect their aging parents; they maintain regular contact. Separate
family units may help the parent–child relationship develop on a more adult-to-adult basis, to the mutual
satisfaction of both the young and the old. If older adults adjust to their new role as parents of independent,
adult children, they may enjoy the freedom from previous responsibilities and the new developments in their
family relationships.
POINT TO PONDER
List at least three ways that your life is different from the lives of your parents and grandparents.
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140

Grandparenting
In addition to experiencing changes in the parenting role that come with age, many older adults enter a new
role as grandparents. Americans’ extended life expectancy enables more people to experience the role of
grandparent and spend more years in that role than previous generations. More than 65 million Americans are
grandparents, and:
Most are baby boomers, more likely to be college educated and employed than previous generations of
grandparents.
One in five grandparents is African American, Hispanic, or Asian.
They are spending more on grandchildren than previous generations (MetLife, 2011).
Grandchildren can bring considerable joy and meaning to the lives of older adults (Fig. 4-1). In turn,
grandparents who are not burdened with the same daily child-rearing responsibilities of parents can offer love,
guidance, and enjoyment to the family’s young. They can share lessons learned from their life experiences and
family history and traditions that help the young understand their roots. There can be as many grandparenting
styles as there are personalities; there is no single model of grandparenthood.
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FIGURE 4-1 • Grandparenting offers new roles and joys for many older adults.
Changes in the family structure and activities present new challenges to today’s grandparents. Most mothers
are employed outside of the home. This is compounded by the fact that approximately one third of children
are being raised by one parent. As a result, grandparents may assume childcare responsibilities to a greater
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extent than previous generations did. Grandparents may even provide for or share a home with their children
and grandchildren. Family structures may differ from older adults’ experience, with an increase in remarriage
and blended families as well as homosexual households. More than one third of children under 18 years live in
blended households, and it is estimated that as many as 9 million children have gay or lesbian parents (Linville
& O’Neil, 2015). As a result of an adult child’s marriage or relationship, older adults may find themselves
becoming step-grandparents, a role for which few are prepared. Conscious choices will be needed to love and
accept these new family members.
In addition to older adults having to adapt to new family lifestyles and structures, children and
grandchildren may need to adapt to grandparents who have different lifestyles from previous generations.
Rather than the stay-at-home grandma who cooked elaborate family dinners and welcomed grandchildren
whenever they needed a sitter, today’s grandmother may have an active career and social calendar and not
want to be burdened with frequent babysitting responsibilities or hosting family functions. Grandparents may
be divorced, causing their children and grandchildren to face issues such as grandmother’s weekend trips with
her new male friend or grandpop’s new, much younger wife. The family may need to be referred for
counseling to help them address these issues.
Grandparenthood is a learned role and some older individuals may need guidance to become effective
grandparents. Older adults may need to be guided in thinking through issues such as:
Respecting their children as parents and not interfering in the parent–child relationship
Calling before visiting
Establishing rules for babysitting
Allowing their children to establish their own traditions within their family and not expecting them to
adhere to the grandparent’s traditions
Nurses can help families locate resources that can assist in meeting the challenges of grandparenting. Also,
nurses can suggest activities that can help grandparents be connected with their grandchildren, particularly if
they are not geographically close; these can include audio- and videotapes, e-mails, videoconferencing, texting,
faxes, and handwritten letters. (In addition to offering a means of communication, these can provide lasting
memories that can be passed from one generation to the next.) Older adults can be encouraged to keep diaries,
scrapbooks, and notebooks of family recipes and customs that can help their grandchildren and future
generations have special insights into their ancestors.
In addition to fulfilling the grandparenting role, many older adults may assume primary child-rearing
responsibilities for their grandchildren. An increasing number of grandparents are raising grandchildren. Over
6 million grandparents have grandchildren under the age of 18 living with them, and many more live with
their grandparents off and on; a grandparent is providing care for nearly one fourth of children younger than 5
years (U.S. Census Bureau, 2012). Full-time caregiving often arises out of crises with the child’s parents, such
as substance abuse, teen pregnancy, or incarceration. Older persons may need help thinking through the
implications of deciding to raise a grandchild; some questions that nurses can raise with grandparents
contemplating this decision include:
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How will raising this child affect your own health, marriage, and lifestyle?
Have you any health conditions that could interfere with this responsibility?
What is your backup plan in the event that you become ill or disabled?
Do you have the energy and physical health required to care for an active child?
Can you afford to care for the child, pay medical and educational expenses, and the like?
What rights and responsibilities will the child’s parent(s) have?
Do you have the legal right to serve as a surrogate parent (e.g., to give consent for medical procedures)?
Have you consulted with an attorney?
Organizations exist to assist grandparents who are raising grandchildren; some are listed at the end of this
chapter.
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LOSS OF SPOUSE
The death of a spouse is a common event that alters family life for many older persons. The loss of that
individual with whom one has shared more love and life experiences and more joys and sorrows than anyone
else may be intolerable. How, after many decades of living with another person, does one adjust to his or her
sudden absence? How does one adjust to setting the table for one, to coming home to an empty house, or to
not touching that warm, familiar body in bed? Adjustment to this significant loss is coupled with the demand
to learn the new task of living alone (Fig. 4-2).
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FIGURE 4-2 • For an older adult, the loss of a spouse means the loss of one’s closest companion of many
years.
The death of a spouse affects more women than men because women tend to have a longer life expectancy
than men. In fact, most women will be widowed by the time they reach their eighth decade of life. Unlike
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many of today’s younger women, who have greater independence through careers and changed norms, most of
today’s older women have led family-oriented lives and have been dependent on their husbands. Their age,
limited education, lack of skills, and long period of unemployment while raising their families are limitations
in a competitive job market. If these women can find employment, adjusting to the new demands of work may
be difficult and stressful. The unemployed widow, however, may learn that pensions or other sources of
income may be reduced or discontinued when the husband dies, necessitating an adjustment to an extremely
limited budget. In addition to financial dependence, the woman may have depended on her husband’s
achievements to provide her with gratification and identity. Frequently, the achievements of children serve
this same purpose. Sexual desires may be unfulfilled because of lack of opportunity, religious beliefs regarding
sex outside marriage, fear of repercussion from children and society, or residual attitudes from early teachings
about sexual mores. If a woman’s marriage promoted friendships with other married couples and only inactive
relationships with single friends, the new widow may find that her number of single female friends is small.
For the most part, when the initial grief of the husband’s death passes, most widows adjust quite well. The
high proportion of older women who are widowed provides an availability of friends who share similar
problems and lifestyles, especially in urban areas. Old friendships may be revived to provide sources of activity
and enjoyment. Some widows may discover that the loss of certain responsibilities, such as cooking and
laundering for their husbands, brings them a new, pleasant freedom. With alternative roles to develop,
sufficient income, and choice over lifestyle, many women are able to make a successful adjustment to
widowhood.
The likelihood of an older adult remarrying after the loss of a spouse diminishes with age. This is
especially true for women who often live longer than men and find a shortage of eligible men, because men of
the same age tend to marry women younger than themselves.
Nurses may facilitate the adjustment to widowhood by identifying sources of friendships and activities
such as clubs, volunteer organizations, or groups of widows in the community and by helping the widow
understand and obtain all the benefits to which she is entitled. This may require reassuring the widow that
enjoying her new freedom and desiring relationships with other men is no reason to feel guilty and may help
her to adjust to the loss of her husband and the new role of widow. (See Chapter 36 for more information on
death and dying.)
KEY CONCEPT
The high prevalence of widows provides opportunities for friendships between women who share
similar challenges and lifestyles.
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148

RETIREMENT
Retirement is another of the major adjustments of an aging individual. This transition brings the loss of a
work role and is often an individual’s first experience of the impact of aging. In addition, retirement can
require adjusting to a reduced income and consequent changes in lifestyle.
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Loss of the Work Role
Retirement is especially difficult in Western society, in which worth is commonly measured by an individual’s
productivity. Work is also often viewed as the dues required for active membership in a productive society.
Many of today’s older persons, raised to value a strong work ethic, hold the attitude that unemployment, for
whatever reason, is an undesirable state.
KEY CONCEPT
Older adults often view work as the dues required for active membership in a productive society.
Occupational identity largely determines an individual’s social position and social role. Although individuals
function differently in similar roles, some behaviors continue to be associated with certain roles, which
promote stereotypes. Certain stereotypes continue to be heard frequently—the tough construction worker, the
wild exotic dancer, the fair judge, the righteous clergyman, the learned lawyer, and the eccentric artist. The
realization that these associations are not consistently valid does not prevent their propagation. Too
frequently, individuals are described in terms of their work role rather than their personal characteristics, for
example, “the nurse who lives down the road” or “my son the doctor.” Considering the extent to which social
identity and behavioral expectations are derived from the work role, it is not surprising that retirement
threatens an individual’s sense of identity (Fig. 4-3). During childhood and adolescence, we are guided toward
an independent, responsible adult role, and in academic settings, we are prepared for our professional roles,
but where and when are we prepared for the role of retiree?
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FIGURE 4-3 • People who define self by their work role may have difficulty adjusting to retirement.
POINT TO PONDER
What do you derive, or think you will derive, from being a nurse in terms of purpose, identity, values,
relationships, activities, and so on? What similar gains are you achieving from other roles in your life?
When one’s work is one’s primary interest, activity, and source of social contacts, separation from work leaves
a significant void in one’s life. Aging individuals should be urged to develop interests unrelated to work.
Retirement is facilitated by learning how to use, appreciate, and gain satisfaction from leisure time throughout
an employed lifetime. In addition, enjoying leisure time is a therapeutic outlet for life stresses throughout the
aging process.
KEY CONCEPT
When work is one’s primary interest, activity, and source of social contacts, separation from work leaves
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a significant void in one’s life.
Gerontological nurses must understand the realities and reactions encountered when working with retired
persons. Although the experience of retirement is unique for each individual, some reactions and experiences
tend to be fairly common. The phases of retirement described by Robert Atchley decades ago continue to
offer insight into this complicated process:
Preretirement phase. When the reality of retirement is evident, preparation for leaving one’s job begins, as
does fantasy regarding the retirement role.
Retirement phase. Following the retirement event, a somewhat euphoric period begins, a “honeymoon
period,” in which fantasies from the preretirement phase are tested. Retirees attempt to do everything
they never had time for simultaneously. A variety of factors (e.g., finances and health) limit this, leading
to the development of a stable lifestyle. As contrasted with those retirees who want to engage in every
fantasy, some individuals choose to rest and do very little; their activity level tends to increase after a few
years.
Disenchantment phase. As life begins to stabilize, a letdown, sometimes a depression, is experienced. The
more unrealistic the preretirement fantasy, the greater the degree of disenchantment.
Reorientation phase. As realistic choices and alternative sources of satisfaction are considered, the
disenchantment with the new retirement routine can be replaced by developing a lifestyle that provides
some satisfaction.
Retirement routine phase. An understanding of the retirement role is achieved, and this provides a
framework for concern, involvement, and action in the older person’s life. Some enter this phase directly
after the honeymoon phase, and some never reach it at all.
Termination of retirement. The retirement role is lost as a result of either the resumption of a work role
or dependency due to illness or disability (Atchley, 1975, 2000).
Different nursing interventions may be required during each phase of retirement. Assisting aging individuals
with their retirement preparations during the preretirement phase is a preventive intervention that enhances
the potential for health and well-being in late life. As a part of such intervention, nurses can encourage aging
individuals to establish and practice good health habits such as following a proper diet; avoiding alcohol, drug,
and tobacco use; and having regular physical examinations. Counseling regarding the realities of retirement
may be part of retirement preparation, whereas helping retirees place their newfound freedom into proper
perspective may be warranted during the honeymoon period of the retirement phase. Being supportive of
retirees during the disenchantment phase without fostering self-pity and helping them identify new sources of
satisfaction may facilitate the reorientation process. Appreciating and promoting the strengths of the stability
phase may reinforce an adjustment to retirement. When the retirement phase is terminated due to disease or
disability, the tactful management of dependency and the respectful appreciation of losses are extremely
important.
As they have done with other life events, baby boomers are changing the thinking about work and
retirement. Increasingly, they are replacing the model of a person being defined by his or her work with one
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that defines a person’s work based on the totality of his or her life. Life coaches and retirement planners are
helping individuals to see that the retirement stage is more meaningful when individuals create a balance of
work, learning, leisure, family time, service to others, and interests and desires postponed during the active
career years (Corbett, 2007). Rather than forfeit working altogether, it is suggested that people stay in the
workforce, but in a different style—that is, one that leaves time for the enjoyment of other interests and a high
quality of life. The baby boomers also are remaining in the workforce longer, with many finding new paths of
employment that enable them to explore their passions and achieve a different sense of purpose, even if it is at
lower levels of compensation.
Nurses’ evaluations of their own attitudes toward retirement are beneficial. Does the nurse see retirement
as a period of freedom, opportunity, and growth or as one of loneliness, dependency, and meaninglessness? Is
the nurse intelligently planning for her own retirement or denying it by avoiding encounters with retirement
realities? Nurses’ views of retirement affect the retiree–nurse relationship. Gerontological nurses can provide
especially good models of constructive retirement practices and attitudes.
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Reduced Income
In addition to the adjustment in work role, retirement often requires older adults to live on a reduced income.
Financial resources are important at any age because they affect our diet, health, housing, safety, and
independence and influence many of our choices in life. Retirement income is less than half the income
earned while fully employed. For most older Americans, Social Security income, originally intended as a
supplement, is actually the primary source of retirement income—and it has not kept pace with inflation. As a
result, the economic profile of many older persons is poor.
Only a minority of the older population has income from a private pension plan, and those who do often
discover that the fixed benefits established when the plan was subscribed are meager by today’s standards
because of inflation. Of the workers who are currently active in the labor force, more than half will not have
pension plans when they retire. More than one in six of all older adults live in poverty, with older African
Americans and Hispanics having nearly twice the rate of poverty as older white persons. Only a minority are
fully employed or financially comfortable. Few older persons have accumulated enough assets during their
lifetime to provide financial security in old age.
A reduction in income is a significant adjustment for many older persons because it triggers other
adjustments. For instance, an active social life and leisure pursuits may have to be markedly reduced or
eliminated. Relocation to less expensive housing may be necessary, possibly forcing the aged to break many
family and community ties. Dietary practices may be severely altered, and health care may be viewed as a
luxury over which other basic expenses, such as food and rent, take priority. If the older parent has to depend
on children for supplemental income, an additional adjustment may be necessary.
Making financial preparations for old age many years before retirement is important. Nurses should
encourage aging working people to determine whether their retirement income plans are keeping pace with
inflation. Also, older individuals need assistance in obtaining all the benefits they are entitled to and in
learning how to manage their income wisely. Nurses should be aware of the impact of economic welfare on
health status and should actively involve themselves in political issues that promote adequate income for all
individuals.
POINT TO PONDER
What are you doing to prepare for your own retirement?
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CHANGES IN HEALTH AND FUNCTIONING
The changes in appearance and bodily function that occur during the aging process make it necessary for the
aging individual to adjust to a new body image. Colorful soft hair turns gray and dry, flexible straight fingers
become bent and painful, body contours are altered, and height decreases. Stairs once climbed several times
daily demand more time and energy to negotiate as the years accumulate. As subtle, gradual, and natural as
these changes may be, they are noticeable and, consequently, affect body image and self-concept.
The manner in which individuals perceive themselves and their functional abilities can determine the roles
they play. A construction worker who has reduced strength and energy may forfeit his work role; a club
member who cannot hear conversations may cease attending meetings; fashion models may stop seeking jobs
when they perceive themselves as old. Interestingly, some persons well into their seventh and eighth decades
refuse to join a senior citizen club because they do not perceive themselves as being “like those old people.”
The nurse will gain insight into the self-concept of older persons by evaluating what roles they are willing to
accept and what roles they reject. Refer to Nursing Diagnosis Highlight 4-1 for a discussion of the possible
nursing diagnosis of Ineffective Role Performance.
It is sometimes difficult for the aging person to accept the body’s declining efficiency. Poor memory, slow
response, easy fatigue, and altered appearance are among the many frustrating results of declining function,
and they are dealt with in various ways. Some older people deny them and often demonstrate poor judgment
in an attempt to make the same demands on their bodies as they did when younger. Others try to resist these
changes by investing in cosmetic surgery, beauty treatments, miracle drugs, and other expensive endeavors that
diminish the budget but not the normal aging process. Still, others exaggerate these effects and impose an
unnecessarily restricted lifestyle on themselves. Societal expectations frequently determine the adjustment
individuals make to declining function.
Common results of declining function are illness and disability. As described in Chapter 1, most older
people have one or more chronic diseases, and more than one third have a serious disability that limits major
activities such as work and housekeeping. Older adults often fear that illness or disability may cause them to
lose their independence. Becoming a burden to their family, being unable to meet the demands of daily living,
and having to enter a nursing facility are some of the fears associated with dependency. Children and parents
may have difficulty exchanging dependent–independent roles. The physical pain arising from an illness may
not be as intolerable as the dependency it causes.
Nurses should help aging persons understand and face the common changes associated with advanced age.
Factors that promote optimum function should be encouraged, including proper diet, paced activity, regular
physical examination, early correction of health problems, effective stress management, and avoidance of
alcohol, tobacco, and drug abuse. Nurses should offer assistance, with attention to preserving as much of the
individual’s independence and dignity as possible.
NURSING DIAGNOSIS HIGHLIGHT 4-1
DISTURBANCE IN THE PERFORMANCE OF THE ROLE
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Overview
Disturbance in the performance of the role exists when there is a change in the perception of how a
person exercises his or her role. This can be associated with a physical, emotional, intellectual,
motivational, educational, or socioeconomic limitation in the ability to fill the role or restrictions in role
performance imposed by others. There can be considerable distress, depression, or anger at not fulfilling
the accustomed role and its associated responsibilities.
Causative or Contributing Factors
Illness, fatigue, pain, declining function, altered cognition, depression, anxiety, knowledge deficit,
limited finances, retirement, lack of transportation, loss of significant other, ageism, and restrictions
imposed by others.
Goal
The client realistically appraises role performance, adjusts to changes in role performance, and learns to
perform responsibilities associated with roles.
Interventions
Assess client’s roles and responsibilities; identify deficits in role performance and reasons for
deficits; review client’s perception of role and feelings associated with altered role performance.
Assist client in realistically evaluating cause of altered role performance and potential for
improvement in role performance.
Identify specific strategies to improve role performance (e.g., instructing, negotiating with family
members to allow client to perform role, counseling client to accept real limitations, referring to
community resources, improving health problem, encouraging client to seek help with
responsibilities, and advising for stress management).
Encourage client to discuss concerns with family members; assist client in arranging family
conference.
Refer client to assistive resources, as appropriate, such as support groups, occupational therapist,
financial counselor, Over 60 Counseling & Employment Service, visiting nurse, or social services.
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CUMULATIVE EFFECTS OF LIFE TRANSITIONS
Shrinking Social World
Many of the changes associated with aging result in loss of social connections and increasing risk of loneliness.
Children are grown and gone, friends and spouse may be deceased, and others who could allay the loneliness
may avoid the older individual because they find it difficult to accept the changes they see or to face the fact
that they too will be old someday. Living in a sparsely populated rural area can geographically isolate older
persons, and fears of crime when living in an urban area may prevent older adults from venturing outside their
homes.
Hearing and speech deficits and language differences can also foster loneliness. Even if in the company of
others, these functional limitations can socially isolate an older person. In addition, insecurity resulting from
multiple losses in communication abilities can lead to suspiciousness of others and a self-imposed isolation.
At a time of many losses and adjustments, personal contact, love, extra support, and attention—not
isolation—are needed. These are essential human needs. It is likely that a failure to thrive will occur in adults
who feel unwanted and unloved just as it does in infants, who display anxiety, depression, anorexia, and
behavioral and other difficulties when they perceive love and attention to be inadequate.
Nurses should attempt to intervene when they detect isolation and loneliness in an older person. Various
programs provide telephone reassurance or home visits as a source of daily human contact. The person’s faith
community may also provide assistance. Nurses can help the older adult locate and join social groups and
perhaps even accompany the individual to the first meeting. A change in housing may be necessary to provide
a safe environment conducive to social interaction. If the older person speaks a language other than English,
relocation to an area in which community members speak that language can often remedy loneliness.
Frequently, pets serve as significant and effective companions for older adults.
Using common sense in nursing care will facilitate social activity. The nurse can review and perhaps
readjust the person’s schedule to conserve energy and maximize opportunities for socialization. Medication
administration should be planned so that during periods of social activity analgesics will provide relief,
tranquilizers will not sedate, diuretics will not reach their peak, and laxatives will not begin working. Likewise,
fluid intake and bathroom visits before activities begin should be planned to reduce the fear or actual
occurrence of incontinence; activities for older adults should include frequent break periods for bathroom
visits. The control of these minor obstacles can often facilitate social interaction.
Nurses should also understand that being alone is not synonymous with being lonely. Periods of solitude
are essential at all ages and provide the opportunity to reflect, analyze, and better understand the dynamics of
one’s life. Older individuals may want periods of solitude to reminisce and review their lives. Some
individuals, young and old, prefer and choose to be alone and do not feel isolated or lonely in any way. Of
course, nurses should always be alert to hearing, vision, and other health problems that may be the cause of
social isolation.
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CONSIDER THIS CASE
Mrs. Ko is a 66-year-old Korean woman who has been widowed for 5 years. She and
her late husband immigrated to the United States 25 years ago and until his death ran a small
convenience store in an area close to where she currently lives. They worked hard and were able to put
their two sons through college. Her health is good, and she manages her home without any problem.
She has two sons, one of which has lived in another state for the past 15 years and the other who has
just married and moved to another state. Mrs. Ko doesn’t drive nor does she live in an area that has
public transportation. She attends a Korean church and is friends with a couple who drive her to church
and take her shopping.
The couple with whom she is friends informs Mrs. Ko that they will be moving in with their
daughter, who lives in another part of the state, so they will not be able to continue their visits with her.
They suggest that she speak to her sons about moving in with one of them, stating that “our children are
supposed to take care of us.” Mrs. Ko agrees that this is the tradition with which she was raised.
During her next telephone conversations with her sons, Mrs. Ko shares the news about her friends’
upcoming relocation and mentions that this has caused her to give some thought to her own future.
Neither son volunteers to have her live with his family. A few days later, she receives a call from one of
her sons, who says, “Mom, Ron (his brother) and I were talking and we think it may be best if you
moved. We found a retirement village not far from where you live that will be good for you and that we
are willing to pay for. We’re coming into town next week to take you there to fill out the paperwork.”
Mrs. Ko is shocked by this because she has never thought of living in a retirement community, but she
doesn’t feel she should object to her sons’ decision.
THINK CRITICALLY
1. What options are there for an older adult like Mrs. Ko to make someone aware of her situation so
that they can assist her in having her preferences expressed and respected?
2. If Mrs. Ko’s sons are unable or unwilling to have her move in with them, what options could be
recommended?
3. How would you counsel a family when a parent’s traditional views about children’s responsibility for
their older parents conflict with the children’s views?
KEY CONCEPT
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Periods of solitude are essential to reflect, analyze, and better understand the dynamics of life.
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Awareness of Mortality
Widowhood, the death of friends, and the recognition of declining functions heighten older persons’
awareness of the reality of their own deaths. During their early years, individuals intellectually understand they
will not live forever, but their behaviors often deny this reality. The lack of a will and burial plans may be
indications of this denial. As the reality of mortality becomes acute with advancing age, interest in fulfilling
dreams, deepening religious convictions, strengthening family ties, providing for the ongoing welfare of
family, and leaving a legacy are often apparent signs.
The thought of impending death may be more tolerable if people understand that their life has had depth
and meaning. Unresolved guilt, unachieved aspirations, perceived failures, and other multitudinous aspects of
“unfinished business” may be better understood and perhaps resolved. Although the state of old age may
provide limited opportunities for excitement and achievement, satisfaction may be gained in knowing that
there were achievements and excitements in other periods of life. The old woman may be frail and wrinkled,
but she can still delight in remembering how she once drove young men wild. The retired old man may feel
that he is useless to society now, but he realizes his worth through the memory of wars he fought to protect
his country and the pride he feels in knowing he enabled his children to obtain an education and start in life
that his parents were unable to provide him. Nurses can help older adults gain this perspective on their lives
through some of the interventions discussed in the following sections.
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RESPONDING TO LIFE TRANSITIONS
When faced with ageism and numerous changes affecting relationships, roles, and health, older adults may
respond in a variety of ways. The older adult’s ability to cope and adjust to life changes determines whether
they reach a stage of integrity or fall to despair. Nurses can help older adults respond to life transitions by
facilitating life review and eliciting a life story, promoting self-reflection, and strengthening older adults’ inner
resources.
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Life Review and Life Story
Life review is the process of intentionally reflecting on past experiences in an effort to resolve troublesome or
traumatic life events and assess one’s life in totality. The significance of a life review in interpreting and
refining our past experiences as they relate to our self-concept and help us understand and accept our life
history has been well discussed (Butler & Lewis, 1982; Webster & Haight, 2002). In gerontological care, life
review has long been recognized as an important process to facilitate integrity in old age (i.e., to help older
people appreciate that their lives have had meaning).
Rather than being a pathologic behavior, discussing the past is therapeutic and important for older
individuals (Fig. 4-4). Life review can be a positive experience because older adults can reflect on the obstacles
they have overcome and accomplishments they have made. It can provide the incentive to heal fractured
relationships and complete unfinished business. Life review, however, can be a painful experience for older
adults who realize the mistakes they’ve made and the lives they’ve hurt. Rather than conceal and avoid these
negative feelings, older adults can benefit by discussing them openly and working through them; referrals to
therapists and counselors may be indicated to assist with unresolved grief, depression, or anxiety.
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FIGURE 4-4 • Reminiscing is a culturally universal phenomenon of aging. It is a way for the older adult to
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reassess life experiences and further develop a sense of accomplishment, fulfillment, and reward in life.
The young can also benefit from the reminiscences of older adults by gaining a new perspective on life as they
learn about their ancestry. Imagine the impact of hearing about slavery, immigration, epidemics,
industrialization, or wars from an older relative who has been part of that history. What history book’s
description of the Great Depression can compare with hearing a grandparent describe events one’s own family
experienced, such as going to bed hungry at night? In addition to their place in the future, the young can fully
realize their link with the past when the desire of older people to reminisce is appreciated and fostered.
The nurse can facilitate life review by eliciting the older adult’s life story. Rich threads of life experience
that create the unique fabric of one’s life are accumulated with aging. When seen in isolation, some of these
threads may seem to have little value or make little sense, much like a network of threads on the undersurface
of a tapestry. However, when the threads are woven together and the tapestry can be viewed as a whole, a
person can see the special purpose of individual life experiences—good and bad. Weaving the threads of life
experiences into the tapestry of a life story can be highly beneficial to the older person and others. Successes
can be appreciated and the value of trials and failures can be realized. Others are able to gain insight into the
person’s life in totality rather than have their understanding limited by what may be an unrepresentative
segment of life that now presents. Customs, knowledge, and wisdom can be recognized, preserved, and passed
to younger generations.
Point to Ponder
What are the major threads that have woven your life tapestry thus far?
Eliciting life stories from older persons is not a difficult process; in fact, many older adults welcome
opportunities to share their life histories and life lessons to interested listeners. Nurses can encourage older
adults to discuss and analyze the dynamics of their lives, and they can be receptive and accepting listeners. Box
4-1 outlines some of the variety of approaches nurses can use to elicit life stories.
Box 4-1 Eliciting Life Stories
Older adults possess rich life histories that have accrued during the many years they have lived. These
unique histories contribute to each person’s identity and individuality. Learning about life histories aids
nurses in understanding older adults’ preferences and activities, facilitating self-actualization, and
preserving identity and continuity of life experiences. Knowledge of life histories also enables caregivers
to see their patients in a larger context, connected to a past full of varied roles and experiences.
A basic requisite to eliciting life stories is a willingness to listen. Often, a direct request will be
sufficient to open the door to a life history. Activities to facilitate this process include the following:
Tree of Life. Ask the older adult to write significant events (graduation, first job, relocations,
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marriages, deaths, childbirths, etc.) from the past on each branch and then discuss each.
Time Line. Ask the older person to write significant events on or near the year when they
occurred and then discuss each.
Life Map. Ask the older adult to write significant events on the map and discuss each.
Oral History. Ask the older adult to start with his or her earliest memory and record the story of
his or her life into a tape recorder. (Suggest that the older person make this recording as a gift for
younger family members.) If the person needs guidance in telling their history, offer a written
outline or questions, or have a volunteer function as an interviewer.
For older adults who may require some facilitation, creative activities, such as compiling a scrapbook or
dictating a family history, can stimulate the process. These creative efforts, as unsophisticated as they may be,
should be recognized as significant legacies from the old to the young. For example, one 75-year-old man
started a family scrapbook for each of his children. Any photograph, newspaper article, or announcement
pertaining to any family member was reproduced and included in every album. The family patiently tolerated
this activity and sent him copies of graduation programs and photographs for every scrapbook. The family
viewed the main value of this activity as providing something benign to keep him occupied. It was not until
years after his death that the significance of this great task was appreciated as a priceless gift. Such tangible
items may serve as an assurance to both young and old that the impact of an aged relative’s life will not cease
at death. Guiding older adults through this experience of compiling a life story not only provides a therapeutic
exercise for them and an invaluable legacy for loved ones but also offers the gerontological nurse the gift of
sharing and honoring the unique life journeys of older adults.
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Self-Reflection
One of the hallmarks of successful aging is knowledge of self—that is, an awareness of the realities of who one
is and one’s place in the world. From infancy on, we engage in dynamic experiences that mold the unique
individuals we are. By adulthood, we have formed the skeleton of our identities. Continued interactions and
life experiences as we journey through life further add to the development of our identities.
The self, the personal identity an individual possesses, has several dimensions that basically can be
described as body, mind, and spirit. The body includes physical characteristics and functioning; the mind
encompasses cognition, perception, and emotions; and the spirit consists of meaning and purpose derived
from a relationship with God or other higher power. A variety of factors affect the development of body,
mind, and spirit, such as genetic makeup, family composition and dynamics, roles, ethnicity, environment,
education, religious experiences, relationships, culture, lifestyle, and health practices (Fig. 4-5).
FIGURE 4-5 • The holistic self.
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POINT TO PONDER
What are the significant factors of your background that influenced your unique body, mind, and spirit?
Although a realistic appraisal of one’s identity and place in the world fosters healthy aging, not all persons
complete this task successfully. Some people may live with unrealistic expectations or views of themselves,
going through life playing parts that are ill suited for them and wasting time in fruitless or unfulfilling
activities. Harry is an example of this:
Harry, the eldest of five children, was raised in an inner-city community in which poverty was the norm. His
father was an auto mechanic who had difficulty holding jobs. His mother didn’t miss an opportunity to voice her
dissatisfaction with her husband’s meager income nor to emphasize to Harry that he needed to be sure to “make it big
and not be like his father.”
The message instilled by his mother and his desire for a better life than he enjoyed as a child fueled Harry to be a
high achiever. By age 30, Harry owned a small chain of convenience stores, a large home in the suburbs, several luxury
cars, and most of the possessions that reflected an upper-middle-class lifestyle. Harry was proud that he could provide a
comfortable life for his wife and expensive education for his children—quite the opposite of what his father achieved.
Yet, something was missing. His business demanded most of his time and energy; therefore, he had little left of himself
to offer his family. He also rarely had the time for his passion, restoring classic cars. His life seemed to consist of
managing his businesses and sleeping, with an occasional social event with his family. Time for relaxation and
reflection had no place in Harry’s busy life.
In his late 50s, with children grown and his business worth enough to provide a comfortable retirement income,
Harry was in a position where he didn’t have to work the long days—or at all for that matter. His wife encouraged
him to consider selling his business and spend his time “tinkering with cars and taking it easy.” Although he was
tempted, Harry felt that he just couldn’t do this. Unfortunately, the script to “make it big,” programmed into Harry’s
mind as a child, held him prisoner to a role that brought him little joy and fulfillment. Furthermore, he had no idea of
what his purpose and identity was other than being an entrepreneur.
Like Harry, many individuals may reach their senior years without having evaluated who they really are,
what drives them to behave as they do, or what their true purposes and pleasures are.
KEY CONCEPT
Some adults may not have invested the time and effort in self-evaluation and, consequently, reach old
age with a lack of clarity of their identity.
Exploring and learning about one’s true self are significant to holistic health in late life. Examining and
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coming to terms with thoughts, feelings, beliefs, and behaviors foster older adults’ reaching a state of integrity
rather than feeling despair over the lives they’ve lived. However, as important a process as it is, self-reflection
does not come easily or naturally for some individuals. They may require interventions to facilitate this
process; therefore, guiding aging people through self-reflective activities is an important therapeutic measure
that gerontological nurses may need to offer. Life review and telling one’s life story can function as self-
reflective activities. In addition, other activities that facilitate self-reflection include journaling, writing letters
and e-mails, and reflecting through art. These certainly do not exhaust the strategies that can be used to foster
self-reflection. Nurses are bound only by their creativity in the approaches used for promoting self-reflection.
Journaling
Whether it is done with pencil and paper or a word processing program, the process of writing often facilitates
self-reflection. There is no one right way to keep a journal or diary; individuals should develop styles that are
comfortable for them. Some people may make daily entries that include details about their communications,
sleep patterns, mood, and activities, whereas others make periodic entries that address major emotional and
spiritual issues. Nurses can assist individuals who have not kept journals and diaries by guiding them in the
selection of a blank book and writing instrument. This is an important step, not only because these tools will
be used often but also because the book will be a tangible compilation of significant thoughts and feelings that
could have meaning to others in years to come. Novices to journaling can be encouraged to start by reflecting
on their lives and beginning their journals/diaries with a summary of the past. Suggesting that feelings and
thoughts be written, in addition to the events of the day, can contribute to the process being one that fosters
self-reflection.
Writing Letters and E-Mails
Letters or e-mails are another means to reflect and express feelings. Often, thoughts and feelings that
individuals may not feel comfortable verbalizing can be expressed in writing. For some older adults, letters of
explanation and apology to friends and family with whom there have been strained relationships can be a
healing exercise. Older people can be encouraged to locate friends and family in other parts of the country (or
world) with whom they have not had contact for a while and to initiate communication concerning what has
transpired in their lives and current events. Letters to grandchildren and other younger members of the family
can provide a means to share relevant family history and offer special attention (many children love to receive
their own mail!). Older adults may enjoy communicating by e-mail because of the ease and relatively low cost.
If older adults do not own their own computers, nurses can refer them to local senior centers or libraries that
offer free or nominal cost access to the Internet.
Reflecting Through Art
Many people find that painting, sculpting, weaving, and other forms of creative expression facilitate self-
reflection and expression. It is important that the process, not the finished product, be emphasized. Arts and
crafts classes and groups often are offered by local organizations dedicated to specific activities (e.g., weavers’
guild and arts’ council), schools, and senior centers. Nurses can assist older adults in locating such groups in
their communities.
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KEY CONCEPT
Producing a work of art, discussing literature, and sharing one’s life story are among the many
interventions that can be used to foster self-reflection.
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Strengthening Inner Resources
The declines and dependencies that increasingly are present in late life can cause us to view older adults as
being fragile and incapable. However, most older individuals possess significant inner resources—physical,
emotional, and spiritual—that have enabled them to survive to old age. Behaviors that exemplify their survivor
capabilities are described in Box 4-2.
Box 4-2 Characteristics Reflective of Survivor Competencies
of Aging Individuals
Assumption of responsibility for self-care
Mobilization of internal and external resources to solve problems and manage crises
Development of support system via a network of family, friends, and professional individuals and
groups (e.g., social clubs, churches, physicians, and volunteers)
Sense of control over life events
Adaptation to change
Perseverance in the face of obstacles and difficulties
Recovery from trauma
Realization and acceptance of reality that life includes positive and negative events
Discovery of meaning in life events
Determination to fulfill personal, family, community, and work expectations despite difficulties
and distractions
Recognition of limitations and competencies
Ability to trust, love, and forgive and to accept trust, love, and forgiveness
KEY CONCEPT
By considering the strengths displayed by older adults as they navigate the aging process, nurses and
others can develop an enlightened perspective of the older population.
Against the backdrop of threats to independence and self-esteem, nurses best serve older adults by
maintaining and bolstering their inner strengths. Basic to this effort is ensuring physical health and well-
being. It is quite challenging for persons of any age to optimally meet intellectual, emotional, socioeconomic,
and spiritual challenges when their basic physical needs are not fully satisfied or they are experiencing the
symptoms associated with deviations from health. Comprehensive and regular assessment of health status and
interventions to promote health provide a solid base from which inner strengths can be nurtured.
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POINT TO PONDER
How would you judge your “survivor competencies?” What experiences have contributed to this?
By being empowerment facilitators, nurses can support older adults’ inner strengths. Nurses must begin this
process by examining and strengthening their own level of empowerment. When nurses develop a mindset of
seeing possibilities despite fiscal and other constraints, they are better able to help older adults see possibilities
despite potential constraints imposed by age and illness. In addition to being role models, nurses can facilitate
empowerment by:
Including and encouraging the active participation of older adults in care planning and caregiving
activities to the maximum extent possible
Avoiding ageist attitudes that can be communicated through the manner of speaking to older adults
(e.g., raising voice due to assumption all older people are hearing impaired and using terms like
“Sweetie” or “Pops”) and practices (e.g., having signs like “Fall Risk” or “Toilet q2h” in view of others
and labeling clothing in a manner that is visible to others)
Providing a variety of options to older people and freedom to choose among them
Equipping older adults for maximum self-care and self-direction by educating, relating, coaching,
sharing, and supporting them
Advocating for older adults as they seek information, make decisions, and execute their own selected
self-care strategies
Offering feedback, positive reinforcement, encouragement, and support
Concept Mastery Alert
Nurses can facilitate empowerment by avoiding ageist attitudes and practices, such as having signs like
“Fall risk” taped to a client’s door, in view of others.
A sense of hope fosters empowerment and is a thread that reinforces the fabric of inner strengths. Hope is an
expectation that a problem will be resolved, relief will be obtained, and something desired will be obtained.
Hope enables people to see beyond the present and make sense of the senseless. It empowers them to take
action. Nurses foster hope in older people by honoring the value of their lives despite infirmities and
limitations, assisting in establishing goals, supporting the use of coping strategies, building on capabilities, and
displaying an optimistic, caring attitude. Spiritual beliefs and practices also provide inner strength that enables
older adults to cope with current challenges and maintain hope and optimism for the future (see Chapter 15);
nurses need to support older individuals in their prayers, devotional readings, church attendance, and other
expressions of spirituality.
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BRINGING RESEARCH TO LIFE
The Role of Transcendence in a Holistic View of Successful Aging: a Concept Analysis and
Model of Transcendence in a Maturation and Aging
Source: McCarthy, V. L., & Bockweg, A. (2013). Journal of Holistic Nursing, 31(2), 84–94.
The authors adapted a method of concept analysis (a technique of systematically describing phenomena to
enhance understanding) to analyze literature from nursing and other disciplines to gain an understanding of
transcendence. Transcendence refers to that which exists beyond the material universe or physical human
experience. They examined empirical studies on transcendence to clarify the meaning of the term and identify
indicators by which it could be measured. They found few studies of transcendence as it related to successful
aging. They did find more studies related to self-transcendence, a process in which there is a gradual
expansion of one’s personal limits and expectations for self, others, and the world; this is a process viewed as
achievable for persons of any age.
Antecedents (conditions that promoted transcendence) and attributes (the products of transcendence)
were identified. Antecedents included storytelling, communicating feelings, opportunities for positive
solitude, time spent in activities, closeness to nature, engagement in art-related activities, intellectual
creativity, lifelong learning, and belonging to a family, group, or community. Attributes of transcendence
included unity with self and God/the sacred, awareness of dimensions greater than oneself, sense of purpose,
altruism, increased self-acceptance, self-fulfillment, and integration of past and future to make sense of the
present. Based on their findings, they identified five domains associated with transcendence: relationships,
creativity, contemplation, introspection, and spirituality.
The conceptual model developed by the authors could offer gerontological nurses guidance in planning
interventions to assist aging individuals in healthy, successful aging. These interventions could include
providing guided imagery to stimulate artistic activities, assisting the older adult in finding periods of solitude
in natural settings, and planning activities that offer the opportunity for the older adult to share his or her life
story.
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PRACTICE REALITIES
Widowed 78-year-old Mrs. Knight lives in the house she was raised in and in which she raised her own
family. Her 56-year-old unemployed son lives with her, and a daughter lives in a neighboring state.
Despite her independence, Mrs. Knight is a cause of concern for her daughter who believes her brother is
taking advantage of their mother. The daughter has suggested to Mrs. Knight that she move in with her. Mrs.
Knight has refused, stating that her son “just couldn’t make it on his own.”
The daughter shares her concerns with the nurse practitioner who works in the practice that manages
Mrs. Knight’s care.
What would be reasonable actions for the nurse practitioner to take?
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CRITICAL THINKING EXERCISES
1. What examples of ageism can be found in television programs, advertisements, and other vehicles of
communication?
2. How will the life experiences of today’s 30-year-old woman affect her ability to adapt to old age? What
factors will enable her to cope more or less as well than her grandmother’s generation of women?
3. Describe actions nurses can take to help aging individuals prepare for retirement.
4. How can you determine if an older individual’s time alone is reflective of needed solitude or social
isolation?
5. How can the gerontological nurse elicit life stories from older adults in the midst of caregiving demands
during a busy shift?
6. In what ways will today’s young generation be in a better or worse position than today’s older population
in developing survivor competencies?
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Chapter Summary
One challenge and transition individuals face as they age is changes in family roles and relationships. Nuclear
families have reduced the daily interaction and fulfillment of needs between older parents and their children.
Many older adults are grandparents, and increased numbers are providing care for minor grandchildren.
The tendency for women to marry men older than themselves and to have a longer life expectancy than
men causes a greater prevalence of older widows than widowers. Adjusting to widowhood can be a challenge
for some older women.
Retirement can be a transition viewed both positively and negatively. The loss of one’s roles, routines, and
relationships can be difficult, but the freedom to explore other interests and shed unwanted responsibilities
can be welcomed. Different types of support can be beneficial during the various phases of retirement.
Changes in health, function, and appearance are significant reminders of the changes with age. Nurses can
aid aging persons by guiding them in positive health practices and measures to promote optimal function.
There are several processes that can help aging persons respond to life transitions in a healthy manner.
These include life review, self-reflections, and strengthening inner resources. Nurses should explore the
manner in which older adults are responding to life transitions and offer support and guidance to assist them
in navigating these new challenges.
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Online Resources
AARP Grandparent Information Center
http://www.aarp.org
AARP Retirement Calculator
http://www.aarp.org
Grandparents Raising Grandchildren
http://www.uwex.edu
International Institute for Reminiscence and Life Review

