Learning Objectives
By the end of this section, you will be able to:
- Identify nursing considerations for the older adult
- Recognize interdisciplinary team referrals for the older adult
Nurses are key to illness prevention and health promotion for older adults. Coordination of care is crucial for minimizing the health consequences of disease and ensuring that appropriate health screenings are completed on time. Primary prevention with available screening tools helps prevent illness and ensures early detection of disease. Nurses can help prevent injuries and falls with diligent safety awareness. By using screening tools for functional health and mental health disorders, nurses can ensure patients have the support tools they need to maintain a good quality of life throughout older adulthood.
Nursing Considerations for the Older Adult
Nurses working in a wide variety of clinical settings will encounter older adults. With a strong knowledge of the nursing theories relating to older adults, developmental changes, and health risks associated with aging, nurses can lead the care team for older adults. Nurses are critical in ensuring that older adults receive individualized care, including ancillary therapies (additional or supplementary therapeutic interventions that are used alongside primary or main forms of treatment), specialty medical evaluations, nutritional support, and screening tests. Nurses are often responsible for assessing functional health, nutritional status, and gaps in care requiring referrals.
While nurses working in most settings will care for older adults, it is important to note there is a specialized branch of nursing, geriatric nursing, dedicated to the comprehensive care of older adults. Geriatric nurses undergo specific training to understand and address the complex healthcare needs associated with aging. Their role encompasses a holistic approach that considers not only the physical health but also the psychological and social aspects of older individuals. They play a vital role in health promotion, educating and guiding older adults on practices that contribute to healthy aging. By tailoring care plans to the unique needs of older adults, geriatric nurses contribute significantly to promoting optimal well-being and improving the quality of life for older individuals.
Assess Functional Health
Nurses are vital in maximizing the quality of life for older adults, particularly those struggling with chronic illnesses. An individual’s ability to complete necessary daily tasks is called functional health. By assessing functional health, nurses create a springboard for various treatment modalities to help older adults maintain their maximum quality of life. Mishra et al. (2020) lists several specific functional health patterns important for integrating nursing and other medical care. The patterns include the following:
- health perception
- ADLs
- cognitive ability
- self-perception
Nurses can utilize various assessment tools aimed at older adults for evaluating the baseline functional health of older adults (Table 41.6).
| Assessment Tool | Nursing Application |
|---|---|
| Activities of daily living (ADLs) |
|
| Instrumental activities of daily living (IADLs) |
|
| Mini-Mental State Exam (MMSE) |
|
| Geriatric Depression Scale (GDS) |
|
| Short Form 12 (SF12) |
|
Link to Learning
The Geriatric Depression Scale and Geriatric Depression Scale (short form) can help nurses understand a patient’s baseline mental health status.
A comprehensive geriatric assessment (CGA) is a detailed assessment that includes many health indexes. A CGA evaluates ADLs, IADLs (activities that allow an individual to live independently in a community, such as cooking, cleaning, and managing medications), mental health, fall risk, pain, polypharmacy (simultaneous use of multiple medications), nutrition, sensory issues, dentition, and advanced care preferences. Nurses work with primary care providers and social workers in developing an individualized CGA.
Provide Health Screenings
Nurses can help manage health screening in older adults. Awareness of age-appropriate health screening is essential for creating a comprehensive nursing care plan that promotes disease prevention. Some health screenings are offered at the community level, such as cholesterol screenings and nutritional assessments. Other screenings require healthcare provider input to determine appropriateness and test ordering. The U.S. Preventive Services Task Force (n.d.) is an excellent source for determining the screening tests recommended for older adults of varying ages. For older adults living in long-term care facilities, some health screenings are done routinely for all individuals. Health screenings may involve comprehensive functional assessments, lab values, and specialty tests such as ultrasounds, mammograms, computed tomography scans, and colonoscopies. Screening test standards for older adults may include the following:
- colon cancer screening
- mammograms
- prostate-specific antigen testing
- cholesterol testing
- osteoporosis screening
- abdominal aortic aneurysm (AAA) screening
- fall risk evaluation
- comprehensive geriatric assessments
- nutritional assessments
- functional assessments
Link to Learning
The U.S. Preventive Services Task Force offers comprehensive graded recommendations for screening tests across the life span.
