NSG210 Hinkle Ch. 8: Management of the Older Adult Patient

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 8, pp. 166-193 (textbooks/HINKLE_MS_CH08.pdf, also in textbooks/exam01/). Week 02 reading; on Exam 1 (management of older adults was 3 of 34 med-surg questions). See also nsg210-week-02-summary.

Learning Outcomes

1. Specify demographic trends and physiologic aspects of aging in the US.
2. Describe preventive health care and health promotion for older adults.
3. Compare common physical and mental health problems of aging and their effects.
4. Identify the nurse’s role in meeting older patients’ needs.
5. Examine health issues in the home, community, acute care, and long-term care.

Key terms:

• ADLs: bathing, dressing, grooming, eating, toileting, transferring
• IADLs: shopping, cooking, housework, telephone, managing medications and finances, travel
• Ageism: bias against older adults based on chronologic age
• Comorbidity: more than one illness at once
• Depression: most common mood disorder of old age
• Durable power of attorney: legal document naming a proxy decision maker
• Elder abuse: physical, emotional, or financial harm, including neglect
• Geriatric syndromes: multifactorial conditions (falls, delirium, frailty, dizziness, urinary incontinence)
• Gerontology: biologic, psychologic, sociologic study of aging; geriatrics: medical practice for older adults
• Polypharmacy: use of multiple prescription and OTC medications
• Presbycusis: loss of high-pitched hearing; presbyopia: loss of near focus (accommodation)
• Urinary incontinence: involuntary loss of urine

I. Overview of Aging

A. Demographics

• 49.2 million Americans 65 and older in 2016 (one in seven, 15.2%); expected to double to 98 million by 2060
• Fastest growth in those 85 and older (6.4 million in 2016 to 14.6 million by 2040)
• Life expectancy 78.6 years (2016); women live about 5 years longer
• Hispanic older adult population growing fastest

B. Health status

• Most have at least one chronic illness; many have several
• Leading causes of death: heart disease and cancer; unintentional injuries now third
• Alzheimer’s deaths rising, expected to quadruple by 2050
• 78% rate health good or better
• Activity limitation declined from 49% (1992) to 44% (2013)

C. Gerontologic nursing

• Interdisciplinary approach; comprehensive geriatric assessment
• Goals: promote and maintain functional status, help older adults use strengths for optimal independence
• Aging is not synonymous with disease; highly individualized
• Functional assessment is the common framework
• Miller’s Functional Consequences Theory: distinguish normal irreversible age-related changes from modifiable risk factors (for example glare sensitivity from normal aging vs cataracts) and design interventions accordingly

II. Physical Aspects of Aging (Table 8-1)

• Intrinsic aging: genetically programmed, universal
• Cells accumulate lipofuscin; elastin and collagen degrade (stiffer connective tissue); more anemia
• Reduced tactile sensation and ability to sense pressure, pain, temperature

A. Cardiovascular

• Heart disease is the leading cause of death in older adults
• Myocardial hypertrophy, valve fibrosis and calcification, fewer pacemaker cells, stiffer arteries leads to reduced stroke volume, increased resistance, hypertension
• Decreased cardiac output, slower heart rate recovery; fatigue with activity
• Atypical presentation: dyspnea, neurologic symptoms, confusion, fatigue, nausea, syncope; burning or sharp upper body pain instead of substernal pain; absence of chest pain does not rule out heart disease
• Orthostatic and postprandial hypotension: check BP in two positions; rise slowly, avoid straining, 5-6 small meals a day, avoid hot showers and whirlpools
• Optimal BP under 130/80; BMI under 25

B. Respiratory

• Increased residual volume; decreased muscle strength, vital capacity, gas exchange, cough efficiency
• Aerobic capacity declines about 10% per decade after the mid-20s
• Infection may present as fatigue, lethargy, anorexia, dehydration, mental status change instead of cough and fever
• Older adults smoke at about 20%; e-cigarettes are not effective cessation aids
• Exercise, fluids, pneumococcal vaccine at 65, yearly influenza vaccine, avoid sick people; cough and deep breathe postop (atelectasis risk)

C. Integumentary

• Thinner dermis, less subcutaneous fat, fewer elastic fibers, less vasodilation leads to poor heat conservation, reduced fever response, hypo- and hyperthermia risk
• Dry, fragile skin; bruises and burns easily
• Limit sun to 10-15 minutes daily for vitamin D; SPF 15 or higher; shower rather than hot tub bath; lotions with petrolatum or mineral oil; report skin changes