UW Superior Home

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http://www.aarp.org

http://www.aarp.org

http://www.uwex.edu

UW Superior Home

References
Atchley, R. C. (1975). The sociology of retirement. Cambridge, MA: Schenkman.
Atchley, R. C. (2000). Social forces and aging (9th ed.). Belmont, CA: Wadsworth.
Butler, R. H., & Lewis, M. I. (1982). Aging and mental health (3rd ed., p. 58). St. Louis, MO: Mosby.
Butler, R. H., Lewis, M. I., & Sutherland, T. (1991). Aging and mental health (4th ed.). New York, NY:
Merrill/MacMillan.
Corbett, D. (2007). Portfolio life. The new path to work, purpose, and passion after 50. San Francisco, CA:
John Wiley and Sons.
Erikson, E. (1963). Childhood and society (2nd ed.). New York, NY: Norton.
Linville, D., & O’Neil, M. (2015). Same sex parents and their children. American Association for Marriage
and Family Therapy. Retrieved July 23, 2015 from
http://www.aamft.org/imis15/aamft/Content/Consumer_Updates/Same-
sex_Parents_and_Their_Children.aspx
MetLife. (2011). The MetLife report on American grandparents: new insights for a new generation of
grandparents. Westport, CT: MetLife Mature Market Institute.
U.S. Census Bureau. (2012). 2007 American community survey. Retrieved April 9, 2012 from
http://www.census.gov/acs/www/
Webster, J. D., & Haight, B. K. (2002). Critical advances in reminiscence work: from theory to application.
New York, NY: Springer.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
178

http://www.aamft.org/imis15/aamft/Content/Consumer_Updates/Same-sex_Parents_and_Their_Children.aspx

http://www.census.gov/acs/www/

http://thepoint.lww.com/Eliopoulos9e

CHAPTER 5
Common Aging Changes
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CHAPTER OUTLINE
Changes To The Body
Cells
Physical Appearance
Respiratory System
Cardiovascular System
Gastrointestinal System
Urinary System
Reproductive System
Musculoskeletal System
Nervous System
Sensory Organs
Endocrine System
Integumentary System
Immune System
Thermoregulation
Changes To The Mind
Personality
Memory
Intelligence
Learning
Attention Span
Nursing Implications Of Age-Related Changes
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. List common age-related changes at the cellular level; in physical appearance; and to the respiratory, cardiovascular, gastrointestinal,
urinary, reproductive, musculoskeletal, nervous, endocrine, integumentary, and immune systems, the sensory organs, and thermoregulation.
2. Describe psychological changes experienced with age.
3. Discuss nursing actions to promote health and reduce risks associated with age-related changes.
TERMS TO KNOW
Crystallized intelligence knowledge accumulated over a lifetime; arises from the dominant hemisphere of the brain
Fluid intelligence involves new information emanating from the nondominant hemisphere; controls emotions, retention of nonintellectual
information, creative capacities, spatial perceptions, and aesthetic appreciation
Immunosenescence the aging of the immune system
Presbycusis progressive hearing loss that occurs as a result of age-related changes to the inner ear
Presbyesophagus a condition characterized by a decreased intensity of propulsive waves and an increased frequency of nonpropulsive waves
in the esophagus
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Presbyopia the inability to focus or accommodate properly due to reduced elasticity of the lens
Living is a process of continual change. Infants become toddlers, prepubescent children blossom into young
men and women, and dependent adolescents develop into responsible adults. The continuation of change into
later life is natural and expected.
The type, rate, and degree of physical, emotional, psychological, and social changes experienced during
life are highly individualized; such changes are influenced by genetic factors, environment, diet, health, stress,
lifestyle choices, and numerous other elements. The result is not only individual variations among older
persons but also differences in the pattern of aging of various body systems within the same individual.
Although some similarities exist in the patterns of aging among individuals, the pattern of aging is unique in
each person.
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CHANGES TO THE BODY
Cells
Organ and system changes can be traced to changes at the basic cellular level. The number of cells is gradually
reduced, leaving fewer functional cells in the body. Lean body mass is reduced, whereas fat tissue increases
until the sixth decade of life. Total body fat as a proportion of the body’s composition increases (St-Onge &
Gallagher, 2010; Woo, Leung, & Kwok, 2007). Cellular solids and bone mass are decreased. Extracellular
fluid remains fairly constant, whereas intracellular fluid is decreased, resulting in less total body fluid. This
decrease makes dehydration a significant risk to older adults.
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Physical Appearance
Many physical changes of aging affect a person’s appearance (Fig. 5-1). Some of the more noticeable effects of
the aging process begin to appear after the fourth decade of life. It is then that men experience hair loss, and
both sexes develop gray hair and wrinkles. As body fat atrophies, the body’s contours gain a bony appearance
along with a deepening of the hollows of the intercostal and supraclavicular spaces, orbits, and axillae.
Elongated ears, a double chin, and baggy eyelids are among the more obvious manifestations of the loss of
tissue elasticity throughout the body. Skinfold thickness is significantly reduced in the forearm and on the
back of the hands. The loss of subcutaneous fat content, responsible for the decrease in skinfold thickness, is
also responsible for a decline in the body’s natural insulation, making older adults more sensitive to cold
temperatures.
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FIGURE 5-1 • Age-related changes noticeable on inspection.
Stature decreases, resulting in a loss of approximately 2 in. in height by 80 years of age. Body shrinkage is due
to reduced hydration, loss of cartilage, and thinning of the vertebrae. The decrease in stature causes the long
bones of the body, which do not shrink, to appear disproportionately long. Any curvature of the spine, hips,
and knees that may be present can further reduce height.
These changes in physical appearance are gradual and subtle. Further differences in physiologic structure
and function can arise from changes to specific body systems.
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185

Respiratory System
The changes to the respiratory system are apparent at the entrance to the system with changes to the nose.
Connective tissue changes cause a relaxation of the tissue at the lower edge of the septum; the reduced support
causes the tip of the nose to slightly rotate downward. Septal deviations can occur, as well. Mouth breathing
during sleep becomes more common as a result, contributing to snoring and obstructive apnea. The
submucosal glands have decreased secretions, reducing the ability to dilute mucus secretion; the thicker
secretions are more difficult to remove and give the older person a sensation of nasal stuffiness.
Various structural changes occur in the chest with age that reduce respiratory activity (Fig. 5-2). The
calcification of costal cartilage makes the trachea and rib cage more rigid; the anterior–posterior chest
diameter increases, often demonstrated by kyphosis; and thoracic inspiratory and expiratory muscles are
weaker. There is a blunting of the cough and laryngeal reflexes. In the lungs, cilia reduce in number and there
is hypertrophy of the bronchial mucous gland, further complicating the ability to expel mucus and debris.
Alveoli reduce in number and stretch due to a progressive loss of elasticity—a process that begins by the sixth
decade of life. The lungs become smaller, less firm, lighter, and more rigid and have less recoil.
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FIGURE 5-2 • Respiratory changes that occur with aging.
The sum of these changes causes less lung expansion, insufficient basilar inflation, and decreased ability to
expel foreign or accumulated matter. The lungs exhale less effectively, thereby increasing the residual volume.
As the residual volume increases, the vital capacity is reduced; maximum breathing capacity also decreases.
Immobility can further reduce respiratory activity. The decline in ventilatory capacity is noticeable primarily
when an extra breathing demand is present, as the lower pulmonary reserve results in dyspnea more easily
occurring. With less effective gas exchange and lack of basilar inflation, older adults are at high risk for
developing respiratory infections. Endurance training can produce a significant increase in lung capacity of
older adults.
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Cardiovascular System
Some cardiovascular changes commonly attributed to age actually result from pathological conditions. Heart
size does not change significantly due to age; rather, enlarged hearts are associated with cardiac disease, and
marked inactivity can cause cardiac atrophy. There is a slight left ventricular hypertrophy with age, and the
aorta becomes dilated and elongated. Atrioventricular valves become thick and rigid as a result of sclerosis and
fibrosis, compounding the dysfunction associated with any cardiac disease that may be present. There may be
incomplete valve closure resulting in systolic and diastolic murmurs. Extra systolic sinus bradycardia and sinus
arrhythmia can occur in relation to irritability of the myocardium.
Age-related physiologic changes in the cardiovascular system appear in a variety of ways (Fig. 5-3).
Throughout the adult years, the heart muscle loses its efficiency and contractile strength, resulting in reduced
cardiac output under conditions of physiologic stress. Pacemaker cells become increasingly irregular and
decrease in number, and the shell surrounding the sinus node thickens. The isometric contraction phase and
relaxation time of the left ventricle are prolonged; the cycle of diastolic filling and systolic emptying requires
more time to be completed.
FIGURE 5-3 • Cardiovascular changes that occur with aging.
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Concept Mastery Alert
Incomplete valve closures can result in systolic and diastolic murmurs in older adults. Diastolic filling
and systolic emptying do not decrease with age but take more time to be completed.
Usually, adults adjust to changes in the cardiovascular system quite well; they learn that it is easier and more
comfortable for them to take an elevator rather than the stairs, to drive instead of walking a long distance, and
to pace their activities. When unusual demands are placed on the heart (e.g., shoveling snow for the first time
of the season, receiving bad news, and running to catch a bus), the person feels the effects. The same holds
true for older individuals who are not severely affected by less cardiac efficiency under nonstressful conditions.
When older persons are faced with an added demand on their hearts, however, they note the difference.
Although the peak rate of the stressed heart may not reach the levels experienced by younger persons,
tachycardia in older people will last for a longer time. Stroke volume may increase to compensate for this
situation, which results in elevated blood pressure, although the blood pressure can remain stable as
tachycardia progresses to heart failure in older adults. The resting heart rate is unchanged.
KEY CONCEPT
Age-related cardiovascular changes are most apparent when unusual demands are placed on the heart.
Maximum exercise capacity and maximum oxygen consumption vary among older people. Older adults in
good physical condition have comparable cardiac function to younger persons who are in poor condition.
Blood vessels consist of three layers, each of which is affected differently by the aging process. The tunica
intima, the innermost layer, experiences the most direct changes, including fibrosis, calcium and lipid
accumulation, and cellular proliferation. These changes contribute to the development of atherosclerosis. The
middle layer, the tunica media, undergoes a thinning and calcification of elastin fibers and an increase in
collagen, which cause a stiffening of the vessels. Impaired baroreceptor function and increased peripheral
resistance occur, which can lead to a rise in systolic blood pressure. Interestingly, although a gradual increase
in blood pressure is common in the United States and other industrialized nations, it does not tend to occur in
less industrialized societies; cross-cultural studies that currently are being conducted will help to clarify if the
rise in blood pressure is a result of normal aging or other factors. The outermost layer, the tunica adventitia, is
not affected by the aging process. Decreased elasticity of the arteries is responsible for vascular changes to the
heart, kidney, and pituitary gland. Reduced sensitivity of the blood pressure–regulating baroreceptors increases
problems with postural hypotension and postprandial hypotension (blood pressure reduction of at least 20 mm
Hg within 1 hour of eating). The reduced elasticity of the vessels, coupled with thinner skin and less
subcutaneous fat, causes the vessels in the head, neck, and extremities to become more prominent.
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190

Gastrointestinal System
Although not as life threatening as respiratory or cardiovascular problems, gastrointestinal symptoms may be
of more bother and concern to older persons. This system is altered by the aging process at all points. Changes
in the teeth and mouth and accessory structures such as the liver also affect gastrointestinal function. Figure 5-
4 summarizes gastrointestinal system changes.
FIGURE 5-4 • Gastrointestinal changes that occur with aging.
Tooth enamel becomes harder and more brittle with age. Dentin, the layer beneath the enamel, becomes
more fibrous and its production is decreased. The nerve chambers become narrower and shorter and teeth are
less sensitive to stimuli. The root pulp experiences shrinkage and fibrosis, the gingiva retracts, and bone
density in the alveolar ridge is lost. Increasing numbers of root cavities and cavities around existing dental
work occur. Flattening of the chewing cusps is common. The bones that support the teeth decrease in density
and height, contributing to tooth loss. Tooth loss is not a normal consequence of growing old, but poor dental
care, diet, and environmental influences have contributed to many of today’s older population being
edentulous. After 30 years of age, periodontal disease is the major reason for tooth loss. More than half of all
older adults must rely on partial or full dentures, which may not be worn regularly because of discomfort or
poor fit. If natural teeth are present, they often are in poor condition; fracture easier; and have flatter surfaces,
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stains, and varying degrees of erosion and abrasion of the crown and root structure. The tooth brittleness of
some older people creates the possibility of aspiration of tooth fragments.
Taste sensations become less acute with age because the tongue atrophies, affecting the taste buds; chronic
irritation (as from pipe smoking) can reduce taste efficiency to a greater degree than that experienced through
aging alone. The sweet sensations on the tip of the tongue tend to suffer a greater loss than the sensations for
sour, salt, and bitter flavors. Excessive seasoning of foods may be used to compensate for taste alterations and
could lead to health problems for older individuals. Loss of papillae and sublingual varicosities on the tongue
are common findings.
Older adults produce approximately one third of the amount of saliva they produced in younger years
(Gupta, Epstein, & Sroussi, 2006; Smith et al., 2013). Saliva often is diminished in quantity and is of
increased viscosity as a result of some of the medications commonly used to treat geriatric conditions. Salivary
ptyalin is decreased, interfering with the breakdown of starches. Diminished muscle strength and tongue
pressure can interfere with mastication and swallowing (Hiramatsu, Kataoka, Osaki, & Hagino, 2015; Ney,
Weiss, Kind, & Robinson, 2009).
Esophageal motility is affected by age. Presbyesophagus is a condition characterized by a decreased
intensity of propulsive waves and an increased frequency of nonpropulsive waves in the esophagus. The
esophagus tends to become slightly dilated, and esophageal emptying is slower, which can cause discomfort
because food remains in the esophagus for a longer time. Relaxation of the lower esophageal sphincter may
occur; when combined with the older person’s weaker gag reflex and delayed esophageal emptying, aspiration
becomes a risk.
The stomach is believed to have reduced motility in old age, along with decreases in hunger contractions.
Studies regarding changes in gastric emptying time have been inconclusive, with some claiming delayed
gastric emptying to occur with normal aging and others attributing it to other factors. The gastric mucosa
atrophies. Hydrochloric acid and pepsin decline with age; the higher pH of the stomach contributes to an
increased incidence of gastric irritation in the older population.
Some atrophy occurs throughout the small and large intestines, and fewer cells are present on the
absorbing surface of intestinal walls. There is a gradual reduction in the weight of the small intestine and
shortening and widening of the villi, leading to them developing the shape of parallel ridges rather than the
finger-like projections of earlier years. Functionally, there is no significant change in mean small bowel transit
time with age. Fat absorption is slower, and dextrose and xylose are more difficult to absorb. Absorption of
vitamin B, vitamin B12, vitamin D, calcium, and iron is faulty. The large intestine has reductions in mucous
secretions and elasticity of the rectal wall. Normal aging does not interfere with the motility of feces through
the bowel, although other factors that are highly prevalent in late life do contribute to constipation. An age-
related loss of tone of the internal sphincter can affect bowel elimination. Slower transmission of neural
impulses to the lower bowel reduces awareness of the need to evacuate the bowels.
With advancing age, the liver has reduced weight and volume but this seems to produce no ill effects. The
older liver is less able to regenerate damaged cells. Liver function tests remain within a normal range. Less
efficient cholesterol stabilization and absorption cause an increased incidence of gallstones. The pancreatic
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ducts become dilated and distended, and often, the entire gland prolapses.
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Urinary System
The urinary system is affected by changes in the kidneys, ureters, and bladder (Fig. 5-5). The renal mass
becomes smaller with age, which is attributable to a cortical loss rather than a loss of the renal medulla. Renal
tissue growth declines and atherosclerosis may promote atrophy of the kidney. These changes can have a
profound effect on renal function, reducing renal blood flow and the glomerular filtration rate by
approximately one half between the ages of 20 and 90 years (Cohen et al., 2014; Lerma, 2009).
FIGURE 5-5 • Urinary tract changes that occur with aging.
Tubular function decreases. There is less efficient tubular exchange of substances, conservation of water and
sodium, and suppression of antidiuretic hormone secretion in the presence of hypo-osmolality. Older kidneys
have less ability to conserve sodium in response to sodium restriction. Although these changes can contribute
to hyponatremia and nocturia, they do not affect specific gravity to any significant extent. The decrease in
tubular function also causes decreased reabsorption of glucose from the filtrate, which can cause 1+
proteinurias and glycosurias not to be of major diagnostic significance.
Urinary frequency, urgency, and nocturia accompany bladder changes with age. Bladder muscles weaken
and bladder capacity decreases. Emptying of the bladder is more difficult; retention of large volumes of urine
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may result. The micturition reflex is delayed. Although urinary incontinence is not a normal outcome of
aging, some stress incontinence may occur because of a weakening of the pelvic diaphragm, particularly in
multiparous women.
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Reproductive System
As men age, the seminal vesicles are affected by a smoothing of the mucosa, thinning of the epithelium,
replacement of muscle tissue with connective tissue, and reduction of fluid-retaining capacity. The
seminiferous tubules experience increased fibrosis, thinning of the epithelium, thickening of the basement
membrane, and narrowing of the lumen. The structural changes can cause a reduction in sperm count in some
men. Increases in follicle-stimulating and luteinizing hormone levels occur, along with decreases in both
serum and bioavailable testosterone levels. Venous and arterial sclerosis and fibroelastosis of the corpus
spongiosum can affect the penis with age. The older man does not lose the physical capacity to achieve
erections or ejaculations, although orgasm and ejaculation tend to be less intense (Sampson, Untergasser, Plas,
& Berger, 2007). There is some atrophy of the testes.
Prostatic enlargement occurs in most older men (Marks, Roehrborn, & Andiole, 2006). The rate and type
vary among individuals. Three fourths of men aged 65 years and older have some degree of prostatism, which
causes problems with urinary frequency. Although most prostatic enlargement is benign, it does pose a greater
risk of malignancy and requires regular evaluation.
The female genitalia demonstrate many changes with age, including atrophy of the vulva from hormonal
changes, accompanied by the loss of subcutaneous fat and hair and a flattening of the labia. The vagina of the
older woman appears pink and dry with a smooth, shiny canal because of the loss of elastic tissue and rugae.
The vaginal epithelium becomes thin and avascular. The vaginal environment is more alkaline in older women
and is accompanied by a change in the type of flora and a reduction in secretions. The cervix atrophies and
becomes smaller; the endocervical epithelium also atrophies. The uterus shrinks and the endometrium
atrophies; however, the endometrium continues to respond to hormonal stimulation, which can be responsible
for incidents of postmenopausal bleeding in older women on estrogen therapy. The ligaments supporting the
uterus weaken and can cause a backward tilting of the uterus; this backward displacement along with the
reduced size of the uterus can make it difficult to palpate during an exam. The fallopian tubes atrophy and
shorten with age, and the ovaries atrophy and become thicker and smaller. The ovaries can shrink to such a
small size that they are not palpable during an exam. Despite these changes, the older woman does not lose
the ability to engage in and enjoy intercourse or other forms of sexual pleasure. Estrogen depletion also causes
a weakening of pelvic floor muscles, which can lead to an involuntary release of urine when there is an increase
in intra-abdominal pressure.
Figure 5-6 summarizes age-related changes in male and female reproductive systems.
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FIGURE 5-6 • Changes in the male and female reproductive structures that occur with aging.
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Musculoskeletal System
The kyphosis, enlarged joints, flabby muscles, and decreased height of many older persons result from the
variety of musculoskeletal changes occurring with age (Fig. 5-7). Along with other body tissue, muscle fibers
atrophy and decrease in number, with fibrous tissue gradually replacing muscle tissue. Overall muscle mass,
muscle strength, and muscle movements are decreased; the arm and leg muscles, which become particularly
flabby and weak, display these changes well. Sarcopenia, the age-related loss of muscle mass, strength, and
function, is mostly seen in inactive persons; thus, the importance of exercise to minimize the loss of muscle
tone and strength cannot be emphasized enough. Muscle tremors may be present and are believed to be
associated with degeneration of the extrapyramidal system. The tendons shrink and harden, which causes a
decrease in tendon jerks. Reflexes are lessened in the arms, are nearly totally lost in the abdomen, but are
maintained in the knee. For various reasons, muscle cramping frequently occurs.
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FIGURE 5-7 • Skeletal changes that occur with aging.
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Bone mineral and bone mass are reduced, contributing to the brittleness of the bones of older people,
especially older women who experience an accelerated rate of bone loss after menopause. Bone density
decreases at a rate of 0.5% each year after the third decade of life. There is diminished calcium absorption, a
gradual resorption of the interior surface of the long bones, and a slower production of new bone on the
outside surface. These changes make fractures a serious risk to the older adults. Although long bones do not
significantly shorten with age, thinning disks and shortening vertebrae reduce the length of the spinal column,
causing a reduction in height with age. Height may be further shortened because of varying degrees of
kyphosis, a backward tilting of the head, and some flexion at the hips and knees. A deterioration of the
cartilage surface of joints and the formation of points and spurs may limit joint activity and motion.
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Nervous System
It is difficult to identify with accuracy the exact impact of aging on the nervous system because of the
dependence of this system’s function on other body systems. For instance, cardiovascular problems can reduce
cerebral circulation and be responsible for cerebral dysfunction. There is a decline in brain weight and a
reduction in blood flow to the brain; however, these structural changes do not appear to affect thinking and
behavior (Rabbitt et al., 2007). Declining nervous system function may be unnoticed because changes are
often nonspecific and slowly progressing.
A reduction in neurons, nerve fibers, cerebral blood flow, and metabolism is known to occur. Reduced
cerebral blood flow is accompanied by a reduction in glucose utilization and metabolic rate of oxygen in the
brain. Although β-amyloid and neurofibrillary tangles are associated with Alzheimer’s disease, they can be
present in older adults with normal cognitive function.
The nerve conduction velocity is lower (Fig. 5-8). These changes are manifested by slower reflexes and
delayed response to multiple stimuli. Kinesthetic sense lessens. There is a slower response to changes in
balance, a factor contributing to falls. Slower recognition and response to stimuli is associated with a decrease
in new axon growth and nerve reinnervation of injured peripheral nerves.
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FIGURE 5-8 • Neurologic changes that occur with aging.
The hypothalamus regulates temperature less effectively. Brain cells slowly decline over the years, the cerebral
cortex undergoes some loss of neurons, and there is some decrease in brain size and weight, particularly after
age 55 years. Because the brain affects the sleep–wake cycle, and circadian and homeostatic factors of sleep
regulation are altered with aging, changes in the sleep pattern occur, with stages III and IV of sleep becoming
less prominent (Munch, Knoblauch, Blatter, Wirz-Justice, & Cajochen, 2007). Frequent awakening during
sleep is not unusual, although only a minimal amount of sleep is actually lost.
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203