Pain Management
As with individuals of all ages, older adults may experience acute pain from injuries, procedures, or medical treatments. Chronic pain is also prevalent in older adults and can range from minor to severe. Common causes of chronic pain in older adults include arthritis, degenerative spine disorders, cancer-related pain, and neuropathy. The pain threshold in older adults may be lower due to changes in circulating neurotransmitters (Ali et al., 2018). Pain management in older adults may be complicated by the following factors:
- cognition
- medication interactions
- kidney function
- fall risk
- sleep disturbance
- depression
Pain management in older adults can be complex due to various factors that contribute to the challenges of assessment and treatment. One significant factor is cognition, as many older individuals may experience cognitive decline, including conditions like dementia or Alzheimer disease. This decline can impede effective communication about pain symptoms, making it difficult for healthcare providers to accurately assess and address pain levels. Additionally, the use of multiple medications to manage various health conditions can result in interactions that impact the effectiveness or safety of pain medications. Kidney function, which tends to change with age, is another consideration, as it can influence the choice and dosage of pain medications. Furthermore, pain itself may contribute to a higher risk of falls, impacting mobility and balance. Sleep disturbances, depression, and other mental health factors can further complicate the overall picture of pain management in older adults. Healthcare professionals must carefully navigate these complexities to develop tailored and effective pain management strategies for this population. One effective strategy is to assess pain levels before and after pain medication administration by observing facial expressions and other indicators of discomfort using the Wong-Baker FACES Pain Rating Scale, especially considering the challenge some patients face in describing their pain.
The American Geriatrics Society offers specific guidelines on pain management in older adults (Table 41.7). Medications are classified as low to high risk based on the side effect profile and risk-benefit analysis. There is a balance between safe treatments for pain and untreated pain. Low-risk medications typically exhibit few interactions with other medicines and do not produce side effects that may increase fall risk or affect kidney or liver function at proper dosing.
| Low-risk pain medications (used as first-line treatments) |
|
| High-risk pain treatments |
|
In addition to medication, pain management modalities may include the following:
- physical therapy
- occupational therapy
- physical exercise
- chiropractics
- procedural injections
- stress management
- meditation
Patient Conversations
Managing Arthritis Pain
Scenario: Raelynn is a 67-year-old who lives in an apartment attached to her daughter’s home and spends significant time caring for her three grandchildren. She has osteoarthritis in multiple joints and degenerative disk disease in her lower back. She has had one knee replacement that resulted in a postoperative infection. This has healed, but she is too nervous to undergo a knee replacement on the other leg after her experience. She needs to remain active and spend time outdoors with her family. Josiah is an RN in the pain specialty clinic where Raelynn is a patient. While Josiah records her vital signs, Raelynn explains her pain symptoms and expresses frustration with not being able to do small hikes with her young grandchildren. Josiah initiates a conversation about Raelynn’s pain to facilitate a productive treatment discussion with the orthopedic specialist.
Nurse: How would you describe the pain you experience in your knee? Please rate your pain between zero being no pain and ten being the worst pain you’ve experienced.
Patient: I’ve had knee pain for years. It just keeps getting worse, and I can do less and less of the things I like to do with my family. I have tried topical creams like lidocaine over the counter. And I take acetaminophen regularly, as my primary care provider suggested. When I first get up, my pain can be as high as an eight, but it hovers around a four once I get moving. I do use some topical cannabis ointment that does give me some relief, but it doesn’t last long.
Nurse: It sounds like you’ve tried several things to improve your pain. Does any physical exercise seem to help?
Patient: Well, I was doing yoga for a while, which did help, but I can’t afford the gym membership now.
Nurse: Yoga is great; we work cooperatively with a wellness center to provide low-cost movement classes, like yoga, to our patients. Would this be something you would be interested in?
Patient: Yes, I’d like to try this option. I would also like to get back in with a physical therapist, as this has helped me in the past as well. I want to avoid any medications that will make me tired. I care for my grandchildren while my daughter works, and I need to be alert and interactive.