D. Reproductive

• Older adults value sexual activity; decline mostly from loss of partner (women) or health problems, ED, medications (men)
• Women: thinner, shorter, less elastic vagina; less lubrication; painful intercourse, bleeding; water-soluble lubricant, possibly vaginal estrogen
• Men: testosterone declines from about 50; sperm possible to 90; ED more often from obesity, smoking, CVD, diabetes, medications (vasodilators, antihypertensives, TCAs)
• Slower arousal and response in both; desire remains; refer for sexual dysfunction

E. Musculoskeletal

• Bone density loss, muscle mass loss, joint degeneration; height loss, kyphosis, fractures
• Degenerative joint disease in most adults over 70; osteoporosis is preventable
• “Use it or lose it”: aerobic, resistance, flexibility, balance exercise; weight-bearing exercise 3 times a week; bone density screening; calcium and vitamin D; get hospitalized patients out of bed early

F. Genitourinary

• Nephron loss (significant around 90); one third show no renal decline
• Decreased GFR, concentrating ability, acid-base recovery; drug accumulation risk
• Urinary incontinence: women 2:1 until 80, then equal; not normal aging; mortality up to 44% in long-term care residents
• BPH causes retention and overflow incontinence
• More UTIs; adequate fluids reduce UTIs and incontinence
• Limit evening fluids; avoid caffeine, alcohol, artificial sweeteners; void regularly and completely; pelvic floor exercises for women

G. Gastrointestinal

• Decreased thirst, smell, taste; one third have dry mouth (from medications and disease, not aging)
• Delayed gastric emptying, early satiety; reduced absorption of iron, calcium, B12, vitamin D
• More gallstones
• Dysphagia increases with age; complication of stroke and Parkinson’s; aspiration may occur without coughing or choking
• Constipation from low fiber, laxative overuse, medications, inactivity, low fluid, high fat, ignoring urge; can cause impaction with diarrhea around it
• Brush, floss, dental care; small frequent high-fiber low-fat meals; sit up during and after eating; avoid laxatives and antacids

H. Nutrition

• Fewer calories needed but more nutrient-dense diet
• Need more sugar to taste sweetness; apathy, depression, loneliness, poverty, poor oral health reduce intake
• MyPlate for Older Adults (Fig. 8-2): fruits and vegetables, whole grains, low-fat dairy, varied protein, healthy oils, herbs and spices instead of salt, plenty of fluids
• Calcium 1200 mg/day for women over 50 and men over 70; vitamin D 600 IU to age 70, 800 IU after 70
• Hospitalized older adults, especially with dementia, are at risk for malnutrition; unintentional weight loss needs evaluation

I. Sleep

• Up to 50% at home and 65% in nursing homes report sleep problems
• Causes: sleep apnea, restless legs, nocturia, pain, HF, incontinence, BPH, depression, dementia, environment
• Consequences: cognitive decline, falls, fatigue, poor quality of life
• Sleep hygiene: bed only for sleep and sex, consistent routine, limit naps, one alcoholic drink a day maximum, no caffeine or nicotine after noon, limit evening fluids, daytime activity in bright light; lavender aromatherapy may help

J. Nervous system

• Small loss of brain mass; fewer neurotransmitters; slower nerve conduction - slower reactions and learning
• Autonomic changes cause orthostatic hypotension; gait and balance changes
• Advise more time to respond, move deliberately; adequate B12 (especially vegetarians)
• Slowed reaction leads to falls and driving errors; driving evaluation by OT and neuropsychologist if unsafe
• Sudden confusion may be the first sign of infection or physical change (pneumonia, UTI, drug interaction, dehydration)
• Increased vulnerability to delirium with illness, anesthesia, room changes

K. Sensory

• Sensory deprivation (lack of or inability to interpret stimuli) can cause boredom, confusion, irritability, disorientation, anxiety and mimic cognitive decline; provide meaningful stimulation (colors, textures, music, touch)
• Vision: presbyopia (fifth decade), yellowed cloudy lens scatters light and causes glare, poor blue-green distinction, slow pupil adjustment, need brighter light; nightlights, avoid glare and night driving, large print, contrasting colors
• Age-related macular degeneration: leading cause of vision loss over 65; affects central vision, not peripheral; risk factors sunlight, smoking, heredity, fair skin, blue eyes; sunglasses, hats, stop smoking; laser photocoagulation and photodynamic therapy
• Hearing: presbycusis - high-frequency loss (f, s, th, ch, sh, b, t, p sound alike); may be mistaken for confusion; check for wax; hearing aids underused in long-term care; reduce background noise, face the person, speak clearly in a low pitch, rephrase
• Taste and smell: sweet especially dulled; smell loss greater than taste; may not detect spoiled food or gas; use lemon, herbs, spices instead of salt