Sensory Organs
Each of the five senses becomes less efficient with advanced age, interfering in varying degrees with safety,
normal activities of daily living, and general well-being (Fig. 5-9).
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FIGURE 5-9 • Effects of sensory changes that occur with aging.
Vision
Perhaps the sensory changes having the greatest impact are changes in vision. Presbyopia, the inability to
focus or accommodate properly due to reduced elasticity of the lens, is characteristic of older eyes and begins
in the fourth decade of life. The stiffening of the muscle fibers of the lens that occurs with presbyopia
decreases the eye’s ability to change the shape of the lens to focus on near objects and decreases the ability to
adapt to light. This vision problem causes most middle-aged and older adults to need corrective lenses to
accommodate close and detailed work. The visual field narrows, making peripheral vision more difficult.
There is difficulty maintaining convergence and gazing upward. The pupil is less responsive to light because
the pupillary sphincter hardens, the pupil size decreases, and rhodopsin content in the rods decreases. As a
result, the light perception threshold increases and vision in dim areas or at night is difficult; older individuals
require more light than younger persons to see adequately.
Alterations in the blood supply of the retina and retinal pigmented epithelium can cause macular
degeneration, a condition in which there is a loss in central vision. Changes in the retina and retinal pathway
interfere with critical flicker fusion (the point at which a flickering light is perceived as continuous rather than
intermittent).
The density and size of the lens increase, causing the lens to become stiffer and more opaque.
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Opacification of the lens, which begins in the fifth decade, leads to the development of cataracts, which
increases sensitivity to glare, blurs vision, and interferes with night vision. Exposure to the ultraviolet rays of
the sun contributes to cataract development. Yellowing of the lens (possibly related to a chemical reaction
involving sunlight with amino acids) and alterations in the retina that affect color perception make older
people less able to differentiate the low-tone colors of the blues, greens, and violets.
Depth perception becomes distorted, causing problems in correctly judging the height of curbs and steps.
This change results from a disparity between the retinal images caused by the separation of the two eyes and is
known as stereopsis. Dark and light adaptation takes longer, as does the processing of visual information. Less
efficient reabsorption of intraocular fluid increases the older person’s risk of developing glaucoma. The ciliary
muscle gradually atrophies and is replaced with connective tissue.
The appearance of the eye may be altered; reduced lacrimal secretions can cause the eyes to look dry and
dull, and fat deposits can cause a partial or complete glossy white circle to develop around the periphery of the
cornea (arcus senilis). Corneal sensitivity is diminished, which can increase the risk of injury to the cornea.
The accumulation of lipid deposits in the cornea can cause a scattering of light rays, which blurs vision. In the
posterior cavity, bits of debris and condensation become visible and may float across the visual field; these are
commonly called floaters. Vitreous decreases and the proportion of liquid increases, causing the vitreous body
to pull away from the retina; blurred vision, distorted images, and floaters may result. Visual acuity
progressively declines with age due to decreased pupil size, scatter in the cornea and lens, opacification of the
lens and vitreous, and loss of photoreceptor cells in the retina.
Hearing
Presbycusis is progressive hearing loss that occurs as a result of age-related changes to the inner ear, including
loss of hair cells, decreased blood supply, reduced flexibility of basilar membrane, degeneration of spiral
ganglion cells, and reduced production of endolymph. This degenerative hearing impairment is the most
serious problem affecting the inner ear and retrocochlea. High-frequency sounds of 2,000 Hz and above are
the first to be lost; middle and low frequencies also may be lost as the condition progresses. A variety of
factors, including continued exposure to loud noise, may contribute to the occurrence of presbycusis. This
problem causes speech to sound distorted as some of the high-pitched sounds (s, sh, f, ph, and ch) are filtered
from normal speech and consonants are less able to be discerned. This change is so gradual and subtle that
affected persons may not realize the extent of their hearing impairment. Hearing can be further jeopardized by
an accumulation of cerumen in the middle ear; the higher keratin content of cerumen as one ages contributes
to this problem. The acoustic reflex, which protects the inner ear and filters auditory distractions from sounds
made by one’s own body and voice, is diminished due to a weakening and stiffening of the middle ear muscles
and ligaments. In addition to hearing problems, equilibrium can be altered because of degeneration of the
vestibular structures and atrophy of the cochlea, organ of Corti, and stria vascularis.
KEY CONCEPT
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Although hearing declines with age, impaired hearing can occur at younger ages due to exposure to loud
music, traffic, and other environmental noise. This noise-induced hearing loss is preventable.
Taste and Smell
Approximately half of all older persons experience some loss of their ability to smell. The sense of smell
reduces with age because of a decrease in the number of sensory cells in the nasal lining and fewer cells in the
olfactory bulb of the brain. By age 80 years, the detection of scent is almost half as sensitive as it was at its
peak. Men tend to experience a greater loss in the ability to detect odors than women.
As most of the taste acuity is dependent on smell, the reduction in the sense of smell alters the sense of
taste. Atrophy of the tongue with age can diminish taste sensations, although there is no conclusive evidence
that the number or responsiveness of taste buds decreases (Fukunaga, Uematsu, & Sugimoto, 2005; Mondon,
Naudin, Beaufilis, & Atanasova, 2014). The ability to detect salt is affected more than other taste sensations.
Reduced saliva production, poor oral hygiene, medications, and conditions such as sinusitis can also affect
taste.
Touch
A reduction in the number of and changes in the structural integrity of touch receptors occurs with age.
Tactile sensation is reduced, as observed in the reduced ability of older persons to sense pressure and pain and
differentiate temperatures. These sensory changes can cause misperceptions of the environment and, as a
result, profound safety risks.
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Endocrine System
The endocrine system has groups of cells and glands that produce the chemical messengers known as
hormones. With age, the thyroid gland undergoes fibrosis, cellular infiltration, and increased nodularity. The
resulting decreased thyroid gland activity causes a lower basal metabolic rate, reduced radioactive iodine
uptake, and less thyrotropin secretion and release. Protein-bound iodine levels in the blood do not change,
although total serum iodide is reduced. The release of thyroidal iodide decreases with age, and excretion of the
17-ketosteroids declines. The thyroid gland progressively atrophies, and the loss of adrenal function can
further decrease thyroid activity. Secretion of thyroid-stimulating hormone (TSH) and the serum
concentration of thyroxine (T4) do not change, although there is a significant reduction in triiodothyronine
(T3), believed to be a result of the reduced conversion of T4 to T3. Overall, the thyroid function remains
adequate.
Much of the secretory activity of the adrenal cortex is regulated by adrenocorticotropic hormone
(ACTH), a pituitary hormone. As ACTH secretion decreases with age, secretory activity of the adrenal gland
also decreases. Although the secretion of ACTH does not affect aldosterone secretion, it has been shown that
less aldosterone is produced and excreted in the urine of older persons. The secretion of glucocorticoids, 17-
ketosteroids, progesterone, androgen, and estrogen, also influenced by the adrenal gland, is reduced as well.
The pituitary gland decreases in volume by approximately 20% in older persons. Somatotropic growth
hormone remains present in similar amounts, although the blood level may be reduced with age. Decreases are
seen in ACTH, TSH, follicle-stimulating hormone, luteinizing hormone, and luteotropic hormone to varying
degrees. Gonadal secretion declines with age, including gradual decreases in testosterone, estrogen, and
progesterone. With the exception of alterations associated with changes in plasma calcium level or dysfunction
of other glands, the parathyroid glands maintain their function throughout life.
There is a delayed and insufficient release of insulin by the beta cells of the pancreas in older people, and
there is believed to be decreased tissue sensitivity to circulating insulin. The older person’s ability to
metabolize glucose is reduced, and sudden concentrations of glucose cause higher and more prolonged
hyperglycemia levels; therefore, it is not unusual to detect higher blood glucose levels in nondiabetic older
persons.
KEY CONCEPT
Higher blood glucose levels than are normal in the general adult population are not unusual in
nondiabetic older people.
208

209

Integumentary System
Diet, general health, activity, exposure, and hereditary factors influence the normal course of aging of the skin.
This system’s changes are often the most bothersome because they are obvious and clearly reflect advancing
years. Flattening of the dermal–epidermal junction, reduced thickness and vascularity of the dermis, slowing
of epidermal proliferation, and an increased quantity and degeneration of elastin fibers occur. Collagen fibers
become coarser and more random, reducing skin elasticity. The dermis becomes more avascular and thinner.
As the skin becomes less elastic and more dry and fragile, and as subcutaneous fat is lost, lines, wrinkles, and
sagging become evident. Skin becomes irritated and breaks down more easily. There is a reduction in the
number of melanocytes by 10% to 20% each decade beginning by the third decade of life, and the melanocytes
cluster, causing skin pigmentation, commonly referred to as age spots; these are more prevalent in areas of the
body exposed to the sun. The reduction in melanocytes causes older adults to tan more slowly and less deeply.
Skin immune response declines, causing older people to be more prone to skin infections. Benign and
malignant skin neoplasms occur more with age.
Scalp, pubic, and axillary hair thins and grays due to a progressive loss of pigment cells and atrophy and
fibrosis of hair bulbs; hair in the nose and ears becomes thicker. By age 50 years, most white men have some
degree of baldness and about half of all people have evidence of gray hair. Growth rate of scalp, pubic, and
axillary hair declines; the growth of facial hair may occur in older women. An increased growth of eyebrow,
ear, and nostril hair occurs in older men. Fingernails grow more slowly, are fragile and brittle, develop
longitudinal striations, and experience a decrease in lunula size. Perspiration is slightly reduced because the
number and function of the sweat glands are lessened.
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Immune System
The aging of the immune system, known as immunosenescence, includes a depressed immune response,
which can cause infections to be a significant risk of older adults. After midlife, thymic mass decreases
steadily, to the point that serum activity of thymic hormones is almost undetectable in the aged. T-cell activity
declines and more immature T cells are present in the thymus. A significant decline in cell-mediated
immunity occurs, and T lymphocytes are less able to proliferate in response to mitogens. Changes in the T
cells contribute to the reactivation of varicella zoster and Mycobacterium tuberculosis, infections that are
witnessed in many older individuals. Serum immunoglobulin (Ig) concentration is not significantly altered;
the concentration of IgM is lower, whereas the concentrations of IgA and IgG are higher. Responses to
influenza, parainfluenza, pneumococcus, and tetanus vaccines are less effective (although vaccination is
recommended because of the serious potential consequences of infections for older adults). Inflammatory
defenses decline, and, often, inflammation presents atypically in older individuals (e.g., low-grade fever and
minimal pain). In addition, an increase in proinflammatory cytokines occurs with age, which is believed to be
linked to atherosclerosis, diabetes, osteoporosis, and other diseases that increase in prevalence with age.
In addition to maintaining a good nutritional state, older people can include foods in their diet that
positively affect immunity, such as milk, yogurt, nonfat cottage cheese, eggs, fresh fruits and vegetables, nuts,
garlic, onion, sprouts, pure honey, and unsulfured molasses. A daily multivitamin and mineral supplement is
also helpful. Regular physical activity can enhance immune function, including exercises such as yoga and t’ai
chi, which are low impact and have a positive effect on immunity. Stress can affect the function of the
immune system because elevated cortisol levels can lead to a breakdown in lymphoid tissue, inhibition of the
production of natural killer cells, increases in T-suppressor cells, and reductions in the levels of T-helper cells
and virus-fighting interferon.
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Thermoregulation
Normal body temperatures are lower in later life than in younger years. Mean body temperature ranges from
96.9°F to 98.3°F orally and 98°F to 99°F rectally. Rectal and auditory canal temperatures are the most accurate
and reliable indicators of body temperature in older adults.
There is a reduced ability to respond to cold temperatures due to inefficient vasoconstriction, reduced
peripheral circulation, decreased cardiac output, diminished shivering, and reduced muscle mass and
subcutaneous tissue. At the other extreme, differences in response to heat are related to impaired sweating
mechanisms and decreased cardiac output. These age-related changes cause older adults to be more
susceptible to heat stress. Alterations in response to cold and hot environments increase the risks for
accidental hypothermia, heat exhaustion, and heat stroke.
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CHANGES TO THE MIND
Psychological changes can be influenced by general health status, genetic factors, educational achievement,
activity, and physical and social changes. Sensory organ impairment can impede interaction with the
environment and other people, thus influencing psychological status. Feeling depressed and socially isolated
may obstruct optimum psychological function. Recognizing the variety of factors potentially affecting
psychological status and the range of individual responses to those factors, some generalizations can be
discussed.
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Personality
Drastic changes in basic personality normally do not occur as one ages. The kind and gentle old person was
most likely that way when young; likewise, the cantankerous old person probably was not mild and meek in
earlier years. Excluding pathologic processes, the personality will be consistent with that of earlier years;
possibly, it will be more openly and honestly expressed. The alleged rigidity of older persons is more a result of
physical and mental limitations than a personality change. For example, an older person’s insistence that her
furniture not be rearranged may be interpreted as rigidity, but it may be a sound safety practice for someone
coping with poor memory and visual deficits. Changes in personality traits may occur in response to events
that alter self-attitude, such as retirement, death of a spouse, loss of independence, income reduction, and
disability. No personality type describes all older adults; personality in late life is a reflection of lifelong
personality. Morale, attitude, and self-esteem tend to be stable throughout the life span.
214

Memory
The three types of memory are short term, lasting from 30 seconds to 30 minutes; long term, involving that
learned long ago; and sensory, which is obtained through the sensory organs and lasts only a few seconds.
Retrieval of information from long-term memory can be slowed, particularly if the information is not used or
needed on a daily basis. The ability to retain information in the consciousness while manipulating other
information—working memory function—is reduced. Older adults can improve some age-related
forgetfulness by using memory aids (mnemonic devices) such as associating a name with an image, making
notes or lists, and placing objects in consistent locations. Memory deficits can result from a variety of factors
other than normal aging.
215

Intelligence
In general, it is wise to interpret the findings related to intelligence and the older population with much
caution because results may be biased from the measurement tool or method of evaluation used. Early
gerontological research on intelligence and aging was guilty of such biases. Sick old people cannot be
compared with healthy persons; people with different educational or cultural backgrounds cannot be
compared; and one group of individuals who are skilled and capable of taking an IQ test cannot be compared
with those who have sensory deficits and may not have ever taken this type of test. Longitudinal studies that
measure changes in a specific generation as it ages and that compensate for sensory, health, and educational
deficits are relatively recent, and they serve as the most accurate way of determining intellectual changes with
age.
Basic intelligence is maintained; one does not become more or less intelligent with age. The abilities for
verbal comprehension and arithmetic operations are unchanged. Crystallized intelligence, which is the
knowledge accumulated over a lifetime and arises from the dominant hemisphere of the brain, is maintained
through the adult years; this form of intelligence enables the individual to use past learning and experiences
for problem solving. Fluid intelligence, involving new information and emanating from the nondominant
hemisphere, controls emotions, retention of nonintellectual information, creative capacities, spatial
perceptions, and aesthetic appreciation; this type of intelligence is believed to decline in later life. Some
decline in intellectual function occurs in the moments preceding death. High levels of chronic psychological
stress have been found to be associated with an increased incidence of mild cognitive impairment (Wilson et
al., 2007).
COMMUNICATION TIP
Altered vision and hearing, the need for more time to process new information, and the stress of an
interaction with a health care professional can prevent older adults from contributing valuable
information during the assessment process and block them from hearing instructions. While respecting
the individual’s level of function, employ these strategies: Allow time for questions to be answered,
provide examples to trigger memory, and reinforce instructions through repetition and supplementing
oral instructions with written ones.
216

Learning
Although learning ability is not seriously altered with age, other factors can interfere with the older person’s
ability to learn, including motivation, attention span, delayed transmission of information to the brain,
perceptual deficits, and illness. Older persons may display less readiness to learn and depend on previous
experience for solutions to problems rather than experiment with new problem-solving techniques.
Differences in the intensity and duration of the older person’s physiologic arousal may make it more difficult
to extinguish previous responses and acquire new material. The early phases of the learning process tend to be
more difficult for older persons than younger individuals; however, after a longer early phase, they are then
able to keep equal pace. Learning occurs best when the new information is related to previously learned
information. Although little difference is apparent between the old and young in verbal or abstract ability,
older persons do show some difficulty with perceptual motor tasks. Some evidence indicates a tendency
toward simple association rather than analysis. Because it is generally a greater problem to learn new habits
when old habits exist and must be unlearned, relearned, or modified, older persons with many years of history
may have difficulty in this area.
KEY CONCEPT
Older adults maintain the capacity to learn, although a variety of factors can easily interfere with the
learning process.
217

Attention Span
Older adults demonstrate a decrease in vigilance performance (i.e., the ability to retain attention longer than
45 minutes). They are more easily distracted by irrelevant information and stimuli and are less able to perform
tasks that are complicated or require simultaneous performance.
POINT TO PONDER
In the past 10 years, what changes have you experienced in regard to appearance, behaviors, and
attitudes? How do you feel about these changes?
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NURSING IMPLICATIONS OF AGE-RELATED
CHANGES
An understanding of common aging changes is essential to ensure competent gerontological nursing practice.
Such knowledge can aid in promoting practices that enhance wellness, thereby reducing risks to health and
well-being. Differentiating normal from unusual findings in older adults and the atypical presentation of
illness can be invaluable in identifying pathology and obtaining treatment in a timely manner. Table 5-1 lists
some nursing actions related to age-related changes.
TABLE 5-1 Nursing Actions Related to Age-Related Changes
219

220

CONSIDER THIS CASE
Mr. G is a 72-year-old retired truck driver admitted to the hospital
for the treatment of acute glomerulonephritis. His height is 5 ft 11 in., and his weight is 180 lb. You
note from the record that he weighed 220 lb last year and has experienced a reduction in weight at each
of his monthly physician’s visits. Although he has a moderate degree of chronic obstructive pulmonary
disease, he continues to smoke one pack of cigarettes daily. He has varicosities on both lower extremities
and hemorrhoids. Mr. G is coherent and responds appropriately. His wife comments that he has always
had a sharp mind, although in the past few years he has become considerably quieter and less gregarious.
As you observe Mr. G throughout the day, you note that he:
Becomes short of breath with minimal exertion
Develops edema
Has urinary hesitancy and scanty urine output
Adds considerable salt to his food before tasting it
Has difficulty hearing normal conversation
Moves very little when in bed
THINK CRITICALLY
Which signs and observations are related to normal aging and which can you attribute to
pathology?
What factors contributed to the health conditions possessed by Mr. G?
Describe the risks that are high for Mr. G and list nursing measures that could minimize them.
KEY CONCEPT
By promoting positive practices in persons of all ages, nurses can help greater numbers of individuals
enter late life with high levels of health and function.
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Nurses caring for older adults must realize that, despite the numerous changes commonly experienced with
age, most older adults function admirably well and live normal, satisfying lives. Although nurses need to
acknowledge factors that can alter function with aging, they should also emphasize the capabilities and assets
possessed by older adults and assist persons of all ages in achieving a healthy aging process.
222

BRINGING RESEARCH TO LIFE
The Effects of an 8-Week Hatha Yoga Intervention on Executive Function in Older Adults
Source: Gothe, N. P., Kramer, A. F., & McAuley, E. (2014). The Journals of Gerontology Series A: Biological Sciences
and Medical Sciences, 69(9), 1109–1116.
In this study, community-dwelling older adults were randomly placed into two groups. One group
participated in a Hatha yoga intervention and the other a stretching–strengthening control intervention. Both
groups engaged in hour-long exercise classes over an 8-week period and completed tests of executive function
at the beginning of the intervention and at its end.
Results showed significant improvement in executive function measures of working memory capacity and
efficiency of mental set shifting and flexibility in the group who participated in yoga. There is a need for
further research to gain an understanding of the underlying mechanisms affecting the results.
This research demonstrates that there are a variety of exercises that can impact cognitive function. It also
alerts nurses to the importance of being open to complementary and alternative modalities that can have a
positive impact on health and aging, and the need to learn how to use these modalities in practice.
223

PRACTICE REALITIES
You are working in an office with a group of medical doctors who have had some of the same patients in their
practice for nearly two decades. Although many of their patients have aged, the physicians use basically the
same approach, reorder the same medications, and include no review of psychosocial issues.
What could you suggest to update the practice to assure the needs of the aging patients are adequately
being addressed?
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CRITICAL THINKING EXERCISES
1. What efforts do you see to educate persons of all ages in practices that will foster a healthy aging
experience?
2. What age-related changes can you identify in yourself and in your parents?
3. Consider recommendations that you would give young adults for promotion of a healthy aging process.
225

Chapter Summary
Changes at the basic cellular level impact all body systems. The atrophy of body fat, loss of tissue elasticity,
and reduction in subcutaneous fat contribute to changes in the appearance of the body with age. Changes to
body systems contribute to a higher prevalence in the older population of conditions such as infections,
hypertension, poor dental status, indigestion, constipation, urinary frequency, prostatic enlargement, fractures,
reduced vision, presbycusis, hypothermia, and hyperthermia. Basic intelligence is maintained, and there is
some reduction in fluid intelligence. The ability to retain new information is reduced, and the retrieval of
information from long-term memory can be slower. Learning ability is maintained, although several factors
that can interfere with learning. A variety of nursing actions can be utilized to prevent and reduce the negative
impact of aging changes and promote optimal health and function in older adults.
226

References
Cohen, E., Nardi, Y., Krause, I., Goldberg, E., Milo, G., Garty, M., & Krause, I. (2014). A longitudinal
assessment of the natural rate of decline in renal function with age. Journal of Nephrology, 27(6), 635–641.
Fukunaga, A., Uematsu, H., & Sugimoto, K. (2005). Influences of aging on taste perception and oral somatic
sensation. Journal of Gerontology, Series A, Biological Sciences, 60(1), 109–113.
Gupta, A., Epstein, J. B., & Sroussi, H. (2006). Hyposalivation in elderly patients. Journal of the Canadian
Dental Association, 72(9), 841–846.
Hiramatsu, T., Kataoka, H., Osaki, M., & Hagino, H. (2015). Effect of aging on oral and swallowing
function after meal consumption. Clinical Interventions in Aging, 10(1), 229–235.
Lerma, E. V. (2009). Anatomic and physiologic changes of the aging kidney. Clinics in Geriatric Medicine,
25, 325–329.
Marks, L. S., Roehrborn, C. G., & Andiole, G. L. (2006). Prevention of benign prostatic hyperplasia disease.
Journal of Urology, 176(4), 1299–1406.
Mondon, K., Naudin, M., Beaufilis, E. & Atanasova, B. (2014). Perception of taste and smell in normal and
pathological aging: An update. Geriatric Psychology and Neuropsychiatry, 12(3), 313–320.
Munch, M., Knoblauch, V., Blatter, K., Wirz-Justice, A., & Cajochen, C. (2007). Is homeostatic sleep
regulation under low sleep pressure modified by age? Sleep, 30(6), 781–792.
Ney, D., Weiss, J, Kind, A., & Robinson, J. A. (2009). Senescent swallowing: Impact, strategies and
interventions. Nutrition in Clinical Practice, 24(3), 395–413.
Rabbitt, P., Scott, M., Lunn, M., Thacker, N., Lowe, C., Pendleton, N., … Jackson, A. (2007). White
matter lesions account for all age-related declines in speed but not in intelligence. Neuropsychology, 21(3),
363–370.
Sampson, N., Untergasser, G., Plas, E., & Berger, P. (2007). The aging male reproductive tract. Journal of
Pathology, 211(2), 206–218.
Smith, C. H., Boland, B., Daureeawoo, Y., Donaldson, E., Small, K., & Tuomainen, J. (2013). Effect of
aging on stimulated salivary flow in adults. Journal of the American Geriatrics Society, 61(5), 805–808.
St-Onge, M. P., & Gallagher, D. (2010). Body composition changes with aging: The cause or the result of
alternations in metabolic rate and macronutrient oxidation? Nutrition, 26(2), 152–155.
Wilson, R. S., Schneider, J. A., Boyle, P. A., Arnold, S. E., Tang, Y., & Bennett, D. A. (2007). Chronic
distress and incidence of mild cognitive impairment. Neurology, 68(24), 2085–2092.
Woo, J., Leung, J., & Kwok, T. (2007). BMI, body composition, and physical functioning in older adults.
Obesity, 15(7), 1886–1894.
Recommended Readings
Recommended readings associated with this chapter can be found on the Web site that accompanies the
book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
227

http://thepoint.lww.com/Eliopoulos9e

additional resources associated with this chapter.
228

UNIT 2 Foundations of Gerontological Nursing
229

230

6. The Specialty of Gerontological Nursing
7. Holistic Assessment and Care Planning
8. Legal Aspects of Gerontological Nursing
9. Ethical Aspects of Gerontological Nursing
10. Continuum of Care in Gerontological Nursing
231

CHAPTER 6
The Specialty of Gerontological Nursing
232

CHAPTER OUTLINE
Development Of Gerontological Nursing
Core Elements Of Gerontological Nursing Practice
Evidence-Based Practice
Standards
Competencies
Principles
Gerontological Nursing Roles
Healer
Caregiver
Educator
Advocate
Innovator
Advanced Practice Nursing Roles
Self-Care And Nurturing
Following Positive Health Care Practices
Strengthening and Building Connections
Committing to a Dynamic Process
The Future Of Gerontological Nursing
Utilize Evidence-Based Practices
Advance Research
Promote Integrative Care
Educate Caregivers
Develop New Roles
Balance Quality Care and Health Care Costs
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Describe the importance of evidence-based practice in gerontological nursing.
2. Identify standards used in gerontological nursing practice.
3. List principles guiding gerontological nursing practice.
4. Discuss major roles for gerontological nurses.
5. Discuss future challenges for gerontological nursing.
6. Describe activities that contribute to self-care for gerontological nurses.
TERMS TO KNOW
Competency having skill, knowledge, and ability to do something according to a standard
Evidence-based practice using research and scientific information to guide actions
233

Geriatric nursing nursing care of sick older adults
Gerontological nursing nursing practice that promotes wellness and highest quality of life for aging individuals
Standard desired, evidence-based expectations of care that serve as a model against which practice can be judged
234

The specialty of gerontological nursing was not always a popular or well-respected area of practice. However,
over the past few decades, the specialty has experienced profound growth and has benefited from societal
recognition of the importance of the older segment of the population. Nurses have many opportunities to play
significant roles in the care of the aging population today and to shape the future of gerontological nursing.
235