Nurse: I’ll note your interest so the provider can discuss options with you, and we can get these referrals processed. The provider will also discuss other medication options with you that are nonsedating. The provider will also be able to tell you if any injections in your joint might be helpful for a more extended period.
Promote Physical Activity
Physical movement is crucial for older adults. High- and low-intensity activity helps maintain muscle mass, improve balance, improve circulation, and minimize fat deposition. Group exercise in community settings or long-term care facilities promotes mental functioning. By focusing on physical activity, nurses can promote healthy elimination and digestion. The CDC (2021) explains that even short-duration physical activity, such as brisk walking, can help manage symptoms of most chronic illnesses. Physical exercise also improves alertness and plays a role in reducing anxiety and depression. Nurses in various clinical settings can help clients resume or begin physical activity after setbacks due to illness or injury (Table 41.8). Nurses can guide clients to community exercise groups, outdoor walking groups, and senior centers offering gentle motion classes. The CDC recommends 150 minutes of moderate-intensity exercise weekly for older adults and muscle-strengthening exercises at least two days per week.
| Fall Risk Factor | Nursing Interventions |
|---|---|
| Altered mental status |
|
| Impaired mobility |
|
| Frequent toileting needs |
|
| Visual impairment |
|
| High-risk medications |
|
| Frequent falls |
|
Medication Education
Medication education is vital during several key patient interactions. Nurses have opportunities to explain medication treatments during admission assessments, medication administration, discharge planning, patient education sessions, outpatient clinics, follow-up visits, and home health visits, ensuring patients understand the purpose, potential side effects, and proper administration of their medications. Nurses work directly with pharmacists and prescribers to maintain patient safety with medication treatments. During hospital stays, nurses administer medications routinely. In addition to the five rights, medication administration involves educating patients on the purpose of the prescribed medications. Medications for pain are tailored specifically for each patient’s level of pain.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Definition: Reducing a patient’s risk of harm by incorporating individual quality performance standards and system effectiveness.
Knowledge: Chronic disease prevalence in the older adult population increases the risk of polypharmacy and associated complications in this age group. Polypharmacy refers to using multiple medications simultaneously to treat one or more medical disorders. Typically, polypharmacy refers to the use of five or more medications. With each addition of medication, the risk for drug-drug interactions significantly increases. There is a risk for compounded side effects and a risk to organs such as the kidney and liver.
Skill: Nurses can always be alert for polypharmacy, monitor for any medication indication duplication, and be aware of when medications can be stopped. It is appropriate to bring concerns about polypharmacy to the attention of healthcare providers, particularly in long-term care settings where several patients’ medications are stored.
Attitude: Polypharmacy is common; nurses also play a role when new medications are added, understanding and being proactive about checking medication interactions, discussing medication management with patients, and keeping open communication with pharmacists about minimizing side effects and interactions.
The AGS Beers Criteria, formulated by the American Geriatrics Society, serve as a crucial reference tool for healthcare professionals in identifying potentially inappropriate medications for older adults (Cleveland Clinic, 2023). Among the medications commonly listed are benzodiazepines like diazepam, lorazepam, and alprazolam, frequently prescribed for anxiety or insomnia. The caution arises from the heightened risk of falls, cognitive impairment, and other adverse effects associated with the use of these drugs in older individuals. Additionally, nonbenzodiazepine hypnotics, such as zolpidem, commonly prescribed for sleep-related issues, are flagged due to their potential contribution to drowsiness, falls, and impaired cognitive function.
The role of a nurse becomes pivotal when medications listed on the AGS Beers Criteria are identified during patient care. The nurse’s responsibilities encompass a comprehensive assessment of the patient’s medication history, with a keen focus on prescriptions and over-the-counter drugs, and diligent documentation of any medications flagged by the Beers list. Effective communication with pharmacists, prescribers, and the broader healthcare team is paramount, fostering collaborative discussions to explore safer alternatives. Patient education becomes a crucial aspect, with the nurse providing clear explanations of potential risks associated with identified medications and actively involving the patient in decisions about their health care.
Link to Learning
The American Geriatrics Society updates the AGS Beers Criteria every three years (Cleveland Clinic, 2023). At this website, you can learn more about the AGS Beers Criteria, including the medication classes that are not recommended for use in the older adult population.