III. Psychosocial Aspects

• Successful aging: adapting to losses with resiliency and coping
• Ageism and stereotypes; older adults may internalize them
• Retirement planning: income, new routines, new friends, varied leisure
• Coping patterns stay consistent through life; common stressors include functional decline, chronic illness, loss of income and roles, death of loved ones
• High coping self-efficacy associated with 92% lower odds of frailty (Chart 8-2)

A. Living arrangements

• 93% live in the community; about 2.3% in nursing homes; 76% own their homes; 28% live alone (mostly widowed women)
• 70% of men over 65 married vs 40% of women
• Most prefer to stay home (“age in place”); home modifications and support services help
• Living with adult children: rewarding but potentially stressful; plan ahead before crisis; include the older adult in decisions
• Continuing care retirement communities (CCRCs): independent, assisted, and skilled care on one campus; large down payment
• Assisted living: minimal supervision, medication help, ADL assistance, meals, laundry; mostly out-of-pocket
• Long-term care: percentage of older adults in nursing homes fell from 5.4% (1985) to 2.3% (2018)
• Medicare covers short-term skilled nursing (often 30-90 days) after hospitalization when therapy shows continued improvement; long-term custodial care is mostly out-of-pocket until resources are exhausted, then Medicaid; family members are not responsible for nursing home costs
• Subacute units in skilled facilities can avoid hospital transfers

B. Role of the family

• Spouse usually primary caregiver, then adult child
• Myths of alienation and abandonment are false; families remain the main support
• Informal caregivers gave 18.5 billion hours of unpaid care in 2018
• Caregiving increases risk of psychiatric and physical illness; effective interventions: psychoeducation and skill building, CBT, combined approaches; web-based programs fit busy caregivers

IV. Cognitive Aspects

• Cognition affected by sensory loss, health, environment, sleep, psychosocial factors
• Temporary cognitive changes (delirium) common with hospitalization or facility admission
• Mini-Mental State Examination (MMSE) screens cognition (orientation, naming, reading)
• Healthy diet, 30 minutes of daily activity, adequate sleep support cognition
• Fluid intelligence (flexible thinking, problem solving) declines; crystallized intelligence (education, experience, verbal skills) remains intact
• Higher education, good senses, nutrition, complex jobs preserve learning

Teaching strategies (Chart 8-4):

• Mnemonics; link new to familiar information; visual and auditory cues
• Glasses and hearing aids on; glare-free light; quiet room
• Short-term goals set with learner; prioritize key information; short sessions paced to endurance
• Encourage verbal participation; reinforce success positively

V. Pharmacologic Aspects

• Older adults use the most medications; adverse reactions common (interactions, wrong doses, polypharmacy)
• Medications affect nutrition: antacids cause thiamine deficiency; laxatives reduce absorption; antibiotics and phenytoin reduce folic acid use; phenothiazines, estrogens, corticosteroids increase appetite and weight
• St. John’s wort decreases warfarin effect
• AGS Beers Criteria: lists potentially inappropriate medications; updated every 4 years

Altered pharmacokinetics (Table 8-2):

• Absorption: less gastric acid, slower motility - rate may be delayed (vitamins, calcium)
• Distribution: less plasma protein leads to more free drug for highly protein-bound drugs (warfarin, sulfonylureas, barbiturates, calcium channel blockers, furosemide, NSAIDs, phenytoin); more body fat stores fat-soluble drugs longer (diazepam, barbiturates, lidocaine, phenothiazines, morphine); less body water and lean mass give higher peaks
• Metabolism: smaller liver, less blood flow leads to prolonged action and toxicity for liver-metabolized drugs
• Excretion: less renal flow and fewer nephrons leads to accumulation (aminoglycosides, cimetidine, digoxin, lithium, procainamide)

Nursing implications:

• “Start low and go slow”; keep regimens simple; reconcile medications at discharge
• Thorough history including alcohol, recreational drugs, OTC, herbals; have patient bring all medications (“brown bag”)
• Assess understanding, health literacy, beliefs about each medication
• Nonadherence causes: number and complexity of drugs, hard-to-open containers, poor teaching, cost, side effects, vision and hearing problems

