9.4 Care of the Older Adult: Delirium, Dementia, Falls & Healthy Ageing

Care of the Older Adult: Delirium, Dementia, Falls and Healthy Ageing

The CARICOM Blueprint's oldest age group is 65 years and older. Its degenerative problems include osteoarthritis, Parkinson's disease, Alzheimer's disease and "senility", visual and hearing defects, urinary incontinence, emphysema and heart disease. Caribbean populations are ageing, so a growing share of every ward's clients are older adults. Erikson's final stage, integrity versus despair, reminds nurses that dignity and meaning matter as much as physical care.

Normal Ageing and Atypical Illness

Rule: a sudden change in an older adult's thinking or function is an illness until proven otherwise. It is not "just old age".

Delirium, Dementia and Depression

The Confusion Assessment Method (CAM) identifies delirium by:

1. acute onset with a fluctuating course; and
2. inattention; plus
3. disorganised thinking or an altered level of consciousness.

Hunt for causes with the mnemonic PINCH ME:

• Pain;
• Infection;
• Nutrition;
• Constipation;
• Hydration;
• Medication, especially new drugs; and
• Environment.

Also check for urinary retention, low oxygen and low glucose. Prevention and care include:

• orientation cues (a clock, a calendar, familiar faces);
• glasses and hearing aids in use;
• a normal sleep-wake cycle;
• early mobilisation;
• hydration; and
• avoiding restraints and unnecessary sedatives.

Dementia care:

• Keep a calm routine and use simple, one-step instructions.
• Approach from the front and use the person's name.
• Use validation of feelings rather than arguing with confused beliefs.
• Manage wandering safely and expect sundowning (worse confusion late in the day).
• Support the caregiver, because caregiver strain is high.

Advance care planning should happen while the person can still take part.

Falls

Falls are a leading cause of injury and loss of independence. Risk factors include:

• a previous fall;
• gait or balance problems;
• postural hypotension;
• sedatives, antihypertensives and diuretics;
• urinary urgency or nocturia;
• poor vision;
• unsafe footwear;
• clutter and poor lighting; and
• delirium.

Use a validated tool such as the Morse Fall Scale. Preventive actions:

• keep the bed in its lowest position and the call bell within reach;
• provide non-slip footwear and a night light;
• offer scheduled toileting;
• review medicines; and
• support strength and balance exercise.

After a fall:

1. Do not lift the client at once. Assess for injury, especially to the head and hip, and check vital signs and neurological status.
2. Call for help and move the client safely.
3. Notify the medical officer.
4. Monitor for delayed signs, particularly if the client takes anticoagulants.
5. Document objectively and complete an incident report (Section 2.3).

Medicines in Older Adults

Polypharmacy increases falls, confusion and admissions. The American Geriatrics Society Beers Criteria list potentially inappropriate medicines for older adults, including:

• long-acting benzodiazepines;
• first-generation antihistamines such as diphenhydramine;
• other strongly anticholinergic drugs; and
• long-term NSAIDs.

Start low and go slow, review the medicines at every transition, and simplify regimens with pill organisers and teach-back.

Continence, Mobility and Common Conditions

Never insert an indwelling catheter for staff convenience (Section 4.4).

• Parkinson's disease: the features are Tremor at rest, Rigidity, Akinesia/bradykinesia and Postural instability (TRAP).
  • Give levodopa-carbidopa on time, because delays cause "off" periods.
  • High-protein meals can reduce its absorption.
  • Watch for falls, swallowing problems and constipation.
• Osteoarthritis: use exercise, weight control and paracetamol first-line. Joint replacement precautions are in Section 7.4.
• Osteoporosis: prevent falls and fractures.

Elder Abuse and Neglect

Elder abuse can be:

• physical (unexplained bruises);
• psychological;
• financial (sudden loss of money or property);
• sexual; or
• neglect (poor hygiene, untreated pressure injuries, malnutrition).

Interview the older person privately, document objectively, and report through institutional and social-services channels.

Healthy Ageing

Support healthy ageing through:

• influenza and pneumococcal vaccination;
• nutrition and oral health;
• physical and social activity;
• vision and hearing checks; and
• planning for long-term care, including community services and parish infirmaries.

Care for an older adult always involves the family and community.