Assess for Neglect or Abuse
Nurses must always remain diligent in monitoring for signs of abuse and neglect in older adult populations. This is especially true for individuals with dementia, those who live alone, and those with financial strain. Nurses can employ a variety of abuse screening tools, such as the Elder Abuse Suspicion Index and the Vulnerability to Abuse Screening Scale, in the event of abuse suspicion (National Center on Elder Abuse, 2016). These assessment tools focus on physical care, medical management, emotional abuse, sexual abuse, financial abuse, and neglect. It is important to note these tools are not diagnostic but serve as indicators for further assessment and intervention. Professionals using these tools must follow appropriate protocols and ethical guidelines when suspicions of abuse or neglect arise, involving appropriate authorities and support services as needed.
Clinical Judgment Measurement Model
Fall Risk Assessment in Clinical Practice
In caring for older adults, nurses can rely on the Clinical Judgment Measurement Model (CJMM) to guide client assessment, individualize care based on clinical cues, and evaluate the effectiveness of nursing interventions across practice sites. Fall risk assessment offers a clear example of application in clinical practice (Table 41.9).
| CJMM Step | Clinical Application |
|---|---|
| Recognize clues | The nurse notices a patient has an uneven gait, shows physical weakness, and expresses dizziness. The nurse witnesses a near fall and sees several bruises on the patient’s forearms. |
| Analyze clues | The nurse determines the patient is at high risk for falls. The nurse understands that medications, general weakness, floor rugs, and lack of assistive device are playing a role in fall risk. |
| Prioritize hypotheses | The nurse prioritizes the need to improve the physical environment of the client and then reporting physical symptoms of dizziness, weakness, and possible medication effects to the healthcare provider. |
| Generate solutions | The nurse creates a plan with the patient, family, and other caregivers to improve the physical environment by removing floor rugs, obtaining a walker, and creating a plan for toileting to avoid rushing. |
| Take actions | The nurse requests an order for a walker and enlists family to help keep floor areas free of debris. |
| Evaluate outcomes | The nurse notices a reduction in injuries over the next several months. The patient vocalizes a sense of safety when moving around the home. |
Interdisciplinary Team Referrals
Working within the medical community means nurses must work closely with colleagues in other specialties. In caring for older adults, nurses will frequently collaborate with nurses and other healthcare providers in specialties such as orthopedics, endocrinology, cardiology, pulmonology, and dermatology. Additionally, ancillary specialty services play a key role in the health of older adults, and nurses will frequently interact with physical therapists, occupational therapists, cardiac rehabilitation specialists, and mental health professionals, among others. Collaborative care is essential for quality and streamlined patient care. Nurses may work in formal interdisciplinary teams or document and forward referrals to specialists for additional care. When a patient requires specialty care, a nurse will provide a referral for these services by forwarding appropriate records, arranging appointments, and coordinating care.
Nutritional Support
Nutritional support may relate to general health eating or may focus on specific disease management. Nutritional support is necessary for many common chronic disease states, including the following:
- diabetes
- heart disease
- colitis
- celiac disease
- obesity
- high cholesterol
- hypertension
Nurses rely on nutritionists to educate older adults with diabetes on proper nutrition to manage the disease and minimize complications. Nutrition services are essential in long-term care facilities and for individuals living at home. Some older adults struggle with financial strain and may struggle to afford food. Nurses can guide these clients to community resources, such as meals-on-wheels and the Older Americans Act nutrition programs, to minimize hunger in the adult population.
Link to Learning
At this website, facts about the Older Americans Act Nutrition Programs are available.
