10.2 Gerontological Nursing and Care of the Older Adult
Key Takeaways
- Delirium is acute, fluctuates over hours, impairs attention, and is reversible; dementia is insidious, progressive, and irreversible; depression is subacute with a low mood and frequent "I do not know" responses.
- Atypical presentation is the rule in older adults: infection may present as new confusion or a fall without fever, and myocardial infarction may present as dyspnoea or fatigue without chest pain.
- Age-related decline in renal and hepatic clearance, reduced lean body mass, and increased fat mass alter drug handling, so most medications are started low and increased slowly.
- Beers criteria medications to question in older adults include long-acting benzodiazepines, first-generation antihistamines, and strongly anticholinergic drugs, all of which raise the risk of falls, confusion, and retention.
- Physical restraint increases rather than reduces injury in confused older adults; environmental modification, orientation, sleep protection, and treating the underlying cause are the evidence-based alternatives.
10.2 Gerontological Nursing and Care of the Older Adult
Most adult nursing questions in a licensing exam involve an older patient, and the trap is always the same: applying adult norms to a physiology that has changed. Ageing narrows the margin between compensation and collapse, so the same insult that a 30-year-old absorbs unnoticed produces a fall, a delirium, or an acute kidney injury at 80.
Normal Age-Related Change vs. Disease
| System | Normal ageing change | Clinical consequence |
|---|---|---|
| Cardiovascular | Arterial stiffening, reduced maximum heart rate, blunted baroreceptor response | Orthostatic hypotension; poor tolerance of fluid shifts |
| Respiratory | Reduced elastic recoil, weaker cough, decreased ciliary action | Higher pneumonia and atelectasis risk |
| Renal | Fewer nephrons, reduced GFR and concentrating ability | Drug accumulation; dehydration risk; creatinine may look "normal" despite poor function |
| Neurological | Slower processing, reduced reserve | Vulnerability to delirium; slower but intact learning |
| Musculoskeletal | Sarcopenia, reduced bone density | Falls, fracture, reduced functional reserve |
| Gastrointestinal | Reduced gastric acid and motility | Constipation; altered absorption of some drugs |
| Sensory | Presbyopia, presbycusis, reduced thirst sensation | Communication barriers; dehydration risk |
| Skin | Thinner dermis, less subcutaneous fat, fragile capillaries | Skin tears, pressure injury, impaired thermoregulation |
| Immune | Immunosenescence | Blunted fever response; atypical infection presentation |
Confusion is never a normal part of ageing. Slower recall is; disorientation is not. Any new confusion demands assessment, not acceptance.
Atypical Presentation
This is the highest-yield concept in gerontological nursing. In an older adult:
- Infection may present as new confusion, functional decline, a fall, anorexia, or incontinence — often with no fever and no leucocytosis.
- Myocardial infarction may present as dyspnoea, fatigue, syncope, or epigastric discomfort rather than crushing chest pain, particularly in women and people with diabetes.
- Acute abdomen may present with minimal guarding and little pain because the abdominal musculature and pain perception are both reduced.
- Thyroid disease may present as apathy and depression rather than the classic hyper- or hypothyroid picture.
- Heart failure may present as confusion or fatigue before oedema or orthopnoea are described.
The practical rule for the exam and for the ward: a sudden change in function or cognition in an older adult is a physiological emergency until you have excluded one.
Delirium, Dementia, and Depression
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Hours to days, acute | Months to years, insidious | Weeks to months |
| Course | Fluctuates, worse at night | Steadily progressive | Relatively stable, diurnal variation |
| Attention | Markedly impaired | Preserved until late | Variable, effort-dependent |
| Consciousness | Altered — hyperalert or drowsy | Clear until late | Clear |
| Memory complaint | Not offered | Patient often conceals or confabulates | Patient often emphasises; "I don't know" answers |
| Reversible | Yes | No | Yes |
Delirium causes are best remembered as a checklist you actively work through: infection (especially urinary and respiratory), dehydration, hypoxia, electrolyte disturbance, pain, urinary retention, constipation, medications (particularly anticholinergics, benzodiazepines, and opioids), alcohol withdrawal, and sensory deprivation. Hypoactive delirium — the quiet, withdrawn, drowsy patient — is more common and far more often missed than the agitated hyperactive form.