DEVELOPMENT OF GERONTOLOGICAL NURSING
Nurses, long interested in the care of older adults, seem to have assumed more responsibility than other
professional disciplines for this segment of the population. In 1904, the American Journal of Nursing printed
the first nursing article on the care of the aged, presenting many principles that continue to guide
gerontological nursing practice today (Bishop, 1904): “You must not treat a young child as you would a grown
person, nor must you treat an old person as you would one in the prime of life.” Interestingly, this same
journal featured an article entitled “The Old Nurse,” which emphasized the value of the aging nurse’s years of
experience (DeWitt, 1904).
After the Federal Old Age Insurance Law (better known as Social Security) was passed in 1935, many
older persons had an alternative to almshouses and could independently purchase room and board. Because
many of the homes that offered these services for older persons were operated by women who called
themselves nurses, such residences later became known as nursing homes.
For many years, care of older adults was an unpopular branch of nursing practice. Geriatric nurses—those
nurses who care for ill older adults—were thought to be somewhat inferior in capabilities, neither good
enough for acute care settings nor ready to retire. Geriatric facilities may have further discouraged many
competent nurses from working in these settings by paying low salaries. Little existed to counter the
negativism in educational programs, where experiences with older persons were inadequate in both quantity
and quality and attention focused on the sick rather than the well, who were more representative of the older
population. Although nurses were among the few professionals involved with older adults, gerontology was
missing from most nursing curriculums until recently.
Frustration over the lack of value placed on geriatric nursing led to an appeal to the American Nurses
Association (ANA) for assistance in promoting the status of this area of practice. After years of study, in
1961, the ANA recommended that a specialty group for geriatric nurses be formed. In 1962, the ANA’s
Conference Group on Geriatric Nursing Practice held its first national meeting. This group became the
Division of Geriatric Nursing in 1966, gaining full recognition as a nursing specialty. An important
contribution by this group was the development in 1969 of Standards for Geriatric Nursing Practice, first
published in 1970. Certification of nurses for excellence in geriatric nursing practice followed, with the first 74
nurses achieving this recognition in 1975. The birth of the Journal of Gerontological Nursing, the first
professional journal to meet the specific needs and interests of gerontological nurses, also occurred in 1975.
Through the 1970s, nurses became increasingly aware of their role in promoting a healthy aging
experience for all individuals and ensuring the wellness of older adults. As a result, they expressed interest in
changing the name of the specialty from geriatric to gerontological nursing to reflect a broader scope than the
care of the ill aged. In 1976, the Geriatric Nursing Division became the Gerontological Nursing Division.
Box 6-1 lists landmarks in the development and growth of gerontological nursing.
Box 6-1 Landmarks in the Growth of Gerontological Nursing
1902 First article on care of aged in American Journal of Nursing written by a physician
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1904 First article on care of aged in American Journal of Nursing written by a nurse
1950 First geriatric nursing text published (Geriatric Nursing, K. Newton)
First master’s thesis on care of aged (Eleanor Pingrey)
Geriatrics recognized as an area of specialization in nursing
1952 First nursing study on care of aged published in Nursing Research
1961 American Nurses Association (ANA) recommends specialty group for geriatric nurses
1962 First national meeting of ANA Conference on Geriatric Nursing Practice
1966 Formation of Geriatric Nursing Division of ANA
First gerontological nursing clinical specialist nursing program (Duke University)
1968 First nurse makes presentation at International Congress of Gerontology (Laurie Gunter)
1969 Development of standards for geriatric nursing practice
1970 First publication of ANA Standards of Gerontological Nursing Practice
1973 First offering of ANA Certification in Gerontological Nursing (74 nurses certified)
1975 First specialty publication for gerontological nurses, Journal of Gerontological Nursing
First nursing conference at International Congress of Gerontology
1976 ANA changes name from Geriatric Nursing Division to Gerontological Nursing Division.
Publication of ANA Standards of Gerontological Nursing
ANA Certification of Geriatric Nurse Practitioners initiated
1980 Geriatric Nursing journal launched by American Journal of Nursing company
1981 First International Conference on Gerontological Nursing
ANA Division of Gerontological Nursing develops statement on scope of practice
1982 Development of Robert Wood Johnson Teaching Home Nursing Program
1983 First university chair in gerontological nursing in the United States (Case Western Reserve)
1984 National Gerontological Nursing Association (NGNA) formed
ANA Division of Gerontological Nursing Practice becomes Council on Gerontological Nursing
1986 National Association for Directors of Nursing Administration in Long-Term Care
(NADONA/LTC) formed
1987 ANA published combined Scope and Standards of Gerontological Nursing Practice
1989 ANA Certification of Gerontological Clinical Specialists first offered
1990 Division of Long-Term Care established within ANA Council of Gerontological Nursing
1996 Hartford Gerontological Nursing Initiatives funding launched by John A. Hartford Foundation
2001 ANA publishes revised Standards and Scope of Gerontological Nursing Practice
2002 Nurse Competence in Aging initiative to provide gerontological education and activities within
specialty nursing associations
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2004 American Association of Colleges of Nursing publishes competencies for advanced practice
programs in gerontological nursing
2007 American Association for Long-Term Care Nursing formed
2008 Retooling for an Aging America published by the Institute of Medicine recommending improved
geriatric competencies for health care workers
KEY CONCEPT
Gerontological nursing involves the care of aging people and emphasizes the promotion of the highest
possible quality of life and wellness throughout the life span. Geriatric nursing focuses on the care of
sick older persons.
In the past few decades, the specialty of gerontological nursing has experienced profound growth. Whereas
only 32 articles on the topic of the nursing care of older adults were listed in the Cumulative Index to Nursing
Literature in 1956, and only twice that number appeared a decade later, the number of articles published has
grown considerably since. Gerontological nursing texts grew from a few in the 1960s to dozens currently, and
the quantity and quality of this literature have been rising as well. Growing numbers of nursing schools are
including gerontological nursing courses in their undergraduate programs and offering advanced degrees with
a major in this area. Certification offers a means by which the nurse’s knowledge and competencies are
validated through a professional nursing organization. Registered nurses can receive certification as a
generalist in gerontological nursing with a basic nursing degree and 2 years of experience in the specialty or
advanced certification as a clinical nurse specialist in gerontological nursing or gerontological nurse
practitioner with graduate education and additional experience. (For information on certification, see the
Resource listing for the American Nurses’ Credentialing Center at the end of this chapter.) Nursing
administration in long-term care, geropsychiatric nursing, geriatric rehabilitation, and other areas of
subspecialization has evolved; many nursing specialty associations have developed position papers related to
the integration of geriatric nursing into their unique specialty practice (these often are posted on the
association Web sites). The Hartford Institute for Geriatric Nursing, established in the 1990s, has
significantly contributed to the advancement of the specialty by identifying and developing best practices and
facilitating the implementation of these practices (for more information, visit http://www.hartfordign.org). In
2003, the Hartford Institute for Geriatric Nursing collaborated with the American Academy of Nursing and
the American Association of Colleges of Nursing to develop the Hartford Geriatric Nursing Initiative that
has significantly contributed to the growth of evidence-based practice in the specialty. Gerontological nursing
has indeed advanced rapidly, and all indications are that this growth will continue.
Along with the growth of the specialty, there has been a heightened awareness of the complexity of
gerontological nursing. Older people exhibit great diversity in terms of health status, cultural background,
lifestyle, living arrangement, socioeconomic status, and other variables. Most have chronic conditions that
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uniquely affect acute illnesses, reactions to treatments, and quality of life. Symptoms of illness can be atypical.
Multiple health conditions can coexist and muddle the ability to chart the course of a single disease or identify
the underlying cause of symptoms. The conditions that older adults experience can cut across many clinical
specialties, thereby challenging gerontological nurses to have a broad knowledge base. The risk of
complications is high. Other factors, such as limited finances or social isolation, affect the state of health and
well-being. Also, the elective status of geriatrics in many medical and nursing schools can limit the pool of
colleagues who are knowledgeable about the unique aspects of caring for older adults.
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CORE ELEMENTS OF GERONTOLOGICAL NURSING
PRACTICE
With the formalization and growth of the gerontological nursing specialty, nurses and nursing organizations
have developed informal and formal guidelines for clinical practice. Some of these core elements include
evidence-based practice and standards and principles of gerontological nursing.
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Evidence-Based Practice
There was a time when nursing care was guided more by trial and error than sound research and knowledge.
Fortunately, that has changed, and nursing now follows a systematic approach that uses existing research for
clinical decision making—a process known as evidence-based practice. Testing, evaluating, and using research
findings in the nursing care of older adults are of such importance that it is among the ANA Standards of
Professional Gerontological Nursing Performance.
Evidence-based practice relies on the synthesis and analysis of available information from research.
Among the more popular ways to report this information are the meta-analysis and cost-analysis. Meta-
analysis is a process of analyzing and compiling the results of published research studies on a specific topic.
This process combines the results of many small studies to allow more significant conclusions to be made.
With cost-analysis reporting, cost-related data are gathered on outcomes to make comparisons. Performance
also can be compared with best practices or industry averages through a process of benchmarking. For instance,
the rate of pressure ulcers in one facility may be compared with another facility that has similar characteristics.
The data can be used to stimulate improvements.
KEY CONCEPT
Best practices are evidence based and are built on the expertise of the nurse.
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Standards
Professional nursing practice is guided by standards. Standards reflect the level and expectations of care that
are desired and serve as a model against which practice can be judged. Thus, standards serve to both guide and
evaluate nursing practice.
Standards arise from a variety of sources. State and federal regulations outline minimum standards of
practice for various health care workers (e.g., nurse practice acts) and agencies (e.g., nursing homes). The Joint
Commission has developed standards for various clinical settings that strive to describe the maximum
attainable performance levels. The ANA Scope and Standards of Practice for Gerontological Nursing, as
listed in Box 6-2, are the only standards developed by and for gerontological nurses. Nurses must regularly
evaluate their actual practices against all standards governing their practice areas to ensure their actions reflect
the highest quality care possible.
Box 6-2 ANA Standards of Practice for Gerontological
Nursing
STANDARD 1. ASSESSMENT
The gerontological nurse collects comprehensive data pertinent to the older adult’s physical and mental
health or situation.
STANDARD 2. DIAGNOSIS
The gerontological nurse analyzes the assessment data to determine the diagnoses or issues.
STANDARD 3. OUTCOME IDENTIFICATION
The gerontological nurse identifies expected outcomes for a plan individualized to the older adult or
situation.
STANDARD 4. PLANNING
The gerontological nurse develops a plan to attain expected outcomes.
STANDARD 5. IMPLEMENTATION
The gerontological nurse implements the identified plan.
STANDARD 5A: COORDINATION OF CARE
The gerontological nurse coordinates care delivery.
STANDARD 5B: HEALTH TEACHING AND HEALTH
PROMOTION
The gerontological registered nurse employs strategies to promote health and a safe environment.
STANDARD 5C: CONSULTATION
The gerontological advanced practice registered nurse provides consultation to influence the identified
plan, enhance the abilities of others, and effect change.
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STANDARD 5D: PRESCRIPTIVE AUTHORITY AND
TREATMENT
The gerontological advanced practice registered nurse uses prescriptive authority, procedures, referrals,
treatments, and therapies in accordance with state and federal laws and regulations.
STANDARD 6. EVALUATION
The gerontological nurse evaluates the older adult’s progress toward attainment of expected outcomes.
Source: American Nurses Association. (2010). Gerontological nursing scope and standards of practice.
Silver Spring, MD: Nursebooks.org. (A full copy of the standards that includes the measurement
criteria and Standards of Professional Performance for Gerontological Nursing can be ordered from the
American Nurses Association, http://www.nursesbooks.org.)
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Competencies
Nurses who work with older adults need to have competencies specific to gerontological nursing to promote
the highest possible quality of care to older adults. Although they can vary based on educational preparation,
level of practice, and practice setting, some basic competencies of the gerontological nurse include the ability
to:
differentiate normal from abnormal findings in the older adult
assess the older adult’s physical, emotional, mental, social, and spiritual status and function
engage the older adult in all aspects of care to the maximum extent possible
provide information and education on a level and in a language appropriate for the individual
individualize care planning and implementation of the plan
identify and reduce risks
empower the older adult to exercise maximum decision making
identify and respect preferences arising from the older adult’s culture, language, race, gender, sexual
preference, lifestyle, experiences, and roles
assist the older adult in evaluating, deciding, locating, and transitioning to environments that fulfill
living and care needs
advocate for and protect the rights of the older person
facilitate discussion of and honor advance directives
To maintain and improve competencies, nurses need to stay abreast of new research, resources, and best
practices. This is a personal responsibility of the professional nurse.
CONSIDER THIS CASE
Nurse Haley is a new graduate who is employed on a coronary care
unit of an acute hospital. In her short time on the unit, she has noticed that the nurses who have worked
on the unit for many years show certain tendencies when caring for patients over age 65. For example,
they address comments and questions to these patients’ children rather than directly to the patients,
address them in a child-like manner, tend not to inquire about their lifestyles and preferences, assume
they have sedate lives, and omit the discussion of topics that they do discuss with younger patients, such
as sexual activity, exercise, resuming work activities, and using alternative and complementary therapies.
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Nurse Haley feels her coworkers’ behaviors fail to respect the individuality and rights of older patients
and could jeopardize the quality of care they are afforded.
THINK CRITICALLY
What gerontological nursing competencies seem to be absent from the practice of the nurses
Nurse Haley describes?
What are some of the factors that could have contributed to the nurses’ behaviors?
How should Nurse Haley address the problems she observes to promote good gerontological
nursing practice?
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Principles
Scientific data regarding theories, life adjustments, normal aging, and pathophysiology of aging are combined
with selected information from psychology, sociology, biology, and other physical and social sciences (Fig. 6-
1) to develop nursing principles. Nursing principles are those proven facts or widely accepted theories that
guide nursing actions. Professional nurses are responsible for using these principles as the foundation for
nursing practice and ensuring through educational and managerial means that other caregivers use a sound
knowledge base.
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FIGURE 6-1 • Information system of the gerontological nurse.
In addition to the basic principles that direct the delivery of care to persons in general, specific and unique
principles guide care for individuals of certain age groups or those who possess particular health problems.
Some of the principles guiding gerontological nursing practice are listed in Box 6-3 and are discussed below.
Box 6-3 Principles of Gerontological Nursing Practice
Aging is a natural process common to all living organisms.
Various factors influence the aging process.
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Unique data and knowledge are used in applying the nursing process to the older population.
Older adults share similar self-care and human needs with all other human beings.
Gerontological nursing strives to help older adults achieve wholeness by reaching optimum levels
of physical, psychological, social, and spiritual health.
Aging: A Natural Process
Every living organism begins aging from the time of conception. The process of maturing or aging helps the
individual achieve the level of cellular, organ, and system function necessary for the accomplishment of life
tasks. Constantly and continuously, every cell of every organism ages. Despite the normality and naturalness
of this experience, many people approach aging as though it were a pathologic experience. For example,
commonly heard comments associate aging with:
“looking gray and wrinkled”
“losing one’s intellectual function”
“becoming sick and frail”
“obtaining little satisfaction from life”
“returning to child-like behavior”
“being useless”
These are hardly valid descriptions of the outcomes of aging for most people. Aging is not a crippling disease;
even with limitations that could be imposed by pathologies of late life, opportunities for usefulness,
fulfillment, and joy are readily present. A realistic understanding of the aging process can promote a positive
attitude toward old age.
Factors Influencing the Aging Process
Heredity, nutrition, health status, life experiences, environment, activity, and stress produce unique effects in
each individual. Among the variety of factors either known or hypothesized to affect the usual pattern of
aging, inherited factors are believed by some researchers to determine the rate of aging. Malnourishment can
hasten the ill effects of the aging process, as can exposure to environmental toxins, diseases, and stress. In
contrast, mental, physical, and social activity can reduce the rate and degree of declining function with age.
These factors are examined in more detail in Chapter 2.
Every person ages in an individualized manner, although some general characteristics are evident among
most people in a given age category. Just as one would not assume that all 30-year-old people are identical but
would evaluate, approach, and communicate with each person in an individualized manner, nurses must
recognize that no two persons 60, 70, or 80 years of age are alike. Nurses must understand the multitude of
factors that influence the aging process and recognize the unique outcomes for each individual.
The Nursing Process Framework
Scientific data related to normal aging and the unique psychological, biological, social, and spiritual
characteristics of the older person must be integrated with a general knowledge of nursing. The nursing
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process provides a systematic approach to the delivery of nursing care and integrates a wide range of
knowledge and skills. The scope of nursing includes more than following a medical order or performing an
isolated task; the nursing process involves a holistic approach to individuals and the care they require. The
unique physiologic, psychological, social, and spiritual challenges of older adults are considered in every phase
of the nursing process.
Common Needs
Core needs that promote health and optimum quality of life for all patients are:
Physiological balance: respiration, circulation, nutrition, hydration, elimination, movement, rest, comfort,
immunity, and risk reduction
Connection: familial, relational, societal, cultural, environmental, spiritual, and self
Gratification: purpose, pleasure, and dignity
Through self-care practices, people usually perform activities independently and voluntarily to meet these life
requirements. When an unusual circumstance interferes with an individual’s ability to meet these demands,
nursing intervention could be warranted. The requirements for these needs and specific problems that older
persons may experience in fulfilling them are discussed in Units III through V.
Optimal Health and Wholeness
One can view aging as the process of realizing one’s humanness, wholeness, and unique identity in an ever-
changing world. In late life, people achieve a sense of personhood that allows them to demonstrate
individuality and move toward self-actualization. By doing so, they are able to experience harmony with their
inner and external environment, realize their self-worth, enjoy full and deep social relationships, achieve a
sense of purpose, and develop the many facets of their being. Gerontological nurses play an important role in
promoting health and helping people achieve wholeness. Within the framework of the self-care theory,
nursing actions toward this goal are:
Strengthening the individual’s self-care capacity
Eliminating or minimizing self-care limitations
Providing direct services by acting for, doing for, or assisting the individual when demands cannot be
met independently
The thread woven throughout the above nursing actions is the promotion of maximum independence.
Although it may be more time consuming and difficult, allowing older persons to do as much for themselves
as possible produces many positive outcomes for their biopsychosocial health.
POINT TO PONDER
What self-care practices are routine parts of your life? What is lacking?
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GERONTOLOGICAL NURSING ROLES
In their activities with older adults, nurses function in a variety of roles, most of which fall under the
categories of healer, caregiver, educator, advocate, and innovator (Fig. 6-2).
FIGURE 6-2 • Gerontological nursing roles.
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Healer
Early nursing practice was based on the Christian concept of the intertwining of the flesh and spirit. In the
mid-1800s, nursing’s role as a healing art was recognized; this is apparent through Florence Nightingale’s
writings that nursing “puts the patient in the best condition for nature to act upon him” (Nightingale, 1860).
As medical knowledge and technology grew more sophisticated and the nursing profession became grounded
more in science than in healing arts, the early emphasis on nurturance, comfort, empathy, and intuition was
replaced by detachment, objectivity, and scientific approaches. However, the revival of the holistic approach to
health care has enabled nurses to again recognize the interdependency of body, mind, and spirit in health and
healing.
Nursing plays a significant role in helping individuals stay well, overcome or cope with disease, restore
function, find meaning and purpose in life, and mobilize internal and external resources. In the healer role, the
gerontological nurse recognizes that most human beings value health, are responsible and active participants
in their health maintenance and illness management, and desire harmony and wholeness with their
environment. A holistic approach is essential, recognizing that older individuals must be viewed in the context
of their biological, emotional, social, cultural, and spiritual elements. (Information on holistic nursing can be
obtained from the American Holistic Nurses’ Association, listed under Resources at the end of this chapter.)
POINT TO PONDER
Henri Nouwen (1990) spoke of the “wounded healer” who uses his or her own problems or wounds as a
means to assist in the healing of others. What life experiences or “wounds” do you possess that enable
you to assist others in their healing journeys?
For healing to be a dynamic process, nurses need to identify their own weaknesses, vulnerabilities, and need
for continued self-healing. This belief is consistent with the concept of the wounded healer and suggests that
by recognizing the wounds of all human beings, including themselves, nurses can provide services within a
loving, compassionate framework.
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Caregiver
The major role played by nurses is that of a caregiver. In this role, gerontological nurses use gerontological
theory in the conscientious application of the nursing process to the care of older adults. Inherent in this role
is the active participation of older adults and their significant others and promotion of the highest degree of
self-care. This is especially significant in that older adults who are ill and disabled are at risk for having
decisions made and actions taken for them—in the interest of “providing care,” “efficiency,” and “best
interest”—that rob them of their existing independence.
Although the body of knowledge of geriatrics and gerontological care has grown considerably, many
practitioners lack this information. Gerontological nurses are challenged to ensure that the care of older adults
is based on sound knowledge that reflects the unique characteristics, needs, and responses of older persons by
disseminating gerontological principles and practices. Nurses working in this specialty area are challenged to
gain the knowledge and skills that will enable them to meet the unique needs of older adults and to assure
evidence-based practices are utilized.
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Educator
Gerontological nurses must be prepared to take advantage of formal and informal opportunities to share
knowledge and skills related to the care of older adults. This education extends beyond professionals to the
general public. Areas in which gerontological nurses can educate others include normal aging,
pathophysiology, geriatric pharmacology, health promotion, and available resources. With the diversity and
complexities of health insurance plans, an important area for consumer education is teaching older adults how
to interpret and compare various plans to enable them to make informed decisions. Essential to the educator
role is effective communication involving listening, interacting, clarifying, coaching, validating, and
evaluating.
The nurse’s educator role also surfaces during routine nurse–patient interactions. The nurse educates the
patient to address knowledge deficits identified during the assessment process. New medications, treatments,
and choices create the need for teaching to assure the patient has the knowledge and skill to competently
make decisions and engage in care. Box 6-4 outlines some of the principles of adult learning and some of the
barriers to learning.
Box 6-4 Teaching Older Adults
When teaching older adults:
Assess knowledge deficits, readiness to learn, and obstacles that could interfere with the learning
process
Organize the material prior to the teaching experience
Plan strategies to actively engage them in the learning process
Assure the environment is conducive to learning (e.g., comfortable room temperature, noise
control, avoidance of glare, and lack of distractions and interruptions)
Be sensitive to vision and hearing deficits that are present
Speak on a level and in a language that is understandable
Avoid medical jargon
Use several different teaching methods to supplement verbal presentation (e.g., videos,
demonstration, PowerPoint slides, pamphlets, and fact sheets)
Provide written material to complement verbal instruction; as blues and greens are difficult colors
for older eyes, avoid using blue print on green paper
Summarize what has been taught and recognize knowledge gains
Be aware of potential barriers to learning:
Stress
Sensory deficits
Limited educational or intellectual abilities
Emotional state
Pain, fatigue, and other symptoms
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Unmet physiological needs
Attitudes or beliefs held about topic
Prior experience with issue
Feelings of helplessness and hopelessness
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Advocate
The gerontological nurse can function as an advocate in several ways. First and foremost, advocacy for
individual clients is essential and can include aiding older adults in asserting their rights and obtaining
required services. In addition, nurses can advocate to facilitate a community’s or other group’s efforts to effect
change and achieve benefits for older adults and to promote gerontological nursing, including new and
expanded roles of nurses in this specialty.
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Innovator
Gerontological nursing continues to be an evolving specialty; therefore, nurses have opportunities to develop
new technologies and different modalities of care delivery. As an innovator, the gerontological nurse assumes
an inquisitive style, making conscious decisions and efforts to experiment for an end result of improved
gerontological practice. This requires the nurse to be willing to think “out of the box” and take risks associated
with traveling down new roads, transforming visions into reality.
These roles can be actualized in a variety of practice settings, discussed in Chapter 10, and offer
opportunities for gerontological nurses to demonstrate significant creativity and leadership.
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ADVANCED PRACTICE NURSING ROLES
To competently and effectively care for the clinical complexities of older adults, nurses need preparation in the
unique principles and best practices of geriatric care. This requires a broad knowledge base, capacity for
independent practice and leadership, and complex clinical problem-solving ability that is possible by nurses
prepared for advanced practice roles. Advance practice roles include geriatric nurse practitioners, geriatric
nurse clinical specialists, and geropsychiatric nurse clinicians. Most of these roles require the completion of a
master’s degree at a minimum.
There is strong evidence that nurses in advanced practice roles make a significant difference to the care of
older adults. Gerontological nurse practitioners and clinical nurse specialists have been shown to improve the
quality and reduce the cost of care for older persons in a variety of settings, including hospitals, nursing
homes, and ambulatory care. The clear positive impact on the health and well-being of older adults should
encourage gerontological nurses to pursue these types of advanced practice roles and to encourage the
employment of these advanced practitioners in their clinical settings.
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SELF-CARE AND NURTURING
The depth and intensity of the nurse–patient relationship that results when nurses function as healers creates a
highly therapeutic and meaningful experience that reflects the essence of professional nursing. Although the
formal educational preparation of nurses offers the foundation for this level of healing relationship, the nurse’s
self-care influences the potential height and depth that can be realized. Some strategies for self-care include
following positive health care practices and strengthening and building connections.
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Following Positive Health Care Practices
Like all human beings, nurses have basic physiological needs. Although most nurses are familiar with the
requirements necessary to meet each of these needs (e.g., proper diet, adequate rest, exercise, etc.), they may
not be applying this knowledge to their personal lives. Self-care can suffer as a result.
A periodic “checkup” of physical status can prove useful in disclosing problems that could not only
minimize the ability to provide optimal services to patients but also threaten personal health and well-being. It
could prove useful for nurses to allocate a few hours, find a quiet place, and critically review their health status.
After identifying problems, nurses can plan realistic actions to improve health. Writing the actions on an
index card and placing that card in an area that is regularly seen (e.g., dresser, desk, or dashboard) can provide
regular reminders of intended corrective actions.
KEY CONCEPT
Efforts to improve self-care practices can be facilitated by partnering with a “buddy” who can offer
support, encouragement, and a means for accountability.
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Strengthening and Building Connections
Humans are relational beings who are intended to live in a community with others. The richness of nurses’
connections in their personal lives provides fertile soil to grow meaningful connections with patients. Yet, as
basic and common as relationships can be, they can be quite challenging. Among the major challenges nurses
may face are finding and protecting the time and energy to connect with others in meaningful ways. Like
many other professionals in helping professions, nurses may find that the physical, emotional, and mental
energies exerted in a typical workday leave little in reserve to invest in nurturing relationships with friends and
family. The reactions to work-related stress can be displaced to significant others, thereby interfering with
positive personal relationships. To compound the problem, concern for patients’ welfare or employer pressure
can lead to excessive overtime work, leaving precious little time and energy for nurses to do anything more in
their off hours than attend to basics. Strained personal connections are the weeds of untended relationship
gardens.
POINT TO PONDER
List five significant individuals in your life. Reflect on the amount of quality time you have with each of
them and determine if this time is conducive to a strong relationship.
Relationships
The allocation of time and energy requires the same planning as the allocation of any finite resource. Ignoring
this reality risks suffering the consequences of poor relationships. Recognizing that there always will be
activities to vie for time and energy, nurses need to take control and develop practices that reflect the value of
personal relationships. This can involve limiting the amount of overtime worked to no more than “x” hours
each week, dedicating every Thursday evening to dining out with the family or blocking out Sunday
afternoons to visit or telephone friends. Expressing intentions through understood “personal policies” (e.g.,
informing a supervisor that you will work no more than one double shift per month) and committing time on
your calendar (e.g., blocking off every Sunday afternoon for time with friends) increase the likelihood that
significant relationships will receive the attention they require.
Spirituality
Time and energy also must be protected to afford ample time for connecting with the nonphysical power that
offers inspiration, gives life meaning, and implies something greater than one’s self. For some, this can be
God, for others, a nondescript higher power, yet for others, a connection with nature and all living things.
The spiritual grounding resulting from this connection enables nurses to better understand and serve the
spiritual needs of patients. Nurses can enhance spiritual connection through prayer, fasting, attending church
or temple, engaging in Bible or other holy book studies, taking periodic retreats, and practicing days of
solitude and silence.
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Connection with Self
Connection with self is essential to nurses’ self-care, and this begins with a realistic self-appraisal. Examples of
strategies to facilitate this process include sharing life stories, journaling, meditating, and taking retreats.
POINT TO PONDER
What does it mean to you to be connected to self?
Sharing Life Stories
Every adult has a unique and rich storehouse of experiences that have been cemented into the life in which he
or she dwells. Oral sharing of life stories with others helps people gain self-insight and puts experiences into a
perspective that affords meaning. As people share stories, they begin to see that their lives are not the only
ones that have been less than ideal and sprinkled with pain or have unfolded in unintended ways. They also
are able to reflect on positive experiences that influenced their lives. Writing one’s life story is a powerful
means of reflection that affords a permanent record that can be revisited and reconsidered as one gains deeper
wisdom about self and others. The process of sharing life stories can be particularly meaningful for
gerontological nurses in their work with older adults who often have interesting life histories that they are
eager to share—and that frequently can offer rich life lessons.
COMMUNICATION TIP
To encourage older adults to write their life stories, discuss the value that this record could have for
younger family members and offer specific suggestions for how their stories could be structured, such as
by:
Significant events during each decade of life
descriptions of major events, people, or issues such as their parents, immigration to this country,
childhood friends, neighborhood in which they grew up, school experiences, firsts (e.g., date, car,
job, home), work experiences, adult friends, hobbies, accomplishments, disappointments, things
they felt positive about, and major societal changes they witnessed
Emphasize that it isn’t the writing skill that matters but the gift of documented memories that will be
shared with future generations.
Journaling
Writing personal notes in a journal or diary can facilitate reflection on one’s life. These writings differ from
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written life stories in that they record current activities and thoughts rather than past ones. An honest written
account of feelings, thoughts, conflicts, and behaviors can help people learn about themselves and work
through issues.
Meditating
The ancient practice of meditation has helped people sort out thoughts and gain clarity of direction for ages.
Many nurses find meditation challenging because the nature of their work consists of doing—and multitask
doing, at that! However, periods of being still enable nurses to offer an optimum healing presence to their
patients.
There are several techniques that can be used for meditating; individuals vary in their preference for the
different forms of meditation. Some people may focus on a word or prayer, whereas others may choose to have
no intentional thought and to be open to whatever thoughts drift into their minds. Essential elements to any
form of meditation are a quiet environment, comfortable position, and calm and passive attitude. The
physiological responses associated with the deep relaxation achieved during meditation have many health
benefits (e.g., improved immunity, reduced blood pressure, and increased peripheral blood flow). Often, issues
a person has been struggling with can be clarified through meditation.
Taking Retreats
To many nurses, taking a few days off “to do nothing” seems like a luxury that cannot be afforded. After all,
there is the house to get in order, shopping that must be done, and overtime that can be worked to gather a
few extra dollars for vacation. In addition to the tasks that compete for attention and time, there may be the
mental script that insidiously gives the message that it is selfish to forfeit tangibly productive activities to
spend time thinking, reflecting, and experiencing. Yet, unless nurses want their interactions with patients to
be solely mechanical (i.e., task oriented), they must treat themselves as more than machines. Their bodies,
minds, and spirits must be restored and refreshed periodically to offer holistic care—and retreats offer an ideal
means to achieve that.
A retreat is a withdrawal from normal activities. It can be structured or unstructured, guided by a leader or
self-directed, and taken with a group or alone. Although retreats are offered in exotic locations that offer
lavish provisions, they need not be luxurious or expensive. Whatever the location or structure, key elements of
the retreat experience include a respite from routine responsibilities; freedom from distractions (telephones, e-
mails, children, and doorbells); no one to care for and worry about other than self; and a quiet place. The
charge that a retreat provides to one’s physical, emotional, and spiritual batteries will more than compensate
for the tasks that were postponed.
KEY CONCEPT
When nurses have strong, grounded connections to themselves, they are in a better position to have
meaningful connections with patients.
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Committing to a Dynamic Process
Self-care is an ongoing process that demands active attention. However, knowing the actions that support
self-care is only the beginning. Committing to engaging in one’s self-care completes the picture. This may
mean that limits are set on the amount of overtime worked to adhere to an exercise schedule or that one is
willing to face the uncomfortable feelings experienced during the process of reflecting on less than pleasant
life experiences. Sacrifices, unpopular decisions, and discomfort can result when one chooses to “work on
oneself.” Yet, it is this inner work that contributes to nurses being effective healers and models of healthy
aging practices.
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THE FUTURE OF GERONTOLOGICAL NURSING
Historically, nurses were the major caregivers to older adults. Going forward, gerontological nurses must strive
to protect both the care of older adults and the specialty of gerontological nursing. Tremendous strides have
been made already. Dynamic professionals are selecting gerontological nursing as a specialty that offers a
multitude of opportunities to use a wide range of knowledge and skills and one that presents many challenges
that can be independently addressed within the realm of nursing practice. Excellent research for and by nurses
is growing to provide a strong scientific foundation for practice. Increasing numbers of nursing schools are
adding specialization in gerontological nursing. New opportunities for gerontological nurses to develop
practice models are emerging in acute hospitals, assisted-living settings, health maintenance organizations,
life-care communities, adult day treatment centers, and other settings (Fig. 6-3). The future of gerontological
nursing appears dynamic and exciting. Nevertheless, more challenges exist.
FIGURE 6-3 • The specialty of gerontological nursing offers multiple opportunities to use a wide range of
knowledge and skills in a variety of settings.
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Utilize Evidence-Based Practices
Considerable knowledge has been gained through research that can guide practice that is based on evidence
rather than assumption; the body of knowledge continuously grows and changes. Practices that were routine
in years past may have since been discovered to be ineffective or even harmful. This challenges nurses in
keeping abreast of and utilizing evidence-based practices.
Gerontological nurses can access literature upon which evidence-based practice can be obtained from
several sources. The Cochrane Collaboration (www.cochrane.org) publishes Cochrane Reviews, systematic
assessments of research that meet the highest standard in evidence-based practice. Among the collaboration’s
valuable resources are links to databases offering online access to medical evidence from other sites. The
National Guideline Clearinghouse (www.guideline.gov), as the name implies, offers evidence-based
guidelines. The Hartford Institute for Geriatric Nursing (www.hartfordign.org) offers many evidence-based
resources to guide geriatric nursing practice. In addition, geriatric and gerontological journals and publications
of professional associations provide reports of recent research.
The gerontological nurse should assure that when new policies and procedures are being developed in the
workplace, they are based on evidence. This may require the nurse to conduct a literature search and
summarize and present findings to other members of the team. Bridging research to the practice setting is an
important function of the gerontological nurse.
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Advance Research
The growing complexity of and demand for gerontological nursing services is exciting and challenging but is
accompanied by the need for a strong knowledge base on which these services can be built. There is no room
for the trial and error that flavored nursing actions in the past; older adults’ delicately balanced health status,
increased consumer expectations, ever-present risk of litigation, and the requisites of professionalism demand
scientific foundations for nursing practice. Fine nursing research is being conducted on a variety of issues, and
gerontological nurses must encourage and support these efforts through various actions.
One way for nurses to advance research is to network with nurse researchers. Researchers can be
important resources. Combining their research skills with the abilities of those in practice settings can help to
solve clinical problems. Local academic institutions, teaching hospitals, and nursing homes may be conducting
research that can be relevant to various gerontological settings or in which a service agency can participate.
Nurses can also help to support research efforts in a variety of ways. As funding is sought for research
projects, nurses can write letters of support and testimony to help funding agencies understand the full benefit
of the research effort. Regular contact with leaders who influence the allocation of funds can provide
opportunities to educate these persons on the value of supporting research. No less significant to the support
of research efforts is the assurance that protocols be followed, because the efforts of researchers can be
facilitated or thwarted by colleagues in clinical settings.
Finally, nurses must keep abreast of new findings. Gerontological nursing knowledge is continuously
expanding, disproving past beliefs and offering new insights. Nurses can engage in independent study, formal
courses, and continuing education programs to keep current. Equally important to acquiring knowledge is
implementing evidence-based practice to improve the care of older adults. Older adults’ delicately balanced
health status and high risk of complications, along with rising consumer expectations and a highly litigious
society, reinforce the importance of evidence-based practice.
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Promote Integrative Care
In the United States, conventional medicine, with an emphasis on the diagnosis and treatment of diseases, has
set the tone for health care practice. Current managed care and reimbursement priorities reinforce the medical
model and disease-focused care. Unfortunately, the care of medical conditions is just one aspect of the services
older adults need to be healthy and experience a high quality of life. In fact, older persons’ wellness practices;
adjustments to life changes; sense of purpose, hopefulness, joy, connections to others; and ability to manage
stress can be equally if not more significant to their health and quality of life than medical care.
Nurses must ensure that gerontological care is holistic, meaning that the physical, emotional, social, and
spiritual facets of individuals are considered (see Chapter 7). This implies that nurses not only practice in a
holistic manner themselves but also advocate for other disciplines to do so.
Alternative and complementary therapies play a role in holistic care. These therapies tend to be more
comforting, safe, and less invasive than conventional treatments and empower older adults and their caregivers
in self-care. Many people who use these therapies report positive experiences with their alternative therapists,
who frequently spend more time getting to understand and address the needs of the total person than do staff
in the typical medical office or hospital. However, the use of alternative therapies does not equate with holistic
care. An alternative therapist with tunnel vision, believing that every malady can be corrected with the one
modality he or she practices and excluding effective conventional treatments, is no different from the
physician who prescribes an analgesic but does not consider imagery, massage, relaxation exercises, and other
nonconventional forms of pain relief. Integrating the best of conventional and alternative/complementary
therapy supports holistic care.
Part of a holistic approach to care includes care of the caregivers as well. Professional and family caregivers
who are in poor health, struggling with psychosocial issues, feeling spiritually empty and disconnected, or
managing stress poorly need to heal themselves before they can be effective caregivers. Nurses can assist these
caregivers in identifying their needs and finding the help needed for their healing.
POINT TO PONDER
Many nurses are in poor physical condition, smoke, regularly eat junk foods, take little time for
themselves, and demonstrate other unhealthy habits. What do you think are some of the reasons for
this? What can be done to improve nurses’ health habits?
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Educate Caregivers
Be it the nursing director, a family member who cares for an older relative, a health aide who has more
frequent contact with the patient than the professional nurse, or the physician who only occasionally has an
older person in the caseload, caregivers at every level require competency in providing services to the older
population. Gerontological nurses can influence the education of caregivers by:
Helping nursing schools identify relevant issues for inclusion in the curricula
Participating in the classroom and field experiences of students
Evaluating educational deficits of personnel and planning educational experiences to eliminate deficits
Promoting interdisciplinary team conferences
Attending and participating in continuing education programs
Reading current nursing literature and sharing information with colleagues
Serving as a role model by demonstrating current practices
With increasing numbers of family members providing more complex care in the home setting than ever
before, it is essential that the education of this group not be overlooked. It should not be assumed that because
the family has had contact with other providers or has been providing care they are knowledgeable in correct
care techniques. The nurse must periodically evaluate and reinforce the family’s knowledge and skills.
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Develop New Roles
As gerontological subspecialties and settings for care grow, so will the opportunities for nurses to carve new
roles for themselves. Nurses can demonstrate creativity and leadership as they break from traditional roles and
settings and develop new models of practice, which may include the following:
Geropsychiatric nurse specialist in the assisted-living setting
Independent case manager for community-based chronically ill patients
Columnist for local newspaper on issues pertaining to health and aging
Owner or director of mature women’s health care center, geriatric day care program, respite agency, or
caregiver training center
Preretirement counselor and educator for private industry
Faith community nurse
Consultant, educator, and case manager for geriatric surgical patients
This list only begins to describe opportunities awaiting gerontological nurses. Many opportunities exist for
nurses to develop new practice models in gerontological care. It will be important for gerontological nurses to
identify nontraditional roles, approach them creatively, test innovative practice models, and share their
successes and failures with colleagues to aid them in their development of new roles. Nurses must recognize
that their biopsychosocial sciences knowledge, clinical competencies, and human relations skills give them a
strong competitive edge over other disciplines in affecting a wide range of services.
POINT TO PONDER
Based on changes in the health care system and society at large, what unique services could
gerontological nurses offer in the future within your community?
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Balance Quality Care and Health Care Costs
The increasing number of older adults is placing increasing demands for diverse health care services than ever
before. At the same time, third-party insurers are trying to control the constantly escalating cost of services.
Earlier hospital discharges, limited home health visits, increased complexity of nursing home residents, and
greater out-of-pocket payment for services by patients demonstrate some of the effects of changes in
reimbursement policy. There is concern that, as a result of these changes, patients are discharged from
hospitals prematurely and suffer greater adverse consequences, nursing homes are confronting residents with
complex problems for whom they are not adequately prepared or staffed, families are being strained by
considerable caregiving burdens, and patients are being deprived of needed but unaffordable services.
Concept Mastery Alert
Changes in reimbursement practices result in the earlier hospital discharge of patients with high acuity
level care needs. The limited reimbursement for nursing home and home health care services may not
provide the resources to adequately provide the type of care required by these individuals.
Such changes are disconcerting and may cause nurses to feel overwhelmed, frustrated, or dissatisfied.
Unfortunately, more cost cutting is likely to occur. Rather than experience burnout or consider a change of
occupation, nurses should become involved in cost-containment efforts so that a balance between quality
services and budgetary concerns can be achieved. Efforts toward this goal can include the following:
Test creative staffing patterns. Perhaps six nurses can be more productive than three nurses and three
unlicensed caregivers. Or, perhaps some of the high nonproductive time costs associated with unlicensed
personnel are related to poor hiring and supervision practices; improved management techniques may
increase the cost-effectiveness of these workers.
Use lay caregivers. Neighbors assisting each other, a family member rooming-in during hospitalizations,
and other methods to increase the resources available for service provision can be explored.
Abolish unnecessary practices. Why must nurses spend time administering medications to patients who
have successfully administered them before admission and who will continue to administer them after
discharge, take vital signs every 4 hours on patients who have shown no abnormalities, bathe all patients
on the same schedule regardless of skin condition or state of cleanliness, or rewrite assessments and care
plans at specified intervals regardless of a patient’s changes or stability? Often regulations and policies
are developed under the assumption that, without them, vital signs would never be taken, baths would
not be given, and other facets of care would not be completed. Perhaps the time has come for nurses to
aggressively convince others that they have the professional judgment to determine the need for and
frequency of assessment, care planning, and care delivery.
Ensure safe care. The implementation of cost-containment efforts should be accompanied by concurrent
studies of its impact on rates of complications, readmissions, incidents, consumer satisfaction, and staff
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turnover, absenteeism, and morale. Specific numbers and documented cases carry more weight than
broad criticisms or complaints that care is suffering.
Advocate for older adults. The priorities of society and professions change. History shows us that at
different times the spotlight has focused on various underserved groups, such as children, pregnant
women, the mentally ill, the disabled, substance abusers, and, most recently, older adults. As interests
and priorities shift to new groups, gerontological nurses must make certain that the needs of older
individuals are not forgotten or shortchanged.
As gerontological nursing continues to shed its image of a less-than-challenging specialty for less-than-
competent nurses and fully emerges as the dynamic, multifaceted, and opportunity-filled area of nursing that
it is, it will be recognized as a specialty for the finest talent the profession has to offer. Gerontological nursing
has just begun to show its true potential.
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BRINGING RESEARCH TO LIFE
Quality Geriatric Care as Perceived by Nurses in Long-Term and Acute Care Settings
Source: Barba, B. E., Hu, J., & Efird, J. (2012). Journal of Clinical Nursing, 21(5), 833–840.
This descriptive study explored the differences between acute and long-term care nurses in regard to their
satisfaction with the quality of care of older adults. The self-selected sample included 298 registered nurses
and licensed practical nurses who provide care to minority, underserved, and disadvantaged older populations
in 89 long-term care facilities and hospitals of less than 100 beds in a southern state. All completed the
Agency Geriatric Nursing Care survey, which consisted of a 13-item scale measuring nurses’ satisfaction with
the quality of geriatric care in their practice settings and an 11-item scale examining obstacles to providing
quality geriatric care.
Significant differences were found between the two groups of nurses in regard to level of satisfaction and
perceived obstacles to providing quality care. Long-term care nurses were more satisfied and perceived fewer
obstacles to providing quality care than nurses in acute hospitals. The long-term care nurses believed their care
was more evidence based and specialized to the geriatric population.
Although acute care nurses commonly do not identify themselves as geriatric nurses, they are engaged in
geriatric nursing practice due to the large number of hospitalized older adults. These nurses need to know best
practices for geriatric care. This study demonstrates that without evidence-based guidelines to assist nurses in
providing care that promotes autonomy, independence, and high-quality services, they feel less satisfied with
the care offered to older patients. It can be beneficial for acute care nurses to discuss this need with managerial
and education staff at their hospitals and support efforts to bridge evidence-based geriatric nursing practices to
their clinical setting.
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PRACTICE REALITIES
Nurse Yen is a new graduate of a BSN program who has joined the staff of a subacute care unit of the local
hospital. Most of the nurses on staff are diplomas and ADN graduates who have been out of school for more
than a decade.
Ms. Yen notices that some of the nurses are unaware of current best practices and trends. In informal
conversations, she has learned that none of the nurses subscribes to professional journals or belongs to a
professional association, and the rare times they have attended continuing education programs was when the
hospital sent them.
What can Nurse Yen do to help these nurses understand the importance and engage in continuing
education?
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CRITICAL THINKING EXERCISES
1. What were some of the reasons for the poor status of gerontological nursing in the past?
2. Why is the nursing role of healer particularly meaningful to gerontological practice?
3. What theme regarding the involvement of the older adult is apparent in the ANA Standards of the
Gerontological Nurse?
4. Describe several issues that could warrant gerontological nursing research activities.
5. Describe how the increased use of holistic practices could have a positive effect on cost and consumer
satisfaction.
6. Outline functions that could be performed by a gerontological nurse in the roles of (a) assisted-living
community preadmission health screener, (b) health counselor in a retirement community, (c) caregiver
trainer, (d) industrial preretirement health educator, and (e) faith community nurse.
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Chapter Summary
Although nurses have a long history of caring for older adults, the formal creation of a specialty of
gerontological nursing did not occur until the 1970s. Since that time the specialty has grown considerably
with the creation of standards, clarification of competencies, and development of several organizations that
address the unique needs of nurses in this specialty. As the specialty has developed there has been
differentiation between geriatric nursing, which involves the nursing care of sick older adults, and
gerontological nursing, which promotes wellness and healthy aging for all individuals.
The major roles for gerontological nurses include that of healer, caregiver, educator, advocate, and
innovator. There also are advanced practice roles for nurses in this specialty.
To effectively care for others, gerontological nurses must care for themselves. This includes positive health
care practices, having positive connections with others, attending to spiritual needs, and taking time for self.
These practices not only promote health in nurses themselves but enable nurses to serve as models of healthy
aging practices to others.
Gerontological nurses face challenges as the specialty continues to grow, such as assuring practice is based
on evidence, advancing research, promoting integrative care, educating caregivers, developing new roles within
the specialty, and balancing quality care with pressures to control health care costs.
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Resources
American Holistic Nurses Association
http://www.ahna.org
American Nurses Credentialing Center
http://www.nursecredentialing.org
Hartford Institute for Geriatric Nursing
http://www.hartfordign.org
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http://www.ahna.org