Specialty Referrals
Specialty referrals are common for patients discharged from the hospital and those seeking care through a primary care provider (Table 41.10).
| Physician Specialties | Indication for Referral |
|---|---|
| Allery and immunology | Asthma, allergies, hives |
| Behavioral health | Depression, anxiety, bipolar disorder |
| Cardiology | Heart attack, heart murmur, chest pain, heart palpitations, stroke |
| Dermatology | Skin cancer, rash, cysts |
| Endocrinology | Diabetes, thyroid dysfunction |
| Gastroenterology | Diarrhea, constipation, rectal bleeding, gastroesophageal reflux disease (GERD), abdominal pain |
| Hematology | Blood cell abnormalities, anemia, leukemia |
| Neurology | Cognitive decline, neuropathy, carpal tunnel |
| Oncology | Any cancer diagnosis |
| Ophthalmology | Acute or chronic vision changes, eye pain, temporal arteritis |
| Orthopedics | Arthritis, degenerative disk disease, traumatic injuries, joint pain |
| Pulmonology | Chronic obstructive pulmonary disease, chemical lung exposures, sleep apnea |
| Rheumatology | Joint pain, elevated arthritis markers |
| Urology | Prostatitis, elevated prostate-specific antigen test, hematuria, prostate enlargement, overactive bladder |
For older adults, accessing a range of ancillary specialty services can significantly contribute to their comprehensive health care. These specialized services cater to diverse aspects of health and functional well-being. Physical therapy focuses on enhancing mobility and strength, while occupational therapy addresses daily living skills. Speech therapy becomes crucial for managing communication disorders and swallowing difficulties. Respiratory therapy specializes in improving lung function and managing breathing difficulties, particularly beneficial for individuals with conditions like chronic obstructive pulmonary disease. Wound care specialists play a vital role in assessing and treating wounds to prevent complications and promote healing. Nutritionists offer guidance on dietary habits, diabetes educators provide support for managing diabetes, and weight management specialists address weight-related concerns. Pain management specialists assess and treat chronic pain conditions, aiming to improve the overall quality of life. This collaborative approach involving various ancillary services, alongside primary care, ensures a holistic and tailored care plan for older adults, addressing their unique needs and enhancing their overall health and functionality.
Community Resources
Community resources for older adults play a crucial role in enhancing their well-being and overall quality of life. While community resources vary by location and size of the city, many communities have volunteer services for older adults, such as senior centers, exercise classes, meals, library book delivery, and read-aloud services. Senior centers serve as social hubs, offering a range of activities, educational programs, and wellness services to promote engagement and connectivity among older community members. Meals-on-wheels programs provide a valuable service by delivering nutritious meals to seniors at home, addressing concerns related to food preparation and ensuring they maintain proper nutrition. Transportation services designed for older adults help address mobility challenges, ensuring they have access to essential services, medical appointments, and community activities. Other community resources might include grief support groups, disease-specific support groups, and hobby groups. These resources collectively contribute to creating an age-friendly community that supports the independence, health, and social connections of older individuals. It is important for seniors and their caregivers to be aware of and utilize these community resources to enhance their overall well-being.
Caregiver Resources
Nursing care for older adults often involves caring for the family and other caregivers. For individuals caring for older adults, there are various caregiver resources available to provide support and guidance. Local aging agencies often offer assistance in the form of information, counseling, and respite services. The term respite refers to a short period of rest or relief, typically provided to caregivers who are responsible for the continuous care of individuals with special needs, disabilities, or chronic illnesses. During respite, caregivers can take a temporary break from their caregiving duties to recharge, attend to their own needs, or engage in activities that promote their well-being. Support groups, whether in-person or online, provide caregivers with opportunities to connect, share experiences, and receive emotional support from others facing similar challenges. Educational programs and workshops help caregivers develop essential skills for managing the physical, emotional, and logistic aspects of caregiving. Additionally, online platforms and helplines offer information on specific health conditions, legal matters, and financial planning related to caregiving. Accessing these resources empowers caregivers with the knowledge and assistance needed to navigate the complexities of providing care for older adults and maintain their own well-being in the process.
Caregivers may find valuable support from organizations such as the Family Caregiver Alliance, Caregiver Action Network, and various support groups, including those focused on grief. The Caregiver Action Network, in particular, offers comprehensive resources to assist family members in their caregiving responsibilities. Nurses can play a vital role in supporting caregivers by facilitating access to these support services, attentively listening to their concerns, and ensuring that caregivers are informed about where to seek assistance for any questions or challenges they may encounter. This collaborative approach helps create a supportive network for caregivers, enhancing their ability to provide effective care while prioritizing their own well-being.
Link to Learning
The Caregiver Action Network provides a comprehensive family caregiver toolbox that provides resources for families, caregivers, and nurses alike.