Adherence strategies (Chart 8-5):

• Assess self-management and psychomotor skills
• Discard old medications; non-childproof caps if no children in home
• Report OTC, herbal, alcohol, recreational drug use; carry a current medication list
• Explain purpose, side effects, dose of each drug; written schedule
• Involve a reliable family member if competence is doubtful
• Use one pharmacy; multi-day pill organizer

VI. Mental Health Problems

• Severe mood swings, uncontrolled laughing or crying, cognitive change, excessive forgetfulness are not normal aging; often treatable

A. Depression

• Most common mood disorder of old age; 15-25% in community, up to 25% in long-term care
• Often follows loss, chronic illness, pain, medication interaction, or undiagnosed illness
• Subtle signs: fatigue, poor memory and concentration, worthlessness, sleep and appetite changes, restlessness, suicidal ideation
• Increased suicide risk; assess routinely
• May be confused with dementia (cognitive problems from apathy, not brain decline)
• Geriatric Depression Scale (Chart 8-6): 30 yes/no items; normal 5 plus or minus 4; mildly depressed 15 plus or minus 6; very depressed 23 plus or minus 5
• Treatment: review and change contributing medications; treat underlying conditions; mild - exercise, bright light, social contact, cognitive and reminiscence therapy; major - antidepressants plus psychotherapy (bupropion, venlafaxine, mirtazapine, SSRIs such as paroxetine; TCAs for some); ECT if drugs fail or are risky
• Antidepressants have anticholinergic, cardiac, orthostatic effects - monitor for falls; may take longer than the usual 4-6 weeks to work; change positions slowly, stay hydrated

B. Substance use disorder

• 7-14% of adults 65 and older report alcohol abuse, dependence, or binge drinking; about 50% drink regularly
• Dangerous because of renal and liver changes and drug interactions; often hidden and denied; screen at routine exams

C. Delirium

• Causes: illness, surgery, medication or alcohol toxicity, dehydration, fecal impaction, malnutrition, infection, head trauma, sensory deprivation or overload
• Older adults especially vulnerable (low reserve, many medications)
• Confusion Assessment Method (CAM, Chart 8-7): acute onset, inattention, disorganized thinking, altered LOC, disorientation, memory impairment, perceptual disturbances, psychomotor agitation or retardation, altered sleep-wake cycle
• Delirium is a medical emergency; report immediately; untreated can cause permanent brain damage or death

D. Alzheimer’s disease (AD)

• Sixth leading cause of death in US (fifth over 65); progressive, irreversible, insidious
• Affects up to half of those 85 and older but is not normal aging; 13.8 million Americans expected by 2050
• Causes: age (greatest risk), genetics, neurotransmitter changes, vascular abnormalities, stress hormones, circadian changes, head trauma, seizures
• Familial (early-onset) under 2% of cases; sporadic late-onset most common
• Pathophysiology: neurofibrillary tangles and neuritic (amyloid) plaques in the cerebral cortex; decreased acetylcholine (memory)
• Early: forgetfulness, subtle memory loss, still independent
• Middle: cannot recognize familiar faces and places, gets lost, repeats questions, word-finding difficulty, concrete thinking, impulsive behavior, trouble with appliances and money; reasoning and reality orientation increase anxiety
• Personality changes: depression, suspicion, paranoia, hostility, combativeness
• Late: nonsense speech, agitation, night wandering, dysphagia, incontinence, total care; death from pneumonia, malnutrition, dehydration
• Diagnosis: definitive only at autopsy; diagnosis of exclusion - rule out depression, delirium, substance abuse, drug toxicity; history and exam; CBC, chemistry, B12, thyroid; EEG, CT, MRI, CSF; GDS and MMSE
• Treatment: cholinesterase inhibitors (donepezil, rivastigmine) slow progression; improvement may occur within 6-12 months; music therapy and behavioral approaches for agitation; drugs only if needed

Nursing management of AD:

• Cognitive support: calm, predictable environment; routine; quiet manner, simple explanations; clocks, calendars, color-coded doors; active participation
• Safety: remove hazards, handrails, lighting, nightlights (sundowning); no driving; supervised smoking; secure doors; ID bracelet; in hospital use distraction or place near nurses’ station; avoid restraints (increase agitation and injury)
• Self-care: break tasks into short steps; OT for adaptive equipment; allow choices; maintain dignity
• Anxiety and agitation: emotional support; familiar, quiet environment; catastrophic reaction (screaming, crying, abuse from overstimulation) - stay calm, do not force the activity, postpone it; music, stroking, rocking, distraction; learn the patient’s triggers
• Communication: unhurried, reduce noise, clear simple sentences, lists early, pointing and nonverbal later, touch conveys security
• Socialization and intimacy: visits, calls, simple activities, pets, plants; intimacy needs continue
• Nutrition: calm simple meals, familiar foods, cueing, small pieces, thickened liquids, check food temperature, adaptive utensils, finger foods, apron rather than bib; eventually needs feeding
• Activity and rest: look for unmet needs behind wandering and sleep problems; daytime exercise, limit naps; music, warm milk, back rub at night
• Family: provide 83% of home care; face hard decisions (driving, finances); caregiver guilt, depression; web-based support; report suspected abuse or neglect to adult protective services (nurse reports, does not need to prove); Alzheimer’s Association, support groups, respite and adult day care

E. Vascular dementia

• Second most common dementia; stepwise decline; multi-infarct dementia most common form
• Risk factors same as CVD (hypertension, cholesterol, smoking, diabetes); controlling them may slow decline

VII. Additional Health Issues

A. Geriatric syndromes

• Multifactorial problems: pressure injuries, poor nutrition, falls, functional decline, urinary and fecal incontinence, delirium, sleep disturbance
• Often acute onset; symptoms may appear in another system first (confusion from UTI, dehydration, MI)
• Geriatric triad: cognitive change, falls, incontinence

B. Impaired mobility

• Causes: stroke, Parkinson’s, diabetic neuropathy, CVD, osteoarthritis, osteoporosis, sensory deficits
• Minimize bed rest (rapid deconditioning); active and passive ROM; frequent position changes

C. Dizziness

• Distinguish true dizziness, vertigo (spinning), near-syncope, disequilibrium
• Causes from ear wax to brain stem or vestibular dysfunction; even minor causes lead to falls

D. Falls

• Unintentional injury is the third leading cause of death in older adults; falls are the most common cause of nonfatal injuries and admissions
• 20-30% of fallers have moderate to serious injury; 1 in 5 falls causes serious injury
• Women injured more; men more likely to die from falls
• 50% of those who cannot get up after a fall and break a hip do not regain prior function
• Causes: extrinsic (lighting, environment) and intrinsic (illness, neuro changes, sensory loss); mobility problems, medications, foot problems, unsafe shoes, orthostatic hypotension, vision, tripping hazards; polypharmacy and alcohol
• Fear of falling and lost confidence follow
• Prevention: small lamps, indirect light, sheer curtains, dull surfaces, nightlights; contrasting colors on stair edges; grab bars at tub, shower, toilet; avoid loose clothing, poor shoes, scatter rugs, clutter, pets underfoot; keep furniture in familiar places
• Quality and Safety Nursing Alert: physical restraints (lap belts, geri-chairs, side rails, vests) and chemical restraints cause many of the injuries they are meant to prevent

E. Urinary incontinence

• Acute or chronic; often unreported unless asked
• Transient causes “DRIP”: delirium and dehydration; restricted mobility; inflammation, infection, impaction; pharmaceuticals and polyuria
• Behavioral approaches can restore continence
• Anticholinergics for urge incontinence often inappropriate (dry mouth, slowed GI, confusion) per Beers criteria
• Detrusor hyperactivity with impaired contractility: no warning, small void then large leak after leaving bathroom; common with dementia; prompted timed voiding, possibly intermittent catheterization; do not show disapproval

F. Infection

• Blunted cell-mediated and humoral immunity; pneumonia, UTI, GI, skin infections common
• Annual influenza vaccine in autumn (high-dose trivalent gives better protection); pneumococcal vaccine; can give both at the same time in separate sites
• Health care workers should be vaccinated
• HIV/AIDS affects older adults too

G. Atypical responses

• Reduced pain perception; MI may present as confusion without chest pain; acute abdomen may lack pain
• Baseline temperature about 1 F lower; 37.8 C (100 F) with systemic symptoms may signal infection; 38.3 C (101 F) almost certainly serious infection; rarely over 39.5 C (103 F); blunted fever means poorer prognosis
• Watch for confusion, increased respirations, tachycardia, skin color change