http://www.nursecredentialing.org

http://www.hartfordign.org

References
Bishop, L. F. (1904). Relation of old age to disease with illustrative cases. American Journal of Nursing, 4(4),
674.
DeWitt, K. (1904). The old nurse. American Journal of Nursing, 4(4), 177.
Nightingale, F. (1860). Notes on nursing: What it is, and what it is not. New York, NY: D. Appleton and
Company.
Nouwen, H. J. M. (1990). The wounded healer. New York, NY: Doubleday.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 7
Holistic Assessment and Care Planning
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CHAPTER OUTLINE
Holistic Gerontological Care
Holistic Assessment Of Needs
Health Promotion–Related Needs
Health Challenges–Related Needs
Requisites to Meet Needs
Gerontological Nursing Processes
Examples Of Application
Applying the Holistic Model: The Case of Mrs. D
The Nurse As Healer
Healing Characteristics
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Explain holistic gerontological nursing care.
2. Describe the needs of older adults pertaining to the promotion of health and the management of health challenges.
3. List the requisites that influence older persons’ abilities to meet self-care needs.
4. Describe the general types of nursing interventions that are employed when older adults present self-care deficits.
5. Describe four characteristics of nurses who function as healers.
TERMS TO KNOW
Holistic pertains to whole person; body, mind, and spirit
Presence being totally “with” or engaged with another individual
Surviving to old age is a tremendous accomplishment. Basic life requirements such as obtaining adequate
nutrition, keeping oneself relatively safe, and maintaining the body’s normal functions have been met with
some success to survive to this time. Older adults have confronted and overcome to varying degrees the
hurdles of coping with crises, adjusting to change, and learning new skills. Throughout their lives, older
individuals have faced many important decisions, such as should they:
Leave their country of birth to make a fresh start in America?
Stay in the family business or seek a job in a local industry?
Risk their lives to defend a cause in which they believe?
Encourage their children to fight in an unpopular war?
Invest their entire savings in launching a business of their own?
Allow their children to continue their education when the children’s employment would ease a serious
financial hardship?
Too often, nurses seek external resources to meet the needs of older persons rather than recognizing that older
adults have considerable inner resources for self-care and empowering them to use these strengths. Older
adults then become passive recipients of care rather than active participants. This seems unreasonable because
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most older adults have had a lifetime of taking care of themselves and others, making their own decisions, and
meeting life’s most trying challenges. They may become angry or depressed at being forced to forfeit their
decision-making functions to others. They may unnecessarily develop feelings of dependency, uselessness, and
powerlessness. Gerontological nurses must recognize and mobilize the strengths and capabilities of older
people so that they can be responsible and active participants in, rather than objects of, care. Tapping the
resources of older individuals in their own care promotes normalcy, independence, and individuality; it aids in
reducing risks of secondary problems related to the reactions of older adults to an unnecessarily imposed
dependent role; and it honors their wisdom, experience, and capabilities.
KEY CONCEPT
Older individuals have had to be strong and resourceful to navigate the stormy waters of life. Nurses
should not overlook these strengths when planning care for older adults.
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HOLISTIC GERONTOLOGICAL CARE
Holism refers to the integration of the biologic, psychological, social, and spiritual dimensions of an individual
in which the synergy creates a sum that is greater than its parts; within this framework, healing the whole
person is the goal of nursing (Dossey & Keegan, 2012). Holistic gerontological care incorporates knowledge
and skills from a variety of disciplines to address the physical, mental, social, and spiritual health of
individuals. Holistic gerontological care is concerned with:
Facilitating growth toward wholeness
Promoting recovery and learning from an illness
Maximizing quality of life when one possesses an incurable illness or disability
Providing peace, comfort, and dignity as death is approached
In holistic care, the goal is not to treat diseases but to serve the needs of the total person through the healing
of the body, mind, and spirit.
KEY CONCEPT
Gerontological nurses help older individuals achieve a sense of wholeness by guiding them in
understanding and finding meaning and purpose in life; facilitating harmony of the mind, body, and
spirit; mobilizing their internal and external resources; and promoting self-care behaviors.
Health promotion and healing through a balance of the body, mind, and spirit of individuals are at the core of
holistic care and have particular relevance for gerontological care. The impact of age-related changes and the
effects of highly prevalent chronic conditions can easily threaten the well-being of the body, mind, and spirit;
therefore, nursing interventions to reduce such threats are essential. Because chronic diseases and the effects of
advanced age cannot be eliminated, healing rather than curative efforts will be most beneficial in
gerontological nursing practice. Equally significant is assisting older adults toward self-discovery in their final
phase of life so that they find meaning, connectedness with others, and an understanding of their place in the
universe.
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HOLISTIC ASSESSMENT OF NEEDS
There are many evidence-based assessment tools that can be useful to gerontological nurses. One of the most
comprehensive listings of these tools can be found at the Hartford Institute for Geriatric Nursing (see
Resource listing), which includes resources for assessment of activities of daily living (ADL), hearing, sleep,
sexuality, elder mistreatment, dementia, hospital admission risk, and other topics. These tools can be used to
supplement the holistic assessment, which has a slightly different emphasis. Holistic assessment identifies
patient needs related to health promotion and health challenges and also identifies the older adult’s requisites
to meet these needs.
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Health Promotion–Related Needs
The concept of health seems simple, yet it is quite complex. Viewing health as the absence of disease offers little
more clarity than defining cold as the absence of hot and creates an image that begs for a more positive, broad
understanding. In regard to older adults, most of whom are living with chronic conditions, this definition
would relegate most of them to the ranks of the unhealthy.
When asked to describe the factors that contribute to health, most people would be likely to list the basic
life-sustaining needs such as breathing, eating, eliminating, resting, being active, and protecting oneself from
risks. These are essential to maintaining the physiological balance that sustains life. However, the reality that
we can have all of our physiological needs satisfied, yet still not feel well, demonstrates that physiological
balance is but one component of overall health. Connection with ourselves, others, a higher power, and nature
are important factors influencing health. The fulfillment of physiological needs and a sense of being connected
promote well-being of the body, mind, and spirit that enables us to experience gratification through achieving
purpose, pleasure, and dignity. This holistic model demonstrates that optimal health includes those activities
that not only enable us to exist but also help us to realize effective, enriched lives (Fig. 7-1).
FIGURE 7-1 • Health promotion–related needs.
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POINT TO PONDER
What does it mean to you to be healthy and whole?
An improved definition of health includes consideration of the root meaning of the word health: whole. Using
this foundation, health is understood as a state of wholeness … an integration of body, mind, and spirit to achieve
the highest possible quality of life each day (Fig. 7-2). For some individuals, this can mean exercising at the gym,
engaging in challenging work, and having a personal relationship with God; for others, it can represent
propelling oneself in a wheelchair to a porch, enjoying the beauty of nature, and connecting with a universal
energy.
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FIGURE 7-2 • Rather than being limited to meaning the absence of disease, health implies a wholeness and
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harmony of body, mind, and spirit.
Views of health differ not only from individual to individual but also within the same individual from one
time to another. Health priorities and expectations in a 70-year-old person may not resemble what they were
when that individual was half that age. Cultural and religious influences can also affect one’s view of health.
Optimal health of older adults rests on the degree to which the needs for physiological balance,
connection, and gratification are satisfied. There is the risk that in busy clinical settings, the less tangible
needs of gratification and connection can be overlooked; as advocates for older adults, gerontological nurses
must assure that comprehensive care is provided by not omitting these important needs.
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Health Challenges–Related Needs
An unfortunate reality is that most older adults live with at least one chronic condition that challenges their
health status. In fact, most involvement that nurses have with older adults typically involves assisting them
with the demands imposed by health challenges. Older adults with acute or chronic conditions have the same
basic health promotion needs as healthy individuals (i.e., physiological balance, connection, and gratification);
however, their conditions may create new needs such as:
Education: As individuals face a new diagnosis, they need to understand the condition and its care.
Counseling: A health condition can trigger a variety of feelings and impose lifestyle adjustments.
Coaching: Just as athletes and musicians require the skills of a professional who can bring out the best in
them, patients, too, can benefit from efforts to improve compliance and motivation.
Monitoring: The complexities of health care and the changing status of aging people warrant oversight
from the nurse who can track progress and needs.
Coordination: Older adults with a health condition often visit several health care providers; assistance
with scheduling appointments, following multiple instructions, keeping all members of the team
informed, and preventing conflicting treatments are often needed.
Therapies: Often, health conditions are accompanied by the need for medications, exercises, special diets,
and procedures. These therapies can include conventional ones that are commonly used in mainstream
practice or complementary ones, such as biofeedback, herbal remedies, acupressure, and yoga. Patients
may need partial or total assistance as they implement these treatments.
Advocacy: There are times when older adults may need support or interception with an issue. This could
involve a nurse encouraging an older adult to express her objection to a treatment that the physician and
her family are pressuring her to accept or assisting a nursing home resident in contacting the state
ombudsman if the resident believes there is mismanagement of his funds.
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Requisites to Meet Needs
As straightforward and clear as the health promotion and health challenges–related needs may seem, these
needs are met with varying degrees of success because they are dependent on several factors unique to the
patient. Nurses assess older adults’ requisites to meet needs to determine areas for intervention.
Physical, Mental, and Socioeconomic Abilities
An individual relies on several factors to meet even the most basic life demands. For example, to normally
fulfill nutritional needs, a person must have the ability to experience hunger sensations; proper cognition to
adequately select, prepare, and consume food; good dental status to chew food; a functional digestive tract to
utilize ingested food; energy to shop and prepare food; and the funds to purchase food. Deficits in any of these
areas can create risks to nutritional status. A variety of nursing interventions can be used to reduce or
eliminate physical, mental, and socioeconomic deficits.
Knowledge, Experience, and Skills
Limitations exist when the knowledge, experience, or skills required for a given self-care action are inadequate
or nonexistent. An individual with a wealth of social skills is capable of a normal, active life that includes
friendship and other social interaction. People who have knowledge of the hazards of cigarette smoking will
be more capable of protecting themselves from health risks associated with this habit. An older man who is
widowed, however, may not be able to cook and provide an adequate diet for himself, having always depended
on his wife for meal preparation. Similarly, the person who has diabetes and cannot self-inject the necessary
insulin may not be able to meet the therapeutic demand for insulin administration. Specific nursing
considerations for enhancing self-care capacities are offered in other chapters.
Desire and Decision to Take Action
The value a person sees in performing the action, as well as the person’s knowledge, attitudes, beliefs, and
degree of motivation, influences the desire and decision for action. Limitations result if a person lacks desire
or decides against action. If an individual is not interested in preparing and eating meals because of social
isolation and loneliness, a dietary deficiency may develop. A hypertensive individual’s lack of desire and
decision not to forfeit potato chips and pork products in the diet because of an attitude that it is not worth the
trade-off may create a real health threat. The person who is not informed of the importance of physical
activity may not realize the need to arise from bed during an illness and consequently may develop
complications. The dying individual who views death as a natural process may decide against medical
intervention to sustain life and may not comply with the prescribed therapies.
Values, attitudes, and beliefs are deeply established and not easily altered. Although the nurse should
respect the right of individuals to make decisions affecting their lives, if limitations restrict their ability to
meet self-care demands, the nurse can help by explaining the benefit of a particular action, providing
information, and motivating. In some circumstances, as with an emotionally ill or mentally incompetent
person, desires and decisions may have to be superseded by professional judgments.
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KEY CONCEPT
There can be vastly different reasons for older adults to have a deficit in meeting a similar need. This
challenges the gerontological nurse to explore the unique and sometimes subtle dynamics of each older
person’s life.
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GERONTOLOGICAL NURSING PROCESSES
The assessment process considers patients’ effectiveness in meeting needs related to health promotion and
health challenges. If the individual is successful in fulfilling needs, there is no need for nursing intervention
except to reinforce the capability for self-care. When the older adult does not have the requisites to meet
needs independently, however, nursing interventions are needed. Nursing interventions are directed toward
empowering the older individual by strengthening self-care capacities, eliminating or minimizing self-care
limitations, and providing direct services by acting for, doing for, or assisting the individual when
requirements cannot be independently fulfilled (Fig. 7-3). Assessment factors pertaining to specific systems
and areas of function are found in the related chapters throughout this book.
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FIGURE 7-3 • If the nurse identifies self-care deficits in the older adult for meeting health promotion– and
health challenges–related needs, nursing interventions are needed.
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EXAMPLES OF APPLICATION
Nursing care for older persons is often associated with implementing actions when health conditions exist.
When individuals face health challenges, new needs frequently arise, such as administering medications,
observing for specific symptoms, and performing special treatments; these needs exceed and may affect the
needs related to health promotion. In geriatric nursing, consideration must be given to assessing the impact of
the health challenge on the individual’s self-care capacity and identifying appropriate nursing interventions to
ensure that the needs related to both health promotion and the management of health challenges are
adequately met. During the assessment, the nurse identifies the specific health challenges–related needs that
are present and the requisites (e.g., physical capability, knowledge, and desire) that need to be addressed to
strengthen self-care capacity.
It is significant that interventions include those actions that can empower the older individual to achieve
maximum self-care in regard to health challenges–related needs. Figure 7-3 demonstrates how the holistic
self-care model becomes operational in geriatric nursing practice. The cases that follow demonstrate the
application of this model.
KEY CONCEPT
More effort may be needed to instruct and coach an older person to perform a self-care task
independently, and more time may be taken for the person to perform the task independently than
would be necessary if a caregiver did the task; however, the benefits of independence to the older
person’s body, mind, and spirit are worth the investment.
CONSIDER THIS CASE
Mr. R, who has lived with diabetes for a long time, administers
insulin daily and follows a diabetic diet. Because of a recent urologic problem, he may now need to take
antibiotics daily and perform intermittent self-catheterization. During the assessment, the nurse
identifies the presence of illness-imposed needs. For instance, Mr. R performs self-catheterization
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according to procedure and is administering his antibiotics as prescribed, but he is not adhering to his
diabetic diet and alters his insulin dosage based on “how he feels that day.” Mr. R has knowledge of the
diabetic diet and wants to comply; however, he had depended on his wife to prepare meals, and now
that she is deceased, he has difficulty cooking nutritious meals independently. He denies ever being
informed of the need for regular doses of his insulin and states that he has relied on the advice of his
brother-in-law, also a diabetic, who told him to “take an extra shot of insulin when he eats a lot of
sweets.”
THINK CRITICALLY
What is the nurse’s next step once Mr. R’s needs have been identified?
What factors must be considered in exploring Mr. R’s deficits in meeting his health challenges–
related needs?
What specific actions could be planned to address Mr. R’s needs?
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Applying the Holistic Model: The Case of Mrs. D
The following case demonstrates how this model can work.
Mrs. D, 78 years old, was admitted to a hospital service for acute conditions with the identified problems of a
fractured neck of the femur, malnutrition, and a need for a different living arrangement. Initial observation revealed
a small-framed, frail-looking lady, with obvious signs of malnutrition and dehydration. She was well oriented to
person, place, and time and was able to converse and answer questions coherently. Although her memory for recent
events was poor, she seldom forgot to inform anyone who was interested that she neither liked nor wanted to be in the
hospital. Her previous and only other hospitalization was 55 years earlier.
Mrs. D had been living with her husband and an unmarried sister for more than 50 years when her husband
died. For the 5 years following his death, she depended heavily on her sister for emotional support and guidance. Then
her sister died, which promoted feelings of anxiety, insecurity, loneliness, and depression.
For the year since her sister’s death, she has lived alone, caring for her six-room home in the country with no
assistance other than that from a neighbor who did the shopping for Mrs. D and occasionally provided her with
transportation.
On the day of her admission to the hospital, Mrs. D had fallen on her kitchen floor, weak from her malnourished
state. Discovering her hours later, her neighbor called an ambulance, which transported Mrs. D to the hospital. Once
the diagnosis of fractured femur was established, plans were made to perform a nailing procedure, to correct her
malnourished state, and to find a new living arrangement because her home demanded more energy and attention
than she was capable of providing.
Nursing Care Plan 7-1 illustrates how Mrs. D’s holistic needs directed nursing diagnoses and related
nursing actions.
NURSING CARE PLAN 7-1
HOLISTIC CARE FOR MRS. D
NEEDS: Respiration and Circulation
Nursing Diagnoses: (1) Impaired Physical Mobility related to fracture and (2) Disruption of Gas
Exchange related to immobility
Goals: The patient demonstrates signs of adequate respiration, is free from respiratory distress and
infection, and is free from signs of impaired circulation.
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NEEDS: Nutrition and Hydration
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements, related to depression and
loneliness
Goals: The patient consumes at least 1,500 mL of fluids and 1,800 calories of nutrients daily; increases
weight to 125 lb.
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NEED: Elimination
Nursing Diagnoses: (1) Constipation related to immobility and (2) Risk of Infection related to
malnutrition and interferences with normal bathing
Goals: The patient is free from infection, establishes a regular bowel elimination schedule, is free from
constipation, and is clean and odor free.
NEED: Movement
Nursing Diagnoses: (1) Activity Intolerance related to malnutrition and fracture and (2) Impaired Physical
Mobility related to fracture
Goals: The patient maintains/achieves sufficient range of joint motion to engage in ADL and is free from
complications secondary to immobility.
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NEED: Rest
Nursing Diagnosis: Disturbed Sleep Pattern related to hospital environment and movement limitations
associated with fracture
Goals: The patient obtains sufficient sleep to be free from fatigue and learns measures to facilitate sleep
and rest.
NEED: Comfort
Nursing Diagnosis: Acute Pain related to fracture
Goals: The patient is free from pain and is able to participate in ADLs without pain-related restrictions.
NEED: Immunity
Nursing Diagnoses: (1) Ineffective Health Maintenance and (2) Risk of Infection
Goals: The patient is free from infection.
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NEED: Risk Reduction
Nursing Diagnoses: (1) Risk of Injury related to sensory deficits; (2) Risk of Impaired Skin Integrity
related to immobility, malnutrition, and decreased sensations; and (3) Impaired Home Maintenance
related to altered health state, convalescence
Goals: The patient is free from injury; possesses intact skin; effectively and correctly uses assistive devices,
eyeglasses, and hearing aids (as prescribed) to compensate for sensory deficits; and has safe, acceptable
living arrangements after discharge.
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NEED: Connection
Nursing Diagnoses: (1) Spiritual Distress, Hopelessness, and Powerlessness related to hospitalization,
health state, and lifestyle changes and (2) Impaired Social Interaction related to hospitalization and health
state
Goals: The patient expresses satisfaction with the amount of social interaction, identifies means for
fulfilling spiritual needs, and is free from signs of emotional distress.
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NEED: Gratification
Nursing Diagnoses: (1) Anxiety, Fear, Hopelessness, and Powerlessness related to hospitalization and
health state, (2) Impaired Social Interaction related to hospitalization, and (3) Chronic Low Self-Esteem
related to health problems and life situation
Goals: The patient demonstrates preinjury level of physical activity, performs self-care activities to
maximum level of independence, expresses satisfaction with the amount of solitude, and is free from signs
of emotional distress.
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COMMUNICATION TIP
A skillful assessment and comprehensive care plan mean little if the information remains in the record
without being communicated to caregivers. A mechanism should be developed to share the care plan in
a format that can be easily used by caregivers and on a level appropriate for them.
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THE NURSE AS HEALER
Nurses are not merely task-doers but important instruments of their patients’ healing process. If completion of
tasks was all that constituted nursing care, robots could easily replace nurses. After all, technology exists that
could enable a machine to administer a medication, reposition a patient, monitor vital signs, record significant
events, and perform other common tasks. Yet the nursing profession emerged as a healing art characterized by
its practitioners offering comfort, compassion, support, and caring—factors that were equally (and perhaps
sometimes more) important to patients’ healing than the procedural tasks of caregiving. The nurse serves as a
healer whose interactions assist the patient in returning to wholeness (i.e., optimal function and harmony
among body, mind, and spirit).
Nurses who support holism and healing do not sit on the sidelines as observers; they actively engage in
patients’ healing processes. This level of engagement is similar to that of the dance instructor who takes the
student by the hand and demonstrates the correct steps instead of merely offering directions from the
sidelines.
KEY CONCEPT
Nurses actively engage in the patient’s dance of healing—teaching, guiding, modeling, coaching,
encouraging, and helping the patient through the various steps.
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Healing Characteristics
Characteristics that enable nurses to engage as healers for older adults include presence, availability,
willingness to form connections, and being models of holism.
Presence
The ability to be present in the moment also characterizes nurse healers. Despite the many real activities that
nurses typically must complete, the “busyness” of the average clinical setting, and the unending “to do” list
lingering over them, nurse healers are able to protect their interactions with patients from distractions. When
with patients, they are with them, giving their full, undivided attention. They actively listen; hear what
patients are saying—and not saying—and use their senses to detect subtle clues about needs. Even if the time
spent with individual patients is brief, the time fully belongs to their patients.
POINT TO PONDER
Reflect on an interaction in which the person with whom you were speaking seemed distracted and
hurried. How did that influence your communication?
Availability
Nurse healers display availability of body, mind, and spirit. They provide the time and space for patients to
express, explore, and experience. “That’s not my job” are words seldom heard from nurse healers. For example,
a nurse may be monitoring a patient who is recovering from cataract surgery in an outpatient surgical unit
when the patient confides to the nurse that he is distressed at learning that his grandchild was arrested for
possession of illegal drugs. A response from the nurse along the lines of “You shouldn’t worry about that now”
gives the message that the nurse is not available to discuss the patient’s concern and most likely will close the
door to further discussion. By contrast, responding, “This must be very difficult for you” could be more helpful
in conveying openness and interest. Although the nurse in the latter example may not be able to provide all
the possible assistance that the patient may require, he or she can allow the patient the safe space to unload
this burden on his mind and offer suggestions for follow-up help.
Willingness to Form Connections
Nurse healers make connections with their patients. They engage with patients in meaningful ways that
require openness, respect, acceptance, and a nonjudgmental attitude. They commit to learning about what
makes each patient a unique individual—the life journey that has been traveled, the story that has formed. At
times, this may require that nurses offer insights from their own journeys and share some of the chapters from
their lives. Exploring the unique threads that have been woven into the tapestry of a patient’s life facilitates
connection.
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Models of Holism
Effective nurse healers are models of holism, which begins with good self-care practices. They not only eat a
proper diet, exercise, obtain adequate rest, and follow other positive health practices, but they also are
attentive to their emotional and spiritual well-being. Integrity demands that nurses know what they want
others to know and behave as they want others to behave. Self-care also is essential to performing any other
role as a nurse healer.
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BRINGING RESEARCH TO LIFE
The Specialized Role of the RN in the Program of All-Inclusive Care for the Elderly (PACE)
Interdisciplinary Care Team
Source: Madden, K.A., Waldo, M., & Cleeter, D. (2014). Geriatric Nursing, 35(3), 199–204.
PACE is the Program of All-inclusive Care for the Elderly, which is considered an innovative
interdisciplinary model of health care delivery for community-based frail older adults, certified by their state to
need skilled nursing care. Although PACE has been shown to provide positive outcomes in providing care for
frail elderly individuals, there has been limited research on the role of the nurse within the PACE
interdisciplinary team. This study was conducted to gain insight into the role of nurses within PACE and the
nursing care delivery models that were used within the program.
The study consisted of an online structured survey of nurse leaders in PACE organizations throughout the
country. A group of these nurses were then interviewed by telephone using a focused survey.
The study found that there was a high percentage of baccalaureate prepared nurses working in PACE
organizations who were directly involved in care planning and nursing care management. A variety of nursing
care models (functional, primary, or care management) were used, and there was no certainty as to which
nursing care delivery model was the most appropriate for the program. The PACE nurses who participated in
the study as well as the researchers saw value in conducting future research using specific quality indicators
(e.g., hospital readmissions, pressure ulcer prevalence, patient satisfaction, etc.) to determine the best model
that should be utilized.
When performing patient assessments, developing care plans, and implementing nursing services, nurses
can use a variety of nursing care delivery models. Although each model has value, some may be more effective
than others for a specific program or patient population. When new programs or services are launched, it
could be beneficial for nurses to test different nursing care delivery models so they can identify relevant quality
indicators that can be tracked and evaluated in an effort to determine the model, which yields the best results.
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PRACTICE REALITIES
As a new staff member of a nursing home, you notice that other staff make decisions and perform activities
for many residents who seem capable of doing these things for themselves. When caring for some of these
residents, you give them the opportunity to make choices about their preferences, which they have been
pleased and able to make. In addition, when encouraging them to feed themselves, residents have performed
the task, although more time was required to complete care.
What could be the possible reasons for staff creating unnecessary dependence in the residents? How could
you encourage a change in their approaches?
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CRITICAL THINKING EXERCISES
1. Identify life experiences that have been unique to today’s older population and that have prepared them to
cope with some of the challenges of old age.
2. List age-related changes that could affect each of the health promotion–related needs.
3. What are some reasons for older adults not wanting to function independently in self-care activities?
4. Describe some situations in which older adults are at risk for losing independence as a result of nurses
doing for them rather than promoting independence.
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Chapter Summary
Holistic gerontological care integrates the biologic, psychological, social, and spiritual dimensions of an
individual in which the synergy creates a sum that is greater than its parts. It not only is concerned with the
treatment of illnesses but also the facilitation of growth toward wholeness, maximization of quality of life, and
the provision of peace, comfort, and dignity during the dying process.
Holistic gerontological nursing assessment considers physiological balance, the connection of the
individual with self, others, the culture and the environment, and the degree to which the person is achieving
gratification. When health challenges are present, the individual may present new needs, such as for
education, counseling, coaching, monitoring, coordination, therapies, and advocacy. The requisites that must
be present for the individual to meet these needs are physical, mental, and socioeconomic abilities; knowledge,
experience, and skills; and the desire and decision to take action.
Nurses need to recognize the considerable inner resources that older adults possess and mobilize these
resources to actively engage these individuals in their own care. Doing so will empower older adults and
facilitate commitment to the plan of care.
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Online Resources
American Holistic Health Association

Home

American Holistic Medical Association
http://www.holisticmedicine.org
American Holistic Nurses Association
http://www.ahna.org
Hartford Institute for Geriatric Nursing Try This Assessment Tool Series
http://hartfordign.org/practice/try_this/
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Home

http://www.holisticmedicine.org

http://www.ahna.org

http://hartfordign.org/practice/try_this/

Reference
Dossey, B. M., & Keegan, L. (2012). Holistic nursing: a handbook for practice (6th ed.). Sudbury, MA: Jones &
Bartlett Publishers.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://thepoint.lww.com/Eliopoulos9e