Prevention and management are overwhelmingly non-pharmacological: ensure spectacles and hearing aids are in place, provide a visible clock and calendar and repeated orientation, maintain a day-night routine with dark quiet nights and daylight exposure, encourage family presence and familiar objects, mobilise early, maintain hydration and nutrition, manage pain adequately, and remove unnecessary catheters and lines. Sedation treats the staff's distress, not the patient's delirium, and antipsychotics are reserved for severe distress or danger.
Polypharmacy and Prescribing Safety
Altered pharmacokinetics in ageing — reduced hepatic first-pass metabolism, reduced renal clearance, lower total body water, higher fat fraction extending the half-life of lipophilic drugs, and reduced serum albumin increasing the free fraction of highly bound drugs — mean that the standard adult dose is often the wrong dose. The operating principle is start low, go slow.
Medications flagged by the Beers criteria that nurses should be ready to question:
| Drug group | Risk in older adults |
|---|---|
| Long-acting benzodiazepines (diazepam) | Prolonged sedation, falls, fractures, delirium |
| First-generation antihistamines (diphenhydramine, promethazine) | Anticholinergic: confusion, retention, constipation, dry mouth |
| Anticholinergics and antispasmodics | Confusion, urinary retention, glaucoma precipitation |
| Non-steroidal anti-inflammatory drugs | GI bleeding, renal impairment, fluid retention |
| Tricyclic antidepressants | Anticholinergic and orthostatic effects |
| Sliding-scale insulin alone | Hypoglycaemia without improved control |
| Muscle relaxants | Sedation and anticholinergic burden |
A structured medication review at every transition of care — asking whether each drug still has an indication, whether the dose suits current renal function, and whether any drug is treating the side effect of another (a prescribing cascade) — is a core nursing contribution.
Falls, Frailty, and Function
Falls are multifactorial: intrinsic factors (gait and balance impairment, visual impairment, orthostatic hypotension, cognitive impairment, incontinence, sarcopenia) combine with extrinsic ones (footwear, lighting, floor surfaces, unfamiliar environment, tubes and lines). Assess with a validated tool, and act on what it finds: non-slip well-fitting footwear rather than socks, the bed at the lowest position with the brakes on, the call bell and personal items in reach, adequate night lighting, timed toileting for the patient with urgency, review of culprit medications, and a mobility plan rather than immobilisation.
Restraints increase harm. In confused older adults, physical restraint raises the risk of serious injury, functional decline, pressure injury, delirium, and death. They are a last resort, require a prescription and continuous monitoring, and must always be preceded by a genuine search for the cause of the behaviour — pain, retention, hypoxia, and constipation are the usual answers.
Functional assessment with a tool such as the Katz index of activities of daily living (bathing, dressing, toileting, transferring, continence, feeding) and instrumental activities (finances, medication management, transport, shopping, cooking) is what determines discharge planning far more reliably than a diagnosis list.
Elder Abuse
Recognise the patterns: injuries inconsistent with the stated mechanism, injuries at different stages of healing, malnutrition or dehydration without medical explanation, pressure injuries in a supposedly well-cared-for patient, poor hygiene, withheld medication or aids, unexplained financial transactions, and a caregiver who answers for the patient, refuses to leave the room, or shows hostility. Interview the patient alone, document objectively using the patient's own words and body maps rather than conclusions, ensure immediate safety, and report according to institutional policy and Qatari law. In Qatar, care of older family members is culturally embedded and highly valued, which can make caregiver strain hard for families to disclose; approach the conversation with respect for that context while keeping the patient's safety paramount.
An 82-year-old admitted two days ago for elective hip surgery is found to be drowsy, inattentive, and disoriented to place, having been fully oriented at admission. The daughter reports that he was "much worse last night and better this morning." Temperature is 36.9 °C. What is the nurse's most appropriate interpretation and first action?
A nurse reviews the medications of a 79-year-old woman admitted after a fall. Which prescription warrants the nurse raising a concern with the prescriber based on age-related risk?
A confused 85-year-old man is repeatedly attempting to climb over the bed rails at night. The night nurse proposes applying a vest restraint for safety. What is the most appropriate response by the charge nurse?