H. Emotional and systemic responses

• Hospitalization threatens well-being; high risk of delirium, anxiety, fear of being a burden
• Encourage autonomy, independent decisions, early mobilization; positive confident demeanor
• Little organ reserve; illness quickly jeopardizes homeostasis - monitor all systems

I. Elder neglect and abuse

• Neglect is most common; also physical, psychological, sexual, abandonment, financial exploitation
• Underreported; professionals often not trained to recognize it
• Community risk factors for physical and emotional abuse: separated or divorced, low income, functional impairment, younger age
• Ask about abuse privately during the history; most states require nurses to report suspected abuse
• Prevent when caregiver strain is evident: psychologist, social worker, chaplain; support groups, respite, Area Agencies on Aging

J. Social services and costs

• Programs: Medicare, Medicaid, Older Americans Act, SSI, Social Security, Section 202 housing, Title XX
• Area Agencies on Aging (AAAs): needs assessment, referral, case management, transportation, homemaker services, day care, meals, legal services, respite, senior centers
• Older adults are about 15% of population but 38% of health care costs, especially last year of life
• Medicare federal; Medicaid state-run (varies); out-of-pocket costs are 28% of income for poor and near-poor older adults
• Hospice: life expectancy 6 months or less, comfort and preparation for death; palliative care: any stage of serious illness, need not be incurable

K. Aging with a disability

• Higher rates of secondary conditions (for example spinal cord injury)
• Aging parents of adults with intellectual or developmental disabilities need transition support
• Interface and Biopsychosocial models support nurses as advocates

L. Ethical and legal issues

• Encourage advance directives before incapacity
• Advance directive: living will (instructions) and/or durable power of attorney for health care (proxy); signed by person and two witnesses; copy to provider and chart; can request full treatment, not only withholding
• Cultural views may see advance directives as denial of care; focus on the patient’s wishes, not the family’s
• If no directive and patient seems incapable: court competency hearing; judge appoints a guardian
• Mild dementia may still allow some decisions (for example naming a proxy)
• Patient Self-Determination Act (1990): hospitals must educate about advance directives at admission and document it
• Ethical dilemma (Chart 8-8): voluntarily stopping eating and drinking (VSED) can only be chosen by a patient with capacity, not by a surrogate; a VSED decision stated in an advance directive remains binding if capacity is lost

High-Yield Numbers

• One in seven Americans is 65 or older; 98 million by 2060; 85 and older growing fastest
• Calcium 1200 mg (women over 50, men over 70); vitamin D 600 IU to 70, 800 IU after 70
• BP goal under 130/80; BMI under 25
• Sun 10-15 minutes daily; SPF 15 or higher
• Weight-bearing exercise 3 times a week; 30 minutes daily activity
• Aerobic capacity declines about 10% per decade
• Urinary incontinence women:men 2:1 until 80; mortality up to 44% in long-term care
• Depression 15-25% community, up to 25% long-term care
• GDS: normal 5 plus or minus 4, mild 15 plus or minus 6, severe 23 plus or minus 5
• Antidepressants: may take longer than 4-6 weeks in older adults
• Fever: 100 F with symptoms suggests infection; 101 F serious; rarely over 103 F
• Falls: 20-30% cause moderate-serious injury; 50% with hip fracture after unassisted fall do not regain function
• Nursing home residence 2.3%; 93% live in community; 28% live alone
• Medicare skilled nursing 30-90 days with continued improvement
• Family provides 83% of AD home care
• Beers Criteria updated every 4 years
• Hospice: prognosis 6 months or less

Priority Nursing Actions and Red Flags

• Sudden confusion: treat as delirium (medical emergency) - look for infection, dehydration, drug toxicity, impaction
• MI and infection may present atypically (confusion, fatigue, no chest pain, low-grade or no fever)
• Check orthostatic BP; teach to rise slowly
• Avoid restraints (physical and chemical)
• Fall prevention: lighting, grab bars, footwear, remove rugs, review medications
• Review medications against Beers Criteria; start low, go slow; reconcile at discharge
• Screen for depression and suicide risk; GDS
• Screen for alcohol misuse
• Ask about abuse privately; report suspected abuse
• Dysphagia: aspiration may be silent
• Encourage annual influenza and pneumococcal vaccines
• Encourage advance directives

Medications in This Chapter

Related

• nsg210-hinkle-ch07-disability-chronic-illness
• nsg210-week-02-summary
• INDEX