CHAPTER 8
Legal Aspects of Gerontological Nursing
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CHAPTER OUTLINE
Laws Governing Gerontological Nursing Practice
Legal Risks In Gerontological Nursing
Malpractice
Confidentiality
Patient Consent
Patient Competency
Staff Supervision
Medications
Restraints
Telephone Orders
Do Not Resuscitate Orders
Advance Directives and Issues Related to Death and Dying
Elder Abuse
Legal Safeguards For Nurses
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Discuss laws governing gerontological nursing practice.
2. Describe legal issues in gerontological nursing practice and ways to minimize risks.
3. List legal safeguards for nurses.
TERMS TO KNOW
Consent granting of permission to have an action taken or procedure performed
Durable power of attorney allows competent individuals to appoint someone to make decisions on their behalf in the event that they
become incompetent
Duty a relationship between individuals in which one is responsible or has been contracted to provide service for another
HIPAA Health Insurance Portability and Accountability Act of 1996, assures confidentiality of health information and consumers’ access
to their health records
Injury physical or mental harm to another or violation of a person’s rights resulting from a negligent act
Malpractice deviation from standard of care
Negligence failure to conform to the standard of care
Private law governs relationships between individuals and/or organizations
Public law governs relationships between private parties and the government
Standard of care the norm for what a reasonable individual in a similar circumstance would do
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Nurses in every specialty must be cognizant of the legal aspects of their practice, and gerontological nurses are
no exception. In fact, legal risks can intensify and legal questions can arise when working in geriatric care
settings. Frequently, gerontological nurses are in highly independent and responsible positions in which they
must make decisions without an abundance of professionals with whom to confer. They are also often
responsible for supervising unlicensed staff and ultimately are accountable for the actions of those they
supervise. In addition, gerontological nurses are likely to face difficult situations in which their advice or
guidance may be requested by patients and families; they may be asked questions regarding how to protect the
assets of the wife of a patient with Alzheimer’s disease, how to write a will, what can be done to cease life-
sustaining measures, and who can give consent for a patient. Also, the multiple problems faced by older
adults, their high prevalence of frailty, and their lack of familiarity with laws and regulations may make them
easy victims of unscrupulous practices. Advocacy is an integral part of gerontological nursing, reinforcing the
need for nurses to be concerned about protecting the rights of their older patients. To fully protect themselves,
their patients, and their employers, nurses must have knowledge of basic laws and ensure that their practice
falls within legally sound boundaries.
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LAWS GOVERNING GERONTOLOGICAL NURSING
PRACTICE
Laws are generated from several sources. Because many laws are developed at the state and local levels,
variation exists among the states. This variation necessitates nurses’ familiarity with the unique laws within
their specific states, particularly those governing professional practice, labor relations, and regulation of health
care agencies.
There are both public and private laws. Public law governs relationships between private parties and the
government and includes criminal law and regulation of organizations and individuals engaged in certain
practices. The scope of nursing practice and the requirements for being licensed as a home health agency fall
under the enforcement of public law. Private law governs relationships among individuals or between
individuals and organizations and involves contracts and torts (i.e., wrongful acts against another party,
including assault, battery, false imprisonment, and invasion of privacy). These laws protect individual rights
and also set standards of conduct, which, if violated, can result in liability of the wrongdoer.
In addition to laws, there are voluntary standards by which a nurse can be judged. The American Nurses
Association publication Scope and Standards of Gerontological Nursing provides guidelines for gerontological
nurses that offer descriptions of what is considered safe and effective care. (See Chapter 6 for a discussion of
these standards.)
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LEGAL RISKS IN GERONTOLOGICAL NURSING
Most nurses do not commit wrongful acts intentionally; however, certain situations can increase the nurse’s
risk of liability. Such situations include working without sufficient resources, not checking agency policy or
procedure, bending a rule, giving someone a break, taking shortcuts, or trying to work when physically or
emotionally exhausted. Not only repeated episodes of carelessness but also the one-time deviation from
standards can result in serious legal problems. Box 8-1 reviews some of the general acts that could make
nurses liable for violating the law. Nurses must be alert to all the potential legal risks in their practice and
make a conscious effort to minimize them. Some of the issues that could present legal risks for nurses are
presented below.
Box 8-1 Acts That Could Result in Legal Liability for Nurses
ASSAULT
A deliberate threat or attempt to harm another person that the person believes could be carried through
(e.g., telling a patient that he will be locked in a room without food for the entire day if he does not stop
being disruptive).
BATTERY
Unconsented touching of another person in a socially impermissible manner or carrying through an
assault. Even a touching act done to help a person can be interpreted as battery (e.g., performing a
procedure without consent).
DEFAMATION OF CHARACTER
An oral or written communication to a third party that damages a person’s reputation. Libel is the
written form of defamation; slander is the spoken form. With slander, actual damage must be proven,
except when:
Accusing someone of a crime
Accusing someone of having a loathsome disease
Making a statement that affects a person’s professional or business activity
Calling a woman unchaste
Defamation does not exist if the statement is true and made in good faith to persons with a legitimate
reason to receive the information. Stating on a reference that an employee was fired from your agency
for physically abusing patients is not defamation if, in fact, the employee was found guilty of those
charges. However, stating on a reference that an employee was a thief because narcotics were missing
every time he or she was on duty can be considered defamation if the employee was never proved guilty
of those charges.
FALSE IMPRISONMENT
Unlawful restraint or detention of a person. Preventing a patient from leaving a facility is an example of
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false imprisonment, unless it is shown that the patient has a contagious disease or could harm himself or
herself or others. Actual physical restraint need not be used for false imprisonment to occur: telling a
patient that he or she will be tied to the bed if he or she tries to leave can be considered false
imprisonment.
FRAUD
Willful and intentional misrepresentation that could cause harm or cause a loss to a person or property
(e.g., selling a patient a ring with the claim that memory will be improved when it is worn).
INVASION OF PRIVACY
Invading the right of an individual to personal privacy. Can include unwanted publicity, releasing a
medical record to unauthorized persons, giving patient information to an improper source, or having
one’s private affairs made public. (The only exceptions are reporting communicable diseases, gunshot
wounds, and abuse.) Allowing a visiting student to look at a patient’s pressure ulcers without permission
can be an invasion of privacy.
LARCENY
Unlawful taking of another person’s possession (e.g., assuming that a patient will not be using his or her
personally owned wheelchair anymore and giving it away to another patient without permission).
NEGLIGENCE
Omission or commission of an act that departs from acceptable and reasonable standards, which can
take several forms:
Malfeasance: committing an unlawful or improper act (e.g., a nurse performing a surgical
procedure)
Misfeasance: performing an act improperly (e.g., including the patient in a research project without
obtaining consent)
Nonfeasance: failure to take proper action (e.g., not notifying the physician of a serious change in
the patient’s status)
Malpractice: failure to abide by the standards of one’s profession (e.g., not checking that a
nasogastric tube is in the stomach before administering a tube feeding)
Criminal negligence: disregard to protecting the safety of another person (e.g., allowing a confused
patient, known to have a history of starting fires, to have matches in an unsupervised situation)
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Malpractice
Nurses are expected to provide services to patients in a careful, competent manner according to a standard of
care. The standard of care is considered the norm for what a reasonable individual in a similar circumstance
would do. When performance deviates from the standard of care, nurses can be liable for malpractice.
Examples of situations that could lead to malpractice include the following:
Administering the incorrect dosage of a medication to a patient, thereby causing the patient to
experience an adverse reaction
Identifying respiratory distress in a patient but not informing the physician in a timely manner
Leaving an irrigating solution at the bedside of a confused patient, who then drinks that solution
Forgetting to turn an immobile patient during the entire shift, resulting in the patient developing a
pressure ulcer
Having a patient fall because one staff member attempted to lift the patient manually when the use of a
lift device was the standard
The fact that a negligent act occurred in itself does not warrant that damages be recovered; instead, it must be
demonstrated that the following conditions were present:
Duty: a relationship between the nurse and the patient in which the nurse has assumed responsibility for
the care of the patient
Negligence: failure to conform to the standard of care (i.e., malpractice)
Injury: physical or mental harm to the patient or violation of the patient’s rights resulting from the
negligent act
KEY CONCEPT
Duty, negligence, and injury must be present for malpractice to exist.
The complexities involved in caring for older adults, the need to delegate responsibilities to others, and the
many competing demands on the nurse contribute to the risk of malpractice. As the responsibilities assumed
by nurses increase, so will the risk of malpractice. Nurses should be aware of the risks in their practice and be
proactive in preventing malpractice (Box 8-2). Also, it is advisable for nurses to carry their own malpractice
insurance and not rely only on the insurance provided by their employers. Employers may refuse to cover
nurses under their policy if it is believed they acted outside of their job descriptions; further, jury awards can
exceed the limits of employers’ policies.
Box 8-2 Recommendations for Reducing the Risk of
Malpractice
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Be familiar with and follow the nurse practice act that governs nursing practice in the specific
state.
Keep current of and adhere to policies and procedures of the employing agency.
Ensure that policies and procedures are revised as necessary.
Do not discuss a patient’s condition, share patient information, or allow access to a patient’s
medical record to anyone unless the patient has provided written consent.
Consult with the physician when an order is unclear or inappropriate.
Know patients’ normal status and promptly report changes in status.
Assess patients carefully and develop realistic care plans.
Read patients’ care plans and relevant nursing documentation before giving care.
Identify patients before administering medications or treatments.
Document observations about patients’ status, care given, and significant occurrences.
Assure that documentation by self and subordinates is accurate and that documentation reflects
care that actually was provided.
Know the credentials and assure competency of all subordinate staff.
Discuss with supervisory staff assignments that cannot be completed due to insufficient staff or
supplies.
Do not accept responsibilities that are beyond your capabilities to perform and do not delegate
assignments to others unless you are certain that they are competent to perform the delegated
tasks.
Report broken equipment and other safety hazards.
Report or file an incident report when unusual situations occur.
Promptly report all actual or suspected abuse to the appropriate state and local agencies.
Attend continuing education programs and keep current of knowledge and skills pertaining to
your practice.
Adapted from Eliopoulos, C. (2002). Legal risks management guidelines and principles for long-term care facilities (p. 28). Glen Arm,
MD: Health Education Network.
POINT TO PONDER
In addition to the time and money involved in defending a lawsuit, what are some consequences of
being accused of malpractice?
Other situations can cause nurses to be liable for negligence, if not malpractice, including the following:
Failing to take action (e.g., not reporting a change in the patient’s condition or not notifying the
administration of a physician’s incompetent acts)
Contributing to patient injury (e.g., not providing appropriate supervision of confused patients or failing
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to lock the wheelchair during a transfer)
Failing to report a hazardous situation (e.g., not letting anyone know that the fire alarm system is
inoperable or not informing anyone that a physician is performing procedures under the influence of
alcohol)
Handling patient’s possessions irresponsibly
Failing to follow established policies and procedures
POINT TO PONDER
Are you familiar with your state’s nurse practice act and the regulations governing the area in which you
practice or will practice?
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Confidentiality
It is the rare patient who is seen by only one health care provider. More often, the patient visits a variety of
medical specialists, therapists, diagnostic facilities, pharmacies, and institutions. These providers often need to
communicate information about the patient to ensure coordinated, quality care. However, with the potentially
high number of individuals who have access to patients’ personal medical information and the ease with which
information is able to be transferred, there are increased opportunities for confidential information to fall into
unintended hands.
In an effort to protect the security and confidentiality of patients’ health information, the federal
government developed the Health Insurance Portability and Accountability Act (HIPAA). HIPAA provides
patients with access to their medical records and control over how their personal health information is used
and disclosed. Patients can ask their providers to change incorrect information that they have discovered in
their record or to add missing information. They also can request that their health information not be shared.
Congress authorized civil and criminal penalties for covered entities that misuse personal health information.
The Administrative Simplification Compliance Act amended HIPAA and required all claims submitted to
Medicare be done so electronically, following guidelines to protect patient privacy.
There can be variations in the procedures providers and facilities use to review HIPAA-related facts with
patients, protect patients’ information, and communicate information related to patients. It is important that
nurses be familiar with and adhere to policies and procedures related to the protection of patients’ privacy.
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Patient Consent
Patients are entitled to know the full implications of procedures and make an independent decision as to
whether they choose to have them performed. This may sound simple enough, but it is easy for consent to be
overlooked or improperly obtained by health care providers. For instance, certain procedures may become so
routine to staff that they fail to realize patient permission must be granted, or a staff member may obtain a
signature from a patient who has a fluctuating level of mental competency and who does not fully understand
what he or she is signing. In the interest of helping patients and delivering care efficiently, or from a lack of
knowledge concerning consent, staff members can subject themselves to considerable legal liability.
Consent must be obtained before performing any medical or surgical procedure; performing procedures
without consent can be considered battery. Usually, when patients enter a health care facility, they sign
consent forms that authorize the staff to perform certain routine measures (e.g., bathing, examination, care-
related treatments, and emergency interventions). These forms, however, do not qualify as carte blanche
consent for all procedures. Even blanket consent forms that patients may sign, authorizing staff to do
anything required for treatment and care, are not valid safeguards and may not be upheld in a court of law.
Consent should be obtained for anything that exceeds basic, routine care measures. Particular procedures for
which consent definitely should be sought include any entry into the body, either by incision or through
natural body openings; any use of anesthesia, cobalt or radiation therapy, electroshock therapy, or
experimental procedures; any type of research participation, invasive or not; and any procedure, diagnostic or
treatment, that carries more than a slight risk. Whenever there is doubt regarding whether consent is
necessary, it is best to err on the safe side.
Consent must be informed. It is unfair to the patient and legally unsound to obtain the patient’s signature
for a procedure without telling the patient what that procedure entails. Ideally, a written consent that
describes the procedure, its purpose, alternatives to the procedure, expected consequences, and risks should be
signed by the patient, witnessed, and dated (Fig. 8-1). It is best that the person performing the procedure
(e.g., the physician or researcher) be the one to explain the procedure and obtain the consent. Nurses or other
staff members should not be in the position of obtaining consent for the physician because it is illegal and
because they may not be able to answer some of the medical questions posed by the patient. Patients who do
not fully comprehend or who have fluctuating levels of mental function are incapable of granting legally sound
consent. Nurses can play an important role in the consent process by ensuring that it is properly obtained,
answering questions, reinforcing information, and making the physician aware of any misunderstanding or
change in the desire of the patient. Finally, nurses should not influence the patient’s decision in any way.
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FIGURE 8-1 • It is important for the patient to give informed consent before any medical or surgical
procedure. Written consent forms should describe the procedure, its purpose, alternatives to the procedure,
expected consequences, and risks.
COMMUNICATION TIP
When consent is being obtained, nurses should assess if the patient or his/her representative fully
understand the procedure, its purpose, alternatives, expected consequences, and risks. If through
questions, comments, or body language there is any indication that the matter is not understood, the
nurse should ask if there are any questions or if more information is needed and to assure the need is
addressed.
Every conscious and mentally competent adult has the right to refuse consent for a procedure. To protect the
agency and staff, it is useful to have the patient sign a release stating that consent is denied and that the
patient understands the risks associated with refusing consent. If the patient refuses to sign the release, this
should be witnessed, and both the professional seeking consent and the witness should sign a statement that
documents the patient’s refusal for the medical record.
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Patient Competency
Increasingly, particularly in long-term care facilities, nurses are caring for patients who are confused,
demented, or otherwise mentally impaired. Persons who are mentally incompetent are unable to give legal
consent. Often in these circumstances, staff will turn to the next of kin to obtain consent for procedures;
however, the appointment of a guardian to grant consent for the incompetent individual is the responsibility
of the court. When the patient’s competency is questionable, staff should encourage family members to seek
legal guardianship of the patient or request the assistance of the state agency on aging in petitioning the court
for appointment of a guardian. Unless they have been judged incompetent by a judge, people are entitled to
make their own decisions.
Various forms of guardianship (also called conservatorship) can be granted when a person has been judged
incompetent (Box 8-3), each with its own restrictions. The guardian is monitored by the court to ensure that
he or she is acting in the best interests of the incompetent individual. In the case of a guardian of property, the
guardian must file financial reports with the court.
Box 8-3 Kinds of Decision-Making Authority That
Individuals Can Legally Possess Over Patients
GUARDIANSHIP
Court appointment of an individual or organization to have the authority to make decisions for an
incompetent person. Guardians can be granted decision-making authority for specific types of issues:
Guardian of property (conservatorship): this limited guardianship allows the guardian to take care
of financial matters but not make decisions concerning medical treatment.
Guardian of person: decisions pertaining to the consent or refusal for care and treatments can be
made by persons granted this type of guardianship.
Plenary guardianship (committeeship): all types of decisions pertaining to person and property can
be made by guardians under this form.
POWER OF ATTORNEY
Legal mechanism by which competent individuals appoint parties to make decisions for them; this can
take the form of:
Limited power of attorney: decisions are limited to certain matters (e.g., financial affairs) and
power of attorney becomes invalid if the individual becomes incompetent.
Durable power of attorney: provides a mechanism for continuing or initiating power of attorney in
the event the individual becomes incompetent.
Guardianship differs from power of attorney in that the latter is a mechanism used by competent individuals
to appoint someone to make decisions for them. Usually, a power of attorney becomes invalid if the individual
granting it becomes incompetent, except in the case of a durable power of attorney. A durable power of
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attorney allows competent individuals to appoint someone to make decisions on their behalf in the event that
they become incompetent; this is a recommended procedure for individuals with dementias and other
disorders in which competency can be anticipated to decline.
To ensure protection of patients’ rights, nurses should recommend that patients and their families seek
legal counsel for guardianship and power of attorney issues and, when such appointment has been made,
clarify the type of decision-making authority that the appointed parties possess.
KEY CONCEPT
A durable power of attorney can be useful for patients with Alzheimer’s disease because they can
appoint someone to make decisions on their behalf at a time when they may be incompetent to do so.
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Staff Supervision
In many settings, gerontological nurses are responsible for supervising other staff, many of whom may be
unlicensed personnel. In these situations, nurses are responsible not only for their own actions but also for the
actions of the staff they are supervising. This falls under the doctrine of respondeat superior (“let the master
answer”). Nurses must understand that if a patient is injured by an employee they supervise while the
employee is working within the scope of the applicable job description, nurses can be liable. Various types of
situations can create risks for nurses:
Permitting unqualified or incompetent persons to deliver care
Failing to follow up on delegated tasks
Assigning tasks to staff members for which they are not qualified or competent
Allowing staff to work under conditions with known risks (e.g., being short staffed and improperly
functioning equipment)
These are considerations that nurses need to keep in mind when they accept responsibility for covering the
house, sending an aide into a home to deliver care without knowing the aide’s competency, or allowing
registry or other employees to work without fully orienting them to agency policies and procedures.
KEY CONCEPT
A nurse needs to ensure that those caregivers to whom tasks are delegated are competent to perform the
tasks and carry out their assignments properly.
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Medications
Nurses are responsible for the safe administration of prescribed medications. Preparing, compounding,
dispensing, and retailing medications fall within the practice of pharmacy, not nursing, and, when performed
by nurses, can be interpreted as functioning outside their licensed scope of practice.
Concept Mastery Alert
An act as seemingly benign as going into the agency’s pharmacy after hours, pouring some tablets into a
container, labeling that container, and taking it to the unit so that a patient can receive the drug that is
urgently needed is illegal.
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Restraints
The Omnibus Budget Reconciliation Act (OBRA) heightened awareness of the serious impact of restraints by
imposing strict standards on their use in long-term care facilities. This increased concern regarding and
sensitivity to the use of chemical and physical restraints has had a ripple effect on other practice settings.
Anything that physically or mentally restricts a patient’s movement (e.g., protective vests, trays on
wheelchairs, safety belts, geriatric chairs, side rails, and medications) can be considered a restraint. Improperly
used restraining devices can not only violate regulations concerning their use but also result in litigation for
false imprisonment and negligence. At no time should restraints be used for the convenience of staff.
Older adults with deliriums and dementias can pose challenges to staff in terms of behavioral
management. There are several medications (e.g., haloperidol, benzodiazepines, and lorazepam) that can be
useful in reducing agitation and the need for physical restraints; however, these can result in complications
such as aspiration due to depression of the gag reflex and pneumonia due to reduced respiratory activity. It
must be recognized that these drugs are forms of chemical restraints and should only be employed after other
measures have proven ineffective. Further, nonpharmacological strategies to manage behaviors can reduce the
amount of drug needed. Consultation with geropsychiatric specialists or psychologists can prove beneficial in
identifying other strategies.
Alternatives to restraints should be used whenever possible. Measures to help manage behavioral problems
and protect the patient include alarmed doors, wristband alarms, bed alarm pads, beds and chairs close to the
floor level, and increased staff supervision and contact. Specific patient behavior that creates risks to the
patient and others should be documented. Assessment of the risk posed by the patient not being restrained
and the effectiveness of alternatives should be included.
When restraints are deemed absolutely necessary, a physician’s order for the restraints must be obtained,
stating the specific conditions for which the restraints are to be used, the type of restraints, and the duration of
use. Agency policies should exist for the use of restraints and should be followed strictly. Detailed
documentation should include the times for initiation and release of the restraints, their effectiveness, and the
patient’s response. The patient requires close observation while restrained.
At times, staff may assess that restraint use is required, but the patient or family objects and refuses to
have a restraint used. If counseling does not help the patient and family understand the risks involved in not
using the restraint, the agency may wish to have the patient and family sign a release of liability that states the
risks of not using a restraint and the patient’s or family’s opposition. Although this may not free the nurse or
agency from all responsibility, some limited protection may be afforded and, by signing the release, the patient
and family may realize the severity of the situation.
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Telephone Orders
In home health and long-term care settings, nurses often do not have the benefit of an on-site physician.
Changes in the patient’s condition and requests for new or altered treatments may be communicated over the
telephone and, in response, physicians may prescribe orders accordingly. Accepting telephone orders
predisposes nurses to considerable risks because the order can be heard or written incorrectly or the physician
can deny that the order was given. It may not be realistic or advantageous to patient care to totally eliminate
telephone orders, but nurses should minimize their risks in every way possible.
Try to have the physician immediately fax the written order, if possible.
Do not involve third parties in the order (e.g., do not have the order communicated by a secretary or
other staff member for the nurse or the physician).
Communicate all relevant information to the physician, such as vital signs, general status, and
medications administered.
Do not offer diagnostic interpretations or a medical diagnosis of the patient’s problem.
Write down the order as it is given and immediately read it back to the physician in its entirety.
Place the order on the physician’s order sheet, indicating it was a telephone order, the physician who
gave it, time, date, and the nurse’s signature.
Obtain the physician’s signature within 24 hours.
Recorded telephone orders may be a helpful way for nurses to validate what they have heard, but they may not
offer much protection in the event of a lawsuit unless the physician is informed that the conversation is being
recorded or unless special equipment with a 15-second tone sound is used.
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Do Not Resuscitate Orders
The caseloads of many gerontological nurses contain a high prevalence of terminally ill patients. It may be
understood by all parties involved that these patients are going to die and that resuscitation attempts would be
inappropriate; however, unless an order specifically states that the patient should not be resuscitated, failure to
attempt to save that person’s life could be viewed as negligence. Nurses must ensure that DNR (do not
resuscitate) orders are legally sound, remembering several points. First, DNR orders are medical orders and
must be written and signed on the physician’s order sheet to be valid. DNR placed on the care plan or a
special symbol at the patient’s bedside is not legal without the medical order. Next, unless it is detrimental to
the patient’s well-being or the patient is incompetent, consent for the decision not to resuscitate should be
obtained; if the patient is unable to consent, family consent should be sought. Finally, every agency should
develop a DNR policy to guide staff in these situations; this could be an excellent item for an ethics
committee to review.
CONSIDER THIS CASE
You are working in a nursing home that supports a restraint-free
environment. In the past month, one of the residents has slipped once from her wheelchair and once off
the edge of her bed; she fell onto the floor both times. Although the resident was not injured in either of
these incidents, the resident’s daughter is concerned that her mother has the potential to seriously hurt
herself during a fall and requests that her mother be restrained while in bed and in her wheelchair. The
resident has not expressed any preference but says she’ll do whatever her daughter wants. You explain
the rationale for not using restraints, but the daughter is insistent that her mother be restrained. “You
know my mother has the tendency to slip to the floor,” the daughter says, “so if you don’t tie her in the
chair and keep her rails up when she is in bed and she falls, I’ll have my lawyers here before you can say
boo!”
THINK CRITICALLY
How do you decide if the resident’s freedom to be unrestrained is worth the risk of her injuring
herself during a fall?
What dilemmas could you present for the resident if you ask her for her preference without
consideration of the daughter’s desires?
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How much should a facility be influenced by the threat of litigation?
What can you do to safeguard the resident and the facility?
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Advance Directives and Issues Related to Death and Dying
A variety of issues surrounding patients’ deaths pose legal concern for nurses. Some of these issues arise long
before death occurs, when patients choose to execute an advance directive or a living will. Advance directives
express the desires of competent adults regarding terminal care, life-sustaining measures, and other issues
pertaining to their dying and death.
KEY CONCEPT
There are two types of advance directives. A durable power of attorney for health care is a document that
appoints a person selected by the patient (called a health care proxy, attorney-in-fact, surrogate, or
agent) to make decisions on the patient’s behalf should the patient be unable to make or communicate
his or her decisions. A living will describes a patient’s preferences and gives instructions to health care
providers if at a future time he or she is unable to make or communicate decisions and has no one
appointed as proxy.
In 1990, Congress passed the Patient Self-Determination Act (which went into effect from December 1,
1991), which requires all health care institutions receiving Medicare or Medicaid funds to ask patients on
admission if they possess a living will or durable power of attorney for health care. The patient’s response must
be recorded in the medical record. Nurses can aid by making physicians and other staff aware of the presence
of a patient’s advance directive, informing patients of any special measures they must take to have the
document accepted into the medical record, and, unless contraindicated, following the patient’s wishes (Fig.
8-2). Following an advance directive protects health care professionals from civil and criminal liability when
they are followed in good faith. Nurses are advised to check the status of advance directive legislation in their
individual states.
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FIGURE 8-2 • Gerontological nurses guide older adults as they consider advance directives.
Other issues arise when patients are terminally ill and dying; one such issue involves wills. Wills are
statements of individuals’ desires for the management of their affairs after their death. For a will to be valid,
the person making it must be of sound mind and legal age and must not be coerced or influenced into making
it. The will should be written—although under certain conditions, some states recognize oral, or nuncupative,
wills—signed, dated, and witnessed by persons not named in the will. The required number of witnesses may
vary among the states.
To avoid problems, such as family accusations that the patient was influenced by the nurse because of his
dependency on her, nurses should avoid witnessing a will. Nurses should, however, help patients obtain legal
counsel when they wish to execute or change a will. Legal aid agencies and local schools of law are also sources
of assistance for older adults wishing to write their wills. If a patient is dying and wishes to dictate a will to the
nurse, the nurse may write it exactly as stated, sign, and date it; have the patient sign it if possible; and forward
it to the agency’s administrative offices for handling. It is useful for gerontological nurses to encourage persons
of all ages to develop a will to avoid having the state determine how their property will be distributed in the
event of their deaths.
The pronouncement of death is another area of concern. Nurses often are placed in the position and are
capable of determining when a patient has died and notifying the family and funeral home. The physician is
then notified of the death by telephone and signs the death certificate at a later time. This rather common and
benign procedure actually may be illegal for nurses because in some states, the act of pronouncing a patient
dead falls within the scope of medical practice, not nursing. Nurses should safeguard their licenses by either
holding physicians responsible for the pronouncement of death if they are required to do so or lobbying to
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have the law changed so that they are protected in these situations.
Postmortem examinations of deceased persons are useful in learning more about the cause of death. They
also contribute to medical education. In some circumstances, such as when the cause of death is suspected to
be associated with a criminal act, malpractice, or an occupational disease, the death may be considered a
medical examiner’s case and an autopsy may be mandatory. Unless it is a medical examiner’s case, consent for
autopsy must be obtained from the next of kin, usually in the order of spouse, children, parents, siblings,
grandparents, aunts, uncles, and cousins.
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Elder Abuse
Elder abuse can occur in patients’ homes or in health care facilities by loved ones, caregivers, or strangers.
Particularly in long-term caregiving relationships, in which family members or staff “burn out,” abuse may be
an unfortunate consequence. Factors contributing to abuse by family caregivers are discussed in Chapter 35.
KEY CONCEPT
Caregiver stress can lead to abuse of older adults.
There are several recognized types of elder abuse (National Center for Elder Abuse, 2012), which include the
following:
Physical abuse
Emotional abuse
Sexual abuse
Exploitation
Neglect
Abandonment
Abuse can assume many forms, including inflicting pain or injury, stealing, mismanaging funds, misusing
medications, causing psychological distress, withholding food or care, or confining a person. Even threatening
to commit any of these acts is considered abuse. Abuse may be undetected due to an older person’s lack of
contact with others (e.g., being homebound and not having communication with anyone but the relative who
is the abuser) or due to the reluctance to report the problem due to fear or shame. Nurses can assess for abuse
using a tool such as the Elder Mistreatment Assessment (Fulmer, 2012). Gerontological nurses must also be
alert to indications of possible abuse or neglect during routine interactions with older adults; signs could
include the following:
Delay in seeking necessary medical care
Malnutrition
Dehydration
Unexplained bruises
Poor hygiene and grooming
Urine odor, urine-stained clothing/linens
Excoriation or abrasions of genitalia
Inappropriate administration of medications
Repeated infections, injuries, or preventable complications from existing diseases
Evasiveness in describing condition, symptoms, problems, and home life
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Unsafe living environment
Social isolation
Anxiety, suspiciousness, and depression
Nurses have a legal responsibility to report all cases of known or suspected abuse. States vary regarding
reporting mechanisms; nurses should thus consult specific state laws. The Resources listing includes
organizations that can provide information on elder abuse and guidance on finding attorneys to assist a person
who is the victim of abuse.
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LEGAL SAFEGUARDS FOR NURSES
Common sense can be the best ally of sound nursing practice. Never forget that patients, visitors, and
employees do not forfeit their legal rights or responsibilities when they are within the health care
environment. Laws and regulations impose additional rights and responsibilities in patient–provider and
employee–employer relationships. Nurses can and should protect themselves in the following ways:
Familiarize themselves with the laws and rules governing their specific care agency/facility, their state’s
nurse practice act, and labor relations.
Become knowledgeable about their agency’s policies and procedures and adhere to them strictly.
Function within the scope of nursing practice.
Determine for themselves the competency of employees for whom they are responsible.
Check the work of employees under their supervision.
Obtain administrative or legal guidance when in doubt about the legal ramifications of a situation.
Report and document any unusual occurrence.
Refuse to work under circumstances that create a risk to safe patient care.
Carry liability insurance
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BRINGING RESEARCH TO LIFE
A Staff Intervention Targeting Resident-to-Resident Elder Mistreatment (R-REM) in Long-
Term Care Increased Staff Knowledge, Recognition, and Reporting: Results from a Cluster
Randomized Trial
Source: Teresi, J. A., Ramirez, M., Ellis, J. M., Silver, S., Boratgis, G. et al. (2013). International Journal of
Nursing Studies, 50(5), 644–656.
Aggression between nursing home residents has not received much attention and can be missed by nursing
staff. Although these incidents can have negative effects for residents and staff, and can result in lawsuits,
before this study, there had been no evidence-based training, interventions, and implementation strategies to
address this issue. This study evaluated the impact of a training intervention to increase nursing staff
knowledge of R-REM.
There were 685 residents selected in the control group and 720 in the intervention group from five
different nursing homes. Staff in the intervention group received training, implementation protocols related to
recognizing and managing R-REM, and guidance in implementing protocols. Data were collected at the start
of the project and at 6 and 12 months.
The study demonstrated that the employees who received the training intervention were superior at
recognizing and reporting R-REM. The intervention group also had significantly fewer incidents of R-REM
despite having similar R-REM at the start of the intervention.
Reducing legal risks requires effective, evidence- based interventions that nursing staff can use. In addition
to developing such resources, nurses need to advocate for staff education and training to enable staff to be
aware and utilize these resources. In nursing homes and other settings where staffing often is limited, there
could be resistance to the allocation of staff time for education and implementation of interventions. By
helping decision makers to understand that such actions can aid not only in reducing the risk of litigation but
also in preventing injuries and dissatisfaction of older adults and their caregivers, the cost–benefit of such
approaches may be appreciated and the interventions supported.
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PRACTICE REALITIES
You are working the night shift, where there have been several call outs on the unit for postoperative patients.
All staff are carrying a heavier than usual load. During tonight’s shift, one of the nurses forgot to raise the side
rail on a heavily sedated patient. In his confused, sedated state, the patient tries to get out of bed and falls.
You and the assigned nurse hurry to his aid. The other nurse tells you to help her lift the patient back to bed.
You resist, stating “He should be examined and the supervisor called.” The other nurse objects, stating “You
know the policy. They’ll either suspend or fire me and I have kids to support. I checked him out and he is fine
… and, he is too doped up to remember anything. There won’t be any harm; come on.”
The patient doesn’t appear injured and you don’t want the nurse to be in jeopardy of losing her job. What
should you do?
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CRITICAL THINKING EXERCISES
1. Discuss the reasons why gerontological nursing is a high-risk specialty for legal liability.
2. Identify the process you would follow in your community to obtain guardianship for an incompetent
older adult who has no family.
3. Describe the approach you would use to discuss the development of an advanced directive with an older
adult.
4. Discuss the actions you would take if faced with the following situations:
A nurse whom you supervise makes repeated errors and does not seem competent to do his job.
You begin documenting your observations but are told by your immediate supervisor to “just bite your
tongue and live with it because he is the administrator’s son.”
A patient confides in you that her son is forging her name on checks and gradually emptying out her
bank accounts.
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Chapter Summary
There are legal risks associated with nursing practice in any specialty. In gerontological nursing, the risks may
be compounded by the unique problems faced by older adults and the care settings, which may be staffed with
a high number of unlicensed caregivers. Gerontological nurses need to understand their legal responsibilities
and risks.
There are both public and private laws that must be respected in practice. Public law governs the
relationship between government and private parties; it includes issues such as the scope of practice,
regulations that care settings must abide by, and criminal law. Private law involves the relationships among
individuals or between individuals and organizations and includes issues such as assault, battery, false
imprisonment, and invasion of privacy. In addition, there are voluntary standards upon which nurses can be
judged, such as those developed by professional nursing associations.
Nurses need to be proactive in protecting themselves, their organizations, and their patients. This
responsibility includes abiding by the laws and rules governing their practice, assuring the competency of
individuals to whom care is delegated, reporting unusual circumstances and incidents, and obtaining legal
consultation as needed.
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Resources
American Association of Retired Persons (AARP) Elder Law Forum
http://www.aarp.org/research/legal-advocacy/
American Bar Association Senior Lawyers Division
http://www.abanet.org/srlawyers/home.html
Elder Justice Coalition

Home

Hartford Institute for Geriatric Nursing
Try This: Best Practices in Nursing Care to Older Adults. Issue Number 15 (Revised 2007), Elder
Mistreatment and Abuse Assessment. http://consultgerirn.org/uploads/File/trythis/try_this_15
National Academy of Elder Law Attorneys
http://www.naela.com
National Center on Elder Abuse
http://www.ncea.aoa.gov
National Senior Citizens Law Center
http://www.nsclc.org
Nursing Home Abuse/Elder Abuse Attorneys Referral Network
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http://www.aarp.org/research/legal-advocacy/

http://www.abanet.org/srlawyers/home.html

Home

http://consultgerirn.org/uploads/File/trythis/try_this_15

http://www.naela.com

http://www.ncea.aoa.gov

http://www.nsclc.org

References
Fulmer, T. (2012). Elder mistreatment assessment. Try This. Hartford Institute for Geriatric Nursing, Issue
No. 15. Retrieved September 12, 2014 from http://consultgerirn.org/uploads/File/trythis/try_this_15
National Center for Elder Abuse. (2014). Fact sheet about elder abuse. Retrieved September 12, 2014 from
http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331
Recommended Readings
Recommended readings associated with this chapter can be found on the Web site that accompanies the
book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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http://consultgerirn.org/uploads/File/trythis/try_this_15

http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331

http://thepoint.lww.com/Eliopoulos9e

CHAPTER 9
Ethical Aspects of Gerontological Nursing
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CHAPTER OUTLINE
Philosophies Guiding Ethical Thinking
Ethics In Nursing
External and Internal Ethical Standards
Ethical Principles
Cultural Considerations
Ethical Dilemmas Facing Gerontological Nurses
Changes Increasing Ethical Dilemmas for Nurses
Measures to Help Nurses Make Ethical Decisions
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Discuss various philosophies regarding right and wrong.
2. Describe ethical standards, principles, and cultural considerations guiding nursing practice.
3. List factors that have increased ethical dilemmas for nurses.
4. Identify measures to help nurses make ethical decisions.
TERMS TO KNOW
Autonomy to respect individual freedoms, preferences, and rights
Beneficence to do good for patients
Confidentiality to respect the privacy
Ethics a system of moral principles that guides behaviors
Fidelity to respect our words and duty to patients
Justice to be fair, treat people equally
Nonmaleficence to prevent harm to patients
Veracity truthfulness
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Although the concept of principles guiding right and wrong conduct is not new to nursing, professional ethics
has received increasing attention in nursing circles. Gerontological nurses commonly face ethical questions
regarding the provision, scope, or cost of care for older adults. Many of these questions arise in nurses’ daily
practice. It is important for nurses to understand both the ethics of the nursing profession and their own
personal ethics and to be aware of the ethical dilemmas facing gerontological nurses today.
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PHILOSOPHIES GUIDING ETHICAL THINKING
The word ethics originated in ancient Greece—ethos means those beliefs that guide life. Most current
definitions of ethics revolve around the concept of accepted standards of conduct and moral judgment.
Basically, ethics help determine right and wrong courses of action. As simple as this sounds, different
philosophies disagree about what constitutes right and wrong; the following are some examples:
Utilitarianism. This philosophy holds that good acts are those from which the greatest number of people
will benefit and gain happiness.
Egoism. At the opposite pole from utilitarianism, egoism proposes that an act is morally acceptable if it
is of the greatest benefit to oneself and that there is no reason to perform an act that benefits others
unless one will personally benefit from it as well.
Relativism. This philosophy can be referred to as situational ethics, in that right and wrong are relative
to the situation. Within relativism are several subgroups of thinking. Some relativists believe that there
can be individual variation in what is ethically correct, whereas others feel that the individual’s beliefs
should conform to the overall beliefs of the society for the given time and situation.
Absolutism. Under the theory of absolutism, there are specific truths to guide actions. The truths can
vary depending on a person’s beliefs; for example, a Christian’s view may differ from an atheist’s view on
certain moral behaviors, and a person who supports a political view of democracy may believe in truths
different from those of a communist.
To illustrate the application of these four different philosophies, consider the hypothetical situation of four
poor old men who share a household. One day, one of these men finds a lottery ticket in the mailBox while
checking the household’s mail. The ticket holds the winning number for a million dollars. Ethically, does he
owe his housemates any of the winnings? A utilitarian would propose that he split the winnings with his
housemates because that would bring good to the greatest number of people. An egoist would encourage him
to keep the winnings because that would do him the most good personally. A relativist might say that
normally he should keep the winnings, but because in this situation he will have more money than he will
need, he should share the winnings. An absolutist who happens to be Christian may say that keeping the ticket
is morally wrong and an effort should be made to find the rightful owner.
Now consider the application of the philosophical approaches to the issue of federal subsidies to older
adults. A utilitarian could say that 12% of the population should not use one third of the gross national
product and that the money instead should be equally allocated on a per capita basis. An egoist would say that
the individual old person should take whatever he feels he needs, regardless of the impact on others. A
relativist could say that older people can use this proportion of the budget unless more is needed for
dependent children or defense, at which point it would no longer be right to do so. Absolutists could hold
various views depending on their belief systems, ranging from giving the older population whatever they need
because of a moral responsibility to care for the sick and aged, to withholding funds from the older population
so that finances are available to build the military and meet specific political goals.
Other philosophies guiding ethics exist, but the few that have been briefly described demonstrate the
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diversity of approaches to ethical thinking and reinforce the fact that determining right and wrong actions can
be a complicated endeavor.
KEY CONCEPT
Individuals can be guided by a wide range of ethical philosophies that cause them to view the same
situations in vastly different ways.
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ETHICS IN NURSING
External and Internal Ethical Standards
Professions such as nursing require a code of ethics on which practice can be based and evaluated. A
professional code of ethics is accepted by those who practice the profession as the formal guidelines for their
actions. For example, the American Nurses Association (ANA) Code of Ethics for Nurses offers ethics that
outline the broad values of the profession. (Information about the Code is available at
http://www.nursingworld.org/codeofethics.) The American Holistic Nurses’ Association has developed the
Code of Ethics for Holistic Nursing that provides guidance for nurses’ actions and responsibilities for self, others,
and the environment (the full document is available at http://www.ahna.org).
Nurses are also subject to ethical standards created outside of the nursing profession. Federal, state, and
local standards, in the form of regulations, guide the nursing practice. In addition, various organizations such
as the Joint Commission and the American Healthcare Association develop standards for specific practitioners
and care settings. Individual agencies, too, have philosophies, goals, and objectives that support a specific level
of nursing practice.
Most importantly, individual nurses possess values that they have developed throughout their lives that
will largely influence ethical thinking. Ideally, a nurse’s individual value system meshes with that of the
profession, society, and employer; conflict can arise when value systems are incompatible.
KEY CONCEPT
It is important for a nurse to understand his or her own values as conflict and distress can result when
the nurse’s values differ from those of the employer or population served.
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http://www.nursingworld.org/codeofethics

http://www.ahna.org

Ethical Principles
Several ethical principles are used to guide health care, including the following:
Beneficence: to do good for patients. This principle is based on the belief that the education and
experience of nurses enable them to make sound decisions that serve patients’ best interests. Nurses are
challenged to take actions that are good for patients while not ignoring patients’ desires. To override
patients’ decisions and invoke professional authority to take actions that nurses view as in patients’ best
interests is viewed as paternalism and interferes with the freedom and rights of patients.
Nonmaleficence: to prevent harm to patients. This principle could be viewed as a subset of beneficence
because the intent is ultimately to take action that is good for patients. In addition to not directly
performing an act that causes harm, actions such as informing management that staffing is inadequate
to provide safe care support nonmaleficence.
Justice: to be fair, treat people equally, and give patients the service they need. At the foundation of this
principle is the belief that patients are entitled to services based on need, regardless of the ability to pay.
Scarce resources have challenged this concept of unrestricted access and use of health care services.
Fidelity and veracity: fidelity means to respect our words and duty to patients; veracity means
truthfulness. This principle is central to all nurse–patient interactions because the quality of this
relationship depends on trust and integrity. Older patients may have higher degrees of vulnerability than
do the younger adults and may be particularly dependent on the truthfulness of their caregivers.
Autonomy: to respect patients’ freedoms, preferences, and rights. Ensuring and protecting older patients’
right to provide informed consent are consistent with this principle.
Confidentiality: to respect the privacy of patients. Patients often share highly personal information with
nurses and need to feel assured that their trust will not be violated. In addition to respecting
confidentiality as being a morally sound principle, the Health Insurance Portability and Accountability
Act and other laws have afforded people the legal right to privacy and consequences if this is violated.
Few nurses would argue with the value of these principles (Fig. 9-1). In fact, practices that reinforce these
principles are widely promoted, such as ensuring that patients receive the care they need, respecting the rights
of patients to consent to or deny consent for treatment, preventing incompetent staff from caring for patients,
and following acceptable standards of practice. Actual nursing practice is seldom simple, however, and
situations emerge that add new considerations to the application of moral principles to patient care. Ethical
dilemmas can emerge when other circumstances interfere with the clear, basic application of ethical principles.
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FIGURE 9-1 • Nurses follow the principles of doing good, treating people equally, honoring their word, and
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respecting older adults’ rights.
POINT TO PONDER
How do you respond to and try to solve ethical dilemmas? If you are in practice, do you accept different
standards in practice from what you would accept in your personal life? If so, why?
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Cultural Considerations
An issue that must be considered in nursing practice is that what may be considered an ethical practice for
some individuals may not be viewed as such by others due to their cultural backgrounds. For instance, a nurse
may be a white, Protestant woman born in the United States who holds the beliefs shown in the bulleted list
below. The nurse may view these as sound ethical beliefs and allow them to guide her practice. Although
these beliefs could be acceptable and appreciated by many individuals, they could conflict with the beliefs of
others; for example:
The belief that individuals have the right to make their own decisions regardless of their sex and should be
empowered to do so. In many Amish, German, Greek, Haitian, Irish, and Puerto Rican families,
individuals discuss important decisions with family members and may prefer to have the family involved
in the decisions. Jewish individuals may seek the advice of a rabbi. Some people may not want to discuss
issues and confront decision making; for instance, Filipinos and Japanese view discussions of death as
taboo.
Women are equal to men. In Arab, Iranian, Hindu, and some Italian families, it is common for males to
assume decision-making roles, and women may yield their decision-making authority to them.
Prayer is a beneficial supplement to medical treatment: Prayer may not be welcomed by patients who are
agnostic or atheistic. Even among persons who do believe in prayer, there may be differences in the
deity worshipped and method of prayer.
People have the right to have the confidentiality of their health information protected, even from relatives. To
individuals who view family involvement in decision making as natural and preferable, there may be a
desire to have health information shared with the family.
Nurses need to appreciate that ethical issues are influenced by culture. Learning about a patient’s culture and
preferences based on it are essential to assuring actions do not inadvertently produce ethical conflicts. Also, it
is important for nurses to remember that not all individuals from the same cultural group may share the same
beliefs and practices, which further reinforces the important of learning about individual preferences.
COMMUNICATION TIP
Older adults, especially when their function is compromised by illness, may look to family members to
make decisions for them. They may accept the decisions others make on their behalf, even if they
conflict with their own beliefs and desires.If the nurse sees that others are making decisions for the older
adult that the person is competent of making independently, it is beneficial to review the decision with
the person to ensure he or she fully understands, present all options available, ask the person to describe
what is important to him or her in relation to the decision, reinforce to the person that he or she has the
right to make a decision that is different from that of family members, and ensure that the person is in
agreement and comfortable with the decision. It is beneficial to discuss with family members the
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importance and right of the older relative to make his or her own decision, even if it conflicts with what
they think is best.
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ETHICAL DILEMMAS FACING GERONTOLOGICAL
NURSES
Nursing practice involves many situations that could produce conflicts—conflicts between nurses’ values and
external systems affecting their decisions and conflicts between the rights of patients and nurses’
responsibilities to those patients. Box 9-1 presents examples of such dilemmas. These examples are typical of
the decisions facing nurses every day and for which there are no simple answers.
Box 9-1 Examples of Ethical Dilemmas in Gerontological
Nursing Practice
While working in an outreach program to bring services to community-based older adults, you meet
Mr. Brooks, a 68-year-old homeless man. Mr. Brooks asks your opinion about respiratory symptoms
that he has been experiencing over the past several months. He reports a chronic cough, hemoptysis,
and dyspnea. He appears thin and admits to having lost weight. He states he has smoked at least one
pack of cigarettes daily for over 50 years and has no intention of changing his smoking habit. Although
he is not cognitively impaired, he strongly resists efforts to find him housing and arrange for medical
evaluation and treatment. You are convinced that without intervention, Mr. Brooks will not survive
much longer.
Do you respect Mr. Brooks’ right to make his own decisions about his life, even if those decisions run
contrary to what is best for his health and well-being?
You are the new director of nursing for a nursing home and were pleased to get the job because
yours has become the sole source of income for your family. Ten cases of diarrhea develop among the
residents, and you know that the regulations require that you report five cases or more. You bring this to
the attention of the medical director and administrator, who direct you not to “cause trouble by putting
the health department on their backs.” The medical director assures you that the problem is not serious
and will pass in a few days. You know you should notify the health department, but you also know that
the administrator fired the last nursing director for opposing him on a similar issue.
Do you allow a regulation to be violated or risk losing a job that you may badly need?
Insurance coverage expires tomorrow for 76-year-old Mrs. Brady, and the physician has written an
order for her discharge. Because Mrs. Brady continued to be weak and slightly confused, she was not
able to be instructed in the safe use of home oxygen and medication administration during her
hospitalization. Her 80-year-old husband, who is expected to be her primary caregiver, is weak and in
poor health himself. The social worker tells you that arrangements have been made for a nurse to visit
the home daily but that the couple does not qualify for 24-hour home care assistance. You and other
nursing staff members firmly believe that Mrs. Brady’s health will be in jeopardy if she is discharged
tomorrow. The physician tells you that you are probably right, but “the hospital cannot be expected to
eat the bills that Medicare does not want to pay.”
Do you increase the hospital’s financial risks by insisting that nonreimbursed care be provided?
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Seventy-nine-year-old Mr. Adams lies in his bed in a fetal position, unresponsive except to deep
painful stimuli. He has multiple pressure ulcers, has recurrent infections, and must be fed with a
nasogastric tube. His wife and children express concern over the quality of his life and state that Mr.
Adams would never have wanted to survive in this state. The children privately tell the multidisciplinary
team that if their father’s care expenses continue, their mother will be destitute, and they beg the staff to
remove the tube. The family expresses that they do not have the emotional or financial resources to take
the issue to court. The physician is sympathetic, but states he feels compelled to continue the feedings
and antibiotics because he does not condone euthanasia; however, privately, the physician tells you that
he will close his eyes and keep quiet if you want to pull the tube without anyone knowing.
Do you exceed your authority and discontinue a life-sustaining measure to grant the family’s request?
Mrs. Smith is dying of cancer and being cared for at home by her husband. The couple has been
married for 63 years and has never been apart during that time. They are highly interdependent and
each one’s world revolves around the other’s. During your home nursing visit, the couple openly
discusses their plans with you. They tell you that they have agreed that when Mrs. Smith’s pain
becomes too severe to tolerate, they will both ingest sufficient medication, which they have
accumulated, to kill themselves, and die peacefully in each other’s arms.
Do you ignore your responsibility to report suicidal intent to respect a couple’s wish to end their lives
together?
It is easy to say that nurses should always follow the regulations, adhere to principles, and do what is best for
the patient. But can nurses realistically be expected to follow these guidelines 100% of the time? What if
following the rules means they may lose the income on which their families depend, violate the rights of
individuals to decide their own destinies, create problems for coworkers or their employers, or cause them to
be labeled troublemakers? Is it alright to knowingly violate a regulation or law if no real harm will result? Do
nurses need to limit how much of an advocacy role they can assume? Should nurses base their decisions on
what is right for themselves, their patients, or their employers? To whom are nurses really most responsible
and accountable?
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Changes Increasing Ethical Dilemmas for Nurses
Questions of ethics are not new to nursing. However, changes within the profession and the entire health care
delivery system have introduced new areas of ethical dilemmas to nursing practice.
Expanded Role of Nurses
Nurses have gone beyond the confines of simply following doctors’ orders and providing basic comfort and
care. They now perform sophisticated assessments, diagnose nursing problems, monitor and give complicated
treatments, use alternative modalities of care, and, particularly in geriatric care settings, increasingly make
independent judgments about patients’ clinical conditions. This wider scope of functions, combined with
higher salaries and greater status, has increased the accountability and responsibility of nurses for the care of
patients.
Medical Technology
Artificial organs, genetic screening, new drugs, computers, lasers, ultrasound, and other innovations have
increased the medical community’s ability to diagnose and treat problems and to save lives that once would
have been given no hope. However, new problems have accompanied these advances, such as determining on
whom, when, and how this technology should be used.
New Fiscal Constraints
In the past, the major concern of health care providers and agencies was to provide quality services to help
people maintain and restore health. Now, there are competing and sometimes overriding concerns, including
the following: being cost-effective, minimizing bad debts, and developing alternate sources of revenue.
Patients’ needs are weighed against economic survival, resulting in some difficult decisions. Further, in this era
of rationed care and scarce resources, questions are raised regarding the right of older adults to expect a high
quality and quantity of health and social services while other groups lack basic assistance.
KEY CONCEPT
Increasingly, questions are raised regarding the right of older adults to expect greater benefits than other
members of the society.
Conflict of Interest
Nurses can face a variety of situations that present a conflict of interest. Examples of this could include the
following: a nurse, believing a resident’s life could be extended with nasogastric feedings and antibiotic
therapy, feeling that a resident’s and family’s rejection of this care is inappropriate; a patient’s physical therapy
discontinued due to insurance restrictions and the nurse knowing that the patient has the potential to make
continued progress with the therapy; and, the nurse knowing the employer is intentionally keeping staffing
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levels below what is needed but not objecting or advocating for proper staffing because the nurse does not
want to jeopardize his or her position.
Greater Numbers of Older Adults
Entitlement programs and services for older persons had less impact when only a small portion of the
population was old, but with growing numbers of people spending more years in old age and the increasing
ratio of dependent individuals to productive workers, society is beginning to feel burdened. Although older
adults’ problems and needs are more evident, the ability and responsibility of society to support these needs are
in question.
Assisted Suicide
The ANA has been clear in its objection to assisted suicide, believing instead that nurses should provide
competent, compassionate end-of-life care. However, although participating in a patient’s assisted suicide is
unethical and inappropriate, nurses may care for terminally ill individuals who accept and desire assisted
suicide. The situation becomes even more complicated by the fact that laws have been enacted in some states
(e.g., Oregon, California, Vermont, and Washington) to allow terminally ill persons to end their lives with
lethal medications, and individuals have the right to refuse care under self-determination directives. Nurses
may face the dilemma of knowing that a competent patient is arranging an assisted suicide and believing that
they must intervene. Or, they may know that a competent patient is arranging an assisted suicide, and while
understanding and respecting the patient’s decision, they feel they are violating professional standards by not
reporting it so that it may be halted.
POINT TO PONDER
Do you believe that gerontological nurses have an ethical responsibility to advocate for older individuals
by objecting to and bringing public attention to policy and reimbursement decisions that are not in
older persons’ best interests?
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Measures to Help Nurses Make Ethical Decisions
Although guidelines exist, no solid answers can solve all of the ethical dilemmas that nurses face. Nurses
should, however, minimize their struggles in making ethical decisions by using critical thinking and
employing the following measures:
Encourage patients to express their desires. Advise patients to express their desires in advance directives,
wills, and other legally binding documents and advocate compliance with patients’ wishes. Box 9-2
offers suggestions on assisting patients in making decisions.
Identify significant others who impact and are impacted. Consider family members, friends, and caregivers
who are involved with the patient and the situation, and their concerns and preferences.
Know yourself. The nurse should review his or her personal value system. The influences of religion,
cultural beliefs, and personal experiences should be explored to understand one’s unique comfort zone
with specific ethical issues.
Read. Review the medical literature for discussions and case experiences of other nurses to gain a wider
perspective into the types of ethical problems confronted within nursing and strategies for managing
them. Literature outside the field of nursing can help add new facets to one’s thinking.
Box 9-2 Assisting Older Adults in Decision Making
Assure the person is competent to make decisions. Even if the person has no diagnosis (e.g.,
dementia) that would interfere with decision making, the stress of a hospitalization and the effects
of medications or other treatments could alter the mental ability to make competent decisions.
Assess for alterations in mental status that could influence competent decision making. If
competency is in question, consult with the organization’s social worker or other designated
professional to have a surrogate properly appointed.
Document the assessment of factors influencing the ability to make decisions, such as mental
status, ability to express preferences, mood, effects of medications, and family influence.
If the individual is competent to make decisions:
Offer explanations and information regarding treatment options to increase the person’s
understanding. Offer to include family members or significant others in the discussion if the
person desires.
Ensure that the person understands the diagnosis, prognosis, treatment options, and risks and
benefits of various treatments.
Encourage the person to ask questions and express any concerns.
If there is question or confusion about procedures for which consent is needed or has been
granted, request that the provider who will perform the procedure meet with the person to discuss
the issue.
Ensure that the person is not being coerced into any decision or feeling intimidated to state a
refusal to give consent.
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Recognize that ability to make competent decisions can fluctuate (e.g., due to medications, pain)
and ensure that explanations are provided and decisions made during times of lucidity.
Document all assessment findings, explanations given, the person’s expressed preferences and
concerns, and other relevant information.
CONSIDER THIS CASE
Seventy-nine-year-old Mr. J has been diagnosed with a rare liver
cancer. The oncologist informs Mr. J that although he is willing to attempt a round of chemotherapy,
no treatment has been effective in extending life for more than a few months for this aggressive type of
cancer. Mr. J and his 66-year-old wife are devastated by this information and look to the Internet for
help. They read testimonials of patients who have had similar liver cancers whose lives allegedly were
extended for several years with an alternative treatment offered by a hospital in Germany. They make
contact with the hospital and learn that Mr. J qualifies for their treatment, which consists of a 2-week-
long stay at the hospital in Germany, every 2 months. Each of the hospitalizations costs $25,000 plus
the couple’s travel expenses. The couple has no savings but owns a very modest house; they have no
children. The couple discusses this option with the oncologist, who discourages the alternative
treatment, stating, “Your time and money would be better spent in enjoying the remaining time you
have together and making preparations for Mr. J’s declining health and ultimate death.” Despite the
physician’s discouraging remarks, Mr. J wants to mortgage the house to pay for the alternative
treatment. Mrs. J wants to help her husband extend his life but is concerned that she will face the
prospect of losing the house or being required to pay off the mortgage on her limited Social Security
check long after Mr. J dies. She is not comfortable with the idea, but feels that if she voices her
concerns, her husband, friends, and family will consider her uncaring.
THINK CRITICALLY
Does Mr. J have the right to deplete the couple’s resources for a questionable treatment that may
only extend his life for a few months?
Does Mrs. J have the right to oppose this plan?
Does Mr. J’s physician have the right to dash Mr. J’s hopes?
How could you assist the couple?
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Discuss. In formal education programs or informal coffee breaks, talk about issues with other health team
members. Members of the clergy, attorneys, ethicists, and others also can provide interesting
perspectives.
Form an ethics committee. Bring together various members of the health team, clergy, attorneys, and lay
persons to study ethical problems within the specific care setting, clarify legal and regulatory boundaries,
develop policies, discuss ethical problems that surface, and investigate charges of ethical misconduct.
Consult. Clinical ethics consultation takes the form of an ethics committee or consultation provided by
expert individuals or groups (e.g., lawyers, philosophers, and clinicians who specialize in bioethics).
Clinical ethics consultants provide education, mediate moral conflict, facilitate moral reflection, and
advocate for patients (American Society for Bioethics and the Humanities, 2010). (For information on
the competencies and practice of Health Care Ethics Consultants, visit http://www.asbh.org/papers.)
Share. When faced with a difficult ethical decision, talk with others and seek guidance and support.
Evaluate decisions. Assess the outcomes of the actions and whether the same courses of action would be
chosen in a similar situation in the future. Even the worst decision holds some lessons.
Gerontological nursing holds its share of ethical questions. Should resources be spent for a heart transplant for
an octogenarian? Should an affluent child rather than public funds pay for a parent’s care? How much sacrifice
must a family endure to care for a relative at home? How much compromise in care can nurses accept to keep
an agency’s budget healthy? Nurses must be active participants in the process of developing ethically sound
policies and practices affecting the care of older adults. The choice between being a leader or an ostrich in this
arena can significantly determine the future status of gerontological nursing practice.
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BRINGING RESEARCH TO LIFE
Examination of Ethical Dilemmas Experienced by Adult Intensive Care Unit Nurses in Physical
Restraint Practices
Source: Yont, G. H., Korhan, E. A., Dizer, B., Gumus, F., and Koyuncu, R. (2014). Holistic Nursing Practice,
28(2), 85–90.
Using physical restraints with patients can create a dilemma for nurses. On one hand, restraints may be
beneficial in protecting a patient and others from injury and facilitating the delivery of care and treatments;
this could be considered nonmaleficence because the restraints prevent harm or beneficence because they keep
the patient safe. On the other hand, if a patient resists or does not want to be restrained but is restrained
anyway, this could be a violation of beneficence and nonmaleficence because the action ignores the patient’s
wishes and can cause emotional harm to the patient.
In this study, 55 nurses responded to questions pertaining to their perceptions of the ethical dilemmas
that arose when they used physical restraints with patients. A descriptive analysis found that the nurses
experienced ethical dilemmas concerning the harm versus benefit of restraint use. The main ethical principles
creating dilemmas involved nonmaleficence and beneficence.
This is an example of how routine procedures that are intended to be beneficial in caring for patients can
create ethical dilemmas. Nurses may be unaware that some of the stress associated with their work can be
related to these ethical dilemmas. It is important that nurses not merely experience and talk about these types
of ethical dilemmas among themselves but also address these issues with the organization’s decision makers.
Nurses who carry out policies that cause them ethical dilemmas risk becoming so distressed about their
choices that they may leave the organization or develop an emotional wall between themselves and their
patients to avoid thinking about the implications of such actions.
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PRACTICE REALITIES
A citizen action group is concerned about taxes and is developing a list of recommendations to offer its
congressional representatives. Among the recommendations is one to limit Medicaid- and Medicare-
reimbursed expensive surgeries (e.g., hip replacements and organ transplant) to only persons under the age of
80. The rationale is that the limited funds are best used in younger persons who have more years left of life.
Although you understand that health care dollars are limited and appreciate the impact of growing tax
burdens, as a gerontological nurse you feel a responsibility to advocate for the rights of older adults to have the
same services available as other age groups.
How would you react to the citizens’ group?
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CRITICAL THINKING EXERCISES
1. What factors have influenced your personal ethics?
2. Discuss the dilemmas arising from the following situations:
Having a terminally ill patient confide plans to commit suicide
Being instructed to discharge a patient whose care is no longer being reimbursed while knowing that the
patient is not ready for discharge
Having to terminate a nursing assistant for attendance problems, knowing that she is the sole wage
earner in her family
Being asked by a senior citizen group to support its position of converting a local playground into a
senior citizen center
Learning of an insurer’s proposed policy of not reimbursing for dialysis and organ transplants for
persons over 75 years of age
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Chapter Summary
Ethics are beliefs that guide life and assist in determining the right course of action to take. Philosophical
differences can cause variation in the way individuals view right and wrong. Some philosophies influencing
ethical decision making include utilitarianism, egoism, relativism, and absolutism. In addition to personal
ethics, nurses’ ethical decision making is influenced by codes of ethics developed by professional associations
and regulatory standards.
Ethical principles that are used in nursing practice include beneficence, nonmaleficence, justice, fidelity
and veracity, autonomy, and confidentiality. Nurses need to appreciate that patients’ cultural backgrounds can
influence ethics for patients. Nurses need to be sensitive to the reality that the “right” action according to their
belief may be in conflict with that which is considered “right” within some patients’ cultures.
Nurses may face ethical dilemmas in their daily work. These dilemmas can be compounded by changes
within the profession and the entire health care system such as the expanded role of nurses, the use of medical
technology, new fiscal constraints, conflicts of interest, growing numbers of older individuals, and growing
interest in assisted suicide.
To foster ethical decision making, it is important for nurses to encourage patients to express their desires
and involve significant others who are in the patients’ lives as appropriate, get in touch with personal values,
continue to read and learn about ethical decision making, discuss and consult with others, form an ethics
committee, and evaluate decisions.
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Resources
American Nurses Association, Center for Ethics and Human Rights
http://www.nursingworld.org/ethics
American Society of Bioethics and Humanities
http://www.asbh.org
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Reference
American Society for Bioethics and the Humanities. (2010). Core competencies for health care ethics
consultation (2nd ed.). Glenview, IL: American Society for Bioethics and the Humanities.
Recommended Readings
Recommended Readings associated with this chapter can be found on the Web site that accompanies
the book. Visit http://thepoint.lww.com/Eliopoulos9e to access the list of recommended readings and
additional resources associated with this chapter.
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CHAPTER 10
Continuum of Care in Gerontological Nursing
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CHAPTER OUTLINE
Services In The Continuum Of Care For Older Adults
Supportive and Preventive Services
Partial and Intermittent Care Services
Complete and Continuous Care Services
Complementary and Alternative Services
Matching Services To Needs
Settings And Roles For Gerontological Nurses
LEARNING OBJECTIVES
After reading this chapter, you should be able to:
1. Describe the continuum of services available to older adults.
2. Discuss factors that influence service selection for older adults.
3. Describe various practice settings for gerontological nurses.
4. List major functions of gerontological nurses.
TERMS TO KNOW
Adult day services centers that provide health and social services for a portion of the day to persons with moderate physical or mental
disabilities and give respite to their caregivers
Assisted living residential care for persons who do not require nursing home level services but who cannot fulfill all personal care and/or
health care needs independently are referred to as assisted living communities, residential care facilities, personal care, and boarding
homes
Case management services provided by registered nurses or social workers who assess an individual’s needs, identify appropriate services,
and help the person obtain and coordinate these services in the community
Hospice services that provide support and palliative care to dying individuals and their families in the home or an institutional setting
Nursing home facility that provides 24-hour supervision and nursing care to persons with physical or mental conditions who are unable to
be cared for in the community
Respite services to provide short-term care to individuals, thereby offering their caregiver’s short-term relief from their caregiving
responsibilities
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The effects of a graying population are all around us. The media report the spiraling costs of Medicare and
Social Security. Banks advertise reverse annuity mortgage programs aimed at helping older adults remain in
their homes. A new continuing care retirement community (CCRC) is constructed. A major corporation
initiates an adult day care program. A family leave law is passed. The local hospital issues a circular informing
the community of new services for senior citizens. A nearby church sponsors a caregiver support group.
One does not need to be a nurse or nursing student to be aware of the impact of older adults on all
segments of society. We are increasingly aware that older adults are major consumers of virtually all health
care services. Consider the following:
Growing numbers of Americans are interested in wellness programs that help them stay youthful, active,
and healthy.
More than one third of all surgical patients are older than 65 years of age (Centers for Disease Control
and Prevention, 2010).
The prevalence of mental health problems increases with age.
Chronic diseases occur at a rate four times greater in old age than at other ages, with 80% of older adults
having at least one chronic condition (Centers for Disease Control and Prevention, 2012).
Approximately 40% of all older persons will spend some time in a nursing home during their lives
(Centers for Medicare and Medicaid Services, 2011).
Most beds in acute medical hospitals are filled by older patients.
Older adults are the most significant users of home health services.
Whether working in nursing homes, health maintenance organizations (HMOs), outpatient surgical centers,
hospice programs, rehabilitation units, or private practice, nurses are likely to be involved in gerontological
nursing.
The diversity of the aging population and the complexity of needs it presents demands a wide range of
nursing services. A continuum of care, including services for older adults who are the most independent and
well at one end and the most dependent and ill at the other, is essential to meet the complex and changing
needs presented by the older population.
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SERVICES IN THE CONTINUUM OF CARE FOR
OLDER ADULTS
The continuum of care consists of supportive and preventive services, partial and intermittent care services,
and complete and continuous care services (Fig. 10-1). This continuum includes opportunities for
community-based services, institution-based services, or a combination of both. Complementary and
alternative services may also be included in the continuum.
FIGURE 10-1 • Continuum of care services for older adults.
To plan care for older adults effectively, nurses must be familiar with the various forms of care available. In
fact, visiting various agencies to learn about their services firsthand can prove beneficial for the gerontological
nurse. Although services can vary from one area to another, some general examples are described in the
sections that follow.
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Supportive and Preventive Services
Most older adults reside in the community and function with minimal or no formal assistance. Many of them
adjust their lives to accommodate changes commonly experienced with aging; some manage complex care
demands. Nurses are challenged to help older adults maintain independence, prevent risks to health and well-
being, establish meaningful lifestyles, and develop self-care strategies for health and medical needs.
Supportive and preventive services support independent individuals in maintaining their self-care capacity
so that they can avoid physical, emotional, social, and spiritual problems. In this category of services, nurses
most likely will be involved with the following:
Identifying service needs
Referring older adults to appropriate services
Supporting and coordinating services
Local offices on aging, commissions on retirement education, libraries, and health departments usually
provide assistance to older persons in learning about available services. Nurses should encourage older persons
to use these resources for any questions and assistance needed. The Silver Pages telephone directory for older
adults is also a useful resource. In addition, the Administration on Aging hosts a Web site that is a gateway to
a wide range of information and services for older adults and their families; this can be accessed through
http://www.aoa.gov/AoARoot/Elders_Families/index.aspx. Examples of supportive and preventive services
for community-based older adults are described below.
KEY CONCEPT
When working with community-based older adults, nurses focus on maintaining independence,
preventing risks to health and well-being, establishing meaningful lifestyles, and developing self-care
strategies for health and medical needs.
Financial Services
The Social Security Administration may be able to help older persons obtain retirement income, disability
benefits, supplemental security income, and Medicare or other health insurances. The district office of the
Social Security Administration can provide direct assistance and information. The Department of Veterans
Affairs (VA) can provide financial aid to older veterans and their families; interested persons should be
directed to the local VA office. Various communities offer discounts to senior citizens at department stores,
pharmacies, theaters, concerts, restaurants, and transportation services. Lists of discounts may be obtained
from the local offices on aging.
Many banks offer free checking accounts and other special services to senior citizens. By completing a
direct deposit form at their bank, older adults can have the Social Security Administration deposit Social
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Security and Supplemental Security Income checks directly to the bank; likewise, pension checks can be
deposited directly into checking accounts. This service saves older adults from having to travel to the bank and
serves as a protection from crime. Reverse annuity mortgages can be arranged through banking institutions to
allow older homeowners to use the equity in their homes to remain in the community. It is advisable for older
persons to explore details of such services with their individual financial institution.
Financial assistance is also available for burial and funeral expenses. For instance, wartime veterans are
eligible for some assistance from the VA. Also, the Social Security Administration provides a small payment
for burial expenses to those who have been insured by that program. Local offices of these administrations can
be contacted for information; funeral directors are also a good source of information about these benefits.
Finally, social service agencies and religious organizations often provide assistance for persons with insufficient
funds to pay for burial expenses.
COMMUNICATION TIP
Discussing finances can be difficult for some older adults. This can be due to their embarrassment at
experiencing financial problems, concern related to protecting their assets, or desire to avoid having
family members and others learn about their financial status. Nurses who have established a trusting
relationship with older adults may be in a good position to introduce discussions of finances. This can
include assisting in identifying sources of aid to ease their financial burden, suggesting how to introduce
topics for discussion (e.g., funeral arrangements, durable power of attorney, desires for distribution of
assets) with family members, and providing referrals to professionals who can assist with financial
planning and the development of wills.
Employment
If older adults desire to work, nurses can refer them to employment services. State employment services and
the Over 60 Counseling & Employment Service conduct programs that provide employment counseling and
job placement. Various states also have foster grandparent programs, older businessperson associations, and
senior aide projects. Local offices on aging can direct older persons to employment programs and
opportunities in their community.
Nutrition
The departments of social services can supply information about and applications for food stamps to help
older persons purchase food within the constraints of their budget. These departments may also provide
grocery shopping services and nutrition classes. Many senior citizen clubs and religious organizations offer
lunch programs that combine socialization with nutritious meals. The local office or department on aging or
the health department can direct persons to the sites of such programs.
Housing
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Local social service agencies and departments of housing and community development can assist older persons
in locating adequate housing at an affordable cost. These agencies also may be able to direct the older
homeowner to resources to assist in home repairs and provide information regarding property tax discounts. A
variety of CCRCs (Box 10-1), villages, mobile home parks, and apartment complexes, specifically designed
for older persons, are available throughout the United States. Some of these housing complexes include special
security patrols, transportation services, health programs, recreational activities, and architectural adjustments
(e.g., low cabinets, grab bars in bathrooms, tinted windows, slopes instead of stairs, and emergency call bells).
Some of these housing options require a “buy-in fee” or purchase price, a monthly fee, or both. The older
person exploring retirement housing should be advised that sound facts are more important to decision
making than exciting promises. Visits to the housing complex and a full investigation of benefits and costs
before making a contractual commitment are essential.
Box 10-1 Continuing Care Retirement Communities
CCRCs offer a continuum of services in one location to provide various levels of housing and services to
meet an older adult’s changing needs. Typically, people pay an entrance fee and a monthly fee, with an
understanding that they will be able to have their needs provided by the community for the remainder
of their lives. Contracts can vary and consist of a set fee for unlimited services, a set fee for time-limited
services, or additional charges if assisted living, home health, or skilled nursing services are required.
Healthy individuals can enter and live in independent housing units, which could consist of single-
family homes, apartments, or condominiums. Housekeeping, laundry, meals, transportation, social
activities, and health services can be provided for additional fees.
As individuals require more assistance, they can receive assistance with personal care in their own
housing unit or move to the assisted living community or nursing home section of the CCRC.
Entrance fees, conditions for refund of entrance fees, monthly costs, services available, and terms of
contracts vary among CCRCs, so it is useful for older adults interested in CCRCs to visit and compare
several and carefully review the contracts.
Health Care
Nurses can encourage older adults to engage in preventive health practices to avoid illness and detect health
problems at an early stage. Health services for older adults are provided by health departments, HMOs,
private practitioners, and hospital outpatient services. In addition to health services, these providers may help
older adults obtain transportation and financial assistance for their health care. Older individuals should
inquire about such services at their nearest health care office.
Social Support and Activities
Churches, synagogues, and mosques offer not only a place of worship but also a community that can provide
tremendous fellowship, support, and assistance to persons of all ages. Many religious groups offer health and
social services such as congregate eating programs, nursing homes, home visitation, and chore assistance. In
many circumstances, recipients of services need not be members of the religious group. Increasing numbers of
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faith communities employ nurses to assist with members’ health and social needs, and Faith Community
Nursing is a blossoming specialty. Individual churches and synagogues or the mother organization (e.g.,
Associated Jewish Charities and Catholic Charities) should be contacted for information.
Bureaus of recreation and other groups may also sponsor clubs and activities expressly for senior citizens.
Local commissions or offices on aging can provide information related to the availability of such programs,
their activities, schedules, and persons to contact for details. Local chapters of the American Association of
Retired Persons (AARP) can provide valuable information on services that keep older persons active and
independent, ranging from creative leisure endeavors at home to discount travel opportunities. Information
about leisure pursuits is just one of the many services the AARP provides. Finally, art museums, libraries,
theaters, concert halls, restaurants, and travel agencies should be contacted for special programs offered to
senior citizens.
Volunteer Work
Nurses can also encourage older adults to participate in volunteer activities. The wealth of knowledge and
experience possessed by older persons makes them especially suited for volunteer work. Not only do older
volunteers provide valuable services to others, but they may also achieve a sense of self-worth from their
contributions to society. Communities offer numerous opportunities for senior volunteers in hospitals, nursing
homes, organizations, schools, and other sites. Older persons should be encouraged to inquire about volunteer
opportunities at the agency in which they are interested in serving. Frequently, agencies without a formal
volunteer program are able to use a volunteer’s service if contacted. National programs also provide
meaningful volunteer services in which older persons can participate. The American Red Cross, Service Corps
of Retired Executives, and Retired and Senior Volunteer Program are a few such programs. Local offices of
these programs should be consulted for details.
Education
Some public schools offer literacy, high school equivalency, vocational, and personal interest courses for older
adults. Many colleges have free tuition for older persons. Individual schools should be contacted for more
details.
Counseling
Financial problems, the need to locate new housing, strained family relationships, widowhood, adjustment to
a chronic illness, and retirement are among the situations that may necessitate professional counseling. Local
social service agencies, religious organizations, and private therapists are among the resources that offer
assistance.
Consumer Affairs
Senior adults are frequent victims of unscrupulous people who profit by making convincing but invalid
promises. It is important for older adults to investigate cure-alls, vacation programs, and get-rich-quick
schemes before investing their funds. Local offices of the Better Business Bureau and consumer protection
agencies provide useful information to prevent fraud and deception and offer counseling if problems do arise.
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Legal and Tax Services
Local legal aid bureaus and lawyer referral services of the Bar Association may help older adults obtain
competent legal assistance at a nominal cost. The Internal Revenue Service can help older people prepare
federal tax returns, and the state comptroller’s office can assist with state tax returns; local offices should be
contacted for additional information. Various colleges and law schools should be investigated for free legal and
tax services offered to senior citizens.
Transportation
Older persons often receive discounts for bus, taxicab, subway, and train services; individual agencies should
be contacted for more information. Commissions or offices on aging, health and social services departments,
and local chapters of the American Red Cross may be able to direct persons to services accommodating
wheelchairs and other special needs. Various health and medical facilities provide transportation for persons
using their services; individual facilities should be explored for specific details.
Personal Emergency Response Systems
A Personal Emergency Response System (PERS), also called a Medical Emergency Response System, is a
small battery-operated transmitter device a person wears (around the next, on a belt or wristband, or in a
pocket) that can be used to signal for help by pressing a button. The transmitter then sends a signal that dials
an emergency response center. When signaled, the response center contacts the person or predesignated
contacts. A variety of companies offer this service, and in most cases, it is not covered by health insurance
programs. The local Area Agency on Aging can assist in advising what systems are available in a specific area.
Shopping at Home
Persons who are homebound, who are geographically isolated from services, or who have busy schedules may
find it useful to shop at home through mail-order catalogs, home-shopping services on television, and the
Internet. Shopping by mail has a long tradition, and along with its newest sibling, Internet shopping reduces
the inconveniences and risks associated with traveling to a shopping district, maneuvering in stores, handling
large sums of money in public, and carrying packages. The shipping and handling charges may be no greater
than transportation costs, not to mention the energy expended in direct shopping.
Additionally, many libraries have a service in which books and tapes can be borrowed by mail; older
persons should be encouraged to inquire about such services at their local branch. The Internet offers many
online books and publications, many of which are free. The U.S. Postal Service provides a service for a
nominal fee in which stamps can be ordered by mail or Internet; order blanks for stamps by mail can be
obtained by contacting the local postal station or postal carrier or visiting www.USPS.com.
CONSIDER THIS CASE
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http://www.USPS.com

A 78-year-old Mrs. Como lives alone and has managed
independently until last month, when she began demonstrating periods of dizziness, weakness, and
confusion. Last week, she had an accident in which she ran her car into a parked car; she reported to her
daughter that this happened because she “couldn’t figure out which pedal was the brake.” Her daughter
and son, concerned with the changes they are witnessing in their mother, take Mrs. Como to her
physician for an examination. It is determined that Mrs. Como has congestive heart failure, and she is
admitted to the hospital for treatment.
Mrs. Como is successfully treated and prepared for discharge. Mrs. Como feels insecure returning to
her own home and indicates she thinks it may be best if she can live with one of her children, who live
in the same city she does. Mrs. Como’s son is adamant that due to his work schedule, he cannot have his
mother live with him. Although her daughter has several children at home, works part-time, and has a
busy life, she feels that she can’t turn her mother away.
THINK CRITICALLY
What factors need to be considered in developing Mrs. Como’s discharge plan?
What are the benefits and risks of the plan for Mrs. Como to live with her daughter?
What services could be of benefit to Mrs. Como after discharge?
Describe the approach that would be effective in discussing discharge plans with Mrs. Como and
her children.
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Partial and Intermittent Care Services
Partial and intermittent care services provide assistance to individuals with a partial limitation in self-care
capacity or a therapeutic demand that requires occasional assistance. Because of either the degree of the self-
care limitation or the complexity of the therapeutic action required, the individual could be at risk for new or a
worsening of existing physical, emotional, and social problems if some assistance were not provided at periodic
intervals. These services can be provided in community or institutional settings.
Assistance with Chores
Social service agencies, health departments, private homemaker agencies, and faith communities have services
for older persons that help them remain in their homes and maintain independence. These services include
light housekeeping, minor repairs, errands, and shopping. Local agencies and programs should be contacted
for specific information.
Home-Delivered Meals
Persons unable to shop and prepare meals independently may benefit from having meals delivered to their
homes. Such a service not only facilitates good nutrition but also provides an opportunity for social contact.
Meals on Wheels is the most popularly known program for home delivery of meals, although various
community groups provide a similar service. If a local Meals on Wheels is unavailable, departments of social
services, health departments, and commissions or offices on aging should be consulted for alternative
programs.
Home Monitoring
Some hospitals, nursing homes, and commercial agencies provide home monitoring systems, whereby the
older adult wears a small remote alarm that can be pressed in the event of a fall or other emergency. The alarm
triggers a central monitoring station to call designated contact persons or the police to assist the individual.
This type of service can be located by calling the local agency on aging or looking in the telephone directory
under listings such as Medical Alarms.
A growing array of telemanagement technologies is affording the opportunity for patients to have vital
signs, blood glucose levels, and other physiological measurements communicated from the home to providers.
Tracking systems and sensors can enable family members or caregivers to monitor patients’ activity in their
homes from a distance. Two-way audio and video devices allow patients to interact with their providers from
their homes. Devices can be used to signal patients when to take medications and perform other tasks.
Medication administration systems exist whereby family members and caregivers in another location can be
informed if a patient has not taken drugs as scheduled. An Internet search of home care and patient care
technology vendors will yield many suppliers of technological aids for home care.
Telephone Reassurance
Older adults who are homebound, disabled, or lonely may benefit from a telephone reassurance program.
Those who participate in the program receive a daily telephone call—usually at a mutually agreed on time—to
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provide them with social contact and ensure that they are safe and well. Local chapters of the American Red
Cross and other health or social service agencies should be consulted for telephone reassurance programs that
they may conduct.
Home Health Care
Home health care provides nursing and other therapies in individuals’ homes. Visiting nurse associations have
a long reputation of providing care in the home and are able to help many older persons remain in their homes
rather than enter an institution. Programs vary, and services can include bedside nursing, home health aides,
physical therapy, health education, family counseling, and medical services. Medicare is limited to skilled
home care, which means that the person must:
Be homebound
Have services ordered by a primary care provider
Require skilled nursing or rehabilitative services
Need intermittent but not full-time care
During the 1970s and the decades that followed, home health services significantly grew due to the enactment
of the Older American’s Act and Title XX Social Services Act in 1975 that provided federal funds for home-
based services and the Federal Health Services Program that gave grants for the establishment and expansion
of these services. By the 1990s, home care became the fastest growing component of Medicare and the rising
costs influenced Congress to place limitations on home care benefits for Medicare recipients as part of the
Balanced Budget Act of 1997. At this same time, in an effort to control the rising costs of nursing home care
on their Medicaid budgets, states began to develop more home care services as an alternative to nursing home
care.
KEY CONCEPT
The changes in home health care demonstrate the impact that government funds can have on the
availability of services to older adults. At present, Medicare covers skilled nursing care but not long-
term nonskilled care. States have various Medicaid programs to assist in nonskilled home care; private
agencies also provide these services.
In addition to Medicare, the VA, Medicaid, and private insurers provide reimbursement for home health
services, although the conditions and length of coverage vary; specific coverage should be reviewed with the
insurer. These programs can be found through health departments, in telephone directories, or through social
workers who assist with discharge planning.
Foster Care and Group Homes
Adult foster care and group home programs offer services to individuals who are capable of self-care but who
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require supervision to protect them from harm. Older persons placed in these homes may need someone to
direct their self-care activities (e.g., remind them to bathe and dress and encourage and provide good
nutrition); they may also need someone to oversee their judgments (e.g., financial management). Foster care
and group living can serve as short- or long-term alternatives to institutionalization for older persons unable to
manage independently in the community. The local department of social services can supply details about
these programs.
Adult Day Services
Adult day services programs have been a growing component of community-based, long-term care, currently
numbering over 4,600 centers in the United States (National Adult Day Services Association, 2014). These
centers provide health and social services to persons with moderate physical or mental disabilities and give
respite to their caregivers. Participants attend the program for a portion of the day and enjoy a safe, pleasant,
therapeutic environment under the supervision of qualified personnel (Fig. 10-2). The programs attempt to
maximize the existing self-care capacity of participants while preventing further limitations. Although the
primary focus is social and recreational, there usually is some health component to these programs, such as
health screening, supervision of medication administration, and monitoring of health conditions. Rest periods
and meals accompany the planned therapeutic activities. Transportation to the site is provided, usually by
vehicles equipped to accommodate wheelchairs and persons with other special needs.
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FIGURE 10-2 • Adult day care centers provide opportunities for a variety of recreational activities.
In addition to helping older persons avoid further limitations and institutionalization, day services programs
are extremely beneficial to the families of participants. Families interested in caring for their older relatives
may be able to continue their routine lifestyle (e.g., maintaining a job and raising small children), knowing
that they can have respite from their caregiving responsibilities for a portion of the day while the older person
is cared for and safe.
Adult day services programs are sponsored by public agencies, religious organizations, and private groups,
with one third being freestanding and the remaining ones affiliated with a larger parent organization; each
varies in schedule, activities, costs, and program focus. The local telephone directory or information and
referral service, as well as the National Adult Day Services Association, can provide information on programs
in specific communities.
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Concept Mastery Alert
Adult day services provide health and social services to persons with moderate physical or mental
disabilities who need some supervision and assistance with activities of daily living. A primary focus of
these programs is to give respite to caregivers.
Day Treatment and Day Hospital Programs
Day treatment and day hospital programs offer social and health services with a primary focus on the latter.
Assistance is provided with self-care activities (e.g., bathing and feeding) and therapeutic needs (e.g.,
medication administration, wound dressing, physical therapy, and psychotherapy). Physicians, nurses,
occupational therapists, physical therapists, psychologists, and psychiatrists are among the care providers
affiliated with programs for day treatment. Like adult day services programs, geriatric day treatment or day
hospital programs usually provide transportation to and from the program. Sponsored by hospitals, nursing
homes, or other agencies, these programs can be used as alternatives to hospitalization and nursing home
admission and can facilitate earlier discharge from these care settings. Many of these programs focus on the
care of persons with psychiatric conditions. The local commission or office on aging can guide persons to
programs for day treatment or day hospitals in their community.
Assisted Living
Assisted living supplements independent living with special services that maximize an individual’s capacity for
self-care. Terminology used to describe assisted living can fall under the categories of residential care facilities,
personal care, and boarding homes; different states use different regulatory designations. The housing unit is
adjusted to meet the needs of older or disabled persons (e.g., wide doorways, low cabinets, grab bars in
bathroom, and call-for-help light). A guard, hostess, or resident screens and greets visitors in the lobby.
Various degrees of personal care assistance may be provided. Residents are encouraged to develop mutual
support systems; one example is a system in which residents check on one another every morning to see if
anyone needs help. Tenant councils may determine policies for the facility. Some facilities have a health
professional on call or on duty during certain hours; recognizing the unique health care needs in this setting
that can be appropriately addressed by nurses, nursing in assisted living communities is a developing specialty.
Social programs and communal meals may also be available. State health department regulatory agencies and
the local office of the Department of Housing and Urban Development may be able to direct interested
persons to such facilities.
Respite Care
A variety of services can be utilized to provide short-term relief to caregivers from their caregiving
responsibilities. The services depend on the need, status of the patient, and funds. For example, private home
health aides/companions or nurses can be hired to live in or occasionally visit the older person while the
caregiver is away; short-term admissions to assistive living communities or nursing homes can provide respite
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when the person’s caregiving demands and/or need for supervision is 24/7.
Health Ministry and Parish Nurse Programs
Many churches and synagogues have programs to assist older adults and their caregivers such as support
groups, health education classes, counseling, housekeeping and home maintenance assistance, meals, and
home nursing visits. Many nurses are volunteers in these programs and some are paid to serve in these roles.
These services are ideal ways to integrate health services with one’s faith. As services offered vary, nurses
should contact the church or synagogue of the patient, or if the patient is not a member of one a local religious
organization representing the patient’s faith, to learn of the availability of services.
KEY CONCEPT
The American Nurses Association has recognized parish nursing as a specialty and in collaboration with
the Health Ministries Association published the Faith Community Nursing: Scope and Standards of
Practice.
Care and Case Management
The identification of needs, location and coordination of services, and maintenance of an independent lifestyle
can be tremendous challenges for older persons with chronic health problems. In response to these challenges,
the field of geriatric care and case management has developed.
Care and case managers most often are registered nurses or social workers who assess an individual’s
needs, identify appropriate services, and help the person obtain and coordinate these services. Such services
include medical care, home health services, socialization programs, financial planning and management, and
housing. By coordinating care and services, geriatric care and case managers assist older persons in remaining
independent in the community for as long as possible. The services of care and case managers often provide
peace of mind to family members who are unable to be involved with their older family members on a daily
basis.
As a system of credentials within this field has surfaced, there is greater distinction between care
management and case management. Both of these disciplines perform some type of assessment, develop plans,
help people implement and coordinate services, and evaluate care. A distinguishing difference between the
two, however, is that care management is a long-term relationship that could endure through multiple
episodes of care (e.g., when a family contracts with a care manager to oversee the care of a relative on a long-
term basis), whereas case management usually focuses on needs during a specific episode of care (e.g., from
hospitalization through rehabilitation for a hip fracture). Case management is viewed as a means to control
health care costs and may emphasize services for cost containment; care management may include case
management in addition to services unrelated to health care.
Social workers, local information and referral services, and the National Association of Professional
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Geriatric Care Managers (http://www.caremanager.org) can provide assistance in locating care and case
managers.
KEY CONCEPT
The American Nurses Association has found professional nurses to be excellent case managers because
of their knowledge and skills training, their ability to deliver care that includes both physical and
sociocultural components, their familiarity with the process of services referral, and the parallels between
the nursing process and the process of case management.
Programs of All-Inclusive Care for the Elderly
Programs of all-inclusive care for the elderly (PACE) is a program that enables persons age 55 or older who
are eligible for nursing home care to have all of their medical, social, and long-term care services provided in
their homes in the community. It is a joint Medicare and Medicaid program available in states that have
chosen to include it in their Medicaid programs. Individuals can find out if there is a PACE program in their
area by calling their state Medicaid office or visiting www.cms.hhs.gov/PACE.
Hospice
Although hospice care is listed here under partial and intermittent care services, it can also be included under
complete and continuous care services. This is because the nature of the patient’s needs determines the level at
which this service is provided.
Rather than a site of care, hospice is a philosophy of caring for dying individuals. Hospice provides
support and palliative care to patients and their families. Typically, an interdisciplinary team helps patients
and families meet physical, emotional, social, and spiritual needs. The focus is on the quality of remaining life
rather than life extension. Survivor support is also an important component of hospice care. Although hospice
programs can exist within an institutional setting, most hospice care is provided in the home. Insurers vary in
the conditions that must be met for reimbursement of hospice services; individual insurers should be consulted
for specific information. Health care and social service agencies can be consulted for information about
hospice programs in specific communities.
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http://www.caremanager.org

http://www.cms.hhs.gov/PACE

Complete and Continuous Care Services
At the far end of the continuum of care are services that provide regular or continuous assistance to individuals
with some limitation in self-care capacity whose therapeutic needs require 24-hour supervision by a health
care professional.
Hospital Care
Hospital care for older persons may be required when diagnostic procedures and therapeutic actions indicate a
need for specialized technologies or frequent monitoring. Older adults can be patients of virtually all acute
hospital services, except, of course, pediatrics and obstetrics (and here they may be encountered as relatives of
the primary patients). Although the procedure or diagnostic problem for which they are hospitalized will
dictate many of their service needs, there are some basic measures that can enhance the quality of the hospital
experience, as described in Box 10-2.
Box 10-2 Measures That Enhance the Quality of Hospital
Care for Older Adults
Perform a comprehensive assessment. It is not uncommon for the patient’s diagnostic problem to be the
primary and sometimes only concern during the hospitalization. However, the patient being treated
for a myocardial infarction or hernia may also suffer from depression, caregiver stress, hearing deficit,
or other problems that significantly affect the health status. By capitalizing on the contact with the
patient during the hospitalization and conducting a comprehensive evaluation, nurses can reveal risks
and problems that affect the health status and that have not been detected before. Broader problems,
other than those for which the patient was admitted to the hospital, should be explored.
Recognize differences. Older patients should not be considered in the same way as younger patients:
different norms may be used to interpret laboratory tests and clinical findings, the signs and
symptoms of disease can appear atypically, more time is needed for care activities, and drug dosages
must be age adjusted. The priorities of older patients can differ from those of younger patients.
Nurses must be able to differentiate normal pathology from pathology in older adults and understand
the modifications that must be made in caring for this population.
Reduce risks. The hospital experience can be traumatic for older patients if special protection is not
afforded. The elderly require more time to recover from stress; therefore, procedures and activities
must be planned to provide rest. Altered function of major systems and decreased immunity make it
easy for infections to develop. Reduced ability of the heart to manage major shifts in fluid load
demands close monitoring of intravenous infusion rates. Lower normal body temperature, the lack of
shivering, and reduced capacity to adapt to severe changes in environmental temperature require that
older patients receive special protection against hypothermia. Differences in pharmacodynamics and
pharmacokinetics in older adults alter their response to medications and heighten the need for close
monitoring of drug therapy. The strange environment, sensory deficits, and effects of illness and
medications cause falls to occur more easily and make injury prevention a priority. Confusion often
emerges as a primary sign of a complication, challenging staff to detect this disorder promptly and
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identify its cause. Nurses should ensure that measures are taken to reduce patients’ risks and
recognize complications promptly when they do occur.
Maintain and promote function. Priorities addressing the primary reason for admission usually take the
forefront during a patient’s hospitalization. For example, the arrhythmia must be corrected, the
infection controlled, and the fracture realigned. In the midst of diagnostic procedures and treatment
activities, there must be consideration of factors that will ensure the older patient’s optimal function
and independence.
Increasingly, hospitals are establishing special services for older adults, such as geriatric assessment centers,
telephone hot lines, long-term care units, and home visits. Local medical societies and state hospital
associations can answer inquiries about specific hospitals.
Two issues that gerontological nurses need to consider regarding the hospital care of older adults are
abbreviated stays and the move toward same-day outpatient services for procedures that once would have
required hospitalization. Although shortening hospital stays can be effective in lowering costs and perhaps
reducing or eliminating a patient’s hospital-induced complications, many older patients require a longer
recovery time than younger adults and may not have adequate assistance in the home. Nurses must assess
older patients’ capacity to care for themselves—the ability to obtain and prepare food and manage their
households—before discharge and arrange assistance as necessary. A telephone call after discharge to check on
the patient’s status is also useful. (Additional information on hospital care of older adults is provided in
Chapter 33.)
Nursing Homes
Nursing homes provide 24-hour supervision and nursing care to persons who are unable to be cared for in the
community. Chapter 34 discusses these facilities and related nursing responsibilities.
KEY CONCEPT
The Centers for Medicare and Medicaid Services offer a free online booklet, Your Guide to Choosing a
Nursing Home, which can aid individuals in finding and comparing facilities, understanding nursing
payment for this care, and learning about alternatives to nursing home care. It is available at
http://publications.usa.gov/USAPubs.php?PubID=5337.
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http://publications.usa.gov/USAPubs.php?PubID=5337

Complementary and Alternative Services
As the emphasis on holistic health and public awareness of and desire for complementary and alternative
therapies grow, older adults may seek new or nonconventional types of services (Fig. 10-3). Examples of
complementary and alternative services include the following:
FIGURE 10-3 • Increasingly, older adults are turning to yoga, meditation, and other complementary health
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practices.
Wellness and renewal centers
Education, counseling, and case management from alternative practitioners
Acupuncture and acupressure
Tai chi, yoga, and meditation classes
Therapeutic touch and healing touch
Medicinal herbal prescriptions
Herbal and homeopathic remedies
Guided imagery sessions
Sound, light, and aromatherapy
Nurses possess a wide range of knowledge and skills that, when combined with additional preparation in
complementary and alternative therapies, makes them ideal providers of some of these nonconventional
services. Even if they are not direct providers of alternative therapies, nurses can advocate for older adults’
rights to make informed choices about using such therapies; educate them about the benefits, risks, and
limitations of therapies; and help them find reputable providers. Ideally, these therapies are used in concert
with conventional ones in an integrative care model to enable patients to use the best of both worlds. Nurses
should ensure the complementary and alternative therapies used have evidence supporting their claims and do
not interfere or interact with other therapies.
POINT TO PONDER
Increasing numbers of nurses are offering complementary therapies in independent practices. What
types of factors must be considered when establishing a private practice? What do you think prevents
more nurses from becoming self-employed nurse entrepreneurs?
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MATCHING SERVICES TO NEEDS
The needs of the aging population are diverse and multitudinous. In addition, the needs of an individual older
adult are dynamic; in other words, needs fluctuate as capacities and life demands change. These conditions
require gerontological nursing services to be planned with consideration of several factors:
Services must address physical, emotional, social, and spiritual factors. Services must be available to meet the
unique needs of the older population in a holistic manner. These services should be planned to address
whatever problems or needs older adults are likely to develop and should be implemented in a manner
relevant to the unique characteristics of this group. For instance, a local health department interested in
meeting the special needs of older adults could add screening programs for hearing, vision, hypertension,
and cancer to their existing services. Likewise, a social service agency with an abundance of programs for
younger families may decide that a widow’s support group and retirement counseling services are
relevant additions. The consideration of physical, emotional, social, and spiritual factors is essential to
providing holistic nursing care.
Services must consider unique and changing needs. Physical, emotional, social, and spiritual services are
based on the individual’s needs at a given time, recognizing that priorities are not fixed. An older adult
could be seen in an outpatient medical service for hypertension control and during that visit express
concern regarding a recent rent increase. Unless assistance is obtained to provide additional income or
lower cost housing, the potential effects of this social problem, such as stress and dietary sacrifices, may
exacerbate the individual’s hypertension. Ignoring this individual’s need for particular social services,
then, can minimize the effectiveness of the health services provided.
Care and services must be flexible. Opportunities must exist for the older individual to move along the
continuum of care, depending on his or her capacities and limitations at different times. Perhaps an
older woman lives with her children and attends a senior citizen recreational program during the day. If
this woman fractures her hip, she may move along the continuum to hospitalization for acute care and
then to a nursing home for convalescence. As her condition improves and she becomes more
independent, she moves along the continuum to home care and then possibly adult day care until she
regains full independence.
Services must be tailored to needs. Individualization must be practiced to match the unique needs of the
individual with specific services. Just as it is inappropriate to assume that all persons over 65 years
require nursing home placement, it is equally inappropriate to assume that all older persons would
benefit from counseling, sheltered housing, home-delivered meals, adult day care, or any other service.
Older individuals’ unique capacities and limitations and, most importantly, their preferences should be
assessed to identify the most appropriate services for them.
The listing of resources at the end of the chapter can help gerontological nurses and nursing students locate
and perhaps stimulate services for older adults. Nurses are encouraged to contact their local agencies on aging
and information and referral services for the location of services within specific communities.
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392

SETTINGS AND ROLES FOR GERONTOLOGICAL
NURSES
Because the continuum of care includes community-based services, institution-based services, or a
combination of both, gerontological nurses have an exciting opportunity to practice in a variety of settings.
Some of these settings, such as long-term care facilities and home health agencies, have a long history of
nursing participation. Others, such as senior housing complexes and adult day care centers, offer new
opportunities for nurses to demonstrate creativity and leadership.
Although nurses’ specific roles and responsibilities can differ vastly in different settings, gerontological
nurses in any setting may serve similar functions (Box 10-3). These functions are varied and multifaceted and
address the following goals:
Educate persons of all ages in practices that promote a positive aging experience.
Assess and provide interventions related to nursing diagnoses.
Identify and reduce risks.
Promote self-care capacity and independence.
Collaborate with other health care providers in the delivery of services.
Maintain health and integrity of the aging family.
Advocate for and protect the rights of older adults.
Promote the use of ethics and standards in the care of older adults.
Help older persons face the transition to death with peace, comfort, and dignity.
Box 10-3 Functions of the Gerontological Nurse
Guide persons of all ages toward a healthy aging process.
Eliminate ageism.
Respect the rights of older adults and ensure others do the same.
Oversee and promote the quality of service delivery.
Notice and reduce risks to health and well-being.
Teach and support caregivers.
Open channels for continued growth.
Listen and support.
Offer optimism, encouragement, and hope.
Generate, support, use, disseminate, and participate in research.
Implement restorative and rehabilitative measures.
Coordinate and manage care.
Assess, plan, implement, and evaluate care in an individualized, holistic manner.
Link services with needs.
Nurture futu